Hüning, B M; Reimann, M; Beerenberg, U; Stein, A; Schmidt, A; Felderhoff-Müser, U
Elternberatung Frühstart is a family-centred care programme for very preterm infants and seriously ill neonates and their parents. The uniqueness of this programme is in its consistency and continuity in parental counselling from pregnancy at risk to follow-up home visits. Family-centred care is provided by specialised nurses, a social education worker, a case manager, a psychologist and neonatologists. They give support and information to parents and facilitate transition to home including co-ordination of health care services and support networks. The programme starts with information for parents at risk of preterm delivery to lessen their anxieties and worries. After birth, parental bonding is encouraged and parents are involved in daily care procedures. The following weeks focus on communication, information and education in order to enhance parental competence. Discharge planning and coordinated follow-up visits involve the family doctor and several members of the welfare and health care system. One of the key objectives is to prevent re-hospitalisation. Over a 4 year period 330 families participated. Funding is provided by: 1) the hospital, from admission to discharge equivalent to one full-time nursing staff, 2) charity donations for follow-up visits and 3) health care insurance for social medical aftercare (Bunter Kreis) following §43, 2 SGB V in severe cases. As a result of this programme, the median length of stay was reduced by 24 days; the number of patients that stayed longer than average were reduced by 64% in the group of patients born < 1 500 g. At the same time the patient throughput increased from 243 to 413. To conclude, a family-centred care programme with coordinated follow-up increases parental satisfaction, reduces the length of the hospital stay and is therefore profitable. © Georg Thieme Verlag KG Stuttgart · New York.
Kumar, A. M. V.; Chinnakali, P.; Rajendran, M.; Valan, A. S.; Rewari, B. B.; Swaminathan, S.
Setting: Children aged <15 years constitute 7% of all people living with the human immunodeficiency virus (HIV) in India. A previous study from an antiretroviral therapy (ART) centre in south India reported 82% loss to follow-up (LTFU) among children in pre-ART care (2006–2011). Objective: To assess the proportion of LTFU within 1 year of registration among HIV-infected children (aged < 15 years) registered in all 43 ART centres in the state of Tamil Nadu, India, during the year 2012. Design: This was a retrospective cohort study involving a review of programme records. Results: Of 656 children registered for HIV care, 20 (3%) were not assessed for ART eligibility. Of those remaining, 226 (36%) were not ART eligible and entered pre-ART care. Among these, at 1 year of registration, 50 (22%) were LTFU, 40 (18%) were transferred out and 136 (60%) were retained in care at the same centre. The child's age, sex, World Health Organization stage or occurrence of opportunistic infection were not associated with LTFU. Conclusion: One in five children registered under pre-ART care were lost to follow-up. Stronger measures to prevent LTFU and reinforce retrieval actions are necessary in the existing National HIV Programme. PMID:28695080
De Carolis, Maria Pia; Cocca, Carmen; Valente, Elisabetta; Lacerenza, Serafina; Rubortone, Serena Antonia; Zuppa, Antonio Alberto; Romagnoli, Costantino
Early discharge of mother/neonate dyad has become a common practice, and its effects are measured by readmission rates. We evaluated the safety of early discharge followed by an individualized Follow-up programme and the efficacy in promoting breastfeeding initiation and duration. During a nine-month period early discharge followed by an early targeted Follow-up was carried out in term neonates in the absence of weight loss <10% or hyperbilirubinaemia at risk of treatment. Follow-up visits were performed at different timepoints with a specific flow-chart according to both bilirubin levels and weight loss at discharge. During the study period early discharge was performed in 419 neonates and Follow-up was carried out in 408 neonates (97.4%). No neonates required readmission for hyperbilirubinaemia and dehydration during the first 28 days of life. Breastfeeding rate was 90.6%, 75.2%, 41.5% at 30, 90 and 180 days of life, respectively. A six-month phone interview was performed for 383 neonates (93.8%) and satisfaction of parents about early discharge was high in 345 cases (90.1%). Early discharge in association with an individualized Follow-up programme resulted safe for the neonate and effective for breastfeeding initation and duration.
The effect of a nurse led telephone supportive care programme on patients' quality of life, received information and health care contacts after oesophageal cancer surgery-A six month RCT-follow-up study.
Malmström, Marlene; Ivarsson, Bodil; Klefsgård, Rosemarie; Persson, Kerstin; Jakobsson, Ulf; Johansson, Jan
Following oesophagectomy, a major surgical procedure, it is known that patients suffer from severely reduced quality of life and have an unmet need for postoperative support. Still, there is a lack of research testing interventions aiming to enhance the patients' life situation after this surgical procedure. The aim of the study was to evaluate the effect of a nurse led telephone supportive care programme on quality of life (QOL), received information and the number of healthcare contacts compared to conventional care following oesophageal resection for cancer. The study was designed as a randomized controlled trial (RCT) aiming to test the effect of a nurse led telephone supportive care program compared to conventional care. Patient assessments were conducted at discharge, 2 weeks, 2, 4 and 6 months after discharge and comprised evaluation of QOL, received information and the number of health care contacts. Statistical testing were conducted with repeated measurements analysis of variance to test if there were differences between the groups during follow-up. The results show that the intervention group was significantly more satisfied with received information for items concerning the information they received about things to do to help yourself, written information and for the global information score. The control group scored significantly higher on the item regarding wishing to receive more information and wish to receive less information. No effect of the intervention was shown on QOL or number of health care contacts. Proactive nurse-led telephone follow-up has a significant positive impact on the patients' experience of received information. This is likely to have a positive effect on their ability to cope with a life that may include remaining side effects and adverse symptoms for a long time after surgery. Copyright Â© 2016 Elsevier Ltd. All rights reserved.
Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care.
Khunti, Kamlesh; Gray, Laura J; Skinner, Timothy; Carey, Marian E; Realf, Kathryn; Dallosso, Helen; Fisher, Harriet; Campbell, Michael; Heller, Simon; Davies, Melanie J
To measure whether the benefits of a single education and self management structured programme for people with newly diagnosed type 2 diabetes mellitus are sustained at three years. Three year follow-up of a multicentre cluster randomised controlled trial in primary care, with randomisation at practice level. 207 general practices in 13 primary care sites in the United Kingdom. 731 of the 824 participants included in the original trial were eligible for follow-up. Biomedical data were collected on 604 (82.6%) and questionnaire data on 513 (70.1%) participants. A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care. The primary outcome was glycated haemoglobin (HbA(1c)) levels. The secondary outcomes were blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, emotional impact of diabetes, and drug use at three years. HbA(1c) levels at three years had decreased in both groups. After adjusting for baseline and cluster the difference was not significant (difference -0.02, 95% confidence interval -0.22 to 0.17). The groups did not differ for the other biomedical and lifestyle outcomes and drug use. The significant benefits in the intervention group across four out of five health beliefs seen at 12 months were sustained at three years (P<0.01). Depression scores and quality of life did not differ at three years. A single programme for people with newly diagnosed type 2 diabetes mellitus showed no difference in biomedical or lifestyle outcomes at three years although there were sustained improvements in some illness beliefs. Current Controlled Trials ISRCTN17844016.
Cinar, Fatma I; Tosun, Nuran; Kose, Sedat
To determine the experiences, problems and the need for care and education of implantable cardioverter defibrillator-implanted patients and to assess the effects of an education and nurse follow-up programme on their quality of life, anxiety, depression and knowledge level. Although implantable cardioverter defibrillator has become a well-established therapy for people experiencing potentially lethal dysrhythmias, implantable cardioverter defibrillator patients may have physical and psychosocial problems due to the implantation. Applying a planning education and follow-up programme to implantable cardioverter defibrillator-implanted patients may prevent the need for more intensive treatment during the postimplantation period. A mixed methods design that used both qualitative and quantitative data collections and analysis was used for this study. The study was performed in the cardiology department in Turkey between 2009-2010. The data were collected using the 'Semi-Structured Interview Form', 'Form for Assessment of Patients' Knowledge Level about implantable cardioverter defibrillator', 'Spielberger's State-Trait Anxiety Inventory', 'Beck Depression Inventory II' and 'The Short-Form 36 Health Survey'. All forms were completed at the beginning of the study and at six months. The study included 27 patients in the experimental group and 27 patients in the control group. The results showed that the patients were living with various physical and psychosocial problems and insufficient knowledge regarding the implantable cardioverter defibrillator. Education and follow-up programme increased knowledge levels, decreased anxiety and depression scores and improved several subscales of quality of life in the experimental group patients. It was recommended that education and follow-up programme be used for patients scheduled to undergo implantable cardioverter defibrillator implantation, starting before implantation and continuing thereafter, to help patients adapt to a life
Maindal, Helle Terkildsen; Støvring, Henrik; Sandbaek, Annelli
The periodic health check-up has been a fundamental part of routine medical practice for decades, despite a lack of consensus regarding its value in health promotion and disease prevention. A large-scale Danish population-based preventive programme 'Check your health' was developed based on available evidence of screening and successive accepted treatment, prevention for diseases and health promotion, and is closely aligned with the current health care system.The objective of the 'Check your health' [CORE] trial is to investigate effectiveness on health outcomes of a preventive health check offered at a population-level to all individuals aged 30-49 years, and to establish the cost-effectiveness. The trial will be conducted as a pragmatic household-cluster randomised controlled trial involving 10,505 individuals. All individuals within a well-defined geographical area in the Central Denmark Region, Denmark (DK) were randomised to be offered a preventive health check (Intervention group, n = 5250) or to maintain routine access to healthcare until a delayed intervention (Comparison group, n = 5255). The programme consists of a health examination which yields an individual risk profile, and according to this participants are assigned to one of the following interventions: (a) referral to a health promoting consultation in general practice, (b) behavioural programmes at the local Health Centre, or (c) no need for follow-up.The primary outcomes at 4 years follow-up are: ten-year-risk of fatal cardiovascular event (Heart-SCORE model), physical activity level (self-report and cardiorespiratory fitness), quality of life (SF12), sick leave and labour market attachment. Cost-effectiveness will be evaluated according to life years gained, direct costs and total health costs. Intention to treat analysis will be performed. Results from the largest Danish health check programme conducted within the current healthcare system, spanning the sectors which share responsibility for
Egger, Matthias; Spycher, Ben D.; Sidle, John; Weigel, Ralf; Geng, Elvin H.; Fox, Matthew P.; MacPhail, Patrick; van Cutsem, Gilles; Messou, Eugène; Wood, Robin; Nash, Denis; Pascoe, Margaret; Dickinson, Diana; Etard, Jean-François; McIntyre, James A.; Brinkhof, Martin W. G.
Background The World Health Organization estimates that in sub-Saharan Africa about 4 million HIV-infected patients had started antiretroviral therapy (ART) by the end of 2008. Loss of patients to follow-up and care is an important problem for treatment programmes in this region. As mortality is high in these patients compared to patients remaining in care, ART programmes with high rates of loss to follow-up may substantially underestimate mortality of all patients starting ART. Methods and Findings We developed a nomogram to correct mortality estimates for loss to follow-up, based on the fact that mortality of all patients starting ART in a treatment programme is a weighted average of mortality among patients lost to follow-up and patients remaining in care. The nomogram gives a correction factor based on the percentage of patients lost to follow-up at a given point in time, and the estimated ratio of mortality between patients lost and not lost to follow-up. The mortality observed among patients retained in care is then multiplied by the correction factor to obtain an estimate of programme-level mortality that takes all deaths into account. A web calculator directly calculates the corrected, programme-level mortality with 95% confidence intervals (CIs). We applied the method to 11 ART programmes in sub-Saharan Africa. Patients retained in care had a mortality at 1 year of 1.4% to 12.0%; loss to follow-up ranged from 2.8% to 28.7%; and the correction factor from 1.2 to 8.0. The absolute difference between uncorrected and corrected mortality at 1 year ranged from 1.6% to 9.8%, and was above 5% in four programmes. The largest difference in mortality was in a programme with 28.7% of patients lost to follow-up at 1 year. Conclusions The amount of bias in mortality estimates can be large in ART programmes with substantial loss to follow-up. Programmes should routinely report mortality among patients retained in care and the proportion of patients lost. A simple
Brandenbarg, D; Berendsen, A J; de Bock, G H
Most survivors of cancer enter a follow-up routine after their treatment, the aim of which is to detect recurrence, provide psychological support, monitor treatment-related side-effects, and to evaluate care. Due to rising numbers of people with cancer and better survival of these patients, current follow-up routines are under pressure. We reviewed the literature on patients' expectations and preferences regarding this care. We systematically searched the databases of Pubmed, CINAHL, and PsychInfo. Studies were screened and data extraction was double performed by three authors. Data were collected from quantitative and qualitative studies and described thematically. After screening, 12 full-text articles were included, comprising 849 patients aged from 28 to 90 years. Patients expect follow-up visits to detect recurrence of cancer. They want to undergo extensive testing to get reassurance. Furthermore, patients expect relevant information to be provided and to get advice about different aspects of their illness. Psychosocial support is also expected. Patients express a desire for consistency of care as well as continuity of care, and prefer long and intensive follow-up. After cancer, patients appear to lose confidence in their bodies and fear cancer recurrence after the end of treatment, which may lead to intensive screening wishes. This is not desirable, since care for cancer is already under pressure due to rising numbers of survivors. We have to ensure that follow-up routines are sustainable and effective. Patients should receive good information about the need for follow-up tests. Doctors should be trained to give this information. Copyright © 2017 Elsevier B.V. All rights reserved.
Ballantyne, M; Stevens, B; Guttmann, A; Willan, A R; Rosenbaum, P
Neonatal Follow-Up (NFU) programmes provide health services for families of infants at high risk of developmental problems following difficult or extremely premature birth: yet, up to 30% of families do not attend these programmes with their infants. The study objective was to determine maternal and infant factors that predicted attendance at NFU programmes. Utilizing Andersen's Behavioural Model of Health Services Use, a prospective two-phase multi-site descriptive cohort study was conducted in three Canadian Neonatal Intensive Care Units (NICU) that refer to two affiliated NFU programmes. In Phase 1, 357 mothers completed standardized questionnaires that addressed maternal and infant factors, prior to their infants' NICU discharge. In Phase 2, attendance at NFU was followed at three time points over a 12-month period. Factors of interest included predisposing factors (e.g. demographic characteristics and social context); enabling factors (e.g. social support, travel distance, and income); and infant illness severity (i.e. needs factors). Multivariate logistic regression was used to estimate the odds ratio for each independent factor. Mothers parenting alone, experiencing higher levels of worry about maternal alcohol or drug use, or at greater distances from NFU were less likely to attend. Mothers experiencing higher maternal stress at the time of the infant's NICU hospitalization were more likely to attend NFU. No infant factors were predictive of NFU attendance. Mothers at risk of not attending NFU programmes with their infants require better identification, triage, referral and additional support to promote engagement with NFU programmes and improved quality of life for their high-risk infants. © 2013 John Wiley & Sons Ltd.
Moore, Julie; Morath, Karen; Harre, Niki
This paper describes the follow-up evaluation of a school-based scalds prevention programme designed to teach children about scalds hazards and encourage safe family practices. It involved two classroom sessions and a homework exercise that targeted five safety practices. The programme was taught to 28 classes in 14 schools in Waitakere City, New…
Alonso Cerezo, C; Simón Martín, J; Fernández Jiménez, G; Rivera Franco, J
To know the opinion of primary care physicians about the criteria that they use in the request of the laboratories tests of hyperlipidemia and to confirm the above-mentioned opinion with the parameters edited in some guides of clinical practice published on hyperlipidemia. Transverse and descriptive study. Accomplishment of 2 questionnaires, one by internal post and another one through personal or telephonic interview. Comparison of most important guides of clinical practice. Primary care of an area of Madrid. In the survey directed to all the 199 primary care physicians, 116 valid answers were obtained. In the survey directed to all 20 coordinators of the centers of primary care, 16 valid answers were obtained. The frequency, the percentage and the confidence interval. 109 (94%) of the primary care physicians request laboratories tests in the goal to exclude secondary reasons of hyperlipidemia. The LDL-cholesterol is considered to be a suitable test for the follow-up of the hyperlipidemia by 108 (93.0%) primary care physicians. According to the opinion of the coordinators, the year of edition and/or review of the existing guide in the center changes between 1992-2000. As strategy of improvement of the clinical practice it is necessary to realize and support an updated guide of clinical practice, where the suitable tests are defined to look for the etiología of hyperlipidemia, the determinations that must be requested for the initial control of the treatment and with which periodicity they are requested.
Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme, a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial.
Weobong, Benedict; Weiss, Helen A; McDaid, David; Singla, Daisy R; Hollon, Steven D; Nadkarni, Abhijit; Park, A-La; Bhat, Bhargav; Katti, Basavraj; Anand, Arpita; Dimidjian, Sona; Araya, Ricardo; King, Michael; Vijayakumar, Lakshmi; Wilson, G Terence; Velleman, Richard; Kirkwood, Betty R; Fairburn, Christopher G; Patel, Vikram
The Healthy Activity Programme (HAP), a brief behavioural intervention delivered by lay counsellors, enhanced remission over 3 months among primary care attendees with depression in peri-urban and rural settings in India. We evaluated the sustainability of the effects after treatment termination, the cost-effectiveness of HAP over 12 months, and the effects of the hypothesized mediator of activation on clinical outcomes. Primary care attendees aged 18-65 years screened with moderately severe to severe depression on the Patient Health Questionnaire 9 (PHQ-9) were randomised to either HAP plus enhanced usual care (EUC) (n = 247) or EUC alone (n = 248), of whom 95% completed assessments at 3 months, and 91% at 12 months. Primary outcomes were severity on the Beck Depression Inventory-II (BDI-II) and remission on the PHQ-9. HAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up (difference in mean BDI-II score between 3 and 12 months = -0.34; 95% CI -2.37, 1.69; p = 0.74), with lower symptom severity scores than participants who received EUC alone (adjusted mean difference in BDI-II score = -4.45; 95% CI -7.26, -1.63; p = 0.002) and higher rates of remission (adjusted prevalence ratio [aPR] = 1.36; 95% CI 1.15, 1.61; p < 0.009). They also fared better on most secondary outcomes, including recovery (aPR = 1.98; 95% CI 1.29, 3.03; p = 0.002), any response over time (aPR = 1.45; 95% CI 1.27, 1.66; p < 0.001), higher likelihood of reporting a minimal clinically important difference (aPR = 1.42; 95% CI 1.17, 1.71; p < 0.001), and lower likelihood of reporting suicidal behaviour (aPR = 0.71; 95% CI 0.51, 1.01; p = 0.06). HAP plus EUC also had a marginal effect on WHO Disability Assessment Schedule score at 12 months (aPR = -1.58; 95% CI -3.33, 0.17; p = 0.08); other outcomes (days unable to work, intimate partner violence toward females) did not statistically significantly differ between the two arms. Economic analyses
Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme, a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial
Weobong, Benedict; Singla, Daisy R.; Hollon, Steven D.; Nadkarni, Abhijit; Park, A-La; Bhat, Bhargav; Anand, Arpita; Dimidjian, Sona; King, Michael; Vijayakumar, Lakshmi; Wilson, G. Terence; Velleman, Richard
Background The Healthy Activity Programme (HAP), a brief behavioural intervention delivered by lay counsellors, enhanced remission over 3 months among primary care attendees with depression in peri-urban and rural settings in India. We evaluated the sustainability of the effects after treatment termination, the cost-effectiveness of HAP over 12 months, and the effects of the hypothesized mediator of activation on clinical outcomes. Methods and findings Primary care attendees aged 18–65 years screened with moderately severe to severe depression on the Patient Health Questionnaire 9 (PHQ-9) were randomised to either HAP plus enhanced usual care (EUC) (n = 247) or EUC alone (n = 248), of whom 95% completed assessments at 3 months, and 91% at 12 months. Primary outcomes were severity on the Beck Depression Inventory–II (BDI-II) and remission on the PHQ-9. HAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up (difference in mean BDI-II score between 3 and 12 months = −0.34; 95% CI −2.37, 1.69; p = 0.74), with lower symptom severity scores than participants who received EUC alone (adjusted mean difference in BDI-II score = −4.45; 95% CI −7.26, −1.63; p = 0.002) and higher rates of remission (adjusted prevalence ratio [aPR] = 1.36; 95% CI 1.15, 1.61; p < 0.009). They also fared better on most secondary outcomes, including recovery (aPR = 1.98; 95% CI 1.29, 3.03; p = 0.002), any response over time (aPR = 1.45; 95% CI 1.27, 1.66; p < 0.001), higher likelihood of reporting a minimal clinically important difference (aPR = 1.42; 95% CI 1.17, 1.71; p < 0.001), and lower likelihood of reporting suicidal behaviour (aPR = 0.71; 95% CI 0.51, 1.01; p = 0.06). HAP plus EUC also had a marginal effect on WHO Disability Assessment Schedule score at 12 months (aPR = −1.58; 95% CI −3.33, 0.17; p = 0.08); other outcomes (days unable to work, intimate partner violence toward females) did not statistically significantly
Pasquali, Sara K; Ravishankar, Chitra; Romano, Jennifer C; Kane, Kristin; Viers, Suzanne; Kennedy, Andrea; Burnham, Nancy; Lowery, Ray; Uzark, Karen; Retzloff, Lauren; Rome, Jonathon J; Rossano, Joseph W; Charpie, John R; Spray, Thomas L; Gaies, Michael G; Ohye, Richard G; Gaynor, J William
With improvements in early survival following congenital heart surgery, it has become increasingly important to understand longer-term outcomes; however, routine collection of these data is challenging and remains very limited. We describe the development and initial results of a collaborative programme incorporating standardised longitudinal follow-up into usual care at the Children's Hospital of Philadelphia (CHOP) and University of Michigan (UM). We included children undergoing benchmark operations of the Society of Thoracic Surgeons. Considerations regarding personnel, patient/parent engagement, funding, regulatory issues, and annual data collection are described, and initial follow-up rates are reported. The present analysis included 1737 eligible patients undergoing surgery at CHOP from January 2007 to December 2014 and 887 UM patients from January 2010 to December 2014. Overall, follow-up data, of any type, were obtained from 90.8% of patients at CHOP (median follow-up 4.3 years, 92.2% survival) and 98.3% at UM (median follow-up 2.8 years, 92.7% survival), with similar rates across operations and institutions. Most patients lost to follow-up at CHOP had undergone surgery before 2010. Standardised questionnaires assessing burden of disease/quality of life were completed by 80.2% (CHOP) and 78.4% (UM) via phone follow-up. In subsequent pilot testing of an automated e-mail system, 53.4% of eligible patients completed the follow-up questionnaire through this system. Standardised follow-up data can be obtained on the majority of children undergoing benchmark operations. Ongoing efforts to support automated electronic systems and integration with registry data may reduce resource needs, facilitate expansion across centres, and support multi-centre efforts to understand and improve long-term outcomes in this population.
Baker, G H; Woods, T J; Anderson, J A
The programme in an intensive rehabilitation unit in a large psychiatric hospital is described. Features include the use of non-medical staff as primary therapists, the use of a mini-bus to facilitate regular visits by patients to their home areas, the inclusion of the mini-bus driver on weekly staff conferences, the use of sociodrama, the re-organization of hospital money payments to patients, the promotion of relations with community-based facilities through occasional "teach-in" days, and a special liaison social worker providing intensive follow-up after discharge. Rehabilitation was prolonged (average stay about one year) and about half of those selected for rehabilitation from the long-stay wards were discharged. Follow-up showed that these patients benefited from discharge, in spite of a relatively high incidence of psychopathology and of social problems. Those transferred back to long-stay wards showed increased institutionalization.
Langhammer, Birgitta; Stanghelle, Johan K
The purpose of this follow-up one and four years post stroke was to find out whether the initial physiotherapy approach had had any long-term effects on mortality, motor function, postural control, activities of daily living, life quality, follow-up from community services and living conditions. A randomized controlled trial of first time ever stroke patients. Group 1 (n = 33) and group 2 (n = 28) had initial physiotherapy according to the Motor Relearning Programme and Bobath, respectively. The Motor Assessment Scale (MAS), the Sødring Motor Evaluation Scale (SMES), the Barthel ADL Index, the Nottingham Health Profile (NHP) and Berg Balance Scale were used. The following parameters were also registered: incidence of new strokes, other diseases, use of assistive devices, the patient's accommodation and use of services from the community. The mortality rates were similar in the two groups. In both groups the motor function, postural control and ADL had decreased rapidly, leaving many of the patients dependent and with a high risk of falling. Life quality had increased compared to the acute stage, but was still low in comparison with healthy persons. Patients in both groups lived at home, but were dependent on help from relatives and community services. Physiotherapy as follow-up service was seldom used. The initial physiotherapy approach did not seem to have a major influence on the patients' ability to cope in the long-term. This follow-up at one and four years post stroke showed no major influence of two different initial physiotherapy regimens on long-term function. The study confirmed a rapid deterioration of ADL and motor function and an increased dependence on relatives. The study reveals a gap between the intense treatment in the acute phase and little or no follow-up of physiotherapy treatment or other rehabilitation activities later.
Italia, Yazdi; Krishnamurti, Lakshmanan; Mehta, Vishal; Raicha, Bhavesh; Italia, Khushnooma; Mehta, Pallavi; Ghosh, Kanjaksha; Colah, Roshan
To evaluate the feasibility of a newborn screening and follow-up programme for sickle cell disease (SCD) among tribal populations of south Gujarat, India. A total of 5467 newborn babies were screened over 2 years using High-performance liquid chromatography, with diagnosis by molecular analysis. The SCD babies were followed-up clinically and haematologically regularly for 1.5 to 5 years to describe the course of the disease. Thirty-three babies (0.60%) were sickle homozygous, 13 (0.23%) were-sickle-β-thalassaemia, 687 (12.5%) were sickle heterozygous, and 4736 were unaffected. The parents of SCD babies were educated and counselled for home care. There were 32 babies (69.5%) who could be clinically and haematologically followed-up; 7 babies (21.8%) presented with severe clinical complications, whereas 18 (56.2%) babies were asymptomatic till the last follow-up. The variation in clinical presentation was seen in spite of the presence of ameliorating factors, such as high fetal haemoglobin, Xmn-I polymorphism, and α-thalassaemia. In addition to demonstrating the possibility of establishing a newborn screening programme for sickle cell disorders among tribal populations, this study has shown that the disease is not always mild among tribal groups in India, as previously believed. There is a need, therefore, for increasing awareness among these tribal groups about the disease, and for regular monitoring of affected babies to reduce morbidity and mortality and to understand the natural course of the disease. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
Jabson, Jennifer M
Cancer survivors require follow-up care to ensure early detection of recurrence, management of late/long term effects, preventive screening for early detection of second primary malignancies, as well as other forms of preventive care. But not all survivors receive necessary follow-up care. Combining survivorship care plans and patient navigation may be a successful strategy to improve survivor's receipt of necessary follow-up care. Using data from the 2010 LIVESTRONG online survey of cancer survivors (N = 3854), this study tested associations between receipt of follow-up care instructions (FCI) and treatment summaries (TS) paired with patient navigation (PN), and survivor's receipt of cancer surveillance, preventive cancer screening, and attendance at regular medical appointments. Survivors who received FCI, TS, and patient navigation were the most likely to report attendance at all medical appointments (aOR 4.17, 95% CI 2.30, 7.57, p ≤ .001) and receipt of preventive cancer screening (aOR 3.56, 95% CI 2.28, 5.55, p ≤ .001). Likelihood of receiving follow-up care was greatest when survivors received FCI, TS, and PN. This pairing appeared to be most beneficial for survivor's attendance at medical appointments and receipt of preventive cancer screening. By improving attendance at medical appointments and prevention cancer screening, pairing SCP and PN could benefit survivors through reduced recurrence, earlier recurrence detection, and prevention of second primaries.
Lupatsch, Judith E; Wengenroth, Laura; Rueegg, Corina S; Teuffel, Oliver; Gumy-Pause, Fabienne; Kuehni, Claudia E; Michel, Gisela
Little is known about follow-up care attendance of adolescent survivors of childhood cancer, and which factors foster or hinder attendance. Attending follow-up care is especially important for adolescent survivors to allow for a successful transition into adult care. We aimed to (i) describe the proportion of adolescent survivors attending follow-up care; (ii) describe adolescents' health beliefs; and (iii) identify the association of health beliefs, demographic, and medical factors with follow-up care attendance. Of 696 contacted adolescent survivors diagnosed with cancer at ≤ 16 years of age, ≥ 5 years after diagnosis, and aged 16-21 years at study, 465 (66.8%) completed the Swiss Childhood Cancer Survivor Study questionnaire. We assessed follow-up care attendance and health beliefs, and extracted demographic and medical information from the Swiss Childhood Cancer Registry. Cross-sectional data were analyzed using descriptive statistics and logistic regression models. Overall, 56% of survivors reported attending follow-up care. Most survivors (80%) rated their susceptibility for late effects as low and believed that follow-up care may detect and prevent late effects (92%). Few (13%) believed that follow-up care is not necessary. Two health beliefs were associated with follow-up care attendance (perceived benefits: odds ratio [OR]: 1.56; 95% confidence interval [CI]: 1.07-2.27; perceived barriers: OR: 0.70; 95%CI: 0.50-1.00). We show that health beliefs are associated with actual follow-up care attendance of adolescent survivors of childhood cancer. A successful model of health promotion in adolescent survivors should, therefore, highlight the benefits and address the barriers to keep adolescent survivors in follow-up care. © 2015 Wiley Periodicals, Inc.
Ashing, Kimlin; Napoles, Anna
Introduction Receiving quality cancer follow-up care influences survivorship outcomes. Among Latinas, breast cancer is the number one cause of cancer death; yet Latinas do not receive adequate follow-up care. This study examined quality of cancer follow-up care among Latina breast cancer survivors (BCS) and whether it differs by participant language and healthcare system variables (provider specialty, and medical setting). Methods Two hundred thirty-two (95 English-speaking Latina and 137 Spanish-speaking) Latina BCS were recruited from the California Cancer Registry, hospital cancer registries, and community agencies. Results English-speaking Latina BCS were more likely to report receiving cancer follow-up care at a doctor’s office (p<0.001). BCS without a regular place for cancer follow-up care were more likely to report not seeing a primary care provider (p<0.05) or cancer specialist (p<0.001) in the past 12 months. English-speaking Latina BCS (p<0.001), BCS who saw a cancer specialist in the past 12 months (p<0.001), and received follow-up care at a doctor’s office (p<0.05) reported higher quality of care. Speaking English, having seen a cancer specialist, and receiving follow-up care at a doctor’s office were independently associated with higher quality of care, explaining 44 % of the variance. Conclusions Our study findings suggest that examining the influence of ethnic and linguistic factors on quality of cancer follow-up care is necessary to address health disparities. Improved access to cancer follow-up care for Spanish-speaking Latina BCS is of particular concern. Implication of Cancer Survivors Identifying follow-up care needs of Latina BCS may contribute to providing high-quality care and improved survivorship outcomes. PMID:24563169
Zürcher, Kathrin; Mooser, Anne; Anderegg, Nanina; Tymejczyk, Olga; Couvillon, Margaret J; Nash, Denis; Egger, Matthias
The retention of patients on antiretroviral therapy (ART) is key to achieving global targets in response to the HIV epidemic. Loss to follow-up (LTFU) can be substantial, with unknown outcomes for patients lost to ART programmes. We examined changes in outcomes of patients LTFU over calendar time, assessed associations with other study and programme characteristics and investigated the relative success of different tracing methods. We performed a systematic review and logistic random-effects meta-regression analysis of studies that traced adults or children who started ART and were LTFU in sub-Saharan African treatment programmes. The primary outcome was mortality, and secondary outcomes were undocumented transfer to another programme, treatment interruption and the success of tracing attempts. We included 32 eligible studies from 12 countries in sub-Saharan Africa: 20 365 patients LTFU were traced, and 15 708 patients (77.1%) were found. Compared to telephone calls, tracing that included home visits increased the probability of success: the adjusted odds ratio (aOR) was 9.35 (95% confidence interval [CI] 1.85-47.31). The risk of death declined over calendar time (aOR per 1-year increase 0.86, 95% CI 0.78-0.95), whereas undocumented transfers (aOR 1.13, 95% CI 0.96-1.34) and treatment interruptions (aOR 1.31, 95% CI 1.18-1.45) tended to increase. Mortality was lower in urban than in rural areas (aOR 0.59, 95% CI 0.36-0.98), but there was no difference in mortality between adults and children. The CD4 cell count at the start of ART increased over time. Mortality among HIV-positive patients who started ART in sub-Saharan Africa, were lost to programmes and were successfully traced has declined substantially during the scale-up of ART, probably driven by less severe immunodeficiency at the start of therapy. © 2017 John Wiley & Sons Ltd.
Nelson, E W; Van Cleve, S; Swartz, M K; Kessen, W; McCarthy, P L
To test the hypothesis that the appropriateness of parents' use of early follow-up care after emergency department (ED) visits can be improved by postvisit support from a nurse practitioner. Randomized controlled trial, single blinded. Urban university hospital ED linked to hospital's primary care center. Parents of 190 children younger than 8 years who sought care in the ED for acute illnesses and who were treated as outpatients with primary care center follow-up at the discretion of ED clinicians. Parents in the experimental group were called by a nurse practitioner who offered both individualized guidance regarding follow-up and access to a nurse practitioner for further help as needed. The control group received "usual" follow-up advice during ED visits. In the week after the ED visits, parents in the experimental group, compared with parents in the control group, were more compliant with instructions regarding follow-up (79% vs 61%), less apt to miss appointments (15% vs 31%), and less apt to "shop" elsewhere for care (2% vs 9%). Appropriateness of follow-up was assessed in "blinded" fashion using preestablished guidelines. Inappropriate use of follow-up care was significantly reduced among experimental group subjects (10% vs 20%). The nurse practitioner's intervention improved parents' use of follow-up care in our sample. Overall care for episodic ED users might be improved by similar interventions.
Toth, Matthew; Holmes, Mark; Van Houtven, Courtney; Toles, Mark; Weinberger, Morris; Silberman, Pam
To assess rural-urban differences in quality of postdischarge care among Medicare beneficiaries, controlling for selection bias of postdischarge services. The Medicare Current Beneficiary Survey (MCBS), Cost and Use Files from 2000 to 2010, the Area Resource File, Provider of Services File, and the Dartmouth Atlas of Health Care. Retrospective analysis of 30- and 60-day hospital readmission, emergency department (ED) use, and mortality using two-stage residual inclusion; receipt of 14-day follow-up care was the main independent variable. We defined index admission from the MCBS as any admission without a previous admission within 60 days. Noninstrumental variables estimation was the preferred estimation strategy. Fourteen-day follow-up care reduced the risk of readmission, ED use, and mortality. There were no rural- urban differences in the effect of 14-day follow-up care on readmission and mortality. Rural beneficiaries experienced a greater effect of 14-day follow-up care on reducing 30-day ED use compared to urban beneficiaries. Follow-up care reduces 30- and 60-day readmission, ED use, and mortality. Rural and urban Medicare beneficiaries experience similar beneficial effects of follow-up care on the outcomes. Policies that improve follow-up care in rural settings may be beneficial. © Health Research and Educational Trust.
Jabson, Jennifer M
Cancer survivors need follow-up care. Survivorship care plans (SCP), including follow-up care instructions (FCI) and treatment summaries (TS), were designed to improve cancer survivors' receipt of follow-up care after cancer treatment. However, there is a paucity of evidence regarding the relationship between survivors' receipt of FCI and TS and their receipt of follow-up care and late/long term effects. This study used data from the 2010 LIVESTRONG online survey of people affected by cancer, including 3541 cancer survivors who had completed treatment. Receipt of FCI was associated with greater likelihood of attendance at all regular medical appointments (aOR 2.28, 95% CI 1.60-3.23), receipt of cancer surveillance (aOR 1.64, 95% CI 1.28-2.09), being up to date on preventive cancer screening (aOR 2.63, 95% CI 2.00-3.47), and with fewer late/long term effects (IRR 0.77, 95% CI 0.69-0.85). Receipt of TS was associated with greater likelihood of attendance at all regular medical appointments (aOR 1.79, 95% CI 1.31-2.44) and being up to date on preventive cancer screening (aOR 1.43, 95% CI 1.14-1.78), but not cancer surveillance or late/long term effects. This study is among the first to document the associations between SCP and survivors' attendance at regular medical appointments, cancer surveillance, preventive cancer screenings, and late/long term effects. The findings suggest that SCP may facilitate follow-up care needed by cancer survivors after cancer treatment is completed.
Lloyd, Jarem B.; Copeli, Nikoli
Introduction. We sought to investigate triathlete adherence to recommendations for follow-up for participants who received event medical care. Methods. Participants of the 2011 Ironman Syracuse 70.3 (Syracuse, NY) who sought evaluation and care at the designated finish line medical tent were contacted by telephone approximately 3 months after the initial encounter to measure adherence with the recommendation to seek follow-up care after event. Results. Out of 750 race participants, 35 (4.6%) athletes received event medical care. Of these 35, twenty-eight (28/35; 80%) consented to participate in the study and 17 (61%) were available on telephone follow-up. Of these 17 athletes, 11 (11/17; 65%) of participants reported that they had not followed up with a medical professional since the race. Only 5 (5/17; 29%) confirmed that they had seen a medical provider in some fashion since the race; of these, only 2 (2/17; 12%) sought formal medical follow-up resulting from the recommendation whereas the remaining athletes merely saw their medical providers coincidentally or as part of routine care. Conclusion. Only 2 (2/17; 12%) of athletes who received event medical care obtained postrace follow-up within a one-month time period following the race. Event medical care providers must be aware of potential nonadherence to follow-up recommendations. PMID:28203462
Ochieng-Ooko, Vincent; Ochieng, Daniel; Sidle, John E; Holdsworth, Margaret; Wools-Kaloustian, Kara; Siika, Abraham M; Yiannoutsos, Constantin T; Owiti, Michael; Kimaiyo, Sylvester
Abstract Objective To determine the incidence of loss to follow-up in a treatment programme for people living with human immunodeficiency virus (HIV) infection in Kenya and to investigate how loss to follow-up is affected by gender. Methods Between November 2001 and November 2007, 50 275 HIV-positive individuals aged ≥ 14 years (69% female; median age: 36.2 years) were enrolled in the study. An individual was lost to follow-up when absent from the HIV treatment clinic for > 3 months if on combination antiretroviral therapy (cART) or for > 6 months if not. The incidence of loss to follow-up was calculated using Kaplan–Meier methods and factors associated with loss to follow-up were identified by logistic and Cox multivariate regression analysis. Findings Overall, 8% of individuals attended no follow-up visits, and 54% of them were lost to follow-up. The overall incidence of loss to follow-up was 25.1 per 100 person–years. Among the 92% who attended at least one follow-up visit, the incidence of loss to follow-up before and after starting cART was 27.2 and 14.0 per 100 person–years, respectively. Baseline factors associated with loss to follow-up included younger age, a long travel time to the clinic, patient disclosure of positive HIV status, high CD4+ lymphocyte count, advanced-stage HIV disease, and rural clinic location. Men were at an increased risk overall and before and after starting cART. Conclusion The risk of being lost to follow-up was high, particularly before starting cART. Men were more likely to become lost to follow-up, even after adjusting for baseline sociodemographic and clinical characteristics. Interventions designed for men and women separately could improve retention. PMID:20865073
Dysvik, Elin; Kvaløy, Jan Terje; Natvig, Gerd Karin
This article is a report of a Norwegian-revised study on the effectiveness of a follow-up multidisciplinary management programme for chronic pain to investigate the change processes associated with treatment. Substantial evidence supports the use of Cognitive Behavioural Therapy approaches to chronic pain. As relapse is often reported, follow-up sessions should be included. A follow-up quasi-experimental design was performed, and a previous control group was used. The study initially included 117 participants, and 104 of the sample completed the 6- and 12-month follow-up programme. The 6-month follow-up consisted of therapeutic dialogue and education combined with physical activity. At the 12-month follow-up, a telephonic consultation was conducted. The data collection period was between September 2006 and January 2008. The statistical and clinical significance were considered. Findings suggest that this follow-up programme can potentially maintain the positive results of the basic programme in terms of reduced pain perception, improved health-related quality of life, and movement towards self-management. These results are consistent with the ultimate goal of Cognitive Behavioural Therapy approaches, which is to help patients with chronic pain to cope more effectively and to improve their health-related quality of life and functioning. To maintain treatment improvements and advance nursing, there is a clear need for research that tests the efficacy of follow-up interventions that are designed to prevent drop out and relapse. © 2011 Blackwell Publishing Ltd.
Kirshbaum, M N; Dent, J; Stephenson, J; Topping, A E; Allinson, V; McCoy, M; Brayford, S
This study evaluated the acceptability of a supportive model of follow-up. One hundred and twelve women recovering from breast cancer were randomised to receive standard breast clinic aftercare (Control n = 56) or on demand by open access aftercare by breast care nurses (Intervention n = 56). Participants attended a support-based psycho-educational programme delivered in four half-day group sessions. Three quality of life questionnaires (EORTC QLQ-C30, QLQ-BR23, HADS) were administered at baseline and 6-monthly intervals for 2 years. Multilevel linear regression modelling methods were used for evaluation. Age was found to be a statistically significant predictor of quality of life in several sub-scales. Increasing age was negatively associated with sexual functioning, systematic therapy side effects and physical functioning, and positively associated with future perspective. Aftercare assignment was not found to be a statistically significant predictor. Women treated for early breast cancer were not disadvantaged by allocation to the open access supportive care model in terms of quality of life experienced. The model for follow-up was demonstrated to be a feasible alternative to routinised hospital-based follow-up and adds to the evidence for stratified follow-up for low-risk cancer patients, incorporating self-management education. Stratified follow-up pathways are viewed as a preferable approach. © 2016 The Authors. European Journal of Cancer Care Published by John Wiley & Sons Ltd.
Muñoz, Miguel A; Subirana, Isaac; Ramos, Rafael; Franzi, Alicia; Vila, Joan; Marrugat, Jaume
Most evidence on the efficacy of intensive preventive programs of secondary prevention of coronary diseases comes from Anglo-Saxon countries and effectiveness remains controversial. We have scarce information about the efficacy of these types of programs in Spain. In the present analysis we show the results of the ICAR (Intervención en la Comunidad de Alto Riesgo coronario) study, aimed to analyze the efficacy of an intensive preventive program primary care based in reducing the cardiovascular recurrences and mortality in patients with coronary heart disease. We designed a randomized clinical trial, multicenter and community based, which included 23 health care areas in Catalonia, Spain. We followed for 5 years 2 cohorts of patients with coronary heart disease, aged 30-80 years. The intervention group was quarterly examined by their general practitioner, who adjusted treatments to control their cardiovascular risk factors thoroughly and reinforced life style behaviours. In order to do that, patient's weight and blood pressure were determined in each visit and laboratory test carried out twice a year. Patients in the control group received the usual care. In order to analyze the effect of the intervention cardiovascular recurrences and mortality were registered. We included 983 patients. Mean (standard deviation) age was 64 (10) and 74.5% were men. During the follow-up 235 patients suffered some non-fatal cardiovascular recurrence (109 vs 126 in the control and intervention group, respectively; p = 0.84), and 45 died from cardiovascular recurrences (23 vs 22, respectively; p = 0.57). Adjusted hazard ratio of cardiovascular event and total mortality, for the intervention group were 1.01 (95% confidence interval, 0.74-1.39), and 0.92 (95% confidence interval, 0.54-1.56), respectively. The implementation of an intensive secondary prevention program based on periodical reminds to patients with stable coronary heart disease to attend their general practitioners did not
Larjani, Soroush; Spivak, Israel; Hao Guo, Ming; Aliarzadeh, Babak; Wang, Wei; Robinson, Sandra; Sockalingam, Sanjeev; Aarts, Mary-Anne
Long-term multidisciplinary care after bariatric surgery is important for weight maintenance and management of co-morbidities. Despite this, the rate of attendance to follow-up appointments is universally low. To identify patient factors that contribute to adherence to follow-up care after bariatric surgery. Three university-affiliated hospitals in Canada A cohort study of 388 patients who underwent bariatric surgery from January 2011 to December 2011 was performed. This program mandates multidisciplinary follow-up care at 3, 6, and 12 months, and annually thereafter. Patients' socioeconomic, psychosocial, and medical and psychiatric co-morbidities were recorded prospectively. Adherence to follow-up care was defined as having attended the majority of clinic visits (3 or 4 out of 4); all other patients were considered nonadherent. The mean age of patients was 45.0 years, 81.2% were female, and the majority underwent a gastric bypass (91.8%) versus a sleeve gastrectomy (8.2%); 62.1% of patients were adherent to follow-up appointments. Patients older than 25 years had a higher adherence rate than those who were younger (63.2% versus 37.5%, P = .040). Patients with full-time or part-time employment had a significantly higher adherence rate than those who were unemployed or retired (65.6% versus 50.0%, P = .017, odds ratio 1.9). Patients with obstructive sleep apnea (OSA) before surgery had higher follow-up adherence than those without OSA (62.2% versus 37.8%, P = .044). In multivariate analysis, employment remained an independent predictor of follow-up adherence (P = .017). Employment was the strongest predictor of attendance to follow-up clinic. Patients with OSA and older patients were also more likely to return consistently for scheduled follow-up. Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
Kher, Ajay; Rodrigue, James; Ajaimy, Maria; Wasilewski, Marcy; Ladin, Keren; Mandelbrot, Didier
Background Currently, many transplantation centers do not follow former living kidney donors on a long-term basis. Several potential barriers have been identified to provide this follow-up of former living kidney donors, including concerns that donor insurance will not reimburse transplantation centers or primary care physicians for this care. Here, we report the rates at which different insurance companies reimbursed our transplantation center for follow-up visits of living donors. Methods We collected data on all yearly follow-up visits of living donors billed from January 1, 2007, to December 31, 2010, representing 82 different donors. Concurrent visits of their recipients were available for 47 recipients and were used as a control group. Results We find that most bills for follow-up visits of living kidney donors were paid by insurance companies, at a rate similar to the reimbursement for recipient follow-up care. Conclusions Our findings suggest that, for former donors with insurance, inadequate reimbursement should not be a barrier in providing follow-up care. PMID:23060280
Kher, Ajay; Rodrigue, James; Ajaimy, Maria; Wasilewski, Marcy; Ladin, Keren; Mandelbrot, Didier
Currently, many transplantation centers do not follow former living kidney donors on a long-term basis. Several potential barriers have been identified to provide this follow-up of former living kidney donors, including concerns that donor insurance will not reimburse transplantation centers or primary care physicians for this care. Here, we report the rates at which different insurance companies reimbursed our transplantation center for follow-up visits of living donors. We collected data on all yearly follow-up visits of living donors billed from January 1, 2007, to December 31, 2010, representing 82 different donors. Concurrent visits of their recipients were available for 47 recipients and were used as a control group. We find that most bills for follow-up visits of living kidney donors were paid by insurance companies, at a rate similar to the reimbursement for recipient follow-up care. Our findings suggest that, for former donors with insurance, inadequate reimbursement should not be a barrier in providing follow-up care.
Liisa, Aho Anna; Marja-Terttu, Tarkka; Päivi, Åstedt-Kurki; Marja, Kaunonen
The aim of this study is to investigate the experiences of health care personnel of a bereavement follow-up intervention for grieving parents and of the ways to develop it. The intervention included three components: a support package for grieving parents, peer supporters' and health care personnel's contact with parents. The sample included 29 health professionals. Data were collected via open-format questionnaires and telephone interviews from health care personnel. Content analysis was used as a means of data analysis. The support package for grieving parents was considered important and versatile. Health care personnel perceived the intervention and its viability as mostly good. Parents' willingness to receive support, health care personnel's good resources and organizational preconditions were important for the follow-up contact. The intervention clarified the policy related to supporting grieving parents. It was enabled by a good attitude, shift arrangements and co-worker support. However, the implementation was considered difficult because of scarce resources. Parental support engendered negative feelings in health care personnel and they desired systematic supervision to deal with these. Follow-up care of grieving parents is a demanding task. Continuous education about bereavement follow-up care and systematic supervision to health care personnel is needed. Family-focused care in supporting grieving families after leaving from hospital should be increased. Inter-organizational cooperation in supporting parents is important and feasible.
Ginde, Adit A; Talley, Brad E; Trent, Stacy A; Raja, Ali S; Sullivan, Ashley F; Camargo, Carlos A
Emergency department (ED) patients often need urgent primary or specialty care follow-up, but access is particularly difficult for those without insurance. To characterize follow-up options for uninsured ED patients and to evaluate differences based on ED characteristics. We mailed a survey to all ED Directors in Colorado, Georgia, Massachusetts, and Oregon (n = 351 EDs). Typical referrals for urgent primary and specialty care follow-up for uninsured patients were classified as: a) private physician or clinic affiliated with the same hospital; b) external public clinic or university hospital; or c) no referral system/policy. Of the 298 (85%) responding EDs, 215 (72%) reported primary care referral to private physicians or clinics at the same hospital and 231 (78%) for specialty care. Twenty (7%) and 27 (9%) EDs had no referral system for primary and specialty care, respectively. Factors associated with typical referral to primary care follow-up at the same hospital were: lower visit volume (85% for EDs with < 1 patient per hour vs. 67% for EDs with ≥ 3 patients per hour); rural area (79% for rural vs. 68% for urban areas), and critical access hospital status (81% critical access vs. 69% non-critical access). Conversely, higher visit volume (87% vs. 58%), urban (81% vs. 72%), and non-critical access hospitals (83% vs. 53%) were more likely to refer for specialty care follow-up at the same hospital. Referral of uninsured ED patients to local follow-up was high for primary and specialty care. Smaller, rural EDs referred within their own hospital more often for primary care but less often for specialty care. Copyright © 2012 Elsevier Inc. All rights reserved.
Smits-Seemann, Rochelle R; Kaul, Sapna; Zamora, Eduardo R; Wu, Yelena P; Kirchhoff, Anne C
Though the need for risk-based follow-up care for survivors of adolescent and young adult (AYA) cancer has been documented, survivors often report forgoing recommended care due to cost. We sought to understand whether additional barriers to follow-up care exist for AYA survivors. We recruited survivors who were diagnosed with cancer between the ages of 15 and 39 using the Utah Cancer Registry (UCR). Overall, 28 survivors participated in 6 focus groups held between March and May 2015 in Salt Lake City and St. George, UT. Focus group discussions focused on the reasons survivors may or may not attend recommended medical visits after completing therapy. Survivors reported myriad barriers to follow-up medical visits, including lack of clear provider recommendation, fear of recurrent cancer diagnosis, wishing to move on with life, competing life responsibilities due to work and children, and not perceiving the need for a visit due to lack of symptoms. Though cost likely plays a major part in follow-up care adherence for survivors of AYA cancer, in our focus groups, participants indicated there were many other psychosocial and logistic barriers to care. Such factors play an important role in the day-to-day lives of survivors and are critical in medical decision-making. Several factors impede follow-up care adherence for survivors of AYA cancer that are amenable to interventions, including clearer provider recommendations, flexible appointment times, and childcare availability in clinics.
Vinson, David R; Patel, Pankaj B
Many emergency department (ED) patients require urgent follow-up in primary care. The most effective way to help patients obtain their needed after-visit care is to secure the appointment on their behalf prior to their departure from the ED. This study describes the development, implementation, and outcomes of an appointment assignment system that facilitates patient follow-up at two community hospitals in an integrated healthcare system. This patient-centered system resulted in a high rate of compliance and a very low rate of unscheduled ED recidivism. Improving access in this manner will likely strengthen the continuum of care, improve quality, and increase patient satisfaction.
Attanasio, Laura; Kozhimannil, Katy B
Negative experiences in the health care system, including perceived discrimination, can result in patient disengagement from health care. Four million US women give birth each year, and the perinatal period is a time of sustained interaction with the health care system, but potential consequences of negative experiences have not been examined in this context. We assessed whether perceived discrimination during the birth hospitalization were associated with postpartum follow-up care. Data were from the Listening to Mothers III survey, a nationally drawn sample of 2400 women with singleton births in US hospitals in 2011-2012. We used multivariate logistic regression to estimate adjusted odds of having a postpartum visit in the 8 weeks following birth by perceptions of discrimination due to (1) race/ethnicity; (2) insurance type; and (3) a difference of opinion with a provider about care. Women who experienced any of the 3 types of perceived discrimination had more than twice the odds of postpartum visit nonattendance (adjusted odds ratio=2.28, P=0.001), after adjusting for socioeconomic and medical characteristics. The postpartum visit is an opportunity for a patient and clinician to address continuing health problems following birth, discuss contraception, and screen for chronic disease. Forgoing this care may have negative health effects. The findings from this study underscore the need to reduce discrimination and improve maternity care experiences.
Street, Jackie; Neuhaus, Susan; Bessen, Taryn
Investigating patients' reports on the quality and consistency of melanoma follow-up care in Australia would assist in evaluating if this care is effective and meeting patients' needs. The objective of this study was to obtain and explore the patients' account of the technical and interpersonal aspects of melanoma follow-up care received. An online survey was conducted to acquire details of patients' experience. Participants were patients treated in Australia for primary melanoma. Qualitative and quantitative data about patient perceptions of the nature and quality of their follow-up care were collected, including provision of melanoma specific information, psychosocial support, and imaging tests received. Inconsistencies were reported in the provision and quality of care received. Patient satisfaction was generally low and provision of reassurance from health professionals was construed as an essential element of quality of care. “Gaps” in follow-up care for melanoma patients were identified, particularly provision of adequate psychosocial support and patient education. Focus on strategies for greater consistency in the provision of support, information, and investigations received, may generate a cost dividend which could be reinvested in preventive and supportive care and benefit patient well-being. PMID:25535589
Brooke, Benjamin S.; Stone, David H.; Cronenwett, Jack L.; Nolan, Brian; DeMartino, Randall R.; MacKenzie, Todd A.; Goodman, David C.; Goodney, Philip P.
IMPORTANCE Follow-up with a primary care provider (PCP) in addition to the surgical team is routinely recommended to patients discharged after major surgery despite no clear evidence that it improves outcomes. OBJECTIVE To test whether PCP follow-up is associated with lower 30-day readmission rates after open thoracic aortic aneurysm (TAA) repair and ventral hernia repair (VHR), surgical procedures known to have a high and low risk of readmission, respectively. DESIGN, SETTING, AND PARTICIPANTS In a cohort of Medicare beneficiaries discharged to home after open TAA repair (n = 12 679) and VHR (n = 52 807) between 2003 to 2010, we compared 30-day readmission rates between patients seen and not seen by a PCP within 30 days of discharge and across tertiles of regional primary care use. We stratified our analysis by the presence of complications during the surgical (index) admission. MAIN OUTCOMES AND MEASURES Thirty-day readmission rate. RESULTS Overall, 2619 patients (20.6%) undergoing open TAA repair and 4927 patients (9.3%) undergoing VHR were readmitted within 30 days after surgery. Complications occurred in 4649 patients (36.6%) undergoing open TAA repair and 4528 patients (8.6%) undergoing VHR during their surgical admission. Early follow-up with a PCP significantly reduced the risk of readmission among open TAA patients who experienced perioperative complications, from 35.0% (without follow-up) to 20.4% (with follow-up) (P < .001). However, PCP follow-up made no significant difference in patients whose hospital course was uncomplicated (19.4% with follow-up vs 21.9% without follow-up; P = .31). In comparison, early follow-up with a PCP after VHR did not reduce the risk of readmission, regardless of complications. In adjusted regional analyses, undergoing open TAA repair in regions with high compared with low primary care use was associated with an 18% lower likelihood of 30-day readmission (odds ratio, 0.82; 95% CI, 0.71–0.96; P = .02), whereas no significant
Hjelmar, Ulf; Hendriksen, Carsten; Hansen, Kirsten
The aim of follow-up visits by the general practitioner and district nurse (within a week after discharge from hospital) is to reduce hospital readmissions and improve the overall wellbeing of the patient. There is strong evidence that these programmes are effective, but are difficult to implement because of a number of organizational obstacles, including co-ordination between the organizations involved in the process. In this paper we look at the factors that affect motivation to participate in a cross-sectoral programme in Copenhagen, Denmark, implementing follow-up home visits to elderly persons. The analysis is based on inter-organizational network theory in an attempt to explain the role of motivation in network formation between organizational systems. The empirical findings are based on focus groups and in-depth interviews with hospital staff, general practitioners, and district nurses. Care providers are motivated to collaborate by a number of factors. The focus of collaboration needs to be clearly defined and agreed upon, there needs to be a high degree of equality between the professionals involved, and there has to be a will to co-operate based on a shared understanding of values and learning potentials. The study concludes that we need to focus on specific care fields and actors to reduce complexity in the area and more fully understand what motivates care providers to participate in cross-sectoral activities, such as a follow-up home visit programme. One lesson for current policy is that motivational factors need to be addressed in future collaborative programmes in order to fully exploit the potential health benefits.
Henwood, Patricia C; Mackenzie, David C; Rempell, Joshua S; Douglass, Emily; Dukundane, Damas; Liteplo, Andrew S; Leo, Megan M; Murray, Alice F; Vaillancourt, Samuel; Dean, Anthony J; Lewiss, Resa E; Rulisa, Stephen; Krebs, Elizabeth; Raja Rao, A K; Rudakemwa, Emmanuel; Rusanganwa, Vincent; Kyanmanywa, Patrick; Noble, Vicki E
We delivered a point-of-care ultrasound training programme in a resource-limited setting in Rwanda, and sought to determine participants' knowledge and skill retention. We also measured trainees' assessment of the usefulness of ultrasound in clinical practice. This was a prospective cohort study of 17 Rwandan physicians participating in a point-of-care ultrasound training programme. The follow-up period was 1 year. Participants completed a 10-day ultrasound course, with follow-up training delivered over the subsequent 12 months. Trainee knowledge acquisition and skill retention were assessed via observed structured clinical examinations (OSCEs) administered at six points during the study, and an image-based assessment completed at three points. Trainees reported minimal structured ultrasound education and little confidence using point-of-care ultrasound before the training. Mean scores on the image-based assessment increased from 36.9% (95% CI 32-41.8%) before the initial 10-day training to 74.3% afterwards (95% CI 69.4-79.2; P < 0.001). The mean score on the initial OSCE after the introductory course was 81.7% (95% CI 78-85.4%). The mean OSCE performance at each subsequent evaluation was at least 75%, and the mean OSCE score at the 58-week follow up was 84.9% (95% CI 80.9-88.9%). Physicians providing acute care in a resource-limited setting demonstrated sustained improvement in their ultrasound knowledge and skill 1 year after completing a clinical ultrasound training programme. They also reported improvements in their ability to provide patient care and in job satisfaction. © 2016 John Wiley & Sons Ltd.
Brooks, Greg; Gorman, Tom; Harman, John; Hutchison, Dougal; Kinder, Kay; Moor, Helen; Wilkin, Anne
The benefits of family literacy programs for children were examined in a 1997 follow-up study in which 154 parents and 237 children who had participated in a family literacy demonstration program in 1994-1995 were interviewed along with the teachers of a subsample of the children and the demonstration program coordinators. The demonstration…
Gyang, Elsie; Zayed, Mohamed; Harris, E John; Lee, Jason T; Dalman, Ronald L; Mell, Matthew W
Rates of inferior vena cava (IVC) filter retrieval have remained suboptimal, in part because of poor follow-up. The goal of our study was to determine demographic and clinical factors predictive of IVC filter follow-up care in a university hospital setting. We reviewed 250 consecutive patients who received an IVC filter placement with the intention of subsequent retrieval between March 2009 and October 2010. Patient demographics, clinical factors, and physician specialty were evaluated. Multivariate logistic regression analysis was performed to identify variables predicting follow-up care. In our cohort, 60.7% of patients received follow-up care; of those, 93% had IVC filter retrieval. Major indications for IVC filter placement were prophylaxis for high risk surgery (53%) and venous thromboembolic event with contraindication and/or failure of anticoagulation (39%). Follow-up care was less likely for patients discharged to acute rehabilitation or skilled nursing facilities (P < .0001), those with central nervous system pathology (eg, cerebral hemorrhage or spinal fracture; P < .0001), and for those who did not receive an IVC filter placement by a vascular surgeon (P < .0001). In a multivariate analysis, discharge home (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.99-8.2; P < .0001), central nervous system pathology (OR, 0.46; 95% CI, 0.22-0.95; P = .04), and IVC filter placement by the vascular surgery service (OR, 4.7; 95% CI, 2.3-9.6; P < .0001) remained independent predictors of follow-up care. Trauma status and distance of residence did not significantly impact likelihood of patient follow-up. Service-dependent practice paradigms play a critical role in patient follow-up and IVC filter retrieval rates. Nevertheless, specific patient populations are more prone to having poorer rates of follow-up. Such trends should be factored into institutional quality control goals and patient-centered care. Copyright © 2013 Society for Vascular Surgery. Published by
Sisler, Jeffrey; Chaput, Genevieve; Sussman, Jonathan; Ozokwelu, Emmanuel
To offer FPs a summary of evidence-based recommendations to guide their follow-up survivorship care of women treated for breast cancer. A literature search was conducted in MEDLINE from 2000 to 2016 using the search words breast cancer, survivorship, follow-up care, aftercare, guidelines, and survivorship care plans, with a focus on review of recent guidelines published by national cancer organizations. Evidence ranges from level I to level III. Survivorship care involves 4 main tasks: surveillance and screening, management of long-term effects, health promotion, and care coordination. Surveillance for recurrence involves only annual mammography, and screening for other cancers should be done according to population guidelines. Management of the long-term effects of cancer and its treatment addresses common issues of pain, fatigue, lymphedema, distress, and medication side effects, as well as longer-term concerns for cardiac and bone health. Health promotion emphasizes the benefits of active lifestyle change in cancer survivors, with an emphasis on physical activity. Survivorship care is enhanced by the involvement of various health professionals and services, and FPs play an important role in care coordination. Family physicians are increasingly the main providers of follow-up care after breast cancer treatment. Breast cancer should be viewed as a chronic medical condition even in women who remain disease free, and patients benefit from the approach afforded other chronic conditions in primary care. Copyright© the College of Family Physicians of Canada.
Lown, E. Anne; Phillips, Farya; Schwartz, Lisa A.; Rosenberg, Abby R.; Jones, Barbara
Childhood cancer survivors (CCS) have a high risk of medical late effects following cancer therapy. Psychosocial late effects are less often recognized. Many CCS do not receive long-term follow-up (LTFU) care, and those who do are rarely screened for psychosocial late effects. An interdisciplinary team conducted a systematic review of qualitative and quantitative studies to assess social, educational, vocational, psychological, and behavioral outcomes along with factors related to receipt of LTFU care. We propose that psychosocial screening be considered a standard of care in long-term follow-up care and that education be provided to promote the use LTFU care starting early in the treatment trajectory. PMID:26700918
Lown, E Anne; Phillips, Farya; Schwartz, Lisa A; Rosenberg, Abby R; Jones, Barbara
Childhood cancer survivors (CCS) have a high risk of medical late effects following cancer therapy. Psychosocial late effects are less often recognized. Many CCS do not receive long-term follow-up (LTFU) care, and those who do are rarely screened for psychosocial late effects. An interdisciplinary team conducted a systematic review of qualitative and quantitative studies to assess social, educational, vocational, psychological, and behavioral outcomes along with factors related to receipt of LTFU care. We propose that psychosocial screening be considered a standard of care in long-term follow-up care and that education be provided to promote the use LTFU care starting early in the treatment trajectory. © 2015 Wiley Periodicals, Inc.
Wilson, Kate; Lydon, Anne; Amir, Ziv
Over recent years, several initiatives have impacted on the referral of patients to secondary care, most notably targets for urgent referral in suspected cancer and the patient choice agenda. At the same time, improved long-term survival in cancer has increased numbers attending follow-up, doubts about the effectiveness of specialist follow-up have emerged, and alternative models of follow-up have been tested. The aim of the study was to explore patient and carer perspectives on the flexibility and responsiveness of cancer services. This article focuses on findings relating to referral, subsequent outpatient appointments and cessation of outpatient follow-up. Issues were explored in a qualitative study using face-to-face interviews with a purposive sample of 54 people affected by cancer. Data were analysed concurrently with data collection, using qualitative analysis software. The study gave rise to a number of salient themes. Links were identified between three of these: choice and responsiveness during referral; the flexibility and responsiveness of outpatient appointment systems; and negotiating cessation of follow-up. It appeared that policy on urgent referrals might be adversely affecting practice relating to appointment systems and the continuance of follow-up. Hospital-based cancer follow-up is being given decreasing priority because of doubts about effectiveness and a target-driven focus on referral. This is impacting on patients, who may value outpatient follow-up as a 'safety net' but have difficulties in obtaining appointments, and may be discharged without negotiation or adequate support. For these reasons, new forms of flexible/responsive aftercare are urgently needed. © 2011 Blackwell Publishing Ltd.
Kvale, Elizabeth A.; Rocque, Gabrielle B.; Demark-Wahnefried, Wendy; Martin, Michelle Y.; Jackson, Bradford E.; Meneses, Karen; Partridge, Edward E.; Pisu, Maria
Background. Treatment summaries and follow-up care plan information should be provided to cancer survivors. This study examines the association of receiving summaries and care plans with cancer survivor self-efficacy for chronic illness management, and whether self-efficacy was associated with health care utilization. Methods. Four hundred forty-one cancer survivors (≥2 years from diagnosis and had completed treatment) ≥65 years old from 12 cancer centers across 5 states completed telephone surveys. Survivors responded to three questions about receiving a written treatment summary, written follow-up plan, and an explanation of follow-up care plans. Respondents completed the Stanford Chronic Illness Management Self-Efficacy Scale and reported emergency room visits and hospitalizations in the past year. Three multiple linear regression models estimated the association of written treatment summary, written follow-up care plan, and verbal explanation of follow-up plan with total self-efficacy score. Log-binomial models estimated the association of self-efficacy scores with emergency room visits and hospitalizations (yes/no). Results. Among survivors, 40% and 35% received a written treatment summary and follow-up care plan, respectively. Seventy-nine percent received an explanation of follow-up care plans. Receiving a verbal explanation of follow-up care instructions was significantly associated with higher self-efficacy scores (β = 0.72, p = .009). Higher self-efficacy scores were significantly associated with lower prevalence ratios of emergency room visits (prevalence ratio, 0.92; 95% confidence interval, 0.88–0.97) and hospitalizations (prevalence ratio, 0.94; 95% confidence interval, 0.89–0.99). Conclusion. Explanation of the follow-up care plan, beyond the written component, enhances survivor self-efficacy for managing cancer as a chronic condition—an important mediator for improving health care utilization outcomes. Implications for Practice: Older
Hazzard, Anthony; Harris, Wendy; Howell, David
Human consciousness is inextricable from communication. The conditions of communication in the clinical context are defined by the caring intention and the unequal relationship, which imply special responsibilities on the part of the clinician. The conventional hermeneutic model of communication proposes a close examination of the context of the other, and an objective effort to get close to their consciousness by interpretation of their expressions. The clinician is supposed to lay aside subjective factors but make use of her/his clinical knowledge and skills. At University College Hospital Critical Care follow-up clinic, the communicative task involves history taking; partly by questionnaire and partly by attention to the patient's agenda - assessing needs, providing information and facilitating access to further help. In recent years the provision of Critical Care has become ever more complex, both in terms of the sophisticated medical and nursing techniques it can offer to patients and in the range of conditions it can undertake to treat. This range and complexity is reflected in the variety of problems and consequences that may be encountered at follow-up. Communicative techniques should take account of the emotional vulnerability of patients emerging from severe illness. Attentive listening should identify special anxieties, and care with phraseology aims to avoid further distress. Issues of memory, depression and trauma may be expected, and the interview technique must be flexible enough to offer emotional containment if need be. The consultation should be therapeutic in its conduct but should not embark upon actual psychotherapy or seek to dismantle the patient's defences. Contemporary hermeneutic perspectives emphasise the contextual situatedness of the clinician's consciousness, and propose a model of communication as 'blending of horizons' rather than as objective interpretation. Systems theory contributes to an understanding of the influence on
Skar, Ane-Marthe Solheim; Sherr, Lorraine; Clucas, Claudine; von Tetzchner, Stephen
Parenting programs have been used to good effect in many settings, yet few are systematically introduced and evaluated in developing countries. This study explores the relative long-term effect of participation in the International Child Development Programme (ICDP) in a group of caregivers in Mozambique. A quasi-experimental design was used to…
Skar, Ane-Marthe Solheim; Sherr, Lorraine; Clucas, Claudine; von Tetzchner, Stephen
Parenting programs have been used to good effect in many settings, yet few are systematically introduced and evaluated in developing countries. This study explores the relative long-term effect of participation in the International Child Development Programme (ICDP) in a group of caregivers in Mozambique. A quasi-experimental design was used to…
Giuliani, Stefano; Decker, Emily; Leva, Ernesto; Riccipetitoni, Giovanna; Bagolan, Pietro
The aim of the study was to assess current international practice in the long term follow-up, in managing active problems and transition of care for teenagers born with anorectal malformations (ARM). An original survey was administered to delegates attending two large colorectal surgical meetings in 2015. The 21 questions covered long term follow-up, specific issues for teenagers and transition of care. 96/236 delegates completed the survey. Follow-up was routinely suspended before 10 year of age by 33% of respondents. 90% of them did not use a scoring system to assess or risks stratify patients, despite 81% stating that an objective score would be beneficial. 40% of respondents felt that >30% of their teenagers had ongoing active medical or psychosocial issues. 42% thought their patients were not ready to be transitioned. The process of transition should start around 13-16 years according to 54% of respondents. 72% had no protocol for transition and 82% did not hold multidisciplinary meetings with adult practitioners before transition. International consensus on the following aspects of the care in ARM is needed: structured long term follow-up, objective assessment and risk stratification scores, pathways of transition and methods to prepare patients, parents and adult practitioners. Copyright © 2016 Elsevier Inc. All rights reserved.
Grunfeld, E; Fitzpatrick, R; Mant, D; Yudkin, P; Adewuyi-Dalton, R; Stewart, J; Cole, D; Vessey, M
BACKGROUND: Routine follow-up of breast cancer patients in specialist clinics is standard practice in most countries. Follow-up involves regularly scheduled breast cancer check-ups during the disease-free period. The aims of follow-up are to detect breast cancer recurrence and to provide psychosocial support to the patient; however, little is known about patients' views on breast cancer follow-up. AIM: To assess the effect on patient satisfaction of transferring primary responsibility for follow-up of women with breast cancer in remission from hospital outpatient clinics to general practice. METHOD: Randomized controlled trial with 18 months' follow-up in which women received routine follow-up either in hospital outpatient clinics or from their own general practitioner. Two hundred and ninety-six women with breast cancer in remission receiving regular follow-up care at two district general hospitals in England were included in the study. Patient satisfaction was measured by means of a self-administered questionnaire supplied three times during the 18-month study period. RESULTS: The general practice group selected responses indicating greater satisfaction than did the hospital group on virtually every question. Furthermore, in the general practice group there was a significant increase in satisfaction over baseline; a similar significant increase in satisfaction over baseline was not found in the hospital group. CONCLUSION: Patients with breast cancer were more satisfied with follow-up in general practice than in hospital outpatient departments. When discussing follow-up with breast cancer patients, they should be provided with complete and accurate information about the goals, expectations, and limitations of the follow-up programme so that they can make an informed choice. PMID:10756611
Darnell, Doyanne; Peterson, Roselyn; Berliner, Lucy; Stewart, Terri; Russo, Joan; Whiteside, Lauren; Zatzick, Douglas
Rape is associated with posttraumatic stress disorder (PTSD) and related comorbidities. Most victims do not obtain treatment for these conditions. Acute care medical settings are well positioned to link patients to services; however, difficulty engaging victims and low attendance at provided follow-up appointments is well documented. Identifying factors associated with follow-up can inform engagement and linkage strategies. Administrative, patient self-report, and provider observational data from Harborview Medical Center were combined for the analysis. Using logistic regression, we examined factors associated with follow-up health service utilization after seeking services for rape in the emergency department. Of the 521 diverse female (n = 476) and male (n = 45) rape victims, 28% attended the recommended medical/counseling follow-up appointment. In the final (adjusted) logistic regression model, having a developmental or other disability (OR = 0.40, 95% CI = 0.21-0.77), having a current mental illness (OR = 0.25, 95% CI = 0.13-0.49), and being assaulted in public (OR = 0.50, 95% CI = 0.28-0.87) were uniquely associated with reduced odds of attending the follow-up. Having a prior mental health condition (OR = 3.02, 95% CI = 1.86-4.91), a completed Sexual Assault Nurse Examiner's (SANE) examination (OR = 2.97, 95% CI = 1.84-4.81), and social support available to help cope with the assault (OR = 3.54, 95% CI = 1.76-7.11) were associated with an increased odds of attending the follow-up. Findings point to relevant characteristics ascertained at the acute care medical visit for rape that may be used to identify victims less likely to obtain posttraumatic medical and mental health services. Efforts to improve service linkage for these patients is warranted and may require alternative service delivery models that engage rape survivors and support posttraumatic recovery.
Darnell, Doyanne; Peterson, Roselyn; Berliner, Lucy; Stewart, Terri; Russo, Joan; Whiteside, Lauren; Zatzick, Douglas
Objective Rape is associated with Posttraumatic Stress Disorder and related comorbidities. Most victims do not obtain treatment for these conditions. Acute care medical settings are well-positioned to link patients to services; however, difficulty engaging victims and low attendance at provided follow-up appointments is well documented. Identifying factors associated with follow-up can inform engagement and linkage strategies. Method Administrative, patient self-report, and provider observational data from Harborview Medical Center were combined for the analysis. Using logistic regression, we examined factors associated with follow-up health service utilization after seeking services for rape in the emergency department. Results Of the 521 diverse female (n=476) and male (n=45) rape victims, 28% attended the recommended medical/counseling follow-up appointment. In the final (adjusted) logistic regression model, having a developmental or other disability (OR=0.40, 95% CI=0.21-0.77), having a current mental illness (OR=0.25, 95% CI=0.13-0.49), and being assaulted in public (OR=0.50, 95% CI=0.28-0.87) were uniquely associated with reduced odds of attending the follow-up. Having a prior mental health condition (OR= 3.02 95% CI=1.86-4.91), a completed SANE examination (OR=2.97, 95% CI=1.84-4.81), and social support available to help cope with the assault (OR=3.54, 95% CI=1.76-7.11) were associated with an increased odds of attending the follow-up. Conclusions Findings point to relevant characteristics ascertained at the acute care medical visit for rape that may be used to identify victims less likely to obtain posttraumatic medical and mental health services. Efforts to improve service linkage among these patients is warranted and may require alternative models to engage these patients to support posttraumatic recovery. PMID:26168030
McDonald, D A; Siegmeth, R; Deakin, A H; Kinninmonth, A W G; Scott, N B
The concepts of Enhanced Recovery Programmes (ERP) are to reduce peri-operative morbidity whilst accelerating patient's rehabilitation resulting in a shortened hospital stay following primary joint arthroplasty. These programmes should include all patients undergoing surgery and should not be selective. We report a consecutive series of 1081 primary total knee arthroplasties undergoing an enhanced recovery programme with a one year follow up period. A comparative cohort of 735 patients from immediately prior to the enhanced recovery programme implementation was also reviewed. The median day of discharge home was reduced from post-operative day six to day four (p<0.001) for the ERP group. Post-operative urinary catheterisation (35% vs. 6.9%) and blood transfusion (3.7% vs. 0.6%) rates were significantly reduced (p<0.001). Within the ERP group median pain scores (0 = no pain, 10 = maximal pain) on mobilisation were three throughout hospital stay with 95% of patients ambulating within 24h. No statistical difference was found in post-operative thrombolytic events (p=0.35 and 0.5), infection (p=0.86), mortality rates (p=0.8) and Oxford Knee Scores (p=0.99) at follow up. This multidisciplinary approach provided satisfactory post-operative analgesia allowing early safe ambulation and expedited discharge to home with no detriment to continuing rehabilitation, infection or complication rates at one year. Copyright © 2011 Elsevier B.V. All rights reserved.
Robertson, W; Thorogood, M; Inglis, N; Grainger, C; Stewart-Brown, S
The high prevalence of obesity in children in the UK warrants continuing public health attention. 'Families for Health' is a family-based group programme for the treatment of childhood obesity. Significant improvements in body mass index (BMI) z-score (-0.21, 95% CI: -0.35 to -0.07, P = 0.007) and other health outcomes were seen in children at a 9-month follow-up. To undertake a 2-year follow-up of families who attended 'Families for Health' in Coventry, to assess long-term outcomes and costs. 'Families for Health' is a 12-week programme with parallel groups for parents and children, addressing parenting skills, healthy lifestyles and emotional well-being. The intervention was delivered at a leisure centre in Coventry, England, with 27 overweight or obese children aged 7-13 years (18 girls, 9 boys) and their parents, from 21 families. A 'before-and-after' evaluation was completed with 19 (70%) children followed up at 2 years. The primary outcome was change in BMI z-score from baseline; secondary outcomes were children's quality of life, parent-child relationships, eating/activity habits and parents' mental health. Costs to deliver the intervention and to families were recorded. Mean change in BMI z-score from baseline was -0.23 (95% CI: -0.42 to -0.03, P = 0.027) at the 2-year follow-up and eight (42%) children had a clinically significant reduction in BMI z-score. Significant improvements were seen in children's quality of life and eating habits in the home, while there were sustained reductions in unhealthy foods and sedentary behaviour. Fruit and vegetable consumption and parent's mental health were not significantly different at 2 years. Costs of the programme were £517 per family (£402 per child), equivalent to £2543 per unit reduction in BMI z-score. Improvements in BMI z-score and certain other outcomes associated with the 'Families for Health' programme were sustained at the 2-year follow-up. 'Families for Health' is a promising new childhood obesity
Progress in therapy has made survival into adulthood a reality for most children, adolescents, and young adults diagnosed with cancer today. Notably, this growing population remains vulnerable to a variety of long-term therapy-related sequelae. Systematic ongoing follow-up of these patients, therefore, is important for providing for early detection of and intervention for potentially serious late-onset complications. In addition, health counseling and promotion of healthy lifestyles are important aspects of long-term follow-up care to promote risk reduction for health problems that commonly present during adulthood. Both general and subspecialty pediatric health care providers are playing an increasingly important role in the ongoing care of childhood cancer survivors, beyond the routine preventive care, health supervision, and anticipatory guidance provided to all patients. This report is based on the guidelines that have been developed by the Children's Oncology Group to facilitate comprehensive long-term follow-up of childhood cancer survivors (www.survivorshipguidelines.org).
Fonsmark, Lise; Rosendahl-Nielsen, Mette
International literature describes that former intensive care unit (ICU) patients suffer considerable physical and neuropsychological complications. Systematic data on Danish ICU survivors are scarce as standardised follow-up after intensive care has yet to be described. This article describes and evaluates the knowledge gained from outpatient follow-up at a tertiary intensive care unit at Rigshospitalet, Copenhagen, during a three-year period. A total of 101 adult former ICU patients attended the outpatient clinic over a three-year period. Patients included were medical and surgical patients with a length of stay exceeding four days. Patients attended the clinic after discharge from hospital and for a minimum of two months from their discharge from the ICU. The patients were assessed for physical, neuropsychological and psychological problems and, if necessary, further treatment or rehabilitation was initiated. Reduced physical ability was seen in 82%. A total of 89% suffered a substantial weight loss. 83.2% had signs indicating acute brain dysfunction during the ICU stay, and approximately half of the patients still had cognitive problems. A total of 66 interventions were initiated. Our data confirmed that a large proportion of ICU survivors suffer considerable long-term physical and neuropsychological sequelae. Intensive care follow-up may contribute to address these specific problems and to initiate the needed interventions. Research is needed to determine whether specialised rehabilitation is required. not relevant. not relevant.
Carmel, Amanda S; Steel, Peter; Tanouye, Robert; Novikov, Aleksey; Clark, Sunday; Sinha, Sanjai; Tung, Judy
Hospital admissions from the emergency department (ED) now account for approximately 50% of all admissions. Some patients admitted from the ED may not require inpatient care if outpatient care could be optimized. However, access to primary care especially immediately after ED discharge is challenging. Studies have not addressed the extent to which hospital admissions from the ED may be averted with access to rapid (next business day) primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol on avoidance of hospitalizations in a large, urban medical center. We conducted a retrospective review of patients referred from the ED to primary care (Weill Cornell Internal Medicine Associates - WCIMA) through a rapid-access-to-primary-care program developed at New York-Presbyterian / Weill Cornell Medical Center. Referrals were classified as either an avoided admission or not, and classifications were performed by both emergency physician (EP) and internal medicine physician reviewers. We also collected outcome data on rapid visit completion, ED revisits, hospitalizations and primary care engagement. EPs classified 26 (16%) of referrals for rapid primary care follow-up as avoided admissions. Of the 162 patients referred for rapid follow-up, 118 (73%) arrived for their rapid appointment. There were no differences in rates of ED revisits or subsequent hospitalizations between those who attended the rapid follow-up and those who did not attend. Patients who attended the rapid appointment were significantly more likely to attend at least one subsequent appointment at WCIMA during the six months after the index ED visit [N=55 (47%) vs. N=8 (18%), P=0.001]. A rapid-ED-to-primary-care-access program may allow EPs to avoid admitting patients to the hospital without risking ED revisits or subsequent hospitalizations. This protocol has the potential to save costs over time. A program such as this can also provide a safe and reliable ED discharge option
Wallace, Neal T; McConnell, K John
This study assessed the impact of Oregon's 2007 parity law, which required behavioral health insurance parity, on rates of follow-up care provided within 30 days of psychiatric inpatient care. Data sources were claims (2005-2008) for 737 individuals with inpatient stays for a mental disorder who were continuously enrolled in insurance plans affected by the parity law (intervention group) or in commercial, self-insured plans that were not affected by the law (control group). A difference-in-difference analysis was used to compare rates of follow-up care before and after the parity law between discharges of individuals in the intervention group and the control group and between discharges of individuals in the intervention group who had or had not met preparity quantitative coverage limits during a coverage year. Estimates of the marginal effects of the parity law were adjusted for gender, discharge diagnosis, relationship to policy holder, and calendar quarter of discharge. The study included 353 discharges in the intervention group and 535 discharges in the control group. After the parity law, follow-up rates increased by 11% (p=.042) overall and by 20% for discharges of individuals who had met coverage limits (p=.028). The Oregon parity law was associated with a large increase in the rate of follow-up care, predominantly for discharges of individuals who had met preparity quantitative coverage limits. Given similarities between the law and the 2008 Mental Health Parity and Addiction Equity Act, the results may portend a national effect of more comprehensive parity laws.
For ethical and economic reasons, follow-up--especially after intensive care--is important as a form of quality control which could serve as a basis for more differentiated indications for patient admission. A follow-up model, involving questionnaires 3 months, 1 year and 3 years after intensive care, and preliminary results of patients in 1985 are presented. Only a few patients described their present health situation as bad, but unstable situations showed little improvement between 3 months and 1 year after intensive care. There was a rather high percentage of rehospitalization and/or need for continued medical care. Only 10% of respondent patients were unable to work 1 year after intensive care, and 12% still depended on help from others. 15-35% described their quality of life as restricted; only 4% had negative memories of intensive care (fear, pain), and only 0.6% of respondent patients thought their previous admission to the intensive care unit had been a wrong decision.
Background eHealth applications for out-of-hospital monitoring and treatment follow-up have been advocated for many years as a promising tool to improve treatment compliance, promote individualized care and obtain a person-centred care. Despite these benefits and a large number of promising projects, a major breakthrough in everyday care is generally still lacking. Inappropriate organization for eHealth technology, reluctance from users in the introduction of new working methods, and resistance to information and communication technology (ICT) in general could be reasons for this. Another reason may be attitudes towards the potential in out-of-hospital eHealth applications. It is therefore of interest to study the general opinions among healthcare professionals to ICT in healthcare, as well as the attitudes towards using ICT as a tool for patient monitoring and follow-up at home. One specific area of interest is in-home follow-up of elderly patients with chronic heart failure (CHF). The aim of this paper is to investigate the attitudes towards ICT, as well as distance monitoring and follow-up, among healthcare professionals working with this patient group. Method This paper covers an attitude survey study based on responses from 139 healthcare professionals working with CHF care in Swedish hospital departments, i.e. cardiology and medicine departments. Comparisons between physicians and nurses, and in some cases between genders, on attitudes towards ICT tools and follow-up at home were performed. Results Out of the 425 forms sent out, 139 were collected, and 17 out of 21 counties and regions were covered in the replies. Among the respondents, 66% were nurses, 30% physicians and 4% others. As for gender, 90% of nurses were female and 60% of physicians were male. Internet was used daily by 67% of the respondents. Attitudes towards healthcare ICT were found positive as 74% were positive concerning healthcare ICT today, 96% were positive regarding the future of
Hein, C; Sourdet, S; Piau, A; Villars, H; Nourhashemi, F; Vellas, B
The following article presents the main points of the follow-up plan of Alzheimer's disease (AD) and related syndromes patients. The general objective of this follow-up plan is to improve the quality of live of these subjects and their family. The key points are assessments of cognitive decline, functional decline and complications such as behavioural and psychological symptoms of dementia (BPSD), malnutrition and gait and balance disorders. In clinical practice, different tools are available, but frequency of evaluation is not consensual. However, the aim of this follow-up is to detect, prevent and treat complications and to improve the use of residual functional abilities in basic activities of daily living. The physician also needs to detect and prevent caregiver's exhaustion and to consider the ethical issues raised by the disease. The care plan is based on non pharmacological and pharmacological measures. The non pharmacological approach must be implemented first. The place of anti-dementia drugs is considered. Lastly, this follow-up plan aims to limit iterative admissions to emergency room and to increase the access to geriatric units. Communication and collaboration between specialist, family practitioner and caregivers are needed in order to reach the objective of quality of life improvement in AD patients.
Neuman, Heather B; Schumacher, Jessica R; Schneider, David F; Winslow, Emily R; Busch, Rebecca A; Tucholka, Jennifer L; Smith, Maureen A; Greenberg, Caprice C
The current guidelines do not delineate the types of providers that should participate in early breast cancer follow-up care (within 3 years after completion of treatment). This study aimed to describe the types of providers participating in early follow-up care of older breast cancer survivors and to identify factors associated with receipt of follow-up care from different types of providers. Stages 1-3 breast cancer survivors treated from 2000 to 2007 were identified in the Surveillance, Epidemiology and End results Medicare database (n = 44,306). Oncologist (including medical, radiation, and surgical) follow-up and primary care visits were defined using Medicare specialty provider codes and linked American Medical Association (AMA) Masterfile. The types of providers involved in follow-up care were summarized. Stepped regression models identified factors associated with receipt of medical oncology follow-up care and factors associated with receipt of medical oncology care alone versus combination oncology follow-up care. Oncology follow-up care was provided for 80 % of the patients: 80 % with a medical oncologist, 46 % with a surgeon, and 39 % with a radiation oncologist after radiation treatment. The patients with larger tumor size, positive axillary nodes, estrogen receptor (ER)-positive status, and chemotherapy treatment were more likely to have medical oncology follow-up care than older patients with higher Charlson comorbidity scores who were not receiving axillary care. The only factor associated with increased likelihood of follow-up care with a combination of oncology providers was regular primary care visits (>2 visits/year). Substantial variation exists in the types of providers that participate in breast cancer follow-up care. Improved guidance for the types of providers involved and delineation of providers' responsibilities during follow-up care could lead to improved efficiency and quality of care.
Savanheimo, Nora; Vehkalahti, Miira M
Dental general anesthesia (DGA) is part of public dental care in Finland, but the intention is to return the patient to routine dental care. The aims of this study were to describe the details of treatments under DGA given to generally healthy children and to explore the outcome of their dental care during a 5-year follow-up, with special focus on preventive care. In particular, we examined the return of the patients to routine dental care, of which, to our knowledge, little is known. Our prospective 5-year follow-up of generally healthy children (aged 0-13 years) treated under DGA by the Helsinki Public Dental Service in 2004 was based on official dental and general anesthesia documents. The statistical analyses employed chi-square tests, t-tests, Pearson's correlation coefficient (r), Fisher's transformation to test r ≠ 0, and logistic regression modeling. The most common reason for DGA was uncooperation (82%), followed by dental fear (56%). Filling therapy predominated in the treatments given under anesthesia, and the mean number of treatments per patients was 9.5 (SD = 4.2). Throughout the follow-up, 54% of the patients continued to have co-operation problems and 53% expressed dental fear; 11% of the patients received repeat DGA. The mean follow-up time was 48 (median 52) months. The postoperative review visit was actualized within 1.5 (SD = 0.8) months and the first visit to the home dental clinic of the patients in 12.0 (SD = 11.8) months for the 0-5-year-olds and in 7.2 (SD = 5.9) months for the 6-13-year-olds (p < 0.001). The mean time elapsed to the first need for treatment was 18.5 (SD = 14.1) months. During the follow-up, the mean number of treatments per patient was 5.3 (SD = 4.9); almost all patients (97%) received preventive treatment at one of two visits, but the control of dental fear remained rare. To return to routine dental care after DGA, most of the generally healthy children in our study still needed special
Williams, Jason; McWilliams, Alisa; Mainieri, Tina; Pecora, Peter J; La Belle, Karin
While family-based placement prevention services, family reunification programs, subsidized guardianship, and aggressive adoption programs are reducing the numbers of children spending long periods of time in substitute care, a significant number of America's children will come of age in foster care. Agencies and policymakers should use research and evaluation to assess the effectiveness of foster care in nurturing healthy adults and to explore ways to improve services. Outcome studies that have focused on locating and interviewing young or middle-aged adults emancipated from foster care have been hampered by modest response rates, limiting the field's ability to evaluate the efficacy of foster care programs. This article describes a set of strategies that were used to achieve higher response rates in two recent follow-up studies.
Burnell, Fiona J; Keijzers, Gerben; Smith, Pete
The prevalence of allergic disorders is rising, with a corresponding increase in patients presenting to an ED with anaphylaxis. Appropriate follow up is required for patients with anaphylaxis. We reviewed two potential performance indicators for the quality of post-discharge care: (i) the rate of self-injectable adrenaline prescription; and (ii) the referral rate for follow-up care with allergy specialists. A search of Cochrane Library, PubMed and Google Scholar was performed using the following initial search string: anaphylaxis and 'emergency department'. We considered any (interventional or observational design) study assessing post-discharge care in anaphylaxis, measured by either adrenaline self-injection prescription or allergist referral. Subjects were patients with (suspected) anaphylaxis or severe allergic reaction, with no age limit. This review summarises findings from 16 relevant papers, all retrospective analyses of post-discharge care for anaphylaxis. Weighted arithmetic means were calculated for rates of prescription of adrenaline auto-injector and referral to an allergist following admission to an ED in patients with (suspected) anaphylaxis or severe allergic reaction. Prescription rates for self-injected adrenaline at the time of discharge following anaphylaxis varied from 0% to 68%, with a mean of 44%. Allergist referral rates ranged from 0% to 84%, with a mean of 33%. This review demonstrates that there is room for improvement in post-discharge care for patients who present to the ED with an anaphylactic reaction. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.
Jorgensen, Mikaela L; Young, Jane M; Solomon, Michael J
Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. With population aging and increases in survival, the number of CRC survivors is projected to rise dramatically. The time following initial treatment is often described as a period of transition from intensive hospital-based care back into “regular life.” This review provides an overview of recommended follow-up care for people with CRC who have been treated with curative intent, as well as exploring the current state of the research that underpins these guidelines. For patients, key concerns following treatment include the development of recurrent and new cancers, late and long-term effects of cancer and treatment, and the interplay of these factors with daily function and general health. For physicians, survivorship care plans can be a tool for coordinating the surveillance, intervention, and prevention of these key patient concerns. Though much of the research in cancer survivorship to date has focused on surveillance for recurrent disease, many national guidelines differ in their conclusions about the frequency and timing of follow-up tests. Most CRC guidelines refer only briefly to the management of side effects, despite reports that many patients have a range of ongoing physiological, psychosocial, and functional needs. Guidance for surveillance and intervention is often limited by a small number of heterogeneous trials conducted in this patient group. However, recently released survivorship guidelines emphasize the potential for the effectiveness of secondary prevention strategies, such as physical activity, to improve patient outcomes. There is also emerging evidence for the role of primary care providers and nurse coordinated care to support the transition and increase the cost-effectiveness of follow-up. The shift in focus from recurrence alone to the assessment and management of a range of survivorship issues will be important for ensuring that this growing group of
This study implies specific guidelines for intervention. It appears that bereavement follow-up may lessen the grief response at 13 months. Therefore, hospice programs should continue this valuable service. Follow-up interventions should focus on the factors which proved significant: rumination, loss of control, and death anxiety. The study also provided the beginnings of a risk assessment tool for bereaved individuals. Increased age was proved to be a risk factor related to a greater grief response. Although most of the literature indicates women are at a higher risk early in the bereavement period, this study showed that at a later time men expressed a greater degree of grief. The implications of the study include the need for ongoing education regarding the normal grief response and the physical and emotional manifestations of grief. The results of the study support emotional care for survivors as well as provision for appropriate referral resources as needed.
Milam, Joel E; Meeske, Kathleen; Slaughter, Rhona I; Sherman-Bien, Sandra; Ritt-Olson, Anamara; Kuperberg, Aura; Freyer, David R; Hamilton, Ann S
Follow-up care is critical for childhood cancer survivors (CCS), who are at high risk for comorbidities and late effects of cancer treatments. Understanding the factors associated with maintaining follow-up care is needed, especially for Hispanic CCS, who have been under-represented in previous studies. Risk factors and protective factors for receiving cancer-related follow-up care were examined among 193 Los Angeles County CCS diagnosed between 2000 and 2007 (54% Hispanic; mean ± standard deviation age, 19.9 ± 2.8 years; age at diagnosis, 12.1 ± 3.0 years; time since diagnosis, 7.8 ± 2.0 years). Self-report surveys were used to assess follow-up care, insurance status, demographics, clinical factors, and psychosocial risk (eg, depression) and protective (eg, self-efficacy [SE]) factors. Multivariable logistic regression was used to identify factors associated with the previous receipt of cancer-related follow-up care (in prior 2 years) and the intent to seek future cancer-related follow-up care. Seventy-three percent of CCS reported a cancer follow-up visit in the previous 2 years, which was positively associated (P < .05) with having health insurance, white ethnicity (vs Hispanic), younger age, and greater treatment intensity. Sixty-nine percent reported an intent to receive follow-up care in the next 2 years, which was positively associated (P < .05) with having health insurance and greater SE. Hispanics and older CCS were more likely to lack previous follow-up care. Because health insurance was strongly associated with both previous follow-up care and the intent to seek care, the current results indicate that recent changes in health coverage may improve follow-up among CCS. Interventions targeting improved SE may help increase intent to receive follow-up care for this population. © 2014 American Cancer Society.
Background Not only single, but also multiple, chronic conditions are becoming the normal situation rather than the exception in the older generation. While many studies show a correlation between multimorbidity and various health outcomes, the long-term effect on care dependency remains unclear. The objective of this study is to follow up a cohort of older adults for 5 years to estimate the impact of multimorbidity on long-term care dependency. Methods This study is based on claims data from a German health insurance company. We included 115,203 people (mean age: 71.5 years, 41.4% females). To identify chronic diseases and multimorbidity, we used a defined list of 46 chronic conditions based on ICD-10 codes. Multimorbidity was defined as three or more chronic conditions from this list. The main outcome was “time until long-term care dependency”. The follow-up started on January 1st, 2005 and lasted for 5 years until December 31st, 2009. To evaluate differences between those with multimorbidity and those without, we calculated Kaplan–Meier curves and then modeled four distinct Cox proportional hazard regressions including multimorbidity, age and sex, the single chronic conditions, and disease clusters. Results Mean follow-up was 4.5 years. People with multimorbidity had a higher risk of becoming care dependent (HR: 1.85, CI 1.78–1.92). The conditions with the highest risks for long-term care dependency are Parkinson’s disease (HR: 6.40 vs. 2.68) and dementia (HR: 5.70 vs. 2.27). Patients with the multimorbidity pattern “Neuropsychiatric disorders” have a 79% higher risk of care dependency. Conclusions The results should form the basis for future health policy decisions on the treatment of patients with multiple chronic diseases and also show the need to introduce new ways of providing long-term care to this population. A health policy focus on chronic care management as well as the development of guidelines for multimorbidity is crucial to secure
Hayes, Daniel F.; Ramsey, Scott D.; Hortobagyi, Gabriel N.; Barlow, William E.; Gralow, Julie R.
Evidence-based guidelines for long-term follow-up of early-stage breast cancer patients developed by oncology societies in the United States and Europe recommend that breast cancer survivors undergo regular evaluation with history and physical examination, as well as annual mammography. Routine blood tests, circulating tumor markers, and/or surveillance imaging studies beyond mammography are not recommended in the absence of concerning symptoms or physical examination findings because of lack of supportive clinical evidence. Despite these guidelines, studies have shown that 20% to 40% of oncologists assess serum tumor markers as part of routine monitoring of early-stage breast cancer patients. As part of efforts to both address the financial challenges confronting the health-care system and optimize patient outcomes, the American Society of Clinical Oncology’s Cost of Care Task Force identified adherence to breast cancer surveillance guidelines as an opportunity to improve care and reduce cost. However, these recommendations are based on trials done in an era of outdated technology and limited therapeutic options. It is possible that recent improvements in diagnostics and treatments could make earlier detection of recurrent disease important for improving both survival and quality of life outcomes. Research is necessary to further inform optimal breast cancer follow-up strategies, which could impact these recommendations. At this time, outside of well-conducted clinical trials, there is no role for ordering routine serial blood or imaging tests in monitoring for recurrence in early-stage breast cancer patients. PMID:24627271
Houston, Eric; Lyons, Thomas; Wolfe, Brenda; Rolfsen, Norma; Williams, Maryanne; Rucker, Monique; Glick, Nancy
Objective: While a growing body of research indicates that implicit cognitive processes play an important role in a range of health behaviors, the assessment of these impulsive, associative mental processes among patients living with HIV has received little attention. This preliminary study explored how multidimensional scaling (MDS) could be used to assess implicit cognitive processes among patients lost to follow-up for HIV care and develop interventions to improve their engagement. Method: The sample consisted of 33 patients who were identified as lost to follow up for HIV care at two urban hospitals. Participants were randomly assigned to either the MDS assessment program or control group. All participants underwent measures designed to gauge behavioral change intentions and treatment motivation. Assessment group participants were interviewed to determine their reactions to the assessment program. Results: The MDS assessment program identified cognitive processes and their relationship to treatment-related behaviors among assessment group participants. Assessment group participants reported significantly greater behavior change intentions than those in the control group (p =.02; Cohen’s d = 0.84). Conclusion: MDS shows promise as a tool to identify implicit cognitive processes related to treatment-related behaviors. Assessments based on MDS could serve as the basis for patient-centered clinical interventions designed to improve treatment adherence and HIV care engagement in general. PMID:27347274
Jaycock, Sue; Persaud, Michelle; Johnson, Robert
This article is presented as a follow-up to exploratory work published in this journal in 2001. It describes a study that aimed to assess the effectiveness of dementia care mapping in supporting practice improvement in intellectual disability residential services. An average of 9 hours of observational data was collected using dementia care mapping in relation to 14 adults with severe or profound intellectual disabilities. Sixteen interviews were also undertaken with staff over a 4 month period.The findings provided a detailed picture of the activities and interactions between the participants involved in the study and raised some issues about 'organizational culture' when developing person-centred approaches. They have helped strengthen the case that care mapping has the potential to be a useful addition to the existing repertoire of tools to support effective practice improvement and person-centred planning.
Background After primary treatment for breast cancer, patients are recommended to use hospital follow-up care routinely. Long-term data on the utilization of this follow-up care are relatively rare. Methods Information regarding the utilization of routine hospital follow-up care was retrieved from hospital documents of 662 patients treated for breast cancer. Utilization of hospital follow-up care was defined as the use of follow-up care according to the guidelines in that period of time. Determinants of hospital follow up care were evaluated with multivariate analysis by generalized estimating equations (GEE). Results The median follow-up time was 9.0 (0.3-18.1) years. At fifth and tenth year after diagnosis, 16.1% and 33.5% of the patients had less follow-up visits than recommended in the national guideline, and 33.1% and 40.4% had less frequent mammography than recommended. Less frequent mammography was found in older patients (age > 70; OR: 2.10; 95%CI: 1.62-2.74), patients with comorbidity (OR: 1.26; 95%CI: 1.05-1.52) and patients using hormonal therapy (OR: 1.51; 95%CI: 1.01-2.25). Conclusions Most patients with a history of breast cancer use hospital follow-up care according to the guidelines. In older patients, patients with comorbidity and patients receiving hormonal therapy yearly mammography is performed much less than recommended. PMID:21708039
Milam, Joel; Meeske, Kathleen; Slaughter, Rhona; Sherman-Bien, Sandra; Ritt-Olson, Anamara; Kuperberg, Aura; Freyer, David R.; Hamilton, Ann S.
Background Follow-up care is critical for childhood cancer survivors (CCS) who are at high risk for co-morbidities and late effects of cancer treatments. Understanding factors associated with maintaining follow-up care is needed, especially for Hispanic CCS who are underrepresented in previous studies. Methods Risk and protective factors for receiving cancer-related follow-up care were examined among 193 Los Angeles County CCS diagnosed between 2000–2007 (54% Hispanic; mean age=19.9, SD=2.8; mean age at diagnosis=12.1, SD=3.0; mean years since diagnosis=7.8, SD=2.0). Self-report surveys assessed follow-up care, insurance status, demographics, clinical factors, and psychosocial risk (e.g., depression) and protective [e.g., self-efficacy (SE)] factors. Multivariable logistic regression was used to determine factors associated with previous (in prior 2 years) and intent for future cancer-related follow-up care. Results Seventy-three percent of CCS reported a cancer follow-up visit in the prior 2 years, which was positively associated (p’s<.05) with having health insurance, White ethnicity (vs. Hispanic), younger age and greater treatment intensity. Sixty-nine percent reported intent for follow-up care in the next two years, which was positively associated (p’s<.05) with having health insurance and greater SE. Conclusions Hispanics and older CCS are more likely to lack previous follow-up care. Because health insurance was strongly associated with both previous follow-up care and intent to seek care, recent changes in health coverage may improve follow-up among CCS. Interventions targeting improved SE may help increase intent to receive follow-up care for this population. PMID:25345867
Ahmed, Syed Nizamuddin; Mann, Carly; Sinclair, D Barry; Heino, Angela; Iskiw, Blayne; Quigley, Daphne; Ohinmaa, Arto
Cost analysis and patient satisfaction with telemedicine in epilepsy care. This controlled study included out-of-town epilepsy patients coming to follow-up at the University of Alberta hospital epilepsy clinic. After an informed consent, patients were randomized to either conventional (n = 18) or telemedicine (n = 23) clinics. Patients or caregivers filled patient satisfaction and travel cost questionnaires in both alternatives. Cost per visit analysis included costs of traveling, lodging, and lost productivity. Average age of the population was 41 years (range 19-73; 45% women). Eighty-three percent of patients preferred their next visit through telemedicine. About 90% of patients indicated a need for companion travel (mainly by car) to conventional clinic. For the conventional group patients the value of lost productivity was CAD $201, hotel cost CAD $8.50, and the value of car mileage CAD $256.50, totaling about CAD $466.00. Patient costs for telemedicine were CAD $35.85. Telemedicine production costs are similar to the patients' savings in traveling and lost productivity. About 90% of patients in both groups were satisfied with the quality of the service. Telemedicine can play a role in follow-up care of epilepsy patients, reduce patient costs, and improve patient satisfaction. This is the first full-time epilepsy telemedicine clinic in Western Canada.
Aakre, Kristin M; Thue, Geir; Svarstad, Einar; Skadberg, Øyvind; Sandberg, Sverre
To explore how CKD stage 3 patients are examined and treated in primary care with emphasis on laboratory analyses. A total of 386 patients with CKD stage 3, and their physician (one patient per general practitioner (GP)) were selected from hospital laboratory databases. GPs received a questionnaire asking them to categorize their patients' renal function based on creatinine and eGFR results, denoting follow-up and what changes in creatinine and eGFR results were considered clinically important. The response rate was 60%, and 210 patients were included. Patients' median creatinine values were 95 μmol/L (females) and 124 μmol/L (males), the median eGFR value was 52 ml/min/1.73 m2. Only 27% of patients were assessed to have CKD stage 3. 2/3 had either a urine dip strip (59%) and/or a urine albumin measurement (42%) and 20% were diagnosed with albuminuria. Median changes to signal improvement or deterioration in renal function or indicate referral were 14 (12%), 20 (18%) and 40 (36%) μmol/L for creatinine and 8 (17%), 8 (17%) and 13 (26%) ml/min/1.73 m2 for eGFR. Albuminuria did not influence follow-up strategy. CKD stage 3 patients were insufficiently examined for albuminuria and seemingly referred to hospital care after larger eGFR declines than recommended in guidelines. Copyright © 2011 Elsevier B.V. All rights reserved.
Hall, Jill J; Katz, Steven J; Cor, M Ken
Patient satisfaction is known to increase with pharmacist intervention in general outpatient clinics and with nurse-led care in rheumatology clinics. The aim of the present study was to describe and compare patient satisfaction with two different types of care: a pharmacist physician collaborative model and a traditional physician model in a rheumatology clinic setting. A cross-sectional survey of inflammatory arthritis patients seen during a follow-up visit in Edmonton, Alberta, Canada, was conducted over a ten-week period. Patient satisfaction was measured using a modified version of the validated Leeds Satisfaction Questionnaire, which uses a five-point Likert scale to measure six dimensions of satisfaction, and compared between the collaborative care and traditional physician models. A total of 62 patients completed the questionnaire (21 collaborative care and 41 traditional physician model). The average age of respondents was 52 years and the majority were female. The mean score for satisfaction across the six dimensions was 4.56 in the collaborative care group and 4.30 in the traditional physician group (p = 0.02). Patient satisfaction in the collaborative care group was consistently higher across all dimensions. No difference was noted between participants seen for the first time compared with those seen two or more times by the pharmacist. A collaborative care model can exceed the already high expectations for care of patients with inflammatory arthritis. Our findings support the role of pharmacists using a collaborative care approach to care for patients in rheumatology clinics. Copyright © 2016 John Wiley & Sons, Ltd.
Grunfeld, E; Gray, A; Mant, D; Yudkin, P; Adewuyi-Dalton, R; Coyle, D; Cole, D; Stewart, J; Fitzpatrick, R; Vessey, M
A randomized controlled trial (RCT) comparing primary-care-centred follow-up of breast cancer patients with the current standard practice of specialist-centred follow-up showed no increase in delay in diagnosing recurrence, and no increase in anxiety or deterioration in health-related quality of life. An economic evaluation of the two schemes of follow-up was conducted concurrent with the RCT. Because the RCT found no difference in the primary clinical outcomes, a cost minimization analysis was conducted. Process measures of the quality of care such as frequency and length of visits were superior in primary care. Costs to patients and to the health service were lower in primary care. There was no difference in total costs of diagnostic tests, with particular tests being performed more frequently in primary care than in specialist care. Data are provided on the average frequency and length of visits, and frequency of diagnostic testing for breast cancer patients during the follow-up period. © 1999 Cancer Research Campaign PMID:10098764
Hudson, Shawna V; O’Malley, Denalee M; Miller, Suzanne M
Background Prostate cancer is the most commonly diagnosed cancer in men in the US, and the second most prevalent cancer in men worldwide. High incidence and survival rates for prostate cancer have resulted in a large and growing population of long-term prostate cancer survivors. Long-term follow-up guidelines have only recently been developed to inform approaches to this phase of care for the prostate cancer population. Methods A PubMed search of English literature through August 2014 was performed. Articles were retrieved and reviewed to confirm their relevance. Patient-reported measures that were used in studies of long-term prostate cancer survivors (ie, at least 2 years posttreatment) were reviewed and included in the review. Results A total of 343 abstracts were initially identified from the database search. After abstract review, 105 full-text articles were reviewed of which seven met inclusion criteria. An additional 22 articles were identified from the references of the included articles, and 29 were retained. From the 29 articles, 68 patient-reported outcome measures were identified. The majority (75%) were multi-item scales that had been previously validated in existing literature. We identified four main areas of assessment: 1) physical health; 2) quality of life – general, physical, and psychosocial; 3) health promotion – physical activity, diet, and tobacco cessation; and 4) care quality outcomes. Conclusion There are a number of well-validated measures that assess patient-reported outcomes that document key aspects of long-term follow-up with respect to patient symptoms and quality of life. However, there are fewer patient-reported outcomes related to health promotion and care quality within the prevention, surveillance, and care coordination components of cancer survivorship. Future research should focus on development of additional patient-centered and patient-related outcomes that enlarge the assessment portfolio. PMID:25834471
Hudson, Shawna V; O'Malley, Denalee M; Miller, Suzanne M
Prostate cancer is the most commonly diagnosed cancer in men in the US, and the second most prevalent cancer in men worldwide. High incidence and survival rates for prostate cancer have resulted in a large and growing population of long-term prostate cancer survivors. Long-term follow-up guidelines have only recently been developed to inform approaches to this phase of care for the prostate cancer population. A PubMed search of English literature through August 2014 was performed. Articles were retrieved and reviewed to confirm their relevance. Patient-reported measures that were used in studies of long-term prostate cancer survivors (ie, at least 2 years posttreatment) were reviewed and included in the review. A total of 343 abstracts were initially identified from the database search. After abstract review, 105 full-text articles were reviewed of which seven met inclusion criteria. An additional 22 articles were identified from the references of the included articles, and 29 were retained. From the 29 articles, 68 patient-reported outcome measures were identified. The majority (75%) were multi-item scales that had been previously validated in existing literature. We identified four main areas of assessment: 1) physical health; 2) quality of life - general, physical, and psychosocial; 3) health promotion - physical activity, diet, and tobacco cessation; and 4) care quality outcomes. There are a number of well-validated measures that assess patient-reported outcomes that document key aspects of long-term follow-up with respect to patient symptoms and quality of life. However, there are fewer patient-reported outcomes related to health promotion and care quality within the prevention, surveillance, and care coordination components of cancer survivorship. Future research should focus on development of additional patient-centered and patient-related outcomes that enlarge the assessment portfolio.
Forsythe, Laura P.; Alfano, Catherine M.; Kent, Erin E.; Weaver, Kathryn E.; Bellizzi, Keith; Arora, Neeraj; Aziz, Noreen; Keel, Gretchen; Rowland, Julia H.
Objective Cancer survivors play an important role in coordinating their follow-up care and making treatment-related decisions. Little is known about how modifiable factors like social support are associated with active participation in follow-up care. This study tests associations between social support, cancer-related follow-up care use, and self-efficacy for participation in decision making related to follow-up care (SEDM). We also identified sociodemographic and clinical factors associated with social support among long-term survivors. Methods The FOllow-up Care Use among Survivors (FOCUS) study is a cross-sectional, population based survey of breast, prostate, colon, and gynecologic cancer survivors (n=1522) 4 to 14 years post-diagnosis. Multivariable regression models were used to test associations between perceived social support (tangible and emotional/informational support modeled separately), follow-up care use (past two years), and SEDM, as well as to identify factors associated with perceived support. Results Neither support type was associated with follow-up care use (all p>0.05), although marital status was uniquely, positively associated with follow-up care use (p<0.05). Both tangible support (B for a standard deviation increase (SE)=9.75(3.15), p<0.05) and emotional/informational support (B(SE)=12.61(3.05), p<0.001) were modestly associated with SEDM. Being married, having adequate financial resources, history of recurrence, and better perceived health status were associated with higher perceived tangible and emotional support (all p<0.05). Conclusions While perceived social support may facilitate survivor efficacy for participation in decision making during cancer follow-up care, other factors, including marital satisfaction, appear to influence follow-up care use. Marital status and social support may be important factors to consider in survivorship care planning. PMID:24481884
Sussman, J.; Varela, N.P.; Cheung, M.; Hicks, L.; Kraftcheck, D.; Mandel, J.; Fraser, G.; Jimenez-Juan, L.; Boudreau, A.; Sajkowski, S.; McQuillan, R.
Objective This evidence summary set out to assess the available evidence about the follow-up of asymptomatic survivors of lymphoma who have received curative-intent treatment. Methods The medline and embase databases and the Cochrane Database of Systematic Reviews were searched for evidence published between 2000 and August 2015 relating to lymphoma survivorship follow-up. The evidence summary was developed by a Working Group at the request of the Cancer Care Ontario Survivorship and Cancer Imaging programs because of the absence of evidence-based practice documents in Ontario for the follow-up and surveillance of asymptomatic patients with lymphoma in complete remission. Results Eleven retrospective studies met the inclusion criteria. The proportion of relapses initially detected by clinical manifestations ranged from 13% to 78%; for relapses initially detected by imaging, the proportion ranged from 8% to 46%. Median time for relapse detection ranged from 8.6 to 19 months for patients initially suspected because of imaging and from 8.6 to 33 months for those initially suspected because of clinical manifestations. Only one study reported significantly earlier relapse detection for patients initially suspected because of clinical manifestations (mean: 4.5 months vs. 6.0 months, p = 0.042). No benefit in terms of overall survival was observed for patients depending on whether their relapse was initially detected because of clinical manifestations or surveillance imaging. Summary Findings in the present study support the importance of improving awareness on the part of survivors and clinicians about the symptoms that might be associated with recurrence. The evidence does not support routine imaging for improving outcomes in this patient population. PMID:27803611
Rey-Bellet, Sarah; Dubois, Julie; Vannotti, Marco; Zuercher, Marili; Faouzi, Mohamed; Devaud, Karen; Rodondi, Nicolas; Rodondi, Pierre-Yves
At the beginning of the medical encounter, clinicians should elicit patients' agendas several times using open-ended questions. Little is known, however, about how many times physicians really solicit a patient's agenda during follow-up encounters. The objective was to analyze the number of agenda solicitations by physicians, of agendas initiated by physicians, and of patients' spontaneous agendas during the beginning and the entire encounter. We analyzed 68 videotaped follow-up encounters at a university primary care outpatient clinic. The number of different types of agenda setting was searched for and analyzed using negative binomial regression or logistic regression models. Physicians solicited agendas a mean ± SD of 0.8 ± 0.7 times/patient during the first 5 minutes and 1.7 ± 1.2 times/patient during the entire encounter. Physicians in 32.4% of encounters did not solicit the patient agenda, and there were never more than two physician's solicitations during the first 5 minutes. The mean number of physician's solicitations of the patients' agenda was 42% lower among female physicians during the first 5 minutes and 34% lower during the entire encounter. The number of agendas initiated by physicians was 1.2 ± 1.2/patient during the beginning and 3.2 ± 2.3/patient during the entire encounter. In 58.8% of the encounters, patients communicated their agendas spontaneously. There were twice as many patient spontaneous agendas (IRR = 2.12, p = .002) with female physicians than with males. This study showed that agenda solicitation with open-ended questions in follow-up encounters does not occur as often as recommended. There is thus a risk of missing new agendas or agendas that are important to the patient.
Reed, Sarah C; Walker, Rod; Ziebell, Rebecca; Rabin, Borsika; Nutt, Stephanie; Chubak, Jessica; Nekhlyudov, Larissa
Prior studies reveal gaps in cancer survivors' discussions with health care providers about follow-up care and receipt of care plans; however, whether survivorship care planning may vary by cancer type is not known. We surveyed 615 survivors of breast, colorectal, prostate, lung cancer, and melanoma enrolled in three health plans to examine cancer survivors' self-reported discussions of follow-up care, including the need for surveillance, late and long-term effects, emotional needs, and health behaviors. We assessed whether cancer survivors received a written treatment summary and post-treatment care instructions. Most (92%) survivors reported having a discussion about the need for surveillance; 75%, late and long-term effects; 69%, lifestyle and health behaviors; and 53%, emotional and social needs. Most (88%) reported receiving post-treatment care instructions and 47%, a treatment summary. While there was little difference among survivors' receipt of surveillance or health behavior recommendations by cancer type (p = 0.85 and p = 0.66, respectively), discussions of late and long-term effects occurred among 82% of prostate, 78% of breast, 73% of melanoma, 72% of colorectal, and 67% of lung survivors (p = 0.06). Approximately half of survivors reported discussions of emotional needs, with modest differences by cancer type (p = 0.08). Our findings indicate that most patient-provider discussions cover information on surveillance, with less emphasis on late and long-term effects, lifestyle and health behaviors, and substantially less focusing on emotional and social needs. No or modest differences in discussions occurred by cancer type. Whether tailoring information to individual cancer survivor needs is beneficial should be examined.
Morier-Genoud, Claire; Bodenmann, Patrick; Favrat, Bernard; Vannotti, Marco
Background Primary care physicians underestimate the prevalence of domestic violence and community violence. Victims are therefore at risk of further episodes of violence, with psychological and physical consequences. We used an interview to assess the prevalence of domestic and community violence among Swiss natives and foreigners. In a follow-up study, we evaluated the consequences of the interview for the positive patients. Methods We evaluated the prevalence of violence by use of a questionnaire in an interview, in an academic general internal medicine clinic in Switzerland. In a follow-up, we evaluated the consequences of the interview for positive patients. The participants were 38 residents and 446 consecutive patients. Questionnaires were presented in the principal language spoken by our patients. They addressed sociodemographics, present and past violence, the security or lack of security felt by victims of violence, and the patients' own violence. Between 3 and 6 months after the first interview, we did a follow-up of all patients who had reported domestic violence in the last year. Results Of the 366 patients included in the study, 36 (9.8%) reported being victims of physical violence during the last year (physicians identified only 4 patients out of the 36), and 34/366 (9.3%) reported being victims of psychological violence. Domestic violence was responsible for 67.3% of the cases, and community violence for 21.8%. In 10.9% of the cases, both forms of violence were found. Of 29 patients who reported being victims of domestic violence, 22 were found in the follow-up. The frequency of violence had diminished (4/22) or the violence had ceased (17/22). Conclusion The prevalence of violence is high; domestic violence is more frequent than community violence. There was no statistically significant difference between the Swiss and foreign patients' responses related to the rates of violence. Patients in a currently violent relationship stated that
Kahn, Katherine L; Liu, Honghu; Adams, John L; Chen, Wen-Pin; Tisnado, Diana M; Carlisle, David M; Hays, Ron D; Mangione, Carol M; Damberg, Cheryl L
Objective To illustrate, using empirical data, methodological challenges associated with patient responses to longitudinal surveys regarding the quality of process of care and health status, including overall response rate, differential response rate, and stability of responses with time. Data Sources/Study Setting Primary patient self-report data were collected from 30,308 patients in 1996 and 13,438 patients in 1998 as part of a two-year longitudinal study of quality of care and health status of patients receiving care delivered by 63 physician organizations (physician groups) across three West Coast states. Study Design We analyzed longitudinal, observational data collected by Pacific Business Group on Health (PBGH) from patients aged 18–70 using a four-page survey in 1996 and a similar survey in 1998 to assess health status, satisfaction, use of services, and self-reported process of care. A subset of patients with self-reported chronic disease in the 1996 study received an enriched survey in 1998 to more fully detail processes of care for patients with chronic disease. Data Collection/Extraction Methods We measured response rate overall and separately for patients with chronic disease. Logistic regression was used to assess the impact of 1996 predictors on response to the follow-up 1998 survey. We compared process of care scores without and with nonresponse weights. Additionally, we measured stability of patient responses over time using percent agreement and kappa statistics, and examined rates of gender inconsistencies reported across the 1996 and 1998 surveys. Principal Findings In 1998, response rates were 54 percent overall and 63 percent for patients with chronic disease. Patient demographics, health status, use of services, and satisfaction with care in 1996 were all significant predictors of response in 1998, highlighting the importance of analytic strategies (i.e., application of nonresponse weights) to minimize bias in estimates of care and
Cigrang, Jeffrey A; Rauch, Sheila A M; Mintz, Jim; Brundige, Antoinette; Avila, Laura L; Bryan, Craig J; Goodie, Jeffrey L; Peterson, Alan L
First-line trauma-focused therapies offered in specialty mental health clinics do not reach many veterans and active duty service members with posttraumatic stress disorder (PTSD). Primary care is an ideal environment to expand access to mental health care. Several promising clinical case series reports of brief PTSD therapies adapted for primary care have shown positive results, but the long-term effectiveness with military members is unknown. The purpose of this study was to determine the long-term outcome of an open trial of a brief cognitive-behavioral primary care-delivered protocol developed specifically for deployment-related PTSD in a sample of 24 active duty military (15 men, 9 women). Measures of PTSD symptom severity showed statistically and clinically significant reductions from baseline to posttreatment that were maintained at the 6-month and 1-year follow-up assessments. Similar reductions were maintained in depressive symptoms and ratings of global mental health functioning. Copyright © 2015 Elsevier Ltd. All rights reserved.
Fernández-Isla, L E; Conde-Valvis-Fraga, S; Fernández-Ruíz, J S
To determine the satisfaction of main caregivers of deceased patients followed-up by palliative care teams. Web research on electronic data bases: PubMed and MEDES, using "Palliative Care" and "Patient Satisfaction" as main descriptors, and "Family", "Professional-Family Relations", "Quality of Health Care" and "Quality Assurance, Health Care" as secondary descriptors. Studies written in Spanish and English were included. Profile of principal caregiver: a woman between her mid-forties and her mid-fifties, usually related with the patient as a daughter, and of primary educational level. The items that the main caregivers valued the most were: a kind manner, feeling free to ask questions about problems during the process, tactful explanations, receiving information, pain management, time for answering questions, interest for emotional problems, and information about treatment. The worse valued items were: symptoms control, lack of psychological support after death, preparation for a death of a relative, keeping in touch after death, help to resolve outstanding issues, and help during grief. In general, a great majority of palliative care teams achieved excellent results. In spite of the good results obtained in satisfaction surveys from caregivers with regard to palliative care teams, it is essential to improve the quality of scientific-technical training (both from the medical and the psychological point of view), as well as to improve communicational skills among palliative care staff. Copyright © 2016 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Jacomet, Christine; Berland, Pauline; Guiguet, Marguerite; Simon, Anne; Rey, David; Arvieux, Cédric; Pugliese, Pascal; Gerbaud, Laurent
The aging population of people living with human immunodeficiency virus (HIV) (PLWH) is exposed to a widening spectrum of non-AIDS-defining diseases. Thus, our objective was to compare the health care offered to PLWH according to age. We conducted a multicenter cross-sectional study on PLWH who consulted at one of 59 French HIV reference centers from 15th to 19th October 2012. Using our survey questionnaires, PLWH self-reported the medical care they received, whether or not tied to HIV infection monitoring, during the previous year. A total of 650 PLWH participated in the survey (median age 48 years, Interquartile range (IQR) 40-54), of which 95 were aged 60 years or over (14.5%). Compared to younger PLWH, 60-and-over PLWH were more often under complementary health insurance cover and less socially deprived based on the French EPICES (Evaluation of Precarity and Inequalities in Health Examination Centers) score. The elderly PLWH presented more comorbidities and less coinfections with hepatitis viruses. During health care, therapeutic education was less often offered to older PLWH (14% vs. 26%, p = .01), but this difference was mainly explained by sociodemographic factors and clinical status. Over the previous 6 months, 74% of PLWH who were followed up in hospital had also consulted another doctor, with a mean of 3.75 consultations (±4.18) without difference between age groups. After adjustment for sociodemographic factors and comorbidities, PLWH over 60 years were more likely to have consulted medical specialists as outpatients in the last 6 months (odds ratio [OR] = 2.63 [1.11-6.20]). Whatever their age, 13% of PLWH had been refused care on disclosure of their HIV status, and 27% of PLWH still did not disclose their HIV status to some caregivers. Coordinated health care throughout patients' lives is crucial, as health-care pathways evolve toward outpatient care as the patients get older.
Saunders, Richard Scott; Fernandes-Taylor, Sara; Rathouz, Paul J.; Saha, Sandeep; Wiseman, Jason T.; Havlena, Jeffrey; Matsumura, Jon; Kent, K. Craig
Background The association between early outpatient follow-up and 30-day readmission has not been evaluated in any surgical population. Our study characterizes the relationship between outpatient follow-up and early readmissions among surgical patients. Methods We queried the medical record at a large, tertiary care institution (July 2008-December 2012) to determine rates of 30-day outpatient follow-up and readmission for general or vascular surgical procedures. Results The majority of discharges for general (84% of 7552) and vascular (75% of 2362) surgery had a follow-up visit before readmission or within 30 days of discharge. General surgery patients who were not readmitted had high rates of follow-up (88%) and received follow-up at approximately 2-weeks post-discharge (median time 11 days after discharge). In contrast, readmitted general surgery patients received first follow-up at one week (a median time of 8 days); 49% had follow-up. Vascular surgery patients showed a similar trend. Over half of patients readmitted after follow-up were readmitted within 24 hours of their most recent outpatient visit. Conclusions Current routine follow-up does not occur early enough to detect adverse events and prevent readmission. Early outpatient care may prevent readmission in some patients, but often serves as a conduit for readmission among patients already experiencing complications. PMID:25239351
Menon, Shailaja; Murphy, Daniel R.; Singh, Hardeep; Meyer, Ashley N. D.
Summary Background Electronic health records (EHRs) have potential to facilitate reliable communication and follow-up of test results. However, limitations in EHR functionality remain, leading practitioners to use workarounds while managing test results. Workarounds can lead to patient safety concerns and signify indications as to how to build better EHR systems that meet provider needs. Objective To understand why primary care practitioners (PCPs) use workarounds to manage test results by analyzing data from a previously conducted national cross-sectional survey on test result management. Methods We conducted a secondary data analysis of quantitative and qualitative data from a national survey of PCPs practicing in the Department of Veterans Affairs (VA) and explored the use of workarounds in test results management. We used multivariate logistic regression analysis to examine the association between key sociotechnical factors that could affect test results follow-up (e.g., both technology-related and those unrelated to technology, such as organizational support for patient notification) and workaround use. We conducted a qualitative content analysis of free text survey data to examine reasons for use of workarounds. Results Of 2554 survey respondents, 1104 (43%) reported using workarounds related to test results management. Of these 1028 (93%) described the type of workaround they were using; 719 (70%) reported paper-based methods, while 230 (22%) used a combination of paper- and computer-based workarounds. Primary care practitioners who self-reported limited administrative support to help them notify patients of test results or described an instance where they personally (or a colleague) missed results, were more likely to use workarounds (p=0.02 and p=0.001, respectively). Qualitative analysis identified three main reasons for workaround use: 1) as a memory aid, 2) for improved efficiency and 3) for facilitating internal and external care coordination
Hospital providers voice concerns about a proposed rule by the Centers for Medicare and Medicaid Services (CMS) that would require providers to devote more resources to discharge planning. The rule would apply to inpatients as well as emergency patients requiring comprehensive discharge plans as opposed to discharge instructions. CMS states that the rule would ensure the prioritization of patient preferences and goals in the discharge planning process, and also would prevent avoidable complications and readmissions. However, hospital and emergency medicine leaders worry that community resources are not yet in place to facilitate the links and follow-up required in the proposed rule, and that the costs associated with implementation would be prohibitive. The proposed rule would apply to acute care hospitals, EDs, long-term care facilities, inpatient rehabilitation centers, and home health agencies. Regardless of the setting, though, CMS is driving home the message that patient preferences should be given more weight during the discharge planning process. Under the rule, hospitals or EDs would need to develop a patient-centered discharge plan within 24 hours of admission or registration, and complete the plan prior to discharge or transfer to another facility. Under the rule, emergency physicians would determine which patients require a comprehensive discharge plan. Both the American Hospital Association and the American College of Emergency Physicians worry that hospitals will have to take on more staff, invest in training, and make changes to their electronic medical record systems to implement the provisions in the proposed rule.
Aubin, Michèle; Giguère, Anik; Martin, Mélanie; Verreault, René; Fitch, Margaret I; Kazanjian, Arminée; Carmichael, Pierre-Hugues
usual care. Given the expected clinical and methodological diversity, median changes in outcomes (and bootstrap confidence intervals) among groups of studies that shared specific features of interest were chosen to analyse the effectiveness of included interventions. Fifty-one studies were included. They used three different models, namely case management, shared care, and interdisciplinary teams. Six additional interventional strategies were used besides these models: (1) patient-held record, (2) telephone follow-up, (3) communication and case discussion between distant healthcare professionals, (4) change in medical record system, (5) care protocols, directives and guidelines, and (6) coordination of assessments and treatment.Based on the median effect size estimates, no significant difference in patient health-related outcomes was found between patients assigned to interventions and those assigned to usual care. A limited number of studies reported psychological health, satisfaction of providers, or process of care measures. However, they could not be regrouped to calculate median effect size estimates because of a high heterogeneity among studies. Results from this Cochrane review do not allow us to conclude on the effectiveness of included interventions to improve continuity of care on patient, healthcare provider or process of care outcomes. Future research should evaluate interventions that target an improvement in continuity as their primary objective and describe these interventions with the categories proposed in this review. Also of importance, continuity measures should be validated with persons with cancer who have been followed in various settings.
Eggly, Susan; Berger, John; Zimmerman, Jerry; Anand, Kanwaljeet J. S.; Newth, Christopher J. L.; Harrison, Rick; Carcillo, Joseph; Dean, J. Michael; Willson, Douglas F.; Nicholson, Carol
Objective To describe a framework to assist pediatric intensive care unit physicians in conducting follow-up meetings with parents after their child's death. Many childhood deaths occur in pediatric intensive care units. Parents of children who die in pediatric intensive care units often desire a follow-up meeting with the physician(s) who cared for their child. Data Sources Prior research conducted by the Collaborative Pediatric Critical Care Research Network on the experiences and perspectives of bereaved parents and pediatric intensive care unit physicians regarding the desirability, content, and conditions of follow-up meetings. Results The framework includes suggestions for inviting families to follow-up meetings (i.e., developing an institutional system, invitation timing, and format); preparing for the meeting (i.e., assessing family preferences; determining location, attendees, and discussion topics; reviewing medical and psychosocial history); structure of the meeting (i.e., opening, closing, and developing a meeting agenda); communicating effectively during the meeting; and follow-up for both parents and physicians. Conclusion This framework is based on the experience and perspectives of bereaved parents and pediatric intensive care unit physicians. Future research should be conducted to determine the extent to which physician-parent follow-up meetings provide a benefit to parents, families, physicians, and other healthcare providers participating in these encounters. PMID:20625339
Eggly, Susan; Meert, Kathleen L; Berger, John; Zimmerman, Jerry; Anand, Kanwaljeet J S; Newth, Christopher J L; Harrison, Rick; Carcillo, Joseph; Dean, J Michael; Willson, Douglas F; Nicholson, Carol
To describe a framework to assist pediatric intensive care unit physicians in conducting follow-up meetings with parents after their child's death. Many childhood deaths occur in pediatric intensive care units. Parents of children who die in pediatric intensive care units often desire a follow-up meeting with the physician(s) who cared for their child. Prior research conducted by the Collaborative Pediatric Critical Care Research Network on the experiences and perspectives of bereaved parents and pediatric intensive care unit physicians regarding the desirability, content, and conditions of follow-up meetings. The framework includes suggestions for inviting families to follow-up meetings (i.e., developing an institutional system, invitation timing, and format); preparing for the meeting (i.e., assessing family preferences; determining location, attendees, and discussion topics; reviewing medical and psychosocial history); structure of the meeting (i.e., opening, closing, and developing a meeting agenda); communicating effectively during the meeting; and follow-up for both parents and physicians. This framework is based on the experience and perspectives of bereaved parents and pediatric intensive care unit physicians. Future research should be conducted to determine the extent to which physician-parent follow-up meetings provide a benefit to parents, families, physicians, and other healthcare providers participating in these encounters.
Van Straaten, Barbara; Rodenburg, Gerda; Van der Laan, Jorien; Boersma, Sandra N; Wolf, Judith R L M; Van de Mheen, Dike
Cognitive impairment is a prevalent problem among the homeless and seems related to more psychosocial problems. However, little is known about the care needs of the subgroup of homeless people with an intellectual disability compared to those without an intellectual disability and how their care needs develop over time. This study explores self-reported care needs within a broad range of life domains among Dutch homeless people with and without a suspected intellectual disability to gain insight into the transition of self-reported care needs from baseline to follow-up in both subgroups. This longitudinal study is part of a cohort study among homeless people who had been accepted for an individual programme plan in four major Dutch cities. The initial cohort consisted of 513 participants who were interviewed in 2011. At 1.5-year follow-up, 336 participants (65.5%) were also interviewed and screened for intellectual disability. Of these participants, 31% (95% CI 26.2-36.1) had a suspected intellectual disability. For both groups, between baseline and follow-up, the number of 'unmet care needs' decreased significantly and the number of 'no care needs' increased significantly, while at follow-up, participants with a suspected intellectual disability reported 'no care needs' on significantly fewer life domains than those without a suspected intellectual disability (mean numbers 16.4 vs. 17.5). Between baseline and follow-up, 'met care needs' decreased significantly on housing for both groups, and increased on finances and dental care for participants with a suspected intellectual disability. At follow-up, participants with a suspected intellectual disability more often preferred housing support available by appointment than those without a suspected intellectual disability. These findings suggest that homeless people who had been accepted for an individual programme plan with a suspected intellectual disability have care needs for a longer period of time than those
Gould, Madelyn S; Lake, Alison M; Galfalvy, Hanga; Kleinman, Marjorie; Munfakh, Jimmie Lou; Wright, James; McKeon, Richard
Continuity of care for suicidal individuals engaged with a variety of health and mental health care systems has become a national priority, and crisis hotlines are increasingly playing a part in the risk management and continuum of care for these individuals. The current study evaluated a national initiative to have crisis centers in the National Suicide Prevention Lifeline network provide follow-up care to suicidal callers. Data were obtained from 550 callers followed by 41 crisis counselors from 6 centers. Two main data sources provided the information for the current study: a self-report counselor questionnaire on the follow-up activities completed on each clinical follow-up call and a telephone interview with follow-up clients, providing data on their perceptions of the follow-up intervention's effectiveness. The majority of interviewed follow-up clients reported that the intervention stopped them from killing themselves (79.6%) and kept them safe (90.6%). Counselor activities, such as discussing distractors, social contacts to call for help, and reasons for dying, and individual factors, such as baseline suicide risk, were associated with callers' perceptions of the impact of the intervention on their suicide risk. Our findings provide evidence that follow-up calls to suicidal individuals can reduce the perceived risk of future suicidal behavior.
Wong, Carlos K H; Lam, Cindy L K; Wan, Eric Y F; Chan, Anca K C; Pak, C H; Chan, Frank W K; Wong, William C W
To examine the effects of a structured group-based education programme, patient empowerment programme (PEP), compared with usual care on 2-year changes in patient-reported outcomes (PRO) in patients with diabetes mellitus (DM). A prospective observational study of 715 patients (PEP/non-PEP: 390/325) was conducted to complete the baseline PRO survey and followed up for 2 years. Health-related quality of life (HRQOL) was measured using the short-form 12 at baseline and annually at two follow-up assessments, which yielded physical and mental component summary and SF-6D preference-based scores. Perceived control over diabetes and general health status were measured using the patient enablement instrument (PEI) and global rating scale (GRS) at follow-ups. When compared with non-PEP, PEP participants significantly reported improvement in health condition (GRS score > 0; 24.55 % vs 10.16 %; odds ratio = 2.502; P = 0.018) in 2 years and enabled the self-perceived control over diabetes (PEI score > 0; 72.20 % vs 38.40 %; odds ratio = 3.25; P < 0.001) in 1-year follow-up but no sustained effects in year 2 (52.65 % vs 39.04 %; odds ratio = 1.366; P = 0.265). There were no significant differences between PEP and non-PEP groups in the changes in quality of life scores (all P > 0.05) at 1 year. Although HRQOL scores deteriorated over 2-year period in both groups, PEP participants reported similar changes in HRQOL scores to that of non-PEP. PEP for DM patients preserved self-perceived disease control and health condition, whereas PEP participants perceived their HRQOL similar to that of non-PEP participants. Findings of PRO should be considered alongside clinical outcomes when evaluating the overall benefits of PEP.
Robin, Michaël; Bronchard, Marion; Kannas, Serge
Ambulatory care for subjects with severe mental problems has been clearly shown to be a valid alternative to hospitalisation. However, very few studies have considered the fate of patients over several years. Ambulatory care services are often experimental set-ups, for small groups, and their impact on subsequent treatment has only been assessed over the first few months of treatment. The value of developing this practice therefore remains unclear. We investigated the possible consequences of generalising ambulatory care services by a mobile crisis intervention team (ERIC) to all requests for the first hospitalisation in a psychiatric department. The principal aim was to determine whether systemic intervention by the crisis intervention team could provide a true alternative to hospitalisation. We also investigated whether problem-resolving approaches and ambulatory care led, in the long term, to fewer prolonged or repeated periods of hospitalisation than practices in which hospitalisation was considered as an ordinary solution. We carried out a prospective, comparative, cohort study over a 5-year period beginning with the creation of ERIC by one of the hospital departments. All patients arriving at this department for the first time were offered immediate ambulatory care by this team for 1 month. Their hospitalisation record (duration of hospital stay, number of days in hospital) was compared with that of subjects hospitalised in the same conditions but in other departments of the hospital. This study included most of the subjects referred for the first time to the psychiatric hospital, in our department. Regardless of their diagnosis, intensive follow-up at home, based on systemic crisis intervention work, was found to be an effective and well-accepted alternative to hospitalisation. Indeed, a highly significant immediate decrease in both the number of admissions and the duration of hospital stay was observed for the experimental group, with no subsequent increase
Baena-Cañada, José M; Ramírez-Daffós, Patricia; Cortés-Carmona, Cristina; Rosado-Varela, Petra; Nieto-Vera, Juan; Benítez-Rodríguez, Encarnación
Hospitals have traditionally been the place where the follow-up of breast cancer patients occurs in Spain. To describe the evolution of long-term survivors of breast cancer according to type of follow-up received (in primary or specialist/hospital care), measuring impact of care type on health, cost, health-related quality of life (HRQL) and satisfaction results. Retrospective study of cohorts with disease-free patients followed up for at least 5 years in Oncology. Using personal questionnaires, the type and cost of the follow-up, events, HRQL and satisfaction were analysed. Ninety-eight women were surveyed, 60 in primary and 38 in specialist care. There were no differences between groups in diagnosis of metastasis or new primary tumours. The number of annual visits per patient was 0.98 (0.48) in primary and 1.11 (0.38) in specialist care (P = 0.19). In primary, 44.6% were programmed and 55.4% on demand; in specialist, 94.6% were programmed and 5.4% on demand (P = 0.0001). The costs of follow-up in primary care were lower--€112.86 (77.54) versus €184.61 (85.87) per patient and year (P = 0.0001). No differences were reported in HRQL. Preference for specialist care was expressed by 80%, versus 10% for primary, with 10% indifferent. Patients showed greater satisfaction with specialist care in all questionnaire dimensions. Compliance with follow-up protocol was high in both groups. In specialist care nearly all the visits were programmed and in primary almost half were on demand. In our locality, primary is more cost-effective than specialist care, but patients express greater satisfaction with specialist follow-up and hence prefer it.
Karliner, LS; Ma, L; Hofmann, M; Kerlikowske, K
Background Breast cancer is frequently diagnosed after an abnormal mammography result. Language barriers can complicate communication of those results. Objectives We evaluated the association of non-English language with delay in follow-up. Methods: Retrospective cohort study of women at three mammography facilities participating in the San Francisco Mammography Registry (SFMR) with an abnormal mammogram result from 1997-2008. We measured median time from report of abnormal result to first follow-up test. Results Of 13,014 women with 16,109 abnormal mammograms, 4,027 (31%) had a non-English patient language. Clinical facilities differed in proportion of non-English-speakers and in time to first follow-up test: facility A (38%; 25 days), facility B (18%; 14 days), facility C (51%; 41 days). Most (67%) mammography examinations had BIRADS 0 (incomplete) assessment, requiring radiographic follow-up. At 30 days of follow-up 67% of all English speakers with incomplete assessments had a follow-up exam compared with 50% of all non-English speakers (p<.0001). The facility with the least delay and the lowest proportion of non-English speakers, had the biggest difference by language; compared to English speakers and adjusting for education, non-English speakers had twice the odds of >30 day delay in follow-up (OR 2.3; 95 CI 1.4-3.9). Conclusions There are considerable differences among facilities in delays in diagnostic follow-up of abnormal mammography results. More attention must be paid to understanding mammography facility factors, such as wait time to schedule diagnostic mammography and radiology workload, in order to improve rates of timely follow-up, particularly for those facilities disproportionately serving vulnerable non-English speaking patients. PMID:21993060
Lichtenthal, Wendy G.; Sweeney, Corinne R.; Roberts, Kailey E.; Corner, Geoffrey W.; Donovan, Leigh A.; Prigerson, Holly G.; Wiener, Lori
After a child’s death to cancer, families commonly want continued connection with the healthcare team that cared for their child, yet bereavement follow-up is often sporadic. A comprehensive literature search found that many bereaved parents experience poor psychological outcomes during bereavement and that parents want follow-up and benefit from continued connection with their child’s health care providers. Evidence suggests that the standard of care should consist of at least one meaningful contact between the health care team and bereaved parents to identify those at risk for negative psychosocial sequelae and to provide resources for bereavement support. PMID:26700929
Pierre, M.; Pacaud, F.; Adami, C.; Alis, S.; Altieri, B.; Baran, N.; Benoist, C.; Birkinshaw, M.; Bongiorno, A.; Bremer, M. N.; Brusa, M.; Butler, A.; Ciliegi, P.; Chiappetti, L.; Clerc, N.; Corasaniti, P. S.; Coupon, J.; De Breuck, C.; Democles, J.; Desai, S.; Delhaize, J.; Devriendt, J.; Dubois, Y.; Eckert, D.; Elyiv, A.; Ettori, S.; Evrard, A.; Faccioli, L.; Farahi, A.; Ferrari, C.; Finet, F.; Fotopoulou, S.; Fourmanoit, N.; Gandhi, P.; Gastaldello, F.; Gastaud, R.; Georgantopoulos, I.; Giles, P.; Guennou, L.; Guglielmo, V.; Horellou, C.; Husband, K.; Huynh, M.; Iovino, A.; Kilbinger, M.; Koulouridis, E.; Lavoie, S.; Le Brun, A. M. C.; Le Fevre, J. P.; Lidman, C.; Lieu, M.; Lin, C. A.; Mantz, A.; Maughan, B. J.; Maurogordato, S.; McCarthy, I. G.; McGee, S.; Melin, J. B.; Melnyk, O.; Menanteau, F.; Novak, M.; Paltani, S.; Plionis, M.; Poggianti, B. M.; Pomarede, D.; Pompei, E.; Ponman, T. J.; Ramos-Ceja, M. E.; Ranalli, P.; Rapetti, D.; Raychaudury, S.; Reiprich, T. H.; Rottgering, H.; Rozo, E.; Rykoff, E.; Sadibekova, T.; Santos, J.; Sauvageot, J. L.; Schimd, C.; Sereno, M.; Smith, G. P.; Smolčić, V.; Snowden, S.; Spergel, D.; Stanford, S.; Surdej, J.; Valageas, P.; Valotti, A.; Valtchanov, I.; Vignali, C.; Willis, J.; Ziparo, F.
Context. The quest for the cosmological parameters that describe our universe continues to motivate the scientific community to undertake very large survey initiatives across the electromagnetic spectrum. Over the past two decades, the Chandra and XMM-Newton observatories have supported numerous studies of X-ray-selected clusters of galaxies, active galactic nuclei (AGNs), and the X-ray background. The present paper is the first in a series reporting results of the XXL-XMM survey; it comes at a time when the Planck mission results are being finalised. Aims: We present the XXL Survey, the largest XMM programme totaling some 6.9 Ms to date and involving an international consortium of roughly 100 members. The XXL Survey covers two extragalactic areas of 25 deg2 each at a point-source sensitivity of ~5 × 10-15 erg s-1 cm-2 in the [0.5-2] keV band (completeness limit). The survey's main goals are to provide constraints on the dark energy equation of state from the space-time distribution of clusters of galaxies and to serve as a pathfinder for future, wide-area X-ray missions. We review science objectives, including cluster studies, AGN evolution, and large-scale structure, that are being conducted with the support of approximately 30 follow-up programmes. Methods: We describe the 542 XMM observations along with the associated multi-λ and numerical simulation programmes. We give a detailed account of the X-ray processing steps and describe innovative tools being developed for the cosmological analysis. Results: The paper provides a thorough evaluation of the X-ray data, including quality controls, photon statistics, exposure and background maps, and sky coverage. Source catalogue construction and multi-λ associations are briefly described. This material will be the basis for the calculation of the cluster and AGN selection functions, critical elements of the cosmological and science analyses. Conclusions: The XXL multi-λ data set will have a unique lasting legacy
Pennington, Andrew V R; O'Reilly, Sharleen L; Young, Doris; Dunbar, James A
This paper investigates factors influencing women's engagement with diabetes preventative care after a pregnancy with gestational diabetes (GDM) from the perspectives of GPs and women and explores the role of the GP in that care. Qualitative research using semi-structured interviews with women who had experienced GDM (n=16) and GPs (n=18) were conducted and a thematic content analysis conducted. Women's interviews explored their experience of GDM, factors influencing, and engagement with, follow-up care for diabetes prevention and role of the GP in that care. GP interviews explored postnatal care provided to women with GDM, the role of the GP in that care and perceived factors influencing a mother's engagement in her self-care. Three themes were identified: (1) advice and testing; (2) role of the GP; and (3) barriers and enablers to care. Significant consensus about the role of the GP and barriers and enablers to care existed. Both groups believed post GDM follow-up is best done by GPs and suggested recall and reminders would improve care. GPs gave consistent exercise advice, but lacked consensus on follow-up testing, dietary and weight-loss advice. Women's health literacy influenced how they viewed their GPs role. Consensus guidelines on follow-up testing and diabetes prevention advice, tailored advice according to health literacy and addressing barriers to care would likely improve the capacity of GPs to prevent unnecessary conversion to type 2 diabetes in these at-risk women.
The quest for the cosmological parameters that describe our universe continues to motivate the scientific community to undertake very large survey initiatives across the electromagnetic spectrum. Over the past two decades, the Chandra and XMM-Newton observatories have supported numerous studies of X-ray-selected clusters of galaxies, active galactic nuclei (AGNs), and the X-ray background. The present paper is the first in a series reporting results of the XXL-XMM survey; it comes at a time when the Planck mission results are being finalized. Aims. We present the XXL Survey, the largest XMM programme totaling some 6.9 Ms to date and involving an international consortium of roughly 100 members. The XXL Survey covers two extragalactic areas of 25 deg2 each at a point-source sensitivity of approx. 5 x 10(exp 15) erg/s/sq cm in the [0.5-2] keV band (completeness limit). The surveys main goals are to provide constraints on the dark energy equation of state from the space-time-distribution of clusters of galaxies and to serve as a pathfinder for future, wide-area X-ray missions. We review science objectives, including cluster studies, AGN evolution, and large-scale structure, that are being conducted with the support of approximately 30 follow-up programs. Methods. We describe the 542 XMM observations along with the associated multi- and numerical simulation programmes. We give a detailed account of the X-ray processing steps and describe innovative tools being developed for the cosmological analysis. Results. The paper provides a thorough evaluation of the X-ray data, including quality controls, photon statistics, exposure and background maps, and sky coverage. Source catalogue construction and multi-associations are briefly described. This material will be the basis for the calculation of the cluster and AGN selection functions, critical elements of the cosmological and science analyses. Conclusions. The XXL multi- data set will have a unique lasting legacy value for
Brink, Helle L; Thomsen, Anja K; Laerkner, Eva
'To identify parents' experience of a follow up meeting and to explore whether the conversation was adequate to meet the needs of parents for a follow-up after their child's death in the Paediatric Intensive Care Unit (PICU). Qualitative method utilising semi-structured interviews with six pairs of parents 2-12 weeks after the follow-up conversation. The interviews were held in the parents' homes at their request. Data were analysed using a qualitative, descriptive approach and thematic analysis. Four main themes emerged: (i) the way back to the PICU; (ii) framework; (iii) relations and (iv) closure. The parents expressed nervousness before the meeting, but were all pleased to have participated in these follow-up meetings. The parents found it meaningful that the follow-up meeting was interdisciplinary, since the parents could have answers to their questions both about treatment and care. It was important that the staff involved in the follow-up meeting were those who had been present through the hospitalisation and at the time of the child's death. Parents experienced the follow-up meeting as being a closure of the course in the PICU, regardless the length of the hospitalisation. Copyright © 2016 Elsevier Ltd. All rights reserved.
Heinonen, J.; Koskela, T.H.; Soini, E.; Ryynänen, O.P.
Objective To explore patient characteristics, resource use, and costs related to different episodes of care (EOC) in Finnish health care. Design Data were collected during a three-month prospective, non-randomized follow-up study (Effective Health Centre) using questionnaires and an electronic health record. Setting Three primary health care practices in Pirkanmaa, Finland. Subjects Altogether 622 patients were recruited during a one-week period. Inclusion criteria: the patient had a doctor’s or nurse’s appointment on the recruiting day and agreed to participate. Exclusion criteria: patients visiting a specialized health guidance clinic for pregnant women, children, and mothers. Main outcome measures Patient characteristics, resource use, and costs based on the ICPC-2 EOC classification. Results On average, the patients had 1.22 EOCs during the three months. Patient characteristics and resource use differed between the EOC chapters. Chapter L, “Musculoskeletal”, had the most episodes (17%). The most common (8%) single EOC was “upper respiratory infection”. The mean cost of an episode (COE) was €389.56 (standard error 61.11) and the median COE was €165.00 (interquartile range €118.46–288.56) during the three-month follow-up. The most expensive chapter was K, “Circulatory”, with a mean COE of €909.85. The most expensive single COE was in chapter K, €32 545.56. The most expensive 1% of the COEs summed up covered 36% of the total COEs. Conclusion Patient characteristics, resource use, and costs differed between the ICPC-2 chapters, which could be taken into account in service planning and pricing. Future studies should incorporate more specific diagnoses, larger data sets, and longer follow-up times.Key pointsThe most common episodes were under the ICPC-2 “Musculoskeletal” chapter, but the highest mean and single-episode costs were related to the “Circulatory” chapter.The mean (median) cost of episodes that started in primary care
, stiffness and fatigue), the Patient Global Assessment of disease activity, measured hand function (e.g. grip strength, thumb web space and hand dexterity) and health-related quality of life. Cost-utility and cost-effectiveness analyses will be conducted. Discussion This study will contribute to the knowledge on both the effect and resource use of an exercise programme with telephone follow-up on self-reported hand activity performance among people with hand OA. Trial registration The trial is registered at ClinicalTrials.gov with registration number: NCT01245842. PMID:24629063
Cárceles-Álvarez, A; Ortega-García, J A; Fuster-Soler, J L; Rivera-Pagán, G A; Bermúdez-Cortés, M; Gomariz-Peñalver, V; Monzó-Nuñez, E; López-Hernández, F A
To assess attitudes, beliefs and knowledge of primary medical care professionals as regards the follow-up of Childhood Cancer Survivors (CCS) and the introduction of a Long-Term Follow-Up Program for Childhood Cancer Survivors in the Region of Murcia (PLASESCAP-MUR). Descriptive cross-sectional study using a structured, self-administered questionnaire. These questionnaires were sent to all primary medical care professionals in Murcia Health District 1. Response rate of 58% (100/172), with 71% and 22% being family physicians and pediatricians, respectively, of whom 49% provided medical care to a CCS in the last 5 years, with 84% reporting that they never or rarely received a detailed report of overall assessment of the survivor. More than 75% found that access to detailed follow-up information was quite or very useful; 95% prefer to consult experts when providing medical care to survivors, and 80% believe that improving the quality of the environment may decrease the morbidity and mortality of the survivors. A statistically significant relationship was found between the length of practicing medicine and the perception of the importance of environmental factors. It seems to be important to increase the training of primary care professionals for the long-term follow-up of CCS, as well as having the detailed information through a personalized long-term follow-up of each survivor. PLASESCAP-MUR offers an integrated follow-up to CCS in a model of shared care between Long Term Monitoring Units and Primary Care Units. Copyright © 2014 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.
Poulsen, Kjeld; Cleal, Bryan; Clausen, Thomas; Andersen, Lars L.
Objectives The rise in prevalence of diabetes is alarming and research ascribes most of the increase to lifestyle. However, little knowledge exists about the influence of occupational factors on the risk for developing diabetes. This study estimates the importance of work and lifestyle as risk factors for developing diabetes mellitus among healthcare workers and explores the association of work factors and obesity, which is a risk factor for diabetes. Methods Questionnaire-based prospective cohort study among 7,305 health care workers followed for seven years in the Danish National Diabetes Register. We used bivariate comparisons to give an unadjusted estimate of associations, followed by adjusted survival analysis and logistic regression models to estimate the influences of potential risk factors related to job, health and lifestyle on diabetes and obesity. Results During seven years of follow up, 3.5% of participants developed diabetes, associated with obesity (HR = 6.53; 95% CI 4.68–9.10), overweight (HR = 2.89; CI 2.11–3.96) age 50–69 y (HR = 2.27; 95% CI 1.57–3.43) and high quality of leadership (HR = 1.60; CI 1.19–2.16). Obesity at baseline was most common among the youngest employees, and was mainly associated with developing diabetes (OR = 3.84; CI 2.85–5.17), impaired physical capacity and physical inactivity. In the occupational setting, obesity was associated with shift work, severe musculoskeletal pain, low influence, but also by good management, fewer role conflicts and a positive work-life balance. Looking only at non-smokers, removed the influence of age and pain. However, non-smokers also had higher depression scores and more role conflicts. Conclusions Confirming obesity as the strongest risk factor for developing diabetes, the present study identified few occupational risk factors. However, obesity, the key risk factor for diabetes, had a more variable relation with work than did diabetes. PMID:25068830
Ennen, Christopher S.; Carrese, Joseph A.; Hill-Briggs, Felicia; Levine, David M.; Nicholson, Wanda K.; Clark, Jeanne M.
Abstract Objectives Women with a history of gestational diabetes mellitus (GDM) have an increased risk of developing type 2 diabetes (T2DM) but often do not return for follow-up care. We explored barriers to and facilitators of postpartum follow-up care in women with recent GDM. Methods We conducted 22 semistructured interviews, 13 in person and 9 by telephone, that were audiotaped and transcribed. Two investigators independently coded transcripts. We identified categories of themes and subthemes. Atlas.ti qualitative software (Berlin, Germany) was used to assist data analysis and management. Results Mean age was 31.5 years (standard deviation) [SD] 4.5), 63% were nonwhite, mean body mass index (BMI) was 25.9 kg/m2 (SD 6.2), and 82% attended a postpartum visit. We identified four general themes that illustrated barriers and six that illustrated facilitators to postpartum follow-up care. Feelings of emotional stress due to adjusting to a new baby and the fear of receiving a diabetes diagnosis at the visit were identified as key barriers; child care availability and desire for a checkup were among the key facilitators to care. Conclusions Women with recent GDM report multiple barriers and facilitators of postpartum follow-up care. Our results will inform the development of interventions to improve care for these women to reduce subsequent diabetes risk. PMID:21265645
Bennett, Wendy L; Ennen, Christopher S; Carrese, Joseph A; Hill-Briggs, Felicia; Levine, David M; Nicholson, Wanda K; Clark, Jeanne M
Women with a history of gestational diabetes mellitus (GDM) have an increased risk of developing type 2 diabetes (T2DM) but often do not return for follow-up care. We explored barriers to and facilitators of postpartum follow-up care in women with recent GDM. We conducted 22 semistructured interviews, 13 in person and 9 by telephone, that were audiotaped and transcribed. Two investigators independently coded transcripts. We identified categories of themes and subthemes. Atlas.ti qualitative software (Berlin, Germany) was used to assist data analysis and management. Mean age was 31.5 years (standard deviation) [SD] 4.5), 63% were nonwhite, mean body mass index (BMI) was 25.9 kg/m(2) (SD 6.2), and 82% attended a postpartum visit. We identified four general themes that illustrated barriers and six that illustrated facilitators to postpartum follow-up care. Feelings of emotional stress due to adjusting to a new baby and the fear of receiving a diabetes diagnosis at the visit were identified as key barriers; child care availability and desire for a checkup were among the key facilitators to care. Women with recent GDM report multiple barriers and facilitators of postpartum follow-up care. Our results will inform the development of interventions to improve care for these women to reduce subsequent diabetes risk.
de Waal, Margot WM; Arnold, Ingrid A; Eekhof, Just AH; Assendelft, Willem JJ; van Hemert, Albert M
Background Better management of affective and somatoform disorders may reduce consultation rates in primary care. Somatoform disorders are highly prevalent in primary care and co-morbidity with affective disorders is substantial, but it is as yet unclear which portion of the health care use may be ascribed to each disorder. Our objective was to investigate the use of primary care for undifferentiated somatoform disorders, other somatoform disorders, anxiety and depressive disorders prospectively. Methods In eight family practices 1046 consulting patients (25–79 yrs) were screened and a stratified sample of 473 was interviewed. Somatoform disorders, anxiety and depressive disorders were diagnosed (DSM IV) using SCAN 2.1. The electronic records of 400 participants regarding somatic diseases, medication and healthcare use were available through their family physicians (FP). Results In the follow-up year patients with psychiatric disorders had more face-to-face contacts with the FP than patients who had no psychiatric disorder: average 7–10 versus 5. The impact on the use of primary care by patients with somatoform disorders was comparable to patients with depressive or anxiety disorders. Undifferentiated somatoform disorders had an independent impact on the use of primary care after adjustment for anxiety and depressive disorders, resulting in 30% more consultations (IRR 1.3 (95% CI: 1.1–1.7)). Anxiety disorders had no independent effect. Conclusion Health care planning should focus on the recognition and treatment of somatoform as well as affective disorders. PMID:18218070
Rodriguez-Cuellar, Elias; Nevado García, Cristina; Casanova Duran, Virginia; Romero Simó, Manuel; Duran Poveda, Manuel; Ruiz Lopez, Pedro
Using the cases included in the Study on the quality of care in colorectal cancer conducted by the Spanish Association of Surgeons in 2008, we present follow-up data. Multicenter, descriptive, longitudinal and prospective study of patients operated on a scheduled basis of colorectal cancer. 35 hospitals have contributed data on 334 patients. Follow-up data: survival, recurrence and complications. Mean follow-up was 28.61±11.32 months. Follow-up by surgeon: 69.2%, tumor recurrence 23.6%, in 83.3% it was systemic; 28.2% underwent salvage surgery. Overall survival was 76.6%, disease-free survival 65.6% (26.49±11.90 months). Tumor related mortality was 12,6%. Percentage of ventral hernias was 5.8%, intestinal obstruction 3.5%. Quality and results of follow-up of patients operated on for CRC in Spain are similar to those reported in the Scientific literature. Areas for improvement: follow-up, earlier diagnosis, increase adjuvant and neoadjuvant treatments and total mesorectal excision as standard surgery for rectal cancer. Copyright © 2013 AEC. Published by Elsevier Espana. All rights reserved.
Tielbur, Brittany R; Rice Cella, Donna E; Currie, Amanda; Roach, Jonathan D; Mattingly, Bryan; Boone, Jack; Watwood, Christina; McGauran, Ann; Kirshner, Howard S; Charles, P David
Disjointed patient care is a well-documented problem in health care systems, often stemming from poor communication between providers, services, and follow-up care resources. A multidisciplinary discharge huddle, augmented with cellular and tablet technology, was implemented on the Neurology Stroke Service to facilitate multidisciplinary communication, improve transition of patients, and increase referrals into affiliated follow-up care. After initiating the huddle, patient length of stay decreased by 1.4 days (25%), patient flow into continuum partners increased by 10%, and the number of patients going without services after their hospital stay decreased by more than 12%. Huddle members reported that the technology was helpful, heavily utilized, and made their work more efficient. This pilot suggests that utilizing modern mobile technologies can help improve efficiency and referrals within the health care system and reduce patient length of stay.
Khidir, Amal; Asad, Humna; Abdelrahim, Huda; Elnashar, Maha; Killawi, Amal; Hammoud, Maya; Al-Khal, Abdul Latif; Haddad, Pascale; Fetters, Michael D
Health care researchers working in the Arabian Gulf need information on how to optimize recruitment and retention of study participants in extremely culturally diverse settings. Implemented in Doha, Qatar in 2012 with 4 language groups, namely Arabic, English, Hindi, and Urdu, this research documents persons' responses to recruitment, consent, follow-up, and reminder procedures during psychometric testing of the Multicultural Assessment Instrument (MAI), a novel self- or interviewer-administered survey. Bilingual research assistants recruited adults in outpatient clinics by approaching persons in particular who appeared to be from a target language group. Participants completed the MAI, a second acculturation instrument used for content-validity assessment, and a demographics questionnaire. Participants were asked to take the MAI again in 2-3 weeks, in person or by post, to assess test-retest reliability. Recruitment data were analyzed by using nonparametric statistics. Of 1503 persons approached during recruitment, 400 enrolled (27%)-100 per language group. The enrollment rates in the language groups were: Arabic-32%; English-33%; Hindi-18%; Urdu-30%. The groups varied somewhat in their preferences regarding consent procedure, follow-up survey administration, contact mode for follow-up reminders, and disclosure of personal mailing address (for postal follow-up). Over all, telephone was the preferred medium for follow-up reminders. Of 64 persons who accepted a research assistant's invitation for in-person follow-up, 40 participants completed the interview (follow-up rate, 63%); among 126 persons in the postal group with a deliverable address, 29 participants mailed back a completed follow-up survey (response rate, 23%). Researchers in the Arabian Gulf face challenges to successfully identify, enroll, and retain eligible study participants. Although bilingual assistants-often from the persons' own culture-recruited face-to-face, and our questionnaire contained no
Chmelka, M. B.; Trout, A. L.; Mason, W. A.; Wright, T.
Although youth with disabilities represent nearly a third of the population served in residential care, little is known about the functioning of these children as compared to their peers without disabilities at program entry, departure and six-month follow-up. This study sought to extend previous research by evaluating the behavioral, mental…
DiMillo, J.; Brosseau, D. C.; Gomez-Garibello, C.; Hall, N. C.; Ezer, H.; Wang, B.; Körner, A.
The objective of this study was to examine the role of interpersonal variables on melanoma survivors' self-efficacy for performing skin self-examinations (SSEs) during melanoma follow-up care. Specifically, the impact of comfort with partner assistance for SSE, SSE support received from one's partner, general partner support, relationship…
Li-Tsang, Cecilia W P; Lee, Maggie Y F; Yeung, Susanna S S; Siu, Andrew M H; Lam, C S
We investigated the long-term effects of an information and communication technology (ICT) training programme for people with intellectual disabilities (ID). A community-based ICT training programme was designed to enhance the computer skills of people with ID and prepare them to make use of ICT in their daily life. Of the 100 who had participated in the original ICT training programme, 59 of them and their caregivers agreed to participate in the follow-up interview. A computer skills checklist was used to assess the ICT competence of the participants before training, after training, and at the 6-month follow-up assessment. All caregivers were interviewed at the 6-month follow-up session to explore the use of ICT by people with ID and their needs for further training. Results from repeated measures ANOVA showed that participants maintained at the 6-month follow-up the basic ICT skills that they acquired during training [F=13.86, p<0.001]. Caregivers reported that participants spent more time in using the computers, but still needed occasional guidance. They also reported a need to advance their ICT skills beyond the basic computer training. We concluded that ICT training for people with ID would help them in maximizing the benefits of information technology via computers.
Sauer, Michael W; Hirsh, Daniel A; Simon, Harold K; Schmitz, Michael L; Sturm, Jesse J
Fractures of the extremities are commonly encountered in pediatric emergency departments (PEDs) nationwide. These fractures can lead to bone malformation and deformities if not managed properly. There are multiple barriers to obtaining necessary outpatient follow-up for fracture care, which leads to increased return to the PED for management. Because of these barriers, a "Fracture Care Program" was implemented at the study hospital's network. This study aimed to determine implementation of a Fracture Care Program would lead to reduced PED utilization. All visits to the study PEDs were examined from January 1 to August 30, 2010. At PED discharge, patients were given a Fracture Care Program handout, which outlined step-by-step instructions for identifying and scheduling an appointment with a local orthopedic surgeon as an outpatient. A telephone hotline number was also provided where they could speak with a representative of the orthopedics department for assistance in obtaining follow-up. Detailed records were reviewed to determine whether these instructions were associated with lower rates of return. A total of 2120 patients met inclusion criteria. Of these, 1233 (58%) received the Fracture Care discharge instructions. After controlling for differences in payor status and demographic differences, patients who received instructions were less likely to return to the PED (odds ratio, 0.616; 95% confidence interval, 0.40-0.95) within 30 days for orthopedic care than patients who did not receive the instructions. This systematic coordination of services of a large tertiary care pediatric health care system, local pediatric orthopedic surgery private practices, academic practices, and hospital-affiliated practices improved overall access for families related to orthopedic follow-up care. This model may also aid in helping to improve follow-up in other pediatric subspecialties.
Willig, James H.; Krawitz, Marc; Panjamapirom, Anantachai; Ray, Midge N.; Nevin, Christa R.; English, Thomas M.; Cohen, Mark P.; Berner, Eta S.
In primary care settings, follow-up regarding the outcome of acute outpatient visits is largely absent. We sought to develop an automated interactive voice response system (IVRS) for patient follow-up with feedback to providers capable of interfacing with multiple pre-existing electronic medical records (EMRs). A system was designed to extract data from EMRs, integrate with the IVRS, call patients for follow-up, and provide a feedback report to providers. Challenges during the development process were analyzed and summarized. The components of the technological solution and details of its implementation are reported. Lessons learned include: (1) Modular utilization of system components is often needed to adapt to specific clinic workflow and patient population needs (2) Understanding the local telephony environment greatly impacts development and is critical to success, and (3) Ample time for development of the IVRS questionnaire (mapping all branching paths) and speech recognition tuning (sensitivity, use of barge-in tuning, use of “known voice”) is needed. With proper attention to design and development, modular follow-up and feedback systems can be integrated into existing EMR systems providing the benefits of IVRS follow-up to patients and providers across diverse practice settings. PMID:23340825
Lieneck, Cristian; Nowicki, Michael
A dynamic health care industry continues to call upon health care leaders to possess not one but multiple competencies. Inherent personality characteristics of leaders often play a major role in personal as well as organizational success to include those in health care finance positions of responsibility. A replication study was conducted to determine the Myers-Briggs personality-type differences between practicing health care finance professionals in 2014, as compared with a previous 2003 study. Results indicate a significant shift between both independent samples of health care finance professionals over the 10-year period from original high levels of introversion to that of extraversion, as well as higher sensing personality preferences, as compared with the original sample's high level of intuition preferences. Further investigation into the evolving role of the health care finance manager is suggested, while continued alignment of inherent, personal characteristics is suggested to meet ongoing changes in the industry.
Manera, Karine E; Hanson, Camilla S; Chapman, Jeremy R; Kanellis, John; Gill, John; Craig, Jonathan C; Chadban, Steve J; Wong, Germaine; Ralph, Angelique F; Tong, Allison
Ensuring donor wellbeing warrants ongoing monitoring after living kidney donation. However, there is considerable variability in donor follow-up processes, including information provided to donors regarding self-care. Loss to follow-up is common, suggesting that the aims and benefits of monitoring and follow-up may not be apparent. We aimed to describe the experiences and expectations of living kidney donors regarding follow-up and self-care after donation. Participants from 3 transplant centers in Australia and Canada participated in 14 focus groups (n = 123). Transcripts were analyzed thematically. We identified 4 themes: lacking identification as a patient (invincibility and confidence in health, immediate return to normality, avoid burdening specialty services, redundancy of specialist attention, unnecessary travel), empowerment for health (self-preservation for devastating consequences, self-advocacy and education, needing lifestyle advice, tracking own results), safety net and reassurance (availability of psychosocial support, confidence in kidney-focused care, continuity and rapport, and access to waitlist priority), and neglect and inattention (unrecognized ongoing debilitations, primary focus on recipient, hospital abandonment, overlooking individual priorities, disconnected from system, coping with dual roles, and lacking support for financial consequences). Living kidney donors who felt well and confident about their health regarded specialist follow-up as largely unnecessary. However, some felt they did not receive adequate medical attention, were prematurely detached from the health system, or held unresolved anxieties about the consequences of their decision to donate. Ongoing access to healthcare, psychosocial support, and education may reassure donors that any risks to their health are minimized.
Aubin, Michèle; Vézina, Lucie; Verreault, René; Fillion, Lise; Hudon, Éveline; Lehmann, François; Leduc, Yvan; Bergeron, Rénald; Reinharz, Daniel; Morin, Diane
PURPOSE There has been little research describing the involvement of family physicians in the follow-up of patients with cancer, especially during the primary treatment phase. We undertook a prospective longitudinal study of patients with lung cancer to assess their family physician’s involvement in their follow-up at the different phases of cancer. METHODS In 5 hospitals in the province of Quebec, Canada, patients with a recent diagnosis of lung cancer were surveyed every 3 to 6 months, whether they had metastasis or not, for a maximum of 18 months, to assess aspects of their family physician’s involvement in cancer care. RESULTS Of the 395 participating patients, 92% had a regular family physician but only 60% had been referred to a specialist by him/her or a colleague for the diagnosis of their lung cancer. A majority of patients identified the oncology team or oncologists as mainly responsible for their cancer care throughout their cancer journey, except at the advanced phase, where a majority attributed this role to their family physician. At baseline, only 16% of patients perceived a shared care pattern between their family physician and oncologists, but this proportion increased with cancer progression. Most patients would have liked their family physician to be more involved in all aspects of cancer care. CONCLUSIONS Although patients perceive that the oncology team is the main party responsible for the follow-up of their lung cancer, they also wish their family physicians to be involved. Better communication and collaboration between family physicians and the oncology team are needed to facilitate shared care in cancer follow-up. PMID:21060123
Chan, Ya-Fen; Lu, Shou-En; Howe, Bill; Tieben, Hendrik; Hoeft, Theresa; Unützer, Jürgen
Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings. To examine rural-urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program. This was an observational study using patient registry. The study included adult enrollees (n = 15,843) with a mental disorder from 133 participating community health clinics. We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits. While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems. Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural-urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.
Avila, P; Marcos, M; Avila, J J; Laso, F J
The problem of high rates of patient drop-out in alcohol treatment programs is frequently reported in the literature. Our aim was to investigate if internal medicine referral could improve abstinence and retention rates in a cohort of alcoholic patients. A retrospective observational study was conducted comparing 200 alcoholic patients attending a psychiatric unit (group 1) with 100 patients attending both this unit and an internal medicine unit (group 2). We collected sociodemographic and clinical variables and analysed differences regarding abstinence and retention rates by means of univariate and multivariate analysis. At 3 and 12 months follow-up, group 2 patients had higher retention and abstinence rates than group 1 patients. Multivariate analysis including potential confounding variables showed that independent predictors of one-year retention were internal medicine referral and being married. Independent predictors of one-year abstinence were being married, age > 44 years and receipt of drug treatment. The higher retention rate found among patients referred to Internal Medicine specialists, a result that has not been previously reported to the best of our knowledge, emphasizes the importance of a multidisciplinary team approach in the treatment of alcoholism.
Wilkinson, Lynne S; Skordis-Worrall, Jolene; Ajose, Olawale; Ford, Nathan
To ascertain estimates of adult patients, recorded as lost to follow-up (LTFU) within antiretroviral treatment (ART) programmes, who have self-transferred care, died or truly stopped ART in low- and middle-income countries. PubMed, EMBASE, Web of Science, Science Direct, LILACS, IndMed and AIM databases (2003-2013) and IAS/AIDS conference abstracts (2011-2013) were searched for tracing studies reporting the proportion of traced patients found to have self-transferred, died or stopped ART. These estimates were then combined using random-effects meta-analysis. Risk of bias was assessed through subgroup and sensitivity analyses. Twenty eight studies were eligible for inclusion, reporting true outcomes for 10,806 traced patients attending approximately 258 ART facilities. None were from outside sub-Saharan Africa. Twenty three studies reported 4.5-54.4% traced LTFU patients self-transferring care, providing a pooled estimate of 18.6% (95% CI 15.8-22.0%). A significant positive association was found between rates of self-transfer and LTFU in the ART cohort. The pooled estimates for unreported deaths were 38.8% (95% CI 30.8-46.8%; 27 studies) and 28.6% (95% CI 21.9-36.0%; 20 studies) for patients stopping ART. A significant decrease in unreported deaths from 50.0% (95% CI 41.5-58.4%) to 30.0% (95% CI 21.1-38.9%) was found comparing study periods before and after 31 December 2007. Substantial unaccounted for transfers and deaths amongst patients LTFU confirms that retention and mortality is underestimated where the true outcomes of LTFU patients are not ascertained. © 2014 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
Fineman, Stanley M; Bowman, Steven H; Campbell, Ronna L; Dowling, Paul; O'Rourke, Dianne; Russell, W Scott; Sublett, J Wesley; Wallace, Dana
Anaphylaxis is a systemic life-threatening allergic reaction that presents unique challenges for emergency care practitioners. Allergists and emergency physicians have a history of collaborating to promote an evidence-based, multidisciplinary approach to improve the emergency management and follow-up of patients with or at risk of anaphylaxis. To review recent scientific literature about anaphylaxis, discuss barriers to care, and recommend strategies to support improvement in emergency anaphylaxis care. An expert panel of allergists and emergency physicians was convened by the American College of Allergy, Asthma and Immunology in November 2014 to discuss current knowledge about anaphylaxis, identify opportunities for emergency practitioners and allergists to partner to address barriers to care, and recommend strategies to improve medical management of anaphylaxis along the continuum of care: from emergency medical systems and emergency department practitioners for acute management through appropriate outpatient follow-up with allergists to confirm diagnosis, identify triggers, and plan long-term care. The panel identified key barriers to anaphylaxis care, including difficulties in making an accurate diagnosis, low rates of epinephrine administration during acute management, and inadequate follow-up. Strategies to overcome these barriers were discussed and recommendations made for future allergist/emergency physician collaborations, and key messages to be communicated to emergency practitioners were proposed. The panel recommended that allergists and emergency physicians continue to work in partnership, that allergists be proactive in outreach to emergency care practitioners, and that easy-to-access educational programs and materials be developed for use by emergency medical systems and emergency department practitioners in the training environment and in practice. Copyright © 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All
Rithpro, Pratuma; Grimes, Richard M; Grimes, Deanna E; Senaratana, Wilawan
Twenty-two persons in Northern Thailand who knew of their HIV positivity but were not in care were identified. They had significant medical, economic, behavioral, and family problems. A nurse researcher carried out a 6-month intervention with them to (1) assess whether they would remain in contact with the researcher for 6 months and (2) assess whether they would make positive changes in their lives. All 22 participants remained in contact for 6 months. A 5-step intervention process resulted in substantial improvements in their lives. Eleven patients entered care. Five needed immediate antiretroviral therapy (ART) and improved their CD4 counts. Six others established primary care relationships for non-HIV care. Twelve obtained legal, full-, or part-time employment. Eight disclosed to family members. Nine participants and/or family members entered counseling. Twelve persons publicly disclosed themselves. Twelve reported reducing or stopping substance abuse. Of 4 sex workers, 2 ceased engaging in that work.
Murphy, Kathleen; Wu, Min; Steber, Dale; Cisler, Ron A.
Vision problems affect many school age children, while only few of children are adequately screened for vision problems. The design of an information system supporting vision screening and follow-up eye care for Milwaukee Public Schools is discussed in this paper, which includes wireless data collection and web-based data management. The implementation of the system is ongoing. The information system will provide service to approximately 5,000 students annually in 30 urban elementary schools. PMID:16779346
Micek, Mark A; Gimbel-Sherr, Kenneth; Baptista, Alberto João; Matediana, Eduardo; Montoya, Pablo; Pfeiffer, James; Melo, Armando; Gimbel-Sherr, Sarah; Johnson, Wendy; Gloyd, Stephen
Introduction Access to antiretroviral treatment (ART) has expanded dramatically in resource-limited settings. Evaluating loss to follow-up from HIV testing through post-ART care can help identify obstacles to care. Methods Routine data was analyzed for adults receiving services in two public HIV care systems in central Mozambique. The proportion of people passing through the following steps was determined: (1) HIV testing, (2) enrollment at an ART clinic, (3) CD4 testing, (4) starting ART if eligible, and (5) adhering to ART. Results During the 12-month study period (2004–2005), an estimated 23,430 adults were tested for HIV, and 7,005 (29.9%) were HIV-positive. Only 3,956 (56.5%) of those HIV-positive enrolled at an ART clinic ≤30 days after testing. CD4 testing was obtained in 77.1% ≤30 days of enrollment. Of 1,506 eligible for ART, 471 (31.3%) started ART ≤90 days after CD4 testing. Of 382 with ≥180 days of potential follow-up time on ART, 317 (83.0%) had pharmacy-based adherence rates ≥90%. Discussion Substantial drop-offs were observed for each step between HIV testing and treatment, but were highest for referral from HIV testing to treatment sites and for starting ART. Interventions are needed to improve follow-up and ensure that people benefit from available HIV services. PMID:19550350
Background There is a tremendous opportunity for innovative mental health care solutions such as psychiatric care through videoconferencing to increase the number of people who have access to quality care. However, studies are needed to generate empirical evidence on the use of psychiatric outpatient care via videoconferencing, particularly in low- and middle-income countries and clinically unsupervised settings. Objective The objective of this study was to evaluate the effectiveness and feasibility of home-based treatment for mild depression through psychiatric consultations via videoconferencing. Methods A randomized controlled trial with a 6- and 12-month follow-up including adults with mild depression treated in an ambulatory setting was conducted. In total, 107 participants were randomly allocated to the videoconferencing intervention group (n=53) or the face-to-face group (F2F; n=54). The groups did not differ with respect to demographic characteristics at baseline. The F2F group completed monthly follow-up consultations in person. The videoconferencing group received monthly follow-up consultations with a psychiatrist through videoconferencing at home. At baseline and after 6 and 12 months, in-person assessments were conducted with all participants. Clinical outcomes (severity of depression, mental health status, medication course, and relapses), satisfaction with treatment, therapeutic relationship, treatment adherence (appointment compliance and dropouts), and medication adherence were assessed. Results The severity of depression decreased significantly over the 12-month follow-up in both the groups. There was a significant difference between groups regarding treatment outcomes throughout the follow-up period, with better results in the videoconferencing group. There were 4 relapses in the F2F group and only 1 in the videoconferencing group. No significant differences between groups regarding mental health status, satisfaction with treatment, therapeutic
Barnes, Lori; And Others
The success of rehabilitative nursing homes has been measured by their ability to return patients to their homes. The rates of reinstitutionalization after discharge are less studied but are basic to the role of alternative levels of care. This research examines the relationship of predischarge factors with long term outcomes of patients…
Melis, René J F; Van Der Aa, Geert C H M; Golüke-Willemse, Gertie A M; De Leest, Benoit J M; Van Raak, Frank H J M; Schölzel-Dorenbos, Carla J M; Verheijen, Desiree C M; Verhey, Frans R J; Visser, Marieke C; Wolfs, Claire A; Adang, Eddy M M; Olde Rikkert, Marcel G M
Objective To examine the effectiveness of post-diagnosis dementia treatment and coordination of care by memory clinics compared with general practitioners. Design Multicentre randomised controlled trial. Setting Nine memory clinics and 159 general practitioners in the Netherlands. Participants 175 patients with a new diagnosis of mild to moderate dementia living in the community and their informal caregivers. Interventions Usual care provided by memory clinic or general practitioner. Main outcome measures Caregiver rated quality of life of the patient measured with the quality of life in Alzheimer’s disease instrument and self perceived burden of the informal caregiver measured with the sense of competence questionnaire (intention to treat analysis). Results The quality of life of the patients in the memory clinic group was 0.5 (95% confidence interval −0.7 to 1.6) points higher than in the general practitioner group. Caregivers’ burden was 2.4 (−5.8 to 1.0) points lower in the memory clinic group than in the general practitioner group. Conclusion No evidence was found that memory clinics were more effective than general practitioners with regard to post-diagnosis treatment and coordination care for patients with dementia. Without further evidence on the effectiveness of these modalities, other arguments, such as cost minimisation, patients’ preferences, or regional health service planning, can determine which type of dementia care is offered. Trial registration Clinical trials NCT00554047. PMID:22589500
Elit, L.; Kennedy, E.B.; Fyles, A.; Metser, U.
Background In 2009, the Program in Evidence-based Care (pebc) of Cancer Care Ontario published a guideline on the follow-up of cervical cancer. In 2014, the pebc undertook an update of the systematic review and clinical practice guideline for women in this target population. Methods The literature from 2007 to August 2014 was searched using medline and embase [extended to 2000 for studies of human papillomavirus (hpv) dna testing]. Outcomes of interest were measures of survival, diagnostic accuracy, and quality of life. A working group evaluated the need for changes to the earlier guidelines and incorporated comments and feedback from internal and external reviewers. Results One systematic review and six individual studies were included. The working group concluded that the new evidence did not warrant changes to the 2009 recommendations, although hpv dna testing was added as a potentially more sensitive method of detecting recurrence in patients treated with radiotherapy. Comments from internal and external reviewers were incorporated. Recommendations Summary Follow-up care after primary treatment should be conducted and coordinated by a physician experienced in the surveillance of cancer patients. A reasonable follow-up strategy involves visits every 3–4 months within the first 2 years, and every 6–12 months during years 3–5. Visits should include a patient history and complete physical examination, with elicitation of relevant symptoms. Vaginal vault cytology examination should not be performed more frequently than annually. Combined positron-emission tomography and computed tomography, other imaging, and biomarker evaluation are not advocated; hpv dna testing could be useful as a method of detection of recurrence after radiotherapy. General recommendations for follow-up after 5 years are also provided. PMID:27122975
Otis, N; Humphries, S
This study explores the impact of client characteristics on waiting times for hostel admission. A sample of 116 clients recommended for hostel care by Victorian aged care assessment teams (ACATs) between April and June 1991 were tracked until they entered a hostel, cancelled their applications, died, or until the end of the study in April 1992. Survival analysis was used to identify possible relationships between specific client characteristics and waiting times. High dependency clients consistently entered more quickly than low dependency clients (p < .05), while cognitive impairment did not appear to have an impact on waiting times for either group. Similarly, client living arrangement did not have a clear impact on waiting time. Possible explanations for the longer waiting times include client preference for a particular hostel and the incentives of the payment system.
Menezes, Maria Alexsandra da S.; Garcia, Daniela Cavalcante; de Melo, Enaldo Vieira; Cipolotti, Rosana
OBJECTIVE: To evaluate clinical outcomes, growth and exclusive breastfeeding rates in premature infants assisted by Kangaroo Mother Care at birth, at discharge and at six months of life. METHODS: Prospective study of a premature infants cohort assisted by Kangaroo Mother Care in a tertiary public maternity in Northeast Brazil with birth weight ≤1750g and with clinical conditions for Kangaroo care. RESULTS: The sample was composed by 137 premature infants, being 62.8% female, with average birth weight of 1365±283g, average gestational age of 32±3 weeks and 26.2% were adequate for gestational age. They have been admitted in the Kangaroo Ward with a median of 13 days of life, weighing 1430±167g and, at this time, 57.7% were classified as small for corrected gestational age. They were discharged with 36.8±21.8 days of chronological age, weighing 1780±165g and 67.9% were small for corrected gestational age. At six months of life (n=76), they had an average weight of 5954±971g, and 68.4% presented corrected weight for gestational age between percentiles 15 and 85 of the World Health Organization (WHO) weight curve. Exclusive breastfeeding rate at discharge was 56.2% and, at six months of life, 14.4%. CONCLUSIONS: In the studied sample, almost two thirds of the children assisted by Kangaroo Mother Care were, at six months of life, between percentiles 15 and 85 of the WHO weight curves. The frequency of exclusive breastfeeding at six months was low. PMID:25119747
Lahuerta, Maria; Lima, Josue; Elul, Batya; Okamura, Mie; Alvim, Maria Fernanda; Nuwagaba-Biribonwoha, Harriet; Horowitz, Deborah; Fernandes, Rufino; Assan, Americo; Abrams, Elaine J.; El-Sadr, Wafaa M.; Nash, Denis
Objective To utilize routinely collected service delivery data from HIV care and treatment clinics in Mozambique to describe the patient population and programmatic outcomes from 2003 to 2009. Methods Data from patient charts were entered into an electronic database at 28 clinics in 5 Mozambican provinces. Patients’ characteristics at enrollment in HIV care and at antiretroviral therapy (ART) initiation were examined. We calculated a corrected 12-month mortality estimate using a recently developed nomogram for sub-Saharan African ART patients. Results A total of 154,188 HIV-infected individuals (10,164 children <15 years old) were enrolled in HIV care services between 2003 and 2009. Of the 51,269 (36%) adults who started ART, 35% initiated ART with CD4 count <100 cells per microliter and 14.4% with World Health Organization stage IV. Just more than 10% (10.5%) of women were documented to be pregnant at enrollment. One-third of the 3,745 (37%) children who initiated ART were <2 years old, and 53%of those <5 years initiated ART severely immunosuppressed (CD4% <15%). Thirty-five percent of all children and 30% of those initiating ART met the definition of severe malnourishment (weight-for-age Z score <−3). Among those who initiated ART, the median estimated 12-month mortality rate across sites was 13.1% (interquartile range: 11.5%–16.0%) and 13.5% (interquartile range: 11.4%–17.4%) for adults and children, respectively. Conclusions A substantial number of HIV-infected patients have been enrolled in HIV care and initiated on ART, with many patients having advanced HIV disease. With the release of new guidelines for ART use for adults, pregnant women, and children, extensive efforts are needed to ensure more timely initiation of ART. PMID:21725246
Kent, Erin E; Mitchell, Sandra A; Oakley-Girvan, Ingrid; Arora, Neeraj K
We examined cancer survivors' experience of bothersome symptoms, association of symptom bother with health-related quality of life (HRQOL), survivors' perception of symptom care, and their symptom-related information needs. Using self-report survey measures, survivors of leukemia, bladder, or colorectal cancer who were 2-5 years post-diagnosis and received follow-up care in the past year (N = 623) provided information about the presence of bothersome symptoms, symptom-related information needs, adequacy of symptom-related care, and their physical and mental HRQOL. Multivariable statistical analyses were conducted to identify correlates of symptom bother, inadequate care, and symptom information needs and to examine the association between symptom bother and HRQOL. Twenty-eight percent of the 606 respondents experienced symptom bother in the past year (46 % of leukemia, 24 % of bladder, and 26 % of colorectal cancer survivors). Younger survivors, those of Hispanic ethnicity, with low income, those with recurrent cancer, and chemotherapy recipients were more likely to report symptom bother (all p < 0.05). Symptom bother was associated with lower physical and mental HRQOL (p < 0.001). While 92 % of survivors with symptoms discussed them with their follow-up care physician, 52 % of these reported receiving inadequate symptom care. Survivors reporting inadequate symptom care were 2.5 times as likely to identify symptom information needs compared to those who received adequate care (p < 0.05). One in four cancer survivors report symptoms 2-5 years post-diagnosis, and only half of these survivors receive adequate care to address those symptoms. Research that refines and tests symptom care interventions for this population is warranted.
Lai, Eliza S. Y.; Kwok, Chi-Leung; Wong, Paul W. C.; Fu, King-Wa; Law, Yik-Wa; Yip, Paul S. F.
Background A pilot study about the effectiveness of a universal school-based programme, “The Little Prince is Depressed”, for preventing depression in Chinese adolescents in Hong Kong was conducted and reported previously. This study used a larger sample to examine the effectiveness and sustainability of the programme. Methods This study used quasi-experimental design. Twelve schools enrolled in “The Little Prince is Depressed” programme either as an intervention or a control condition. The intervention schools carried out the 12-session programme in two phases: the professional-led first phase and the teacher-led second phase. All participants were required to complete a questionnaire at three time points measuring their (1) depressive, anxiety, and stress levels; (2) knowledge of mental health; (3) attitudes towards mental illness; (4) perceived social support; and (5) help-seeking behaviours. Results A total of 3,391 students participated in the study. The level of depressive symptoms did not reduce significantly at post-intervention; however, a delayed effect was observed at follow-up assessment for the participants of the teacher-led group in reducing anxiety and stress levels. Also, the knowledge of mental health and attitudes towards mental illness of the intervention-group participants significantly improved at post-test, and the outcomes were maintained at 4 to 5 months after the intervention in both the professional-led and the teacher-led conditions (p<.05). A preference among schoolchildren for whom to seek help from was identified. Conclusions The universal depression prevention programme was effective in enhancing knowledge of mental health and promoting a more positive attitude towards mental illness among adolescents in Hong Kong. In particular, the teacher-led group showed better outcomes than the professional-led group in reducing students’ anxiety and stress at follow-up period. The programme can achieve sustainability in schools if
Lai, Eliza S Y; Kwok, Chi-Leung; Wong, Paul W C; Fu, King-Wa; Law, Yik-Wa; Yip, Paul S F
A pilot study about the effectiveness of a universal school-based programme, "The Little Prince is Depressed", for preventing depression in Chinese adolescents in Hong Kong was conducted and reported previously. This study used a larger sample to examine the effectiveness and sustainability of the programme. This study used quasi-experimental design. Twelve schools enrolled in "The Little Prince is Depressed" programme either as an intervention or a control condition. The intervention schools carried out the 12-session programme in two phases: the professional-led first phase and the teacher-led second phase. All participants were required to complete a questionnaire at three time points measuring their (1) depressive, anxiety, and stress levels; (2) knowledge of mental health; (3) attitudes towards mental illness; (4) perceived social support; and (5) help-seeking behaviours. A total of 3,391 students participated in the study. The level of depressive symptoms did not reduce significantly at post-intervention; however, a delayed effect was observed at follow-up assessment for the participants of the teacher-led group in reducing anxiety and stress levels. Also, the knowledge of mental health and attitudes towards mental illness of the intervention-group participants significantly improved at post-test, and the outcomes were maintained at 4 to 5 months after the intervention in both the professional-led and the teacher-led conditions (p<.05). A preference among schoolchildren for whom to seek help from was identified. The universal depression prevention programme was effective in enhancing knowledge of mental health and promoting a more positive attitude towards mental illness among adolescents in Hong Kong. In particular, the teacher-led group showed better outcomes than the professional-led group in reducing students' anxiety and stress at follow-up period. The programme can achieve sustainability in schools if teachers are provided with adequate support.
Carballo, Juan J; Baca-Garcia, Enrique; Blanco, Carlos; Perez-Rodriguez, M Mercedes; Arriero, Miguel A Jimenez; Artes-Rodriguez, Antonio; Rynn, Moira; Shaffer, David; Oquendo, Maria A
Few studies have examined the stability of major psychiatric disorders in pediatric psychiatric clinical populations. The objective of this study was to examine the long-term stability of anxiety diagnoses starting with pre-school age children through adolescence evaluated at multiple time points. Prospective cohort study was conducted of all children and adolescents receiving psychiatric care at all pediatric psychiatric clinics belonging to two catchment areas in Madrid, Spain, between 1 January, 1992 and 30 April, 2006. Patients were selected from among 24,163 children and adolescents who received psychiatric care. Patients had to have a diagnosis of an ICD-10 anxiety disorder during at least one of the consultations and had to have received psychiatric care for the anxiety disorder. We grouped anxiety disorder diagnoses according to the following categories: phobic disorders, social anxiety disorders, obsessive-compulsive disorder (OCD), stress-related disorders, and "other" anxiety disorders which, among others, included generalized anxiety disorder, and panic disorder. Complementary indices of diagnostic stability were calculated. As much as 1,869 subjects were included and had 27,945 psychiatric/psychological consultations. The stability of all ICD-10 anxiety disorder categories studied was high regardless of the measure of diagnostic stability used. Phobic and social anxiety disorders showed the highest diagnostic stability, whereas OCD and "other" anxiety disorders showed the lowest diagnostic stability. No significant sex differences were observed on the diagnostic stability of the anxiety disorder categories studied. Diagnostic stability measures for phobic, social anxiety, and "other" anxiety disorder diagnoses varied depending on the age at first evaluation. In this clinical pediatric outpatient sample it appears that phobic, social anxiety, and stress-related disorder diagnoses in children and adolescents treated in community outpatient services may
Lyberg, Anne; Severinsson, Elisabeth
The aim of this study was to illuminate mothers' fear of childbirth and their experiences of the team-midwifery care model during pregnancy, childbirth and the postnatal period. Maternal anxiety and fear of childbirth lead to emotional suffering and affected women's well-being. A previous negative experience of childbirth may result in postnatal depression or avoidance of future pregnancies. This hermeneutic study comprised interviews with 13 women, which were audio-taped and transcribed verbatim, after which interpretative content analysis was performed. Ethical approval was granted. The findings revealed one main theme: The woman's right to ownership of the pregnancy, childbirth and postnatal care as a means of maintaining dignity and three themes; Being aware of barriers and reasons for fear; Being prepared for childbirth and Being confirmed and treated with dignity by the midwife. Each theme contained several sub-themes. The findings contribute insights into how midwives can be educated to reduce fear of childbirth and promote positive birth experiences, despite the existence of negative memories of previous births. In order to achieve continuity and a trusting relationship it is necessary to organise leadership and to adopt models that are flexible and support women's health.
Mello, Bianca Zeponi Fernandes; Neto, Natalino Lourenço; Kobayashi, Tatiana Yuriko; Mello, Marina Barbosa Almeida; Ambrosio, Eloá Cristina Passucci; Yaedú, Renato Yassutaka Faria; Machado, Maria Aparecida Andrade Moreira; Oliveira, Thais Marchini
Epidermolysis bullosa comprises a group of uncommon skin-related diseases, characterized by the formation of blisters on mucocutaneous regions occurring spontaneously, following a trauma, exposure to heat, or as a result of minimal mechanical trauma. The dental treatment of the patient with epidermolysis bullosa raises many questions and discussions, due to the difficulty of carrying out the procedures. This report aimed to detail the clinical considerations of the treatment under general anesthesia of a patient with epidermolysis bullosa. The extraction of all deciduous teeth under general anesthesia was recommended based on the clinical and radiographic examinations. At 24-month follow-up, the patient had great improvement in oral hygiene without new caries lesions. The patient has been followed-up at every month for caries lesion prevention and permanent tooth development. The treatment under general anesthesia provided the ideal safe conditions and was beneficial for the patient. © 2016 Special Care Dentistry Association and Wiley Periodicals, Inc.
Vivar, Cristina G
The aim of the article is to show the psychosocial impact of breast cancer in the long-term survival and to promote the idea of implementing a follow-up plan for survivors. A narrative review of published articles on the experience of survival in breast cancer survivors was conducted. Data were organised according to the domains of measurement (physical, psychological and social) of the Quality of Life of Long-term Breast Cancer Survivors Scale (LTQOL-BC). Breast cancer survivors may feel emotionally affected by the physical sequels (mastectomy, lymphedema, early menopause, and infertility), psychological (fear of recurrence and emotional stress) and/or social (family relationships and employment changes). The data are the foundation of a proposal of specific follow-up care for breast cancer survivors.
Bold, Krysten W.; Rasheed, Abdullah S.; McCarthy, Danielle E.; Jackson, Thomas C.; Fiore, Michael C.; Baker, Timothy B.
Background Most people who quit smoking relapse within a year of quitting. Little is known about what prompts renewed quitting after relapse or how often this results in abstinence. Purpose To identify rates, efficacy, and predictors of renewed quit attempts after relapse during a one-year follow-up. Methods Primary care patients in a comparative effectiveness trial of smoking cessation pharmacotherapies reported daily smoking every 6–12 weeks for 12 months to determine relapse, renewed quitting, and 12-month abstinence rates. Results Of 894 known relapsers, 291 (33%) renewed quitting for at least 24 hours and 99 (34%) of these were abstinent at follow-up. The average latency to renewed quitting was 106 days and longer latencies predicted greater success. Renewed quitting was more likely for older, male, less dependent smokers, and later abstinence was predicted by fewer depressive symptoms and longer past abstinence. Conclusions Renewed quitting is common and produces meaningful levels of cessation. PMID:24796541
Coles, Alasdair J; Cohen, Jeffrey A; Fox, Edward J; Giovannoni, Gavin; Hartung, Hans-Peter; Havrdova, Eva; Schippling, Sven; Selmaj, Krzysztof W; Traboulsee, Anthony; Compston, D Alastair S; Margolin, David H; Thangavelu, Karthinathan; Chirieac, Madalina C; Jody, Darlene; Xenopoulos, Panos; Hogan, Richard J; Panzara, Michael A; Arnold, Douglas L
To evaluate 5-year efficacy and safety of alemtuzumab in patients with active relapsing-remitting multiple sclerosis and inadequate response to prior therapy. In the 2-year Comparison of Alemtuzumab and Rebif Efficacy in Multiple Sclerosis (CARE-MS) II study (NCT00548405), alemtuzumab-treated patients received 2 courses (baseline and 12 months later). Patients could enter an extension (NCT00930553), with as-needed alemtuzumab retreatment for relapse or MRI activity. Annualized relapse rate (ARR), 6-month confirmed disability worsening (CDW; ≥1-point Expanded Disability Status Scale [EDSS] score increase [≥1.5 if baseline EDSS = 0]), 6-month confirmed disability improvement (CDI; ≥1-point EDSS decrease [baseline score ≥2.0]), no evidence of disease activity (NEDA), brain volume loss (BVL), and adverse events (AEs) were assessed. Most alemtuzumab-treated patients (92.9%) who completed CARE-MS II entered the extension; 59.8% received no alemtuzumab retreatment. ARR was low in each extension year (years 3-5: 0.22, 0.23, 0.18). Through 5 years, 75.1% of patients were free of 6-month CDW; 42.9% achieved 6-month CDI. In years 3, 4, and 5, proportions with NEDA were 52.9%, 54.2%, and 58.2%, respectively. Median yearly BVL remained low in the extension (years 1-5: -0.48%, -0.22%, -0.10%, -0.19%, -0.07%). AE exposure-adjusted incidence rates in the extension were lower than in the core study. Thyroid disorders peaked at year 3, declining thereafter. Alemtuzumab provides durable efficacy through 5 years in patients with an inadequate response to prior therapy in the absence of continuous treatment. This study provides Class III evidence that alemtuzumab provides efficacy and slowing of brain atrophy through 5 years. Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
McCoy, Mary A; Roper, Carey; Campa, Emily; Stephens-Stidham, Shelli; Carlin, Debra K; Istre, Gregory R
To assess the functionality of lithium-powered smoke alarms that had been installed through a community-based programme called Operation Installation (OI). A random sample was chosen of homes that had received smoke alarms through OI, 2, 4, 6, 8 and 10 years previously. Sampled homes were visited, and information collected included functional status of smoke alarms. For homes in the 6-, 8- and 10-year sample, smoke alarms were removed and tested for battery and alarm function. 800 homes were included in the survey results; 1884 smoke alarms had been installed through OI. The proportion of homes that had at least one functioning OI smoke alarm ranged from 91.8% for year 2 sample to 19.8% for year 10. Of the originally installed smoke alarms in year 10 sample, 45.5% had been removed and 59% (64/108) of those that were still installed were not functioning. Multivariate analysis showed that the presence of at least one working alarm in the home was associated positively with the number of smoke alarms that were originally installed and whether the original occupant was still living in the home, and negatively with the length of time since the smoke alarm was installed, and whether there was a smoker in the home. Testing of the smoke alarms revealed that most non-functioning alarms had missing or dead batteries. Less than a quarter of the originally installed smoke alarms were still present and functioning by year 10. These findings have important implications for smoke alarm installation programmes.
Matsumoto, Masatoshi; Takeuchi, Keisuke; Tanaka, Junko; Tazuma, Susumu; Inoue, Kazuo; Owaki, Tetsuhiro; Iguchi, Seitaro; Maeda, Takahiro
Given the shortage of physicians, particularly in rural areas, the Japanese government has rapidly expanded the number of medical school students by adding chiikiwaku (regional quotas) since 2008. Quota entrants now account for 17% of all medical school entrants. Quota entrants are usually local high school graduates who receive a scholarship from the prefecture government. In exchange, they temporarily practise in that prefecture, including its rural areas, after graduation. Many prefectures also have scholarship programmes for non-quota students in exchange for postgraduate in-prefecture practice. The objective of this cohort study, conducted by the Japanese Council for Community-based Medical Education, is to evaluate the outcomes of the quota admission system and prefecture scholarship programmes nationwide. There are 3 groups of study participants: quota without scholarship, quota with scholarship and non-quota with scholarship. Under the support of government ministries and the Association of Japan Medical Colleges, and participation of all prefectures and medical schools, passing rate of the National Physician License Examination, scholarship buy-out rate, geographic distribution and specialties distribution of each group are analysed. Participants who voluntarily participated are followed by linking their baseline information to data in the government's biennial Physician Census. Results to date have shown that, despite medical schools' concerns about academic quality, the passing rate of the National Physician License Examination in each group was higher than that of all medical school graduates. The Ethics Committee for Epidemiological Research of Hiroshima University and the Research Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences permitted this study. No individually identifiable results will be presented in conferences or published in journals. The aggregated results will be reported to concerned government ministries
Matsumoto, Masatoshi; Takeuchi, Keisuke; Tanaka, Junko; Tazuma, Susumu; Inoue, Kazuo; Owaki, Tetsuhiro; Iguchi, Seitaro; Maeda, Takahiro
Introduction Given the shortage of physicians, particularly in rural areas, the Japanese government has rapidly expanded the number of medical school students by adding chiikiwaku (regional quotas) since 2008. Quota entrants now account for 17% of all medical school entrants. Quota entrants are usually local high school graduates who receive a scholarship from the prefecture government. In exchange, they temporarily practise in that prefecture, including its rural areas, after graduation. Many prefectures also have scholarship programmes for non-quota students in exchange for postgraduate in-prefecture practice. The objective of this cohort study, conducted by the Japanese Council for Community-based Medical Education, is to evaluate the outcomes of the quota admission system and prefecture scholarship programmes nationwide. Methods and analysis There are 3 groups of study participants: quota without scholarship, quota with scholarship and non-quota with scholarship. Under the support of government ministries and the Association of Japan Medical Colleges, and participation of all prefectures and medical schools, passing rate of the National Physician License Examination, scholarship buy-out rate, geographic distribution and specialties distribution of each group are analysed. Participants who voluntarily participated are followed by linking their baseline information to data in the government's biennial Physician Census. Results to date have shown that, despite medical schools' concerns about academic quality, the passing rate of the National Physician License Examination in each group was higher than that of all medical school graduates. Ethics and dissemination The Ethics Committee for Epidemiological Research of Hiroshima University and the Research Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences permitted this study. No individually identifiable results will be presented in conferences or published in journals. The aggregated
Marín, R; Coca, A; Tranche, S; Rodríguez Mañas, L; Abellán, J; Moyá, A
Patients with type 2 diabetes use to be managed in their primary care settings during the early stages of the disease. The main objective of the study was to determine renal impairment prevalence, and to assess its significance, within type 2 diabetics controlled by their family physicians. Transverse observation of patients with type 2 diabetes who were the first 20 unselected cases seen by 183 family physicians from 16 of the 17 Autonomic Communities of our country. The following variables were determined: serum creatinine, glucose, and HbA1c concentrations, proteinuria (dipstick test in a first-voided morning urine sample), blood pressure levels, and associated cardiovascular disease. Data from 3,583 type 2 diabetic subjects were evaluated. Mean age was 64 +/- 10 years and 45% were male. A serum creatinine > or = 1.2 mg/dl was observed in 523 (15.5%) patients. Proteinuria was present in 794 (23.5%) cases, being > or = 2 + in 215 (6.5%) subjects. Patients with a serum creatinine > or = 1.2 mg/dl were older, shower higher blood pressure levels, and suffered from more cardiovascular disease (32.0 vs 19.5%) than those with a serum creatinine < 1.2 mg/dl. In a multivariate analysis, this difference continued to be significant (OR 1.47; 95% CI 1.14 to 1.90; p = 0.002. Patients with proteinuria showed a higher prevalence of cardiovascular disease (OR 1.83; 95% CI 1.47 to 2.27; p < 0.0001) than those without proteinuria. This association was continuous through no proteinuria to the > or = 2 + proteinuria (p < 0.001). Blood pressure level was > or = 140/90 mmHg in 69% of the cases, being < 130/85 mmHg in only 8% of the subjects. There is a high prevalence of renal impairment, approximately of 25% within type 2 diabetic patients seen at the primary care level. Optimal blood pressure level seems to be extremely infrequent bearing in mind the diagnosis of diabetes and the associated cardiovascular disease.
Leoni, Maurizio; Sadacharan, Radha; Louis, Daniel; Falcini, Fabio; Rabinowitz, Carol; Cisbani, Luca; De Palma, Rossana; Yuen, Elaine; Grilli, Roberto
This study examines the patterns of follow-up care for breast cancer survivors in one region in Italy. This retrospective analysis included 10,024 surgically treated women, with incident cases of breast cancer in the years 2002-2005 who were alive 18 months after their incidence date. Rates of use of follow-up mammograms, abdominal echogram, bone scans and chest x-rays were estimated from administrative data and compared by Local Health Unit (LHU) of residence. Logistic regression analyses were performed to assess possible "overuse", accounting for patient age, cancer stage, type of surgery and LHU of residence. A total of 7168 (72.1%) women received a mammogram within 18 months of their incidence date, while 6432 (64.2%) had an abdominal echogram, 3852 (38.4%) had a bone scan and 5231 (52.2%) had a chest x-ray. The rates of use of abdominal echograms, bone scans and chest x-rays were substantially higher in the population of breast cancer survivors than in the general female population. Taking account of patient age, cancer stage at diagnosis and type of surgery, multivariate analyses demonstrated significant variation in the use of these tests by LHU of residence. The observed variation in the use of abdominal echograms, bone scans and chest x-rays supports the conclusion that there is substantial misuse of these tests in the population of postsurgical breast cancer patients in the Emilia-Romagna region in Italy. In the absence of a documented survival benefit, overtesting has both a human and financial cost. We recommend additional review of the methods of follow-up care in breast cancer patients in the LHUs of Emilia-Romagna, with the aim of developing, disseminating and evaluating the implementation of specific guidelines targeting primary care physicians and oncologists providing care to breast cancer survivors. Patient education materials may also help to reduce unnecessary testing.
Rodríguez-Moldes, B; Carbajo, A J; Sánchez, B; Fernández, M; Garí, M; Fernández, M C; Álvarez, J; García, A; Cela, E
The main aim of the study was to assess the effects of the recommended preventive program in the population affected with Sickle Cell Disease in Primary Care. The program included, antibiotic prophylaxis, immunizations and health education, following the introduction of universal neonatal screening program for Sickle Cell Disease in the Community of Madrid. A cross-sectional observational study was performed with retrospective data collected from a cohort of newborns with Sickle Cell Disease diagnosed by neonatal screening test in the Community of Madrid. From the data obtained from a sample of 20 patients, it was found that 95% had been diagnosed by the newborn screening test performed between 5 and 13 days of life. The mean age was 39 months when the study was conducted. During follow-up, from Primary Care Paediatric clinic, it was observed that the compliance for antibiotic prophylaxis was 90%, and the coverage for the official vaccination schedule was 85%. Specific vaccine coverage as a risk population was highly variable (85% for pneumococcal 23V, 50% for influenza, and 15% for hepatitis A). Health education only reached one in every four families. Acceptable compliance with antibiotic prophylaxis was observed during the follow-up of patients with sickle cell disease in Primary Care, but a low coverage of routine immunization, as well as specific immunizations. Coverage of health education was very low. Improving these parameters would require greater coordination and involvement of Primary Care Professionals so that these patients were followed up appropriately, and could be translated into a reduction of disease complications and an improvement in the quality of life of these patients. Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.
Lindblom, Hanna; Waldén, Markus; Carlfjord, Siw; Hägglund, Martin
Neuromuscular training (NMT) has been shown to reduce anterior cruciate ligament injury rates in highly structured clinical trials. However, there is a paucity of studies that evaluate implementation of NMT programmes in sports. To evaluate the implementation of an NMT programme in female adolescent football 3 years after a randomised controlled trial (RCT). Cross-sectional follow-up after an RCT using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Sports Setting Matrix (RE-AIM SSM) framework. Questionnaires were sent to the Swedish Football Association (FA), to eight district FAs and coaches (n=303) that participated in the RCT in 2009, and coaches who did not participate in the RCT but were coaching female adolescent football teams during the 2012 season (n=496). Response rates were 100% among the FAs, 57% among trial coaches and 36% among currently active coaches. The reach of the intervention was high, 99% of trial coaches (control group) and 91% of current coaches were familiar with the programme. The adoption rate was 74% among current coaches, but programme modifications were common among coaches. No district FA had formal policies regarding implementation, and 87% of current coaches reported no club routines for programme use. Maintenance was fairly high; 82% of trial coaches from the intervention group and 68% from the control group still used the programme. Reach and adoption of the programme was high among coaches. However, this study identified low programme fidelity and lack of formal policies for its implementation and use in clubs and district FAs. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Brown, Gregory K; Green, Kelly L
Follow-up services are an important component of a comprehensive, national strategy for suicide prevention. Increasing our knowledge of effective follow-up care has been identified as an Aspirational Goal by The National Action Alliance for Suicide Prevention's Research Prioritization Task Force. Several recent comprehensive reviews informed the selection of studies included in this brief review. Studies of follow-up services that reported significant effects for the outcomes of death by suicide, suicide attempts, or suicidal ideation were included. Although there is a paucity of research in this area, promising paradigms that have demonstrated effectiveness in preventing suicide and suicide attempts and reducing suicidal ideation will be discussed. The major limitations of the literature in this area include numerous methodological flaws in the design and analyses of such studies and the lack of replication of studies with positive findings. This paper identifies several breakthroughs that would be helpful for advancing this area of research and describes a comprehensive research pathway for achieving both short- and long-term research objectives. Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Lie, Hanne C; Mellblom, Anneli V; Brekke, Mette; Finset, Arnstein; Fosså, Sophie D; Kiserud, Cecilie E; Ruud, Ellen; Loge, Jon H
Given childhood cancer survivors' risk of treatment-induced late effects, long-term follow-up care is recommended. We explored experiences with late effects-related care and preferences for long-term follow-up care among adult survivors of childhood malignant lymphoma in Norway. We conducted five focus group interviews with 34 survivors (19 females; 21 Hodgkin/13 non-Hodgkin lymphoma survivors; mean age 39 years; mean time from diagnosis 26 years). Data was analyzed using principles of thematic analysis. Two main themes were identified: (1) the survivors' experiences with late effects-related care and (2) their preferences for long-term follow-up care. Most of the survivors were dissatisfied with their late effects-related care due to perceptions of poor coordination of healthcare needs in a fragmented system, combined with a perceived lack of knowledge of late effects among themselves and general practitioners (GPs). All survivors valued long-term follow-up care. Oncologists were the preferred care providers, but GPs were considered acceptable providers if they had sufficient knowledge of late effects and routine examinations, short waiting times, and improved GP-oncologist collaboration. Our results suggest that a shared care model of long-term follow-up care involving specialists, GPs, and the survivors themselves is likely to fulfill several of the currently unmet needs among adult survivors of childhood cancers. Improved patient education about late effects and follow-up care would aid self-management. The survivors' concerns regarding lack of sufficient knowledge of late effects among GPs suggest a need for improving access to, and dissemination of, information of late effects.
Andrew, Jane; Taylor, Cara
This paper reports on a longitudinal follow-up evaluation of an interprofessional experiential course to support the development of effective communication and interpersonal relationship skills in palliative care: 'It's good to listen: advanced communication skills in end of life care'. The course was developed from evidence-based guidance produced by the West of Scotland Cancer Network and NHS Education for Scotland in 2009. The aim of the study was to explore the factors that support or hinder the sustainable integration of skills and learning from the course into clinical practice. Three focus groups were held across the NHS Board area. Following analysis of the transcripts the emergent themes were grouped under four headings; impact on practice, facilitating factors, hindering factors, and organisational issues. The findings suggest that organisations should consider the value they place on supporting interpersonal skills in end-of-life care and how they can enhance sustainability and behavioural change.
Chi, Seong In; Lee, Soo Eon; Seo, Kwang-Suk; Choi, Yoon-Ji; Kim, Hyun-Jeong; Kim, Hye-Jung; Han, Jin-Hee; Han, Hee-Jeong; Lee, Eun-Hee; Oh, Aram; Kwon, Suk Jin
Patients were subjected to post-discharge follow-up (by telephone) in order to investigate the potential complications of outpatient general anesthesia or deep sedation that could develop in disabled dental patients discharged from the hospital. The ultimate aim of this study was to establish an appropriate response measure for such complications. The caregivers of 79 disabled patients who underwent dental procedures under general anesthesia at our outpatient clinic were interviewed over telephone. Necessary care instructions were provided during the phone calls when required. The patient satisfaction level regarding the telephonic follow-up care was surveyed by additional telephone calls. Most of the patients did not suffer any serious complications; however, some reported fever and bleeding. The data obtained in this study can be utilized towards the development of caregiver education pertaining to the ambulatory general anesthesia of dental patients with disabilities. Additionally, we hope that the findings of this study will help minimize the effects of complications experienced by disabled dental patients undergoing ambulatory general anesthesia, as well as increase the overall patient satisfaction level.
care or in a low provider density area. 63Joyce C. West et al., “Mental Health Treatment Access and Quality in the Army: Survey of Mental Health ...DEFENSE HEALTH CARE DOD Is Meeting Most Mental Health Care Access Standards, but It Needs a Standard for Follow- up...Government Accountability Office Highlights of GAO-16-416, a report to congressional committees April 2016 DEFENSE HEALTH CARE DOD Is
Davis, Keith L; Misurski, Derek; Miller, Jacqueline M; Bell, Timothy J; Bapat, Bela
The combined costs of acute hospitalization and post-discharge follow-up care in patients with meningococcal disease have not been widely documented. In this study, data were retrospectively analyzed from three large databases of hospital discharge records and commercial insurance claims in the US. Cases of meningococcal disease were defined as admissions with an ICD-9-CM diagnosis code in the range of 036.x. From the 2005 HCUP Nationwide Inpatient Sample, 349 (weighted N=1,710) meningococcal-related hospitalizations were identified with a mean facility cost (in 2009 dollars) of $19,526 per admission. Similar estimates ($18,119 and $20,066, respectively) were obtained from 268 admissions identified in the LifeLink (formerly PharMetrics) database during 1999-2007 and from 1,058 hospitalizations in the Perspective Comparative Database (PCD) during 2000-2007. Using insurance claims from LifeLink, we estimated that payers incur an additional $26,178 in non-facility (professional and other ancillary) costs during the course of a meningococcal admission, as well as $22,230 in additional medical and pharmacy expenses for post-discharge care during the ensuing year. The majority of follow-up costs ($14,637) were attributed to repeat hospitalizations. Mean length of stay for meningococcal disease was consistently estimated across databases at 8 to 9 days. Data from the PCD further suggested that meningococcal disease carries, on average, nearly 2 days of intensive care unit utilization. In conclusion, hospital admissions for meningococcal disease are costly to payers. These costs are heightened when non-facility services and post-discharge care are also considered. Awareness of the full cost burden of meningococcal disease is needed when evaluating vaccination programs targeting the disease.
Jeppesen, Mette Moustgaard; Ezendam, Nicole P M; Pijnenborg, Johanna M A; Caroline Vos, M; Boll, Dorry; Kruitwagen, Roy F P M; Jensen, Pernille Tine; van de Poll-Franse, Lonneke V
The purpose of this paper was to assess the impact of survivorship care plan (SCP) provision and moderating factors on health care use following endometrial cancer treatment. Women newly diagnosed with endometrial cancer were included in a pragmatic cluster randomized trial at 12 hospitals in the Netherlands and were randomly assigned to SCP or usual care (n = 221; 75% response). The SCP was generated using the web-based Registrationsystem Oncological GYnecology (ROGY) and provided tailored information regarding disease, treatment, and possible late-effects. Cancer-related use of general practitioner, specialist, and additional health care was collected through questionnaires after diagnosis and at 6-, 12-, and 24-month follow-up and compared using linear multilevel regression analyses. Women who received an SCP had more cancer-related primary care visits compared to the usual care arm during the first year after diagnosis (β = 0.7, p < 0.01). At 6-month follow-up, women in the SCP group used more additional health care compared to women receiving usual care (24 vs. 11%, p = 0.04). Women with anxious symptoms (p = 0.03) and women who received radiotherapy (p = 0.01) had a higher primary care use within the first year after treatment, when receiving an SCP. The SCP increases primary health care consumption the first year after treatment, particularly in women treated with radiotherapy and women with anxious symptoms. These findings imply that the SCP enables women in need of supportive care to seek relevant care at an early stage after treatment. Whether this results in improved patient-reported outcomes in the long-term needs to be further studied.
Al Hamarneh, Yazid N; Sauriol, Luc; Tsuyuki, Ross T
Introduction There is strong evidence that pharmacist care improves patients’ glycaemic control. However, the sustainability and durability of such interventions beyond the research period is not known. RxING was the first trial of pharmacist prescribing in diabetes and it showed an improvement in glycated haemoglobin (HbA1c) of 1.8% over 6 months. Objective 1° objective: To evaluate glycaemic control in the RxING study patients 12 months after the end of the formal study follow-up. 2° objective: To assess the patients’ risk of cardiovascular events in the next 10 years. Methods We contacted the participating pharmacists to check if the patients who participated in the RxING study are still taking insulin, the dose of insulin they are taking, and their HbA1c. There were no mandated follow-up visits with the pharmacist after the study completion. Results A total of 100 patients with poorly controlled type 2 diabetes were enrolled in the original RxING study; 93 of them completed the study, while 83 participated in the 12-month follow-up. Seventy-five patients were still taking insulin, with the average dose increasing from 31.1 units (SD 18.4) at study completion to 37.4 units (SD 30.8) (95% CI −13.3 to 0.88, p=0.085). HbA1c was reduced from 9.1% (SD 1) at baseline to 7.3% (SD 0.9) at study completion (95% CI 1.4 to 2, p <0.001), and increased to 8.1% (SD 1.3) 12 months later (95% CI −1.1 to −0.5, p <0.001 vs study completion). Conclusions Twelve months after completing the intervention, approximately half of the glycaemic control gains were lost. This highlights the importance of structured follow-up with the pharmacist in this patient population. Trial registration number clinicaltrials.gov; Identifier: NCT01335763. PMID:26270946
Murchie, Peter; Campbell, Neil C; Ritchie, Lewis D; Simpson, Julie A; Thain, Joan
To evaluate the effects of nurse led clinics in primary care on secondary prevention, total mortality, and coronary event rates after four years. Follow up of a randomised controlled trial by postal questionnaires and review of case notes and national datasets. Stratified, random sample of 19 general practices in north east Scotland. 1343 patients (673 intervention and 670 control) under 80 years with a working diagnosis of coronary heart disease but without terminal illness or dementia and not housebound. Nurse led secondary prevention clinics promoted medical and lifestyle components of secondary prevention and offered regular follow up for one year. Components of secondary prevention (aspirin, blood pressure management, lipid management, healthy diet, exercise, non-smoking), total mortality, and coronary events (non-fatal myocardial infarctions and coronary deaths). Mean follow up was at 4.7 years. Significant improvements were shown in the intervention group in all components of secondary prevention except smoking at one year, and these were sustained after four years except for exercise. The control group, most of whom attended clinics after the initial year, caught up before final follow up, and differences between groups were no longer significant. At 4.7 years, 100 patients in the intervention group and 128 in the control group had died: cumulative death rates were 14.5% and 18.9%, respectively (P=0.038). 100 coronary events occurred in the intervention group and 125 in the control group: cumulative event rates were 14.2% and 18.2%, respectively (P=0.052). Adjusting for age, sex, general practice, and baseline secondary prevention, proportional hazard ratios were 0.75 for all deaths (95% confidence intervals 0.58 to 0.98; P=0.036) and 0.76 for coronary events (0.58 to 1.00; P=0.049) CONCLUSIONS: Nurse led secondary prevention improved medical and lifestyle components of secondary prevention and this seemed to lead to significantly fewer total deaths and
Mehta, Aakriti; Forbes, Kathryn Dawn; Kuppala, Venkata Sasidhar
The goal of this study was to assess the current status of neonatal abstinence syndrome management from prenatal counseling to postdischarge follow-up care. An anonymous electronic survey of 26 questions was sent to the medical directors or charge nurses at 383 NICUs. Contact information was obtained by using the American Medical Association's FREIDA online database and the 2011 American Hospital Association Guide Book. Responses were gathered by using the SurveyMonkey online portal, which was designed to grant responders 1-time access. There were 179 responses (47%), and 0.6%, 16.2%, and 83.2% identified themselves as level I, level II, and level III units, respectively. Prenatal counseling for at-risk mothers is offered by 56.5% of responders. Written protocols for neonatal abstinence syndrome management were reported by 72.5%. All but 3 institutions used toxicology screening in cases of suspected in utero drug exposure. Formalized scoring is used by 98.7%. Breastfeeding is recommended by 74.1%. Morphine (56.1%), methadone (24.8%), and tincture of opium (12.7%) are the most common first-line agents reported in opiate withdrawal, whereas morphine (51.0%), methadone (19.7%), and phenobarbital (13.6%) are used in polydrug withdrawal. Less than 20% of NICUs use clonidine. Home treatment programs are offered by 34.0% of responders, and long-term developmental follow-up is offered by 71.3%. There is considerable diversity in the management of neonatal abstinence syndrome. Alternative management strategies, including prenatal counseling and home treatment programs, need to be explored to improve overall patient care.
Boudreau, Denise M.; Arterburn, David; Bogart, Andy; Haneuse, Sebastien; Theis, Mary Kay; Westbrook, Emily; Simon, Greg
Overweight and obese patients commonly suffer from depression and choice of depression therapy may alter weight. We conducted a cohort study to investigate whether obesity is associated with treatment choices for depression; and whether obesity is associated with appropriate duration of depression treatment and receipt of follow-up visits. Adults with a diagnosis of depression between January 1, 2006 and March 31, 2010 who had 1+ new episodes of an antidepressant medication and/or psychotherapy were eligible. Medication use, encounters, diagnoses, height, and weight were collected from health plan databases. We modeled receipt of the different therapies (medication and psychotherapy) by BMI and BMI trajectory during the 9-months prior to initiation of therapy using logistic regression models that accommodated correlation within provider and adjusted for covariates. We modeled BMI via a restricted cubic spline. Fluoxetine was the reference treatment option in the medication models. Lower BMI was associated with greater use of mirtazapine, and a declining BMI prior to treatment was associated with greater odds of initiating mirtazapine and paroxetine. Higher BMI was associated with greater odds of initiating bupropion even after adjustment for smoking status. Obese patients were less likely to receive psychotherapy and less likely to receive appropriate duration (180-days) of depression treatment compared to normal weight subjects. Our study provides evidence that BMI is considered when choosing therapy but associations were weak. Our results should prompt discussion about recommending and choosing depression treatment plans that optimize depression care and weight management concurrently. Differences in care and follow-up by BMI warrant additional research. PMID:23404891
O'Brien, M A; Grunfeld, E; Sussman, J; Porter, G; Mobilio, M Hammond
The U.S. Institute of Medicine recommends that cancer patients receive survivorship care plans, but evaluations to date have found little evidence of the effectiveness of such plans. We conducted a qualitative follow-on study to a randomized controlled trial (rct) to understand the experiences of family physicians using survivorship care plans to support the follow-up of breast cancer patients. A subset of family physicians whose patients were enrolled in the parent rct in Ontario and Nova Scotia were eligible for this study. In interviews, the physicians discussed survivorship care plans (intervention) or usual discharge letters (control), and their confidence in providing follow-up cancer care. Of 123 eligible family physicians, 18 (10 intervention, 8 control) were interviewed. In general, physicians receiving a survivorship care plan found only the 1-page care record to be useful. Physicians who received only a discharge letter had variable views about the letter's usefulness; several indicated that it lacked information about potential cancer- or treatment-related problems. Most physicians were comfortable providing care 3-5 years after diagnosis, but desired timely and informative communication with oncologists. Although family physicians did not find extensive survivorship care plans useful, discharge letters might not be sufficiently comprehensive for follow-up breast cancer care. Effective strategies for two-way communication between family physicians and oncologists are still lacking.
Tao, Mary Jiayi; Montbriand, Janice M; Eisenberg, Naomi; Sniderman, Kenneth W; Roche-Nagle, Graham
The aim of this study was to investigate the practice pattern of inferior vena cava (IVC) filters and to determine factors predictive of filter retrievals at a multicenter, tertiary care institution. A retrospective review of all IVC filter procedures performed between January 2001 and July 2013 was conducted. Data collected included demographics, venous thromboembolism risk factors, medical comorbidities, insertional and retrieval characteristics, referring services, complications, discharge, and follow-up management. During the study period, 1123 IVC filter procedures were performed; 69% (n = 810) were insertions and 31% (n = 313) were retrievals. Of the patients receiving filters, the average age was 61.4 years, and 53.3% were male. Overall, 408 filters (51.5%) were placed with absolute indications, 214 (27.0%) for relative indications, 138 (17.4%) prophylactically, and 32 (4.0%) for reasons outside the established guidelines. Of the 663 retrievable filters, successful removal rate was 41.6% (n = 276); the mean time to first retrieval attempt was 76.4 days (standard deviation = 110.5). Documentation of the filter was present in 342 (43.1%) discharge summaries, and outlined instructions for filter management were seen in 129 (16.3%) cases. Significant predictors of filter removal were thrombosis follow-up (odds ratio [OR], 6.7; P < .01) and the ordering service as filters ordered by medical specialties were less likely to be retrieved than filters ordered by surgical specialties (OR, 0.53; P = .04). Compared with discharge summaries without filter management instructions, those with plans had higher filter retrieval rates (OR, 3.74; P < .00). Filter-related complications was observed in 57 patients. Given the established complications relating to long indwelling times and recent Food and Drug Administration guidelines, a multidisciplinary and systematic follow-up protocol needs to be implemented to optimize filter retrieval rates and to ensure exemplary
Luijsterburg, Pim A J; Verhagen, Arianne P; Ostelo, Raymond W J G; van den Hoogen, Hans J M M; Peul, Wilco C; Avezaat, Cees J J; Koes, Bart W
A randomised clinical trial in primary care with a 12-months follow-up period. About 135 patients with acute sciatica (recruited from May 2003 to November 2004) were randomised in two groups: (1) the intervention group received physical therapy (PT) added to the general practitioners' care, and (2) the control group with general practitioners' care only. To assess the effectiveness of PT additional to general practitioners' care compared to general practitioners' care alone, in patients with acute sciatica. There is a lack of knowledge concerning the effectiveness of PT in patients with sciatica. The primary outcome was patients' global perceived effect (GPE). Secondary outcomes were severity of leg and back pain, severity of disability, general health and absence from work. The outcomes were measured at 3, 6, 12 and 52 weeks after randomisation. At 3 months follow-up, 70% of the intervention group and 62% of the control group reported improvement (RR 1.1; 95% CI 0.9-1.5). At 12 months follow-up, 79% of the intervention group and 56% of the control group reported improvement (RR 1.4; 95% CI 1.1; 1.8). No significant differences regarding leg pain, functional status, fear of movement and health status were found at short-term or long-term follow-up. At 12 months follow-up, evidence was found that PT added to general practitioners' care is only more effective regarding GPE, and not more cost-effective in the treatment of patients with acute sciatica than general practitioners' care alone. There are indications that PT is especially effective regarding GPE in patients reporting severe disability at presentation.
Nwaru, Chioma A; Peutere, Laura; Kivimäki, Mika; Pentti, Jaana; Vahtera, Jussi; Virtanen, Pekka J
Little is known about the work patterns of re-employed people. We investigated the labour market attachment trajectories of re-employed people and assessed the influence of chronic diseases on these trajectories. The study was based on register data of 18 944 people (aged 18-60 years) who participated in a subsidised re-employment programme in Finland. Latent class growth analysis with zero-inflated Poisson was used to model the labour market attachment trajectories over a 6-year follow-up time. Multinomial logistic regression was used to examine the associations between chronic diseases and labour market attachment trajectories, adjusting for age, gender, educational level, size of town and calendar year in subsidised re-employment programme. We identified four distinct labour market attachment trajectories, namely: strengthening (a relatively stable attachment throughout the follow-up time; 77%), delayed (initial weak attachment increasing later; 6%), leavers (attachment declined with time; 10%) and none-attached (weak attachment throughout the study period; 7%). We found that severe mental problems strongly increased the likelihood of belonging in the leavers (OR 3.61; 95% CI 2.23 to 5.37) and none-attached (OR 3.41; 95% CI 1.91 to 6.10) trajectories, while chronic hypertension was associated with none-attached (OR 1.37; 95% CI 1.06 to 1.77) trajectory. The associations between other chronic diseases (diabetes, heart disease, asthma and arthritics) and labour market attachment trajectories were less evident. Re-employed people appear to follow distinct labour market attachment trajectories over time. Having chronic diseases, especially mental disorders appear to increase the risk for relatively poor labour market attachment. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Muirhead, C; Bingham, D; Haylock, R; O'Hagan, J; Goodill, A; Berridge, G; English, M; Hunter, N; Kendall, G
Aims: To extend and analyse follow up of mortality and cancer incidence among men who took part in the UK's atmospheric nuclear weapon tests and experimental programmes 40–50 years ago, with particular reference to multiple myeloma and leukaemia. Methods: A total of 21 357 servicemen and male civilians from the UK who participated in the tests and a control group of 22 333 male controls were followed over the period 1952–98. Analyses were conducted of mortality from various causes, and of mortality and incidence for 27 types of cancer. Results: Rates of mortality from all causes continued to be similar among test participants and controls with the longer follow up, with standardised mortality ratios (SMRs) of 89 and 88 respectively over the full follow up period. For all cancers, the corresponding SMRs were 93 for participants and 92 for controls. Mortality from multiple myeloma was consistent with national rates both for participants and controls, and the relative risk (RR) of myeloma incidence among participants relative to controls was 1.14 (90% CI 0.74 to 1.74) over the full follow up period and 0.79 (90% CI 0.45 to 1.38) during the extended period of follow up (1991–98). Over the full follow up period, leukaemia mortality among participants was consistent with national rates, while rates among controls were significantly lower, and there was a suggestion of a raised risk among test participants relative to controls (RR 1.45, 90% CI 0.96 to 2.17); the corresponding RR for leukaemia incidence was 1.33 (90% CI 0.97 to 1.84). After excluding chronic lymphatic leukaemia (CLL), which is not thought to be radiation inducible, the RR of leukaemia mortality increased to 1.83 (90% CI 1.15 to 2.93), while that for incidence was little changed. Analysis of subgroups of participants with greater potential for exposure provided little evidence of increased risks, although the numbers of men involved were smaller and the statistical power was therefore less. Among
Emery, Jon; Doorey, Juanita; Jefford, Michael; King, Madeleine; Pirotta, Marie; Hayne, Dickon; Martin, Andrew; Trevena, Lyndal; Lim, Tee; Constable, Roger; Hawks, Cynthia; Hyatt, Amelia; Hamid, Akhlil; Violet, John; Gill, Suki; Frydenberg, Mark; Schofield, Penelope
Introduction Men with prostate cancer require long-term follow-up to monitor disease progression and manage common adverse physical and psychosocial consequences of treatment. There is growing recognition of the potential role of primary care in cancer follow-up. This paper describes the protocol for a phase II multisite randomised controlled trial of a novel model of shared care for the follow-up of men after completing treatment for low-moderate risk prostate cancer. Methods and analysis The intervention is a shared care model of follow-up visits in the first 12 months after completing treatment for prostate cancer with the following specific components: a survivorship care plan, general practitioner (GP) management guidelines, register and recall systems, screening for distress and unmet needs and patient information resources. Eligible men will have completed surgery and/or radiotherapy for low-moderate risk prostate cancer within the previous 8 weeks and have a GP who consents to participate. Ninety men will be randomised to the intervention or current hospital follow-up care. Study outcome measures will be collected at baseline, 3, 6 and 12 months and include anxiety, depression, unmet needs, prostate cancer-specific quality of life and satisfaction with care. Clinical processes and healthcare resource usage will also be measured. The principal emphasis of the analysis will be on obtaining estimates of the treatment effect size and assessing feasibility in order to inform the design of a subsequent phase III trial. Ethics and dissemination Ethics approval has been granted by the University of Western Australia and from all hospital recruitment sites in Western Australia and Victoria. Results of this phase II trial will be reported in peer-reviewed publications and in conference presentations. Trial Registration Australian New Zealand Clinical Trial Registry ACTRN12610000938000 PMID:24604487
Riverin, Bruno D.; Li, Patricia; Naimi, Ashley I.; Diop, Mamadou; Provost, Sylvie; Strumpf, Erin
Background: Outpatient follow-up has been a key intervention point in addressing gaps in care after hospital discharge. We sought to estimate the association between enrolment in new team-based primary care practices and 30-day postdischarge physician follow-up among older patients and patients with chronic illnesses who were admitted to hospital in Quebec, Canada. Methods: Patients were selected into this cohort if a primary care physician enrolled them as a "vulnerable patient" between November 2002 and January 2005. Data for this analysis included province-wide health insurance claims for inpatient and outpatient services delivered between November 2002 and January 2009 in Quebec. The primary analysis examined time to the first outpatient postdischarge follow-up service provided by either a primary care physician or a medical specialist. We used marginal structural models to estimate adjusted rates of follow-up with a primary care physician or with a medical specialist by primary care delivery models. Results: We extracted billing data for 312 377 patients that represented 620 656 index admissions for any cause from 2002 to 2009. Rates of 30-day follow-up were 374 visits to primary care physicians and 422 visits to medical specialists per 1000 discharges. Rates of primary care physician follow-up were similar across primary care delivery models, except for patients with very high morbidity; these patients had significantly higher rates of follow-up with a primary care physician if they were enrolled in team-based primary care practices (30-d rate difference [RD] 13.3 more follow-up visits per 1000 discharges, 95% confidence interval [CI] 6.8 to 19.8). Rates of follow-up with a medical specialist were lower among patients enrolled in team-based practices, particularly within 15 days of hospital discharge (15-d RD 25.1 fewer follow-up visits per 1000 discharges, 95% CI 21.1 to 29.1). Interpretation: Our study found lower rates of postdischarge follow-up with a
Zheng, Cindy X; Hu, Wanda D; Tran, Judie; Siam, Linda; Berardi, Giuliana G; Sembhi, Harjeet; Hark, Lisa A; Katz, L Jay; Waisbourd, Michael
This cross-sectional study aimed to evaluate adherence rates and identify barriers to receiving follow-up eye care in participants diagnosed with significant non-glaucomatous eye pathology in the Philadelphia Glaucoma Detection and Treatment Project. This community-based project aimed to improve detection, management, treatment, and follow-up eye care of individuals at high risk for glaucoma in community-based settings. Participants throughout Philadelphia, Pennsylvania, USA were enrolled. After a comprehensive eye examination, follow-up recommendations were given to each participant. A telephone survey was administered to individuals diagnosed with non-glaucomatous ocular pathology 3 months after initial eye examination to assess rates of follow-up and to evaluate potential barriers to follow-up. Of the 1649 participants enrolled in this project, 249 (15 %) were diagnosed with significant non-glaucomatous ocular pathology requiring follow-up care. There were 143 (57 %) who responded to the telephone survey. Respondents had a median age of 72 years, and were predominately female (69 %) and African-American (64 %). Of the respondents, 36 (25 %) attended a follow-up appointment. Participants who did not remember the results of their examinations, did not remember their recommendations, and had not seen an eye doctor within the past year were less likely to make a follow-up appointment (P = 0.04, 0.001 and 0.005, respectively). The Philadelphia Glaucoma Detection and Treatment Program was able to detect a significant amount of non-glaucomatous ocular pathology requiring follow-up care. Actual follow-up rates were sub-optimal. Further research is needed to determine interventions to overcome barriers and increase adherence with follow-up recommendations.
Martínez Olmos, M A; Martínez Vázquez, M J; Montero Hernández, M; Siquier Homar, P; Valdueza Beneitez, J; Morales Gorría, M J; Arbones Fernández-Vega, M J; Pena González, E; Inaraja Bobo, M T
In total parenteral nutrition (TPN) nutritional support multidisciplinary teams (NSMT) must provide a high quality nutritional assistance based on evidence and daily follow-up of patients with TPN. To assess the degree of adherence to quality standards of care provided to patients on TPN by the NSMT in two consecutive annual periods, according to structure, procedure, and outcomes indicators, previously defined in the team working protocol. Prospective study of all patients that received TPN at our Center (421-bed general teaching hospital) during the years 2002 and 2003, using the data introduced in NUTRIDATA by daily follow-up of clinical and analytical conditions, and nutritional and non-nutritional complications, comparing both periods and considering an statistical significance level of p < 0.05. One hundred and sixty-three patients and 145 patients received TPN during 2002 and 2003(65.9% male), respectively, with similar parameters of gender, age, indications for TPN, baseline nutritional status, mean nutritional supply, and non-nutritional complications. As to the different quality indicators established in the comparative study, we found a significant improvement in 2003 vs. 2002 in relation to initial anthropometrical assessment (71.03% vs 51.53%; p < 0.001), initial biochemical assessment (97.93% vs. 92.63%; p < 0.04), performance of systematic monitoring analysis (84.83% vs. 71.78%; p < 0.01), hypernatremia incidence (8.27% vs. 15.34%; p = 0.05) and moderate hyperphosphatemia (26.89% vs. 40.49%; p < 0.02), TPN ending for clinical improve- ment (76.60% vs. 64.40%; p = 0.04), and reduction of days on TPN (15.74 +/- 20.43 vs. 11.88 +/- 8.34; p < 0.02), the impaired electrolyte levels significantly improving as a whole. We also observed a non-significant trend towards an improvement of adequacy of TPN indications, hyperphosphatemia, severe hypophosphatemia, total stay, and post-surgical stay, in 2003 vs. 2002. The NSMT experience shows that analysis of
Holanda, Cristyanne Samara Miranda de; Alchieri, João Carlos; Morais, Fátima Raquel Rosado; Maranhão, Técia Maria de Oliveira
To describe the development of a questionnaire for assessment of prenatal, birth, and postnatal care (Inventário de Avaliação da Assistência ao Pré-natal, Parto e Puerpério, IAAPPP), which was designed taking into consideration the experience of users of a public obstetric service. This mixed methods research was performed in the city of Caicó, state of Rio Grande do Norte, Brazil. The study consisted of two phases: in phase 1, focal groups were organized with 19 users of the health care system for identification of relevant issues for assessment of the pregnancy-postnatal cycle. The first draft of the questionnaire was also designed and tested for validity with seven of the 19 focal group participants; a second draft was produced and retested. In phase 2, the intra-class correlation coefficient was calculated to determine reproducibility. A pilot test was carried out to determine the applicability of the survey and the final version of the IAAPPP was developed. Based on the focal group discussions, the inventory was organized into four domains: 1) socioeconomic information, 2) obstetric history, 3) description of current obstetric experience and 4) assessment of follow-up. Domains 3 and 4 were subdivided into prenatal care, birthcare, postnatal care, and pregnancy-postnatal cycle. The answers of the women who evaluated the instrument for domain 4 were strongly correlated (>0.8), indicating reproducibility of the IAAPPP. The methodological model allowed us to identify needs and demands of women in the pregnancy-postnatal cycle, and allowed us to design a questionnaire that can be applied to other regions with similar sociocultural characteristics.
Rachlis, B; Ochieng, D; Geng, E; Rotich, E; Ochieng, V; Maritim, B; Ndege, S; Naanyu, V; Martin, J; Keter, A; Ayuo, P; Diero, L; Nyambura, M; Braitstein, P
Background The Academic Model Providing Access To Healthcare (AMPATH) program provides comprehensive HIV care and treatment services. Approximately 30% of patients have become lost to follow-up (LTFU). We sought to actively trace and identify outcomes for a sample of these patients. Methods LTFU was defined as missing a scheduled visit by ≥ 3 months. A randomly selected sample of 17% of patients identified as LTFU between January 2009 and June 2011 was generated, with sample stratification on age, antiretroviral therapy (ART) status at last visit, and facility. Chart reviews were conducted followed by active tracing. Tracing was completed by trained HIV-positive outreach workers July 2011 to February 2012. Outcomes were compared between adults and children and by ART status. Results Of 14,811 LTFU patients, 2,540 were randomly selected for tracing (2,179 adults, 1,071 on ART). The chart reviews indicated that 326 (12.8%) patients were not actually LTFU. Outcomes for 71% of sampled patients were determined including 85% of those physically traced. Of those with known outcomes, 21% had died while 29% had disengaged from care for various reasons. The remaining patients had moved away (n=458, 25%) or were still receiving HIV care (n=443 total, 25%). Conclusions Our findings demonstrate the feasibility of a large scale sampling-based approach. A significant proportion of patients were found not to be LTFU and further, high numbers of patients who were LTFU could not be located. Over a quarter of patients disengaged from care for various reasons including access challenges and familial influences. PMID:25692336
Riihimäki, K; Vuorilehto, M; Isometsä, E
Most practice guidelines recommend maintenance antidepressant treatment for recurrent major depressive disorder. However, the degree to which such guidance is actually followed in primary health care has remained obscure. We investigated the provision of maintenance antidepressant treatment within a representative primary care five-year cohort study. In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up. A graphic life chart enabling evaluation of the longitudinal course of episodes plus duration of pharmacotherapies was used. In accordance with national guidelines, an indication for maintenance treatment was defined to exist after three or more lifetime major depressive episodes (MDEs); maintenance treatment was to commence four months after onset of full remission. Of the cohort patients, 34% (46/137) had three or more lifetime MDEs, thus indicating the requirement for maintenance pharmacotherapy. Of these, half (54%, 25/46) received maintenance treatment, for only 29% (489/1670) of the months indicated. In this cohort of depressed primary care patients, half of patients with indications for maintenance treatment actually received it, and only for a fraction of the time indicated. Antidepressant maintenance treatment for the prevention of recurrences is unlikely to be subject to large-scale actualization as recommended, which may significantly undermine the potential public health benefits of treatment. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Smith-Strøm, Hilde; Iversen, Marjolein M; Graue, Marit; Skeie, Svein; Kirkevold, Marit
Diabetic foot ulcers are a feared complication of diabetes. Care delivered via telemedicine is suggested to be a more integrated care pathway to manage diabetic foot ulcers than traditionally delivered healthcare. Our aim was to explore patients' experiences with telemedicine follow-up care as compared to traditional care. Interpretive description was used as an analysis strategy. Data were collected using individual semi-structured interviews in the context of a larger ongoing clustered randomized controlled trial. Twenty-four patients (13 in the intervention group; 11 in the control group), aged 38-88 years were purposively recruited from the RCT in order to obtain a diverse sample in terms of group composition (intervention vs. control), age, gender, marital status, setting, and comorbidities present. The control group received traditional care. Three themes emerged from the interpretive analysis: competence of healthcare professionals, continuity of care, and easy access. This was independed of types of follow-up that had limited impact on the patients' follow-up experiences. Competence of healthcare professionals and continuity of care were crucial, because they can either enhance or jeopardize wound care. If these two latter factors were absent, patients would lose confidence in the wound care process. If this happened, patients pointed out that the expert knowledge of a specialist clinic was essential to receive good care. When telemedicine functioned optimally, telemedicine was an advantage in the treatment, because the images quickly captured changes in the wound healing that immediately could be corrected. Easy access is important for patients, but the importance of accessibility appears to be primary when the other two factors were present. The best wound care pathway for patients with diabetes foot ulcers is depended on a combination of competence and professional skills in wound management, and continuity of care. If telemedicine is functioning as
Machine, Edwin Masese; Gillespie, Susan L; Homedes, Nuria; Selwyn, Beatrice J; Ross, Michael W; Anabwani, Gabriel; Schutze, Gordon; Kline, Mark W
Loss to follow-up (LTFU) is a critical factor in determining clinical outcomes in HIV treatment programs. Identifying modifiable factors of LTFU is fundamental for designing effective patient-retention interventions. We analyzed factors contributing to children LTFU from a treatment program to identify those that can be modified. A case-control study involving 313 children was used to compare the sociodemographic and clinical characteristics of children LTFU (cases) with those remaining in care (controls) at a large pediatric HIV care setting in Botswana. We traced children through caregiver contacts and those we found, we conducted structured interviews with patients' caregivers. Children <5 years were nearly twice as likely as older children to be LTFU (57·8% versus 30·9%, p <0 .01). Approximately half (47·6%, n = 51) of LTFU patients failed to further engage in care after just one clinic visit, as compared to less than 1% (n = 2) in the control group (p < 0.01). Children LTFU were more likely than controls to have advanced disease, greater immunosuppression, and not to be receiving antiretroviral therapy. Among interviewed patient caregivers, psychosocial factors (e.g., stigma, religious beliefs, child rebellion, disclosure of HIV status) were characteristics of patients LTFU, but not of controls. Socioeconomic factors (e.g., lack of transportation, school-related activities, forgetting appointments) were cited predominantly by the controls. Pediatric patients and their caregivers need to be targeted and engaged at their initial clinic visit, with special attention to children <5 years. Possible interventions include providing psychosocial support for issues that deter patients from engaging with The Clinic. Collaboration with community-based organizations focused on reducing stigma may be useful in addressing these complex issues.
Hudson, Shawna V.; Miller, Suzanne M.; Hemler, Jennifer; Ferrante, Jeanne M.; Lyle, Jennifer; Oeffinger, Kevin C.; DiPaola, Robert S.
BACKGROUND Nearly one-third of office visits for cancer are handled by primary care physicians. Yet, few studies examine patient perspectives on these physicians’ roles in their cancer follow-up care or their care preferences. METHODS We explored survivor preferences through qualitative, semistructured, in-depth interviews drawing on patients recruited from 2 National Cancer Institute–designated comprehensive cancer centers and 6 community hospitals. We recruited a purposive sample of early-stage breast and prostate cancer survivors aged 47 to 80 years, stratified by age, race, and length of time from and location of cancer treatment. Survivors were at least 2 years beyond completion of their active cancer treatment RESULTS Forty-two survivors participated in the study. Most participants expressed strong preferences to receive follow-up care from their cancer specialists (52%). They described the following barriers to the primary care physician’s engagement in follow-up care: (1) lack of cancer expertise, (2) limited or no involvement with original cancer care, and (3) lack of care continuity. Only one-third of participants (38%) believed there was a role for primary care in cancer follow-up care and suggested the following opportunities: (1) performing routine cancer-screening tests, (2) supplementing cancer and cancer-related specialist care, and (3) providing follow-up medical care when “enough time has passed” or the survivors felt that they could reintegrate into the noncancer population. CONCLUSION Survivors have concerns about seeing their primary care physician for cancer-related follow-up care. Research interventions to address these issues are necessary to enhance the quality of care received by cancer survivors. PMID:22966105
Chien, Wai Tong; Yip, Annie L K; Liu, Justina Y W; McMaster, Terry W
Family intervention for psychotic disorders is an integral part of psychiatric treatment with positive effects on patients' mental state and relapse rate. However, the effect of such family-based intervention on caregivers' psychological distress and well-being, especially in non-Western countries, has received comparatively much less attention. To test the effects of guided problem-solving-based manual-guided self-learning programme for family caregivers of adults with recent-onset psychosis over a 6-month period of follow-up, when compared with those in usual family support service. A single-centre randomised controlled trial, which was registered at ClinicalTrials.gov (NCT02391649), with a repeated-measures, two-arm (parallel-group) design. One main psychiatric outpatient clinic in the New Territories of Hong Kong. A random sample of 116 family caregiverss of adult outpatients with recent-onset psychosis. Following pre-test measurement, caregivers were assigned randomly to one of two study groups: a 5-month self-help, problem-solving-based manual-guided self-learning (or bibliotherapy) programme (in addition to usual care), or usual family support service only. Varieties of patient and caregiver health outcomes were assessed and compared at baseline and at 1-week and 6-month post-intervention. One hundred and eleven (96%) caregivers completed the 6-month follow-up (two post-tests); 55 of them (95%) completed ≥4 modules and attended ≥2 review sessions (i.e., 75% of the intervention). The family participants' mean age was about 38 years and over 64% of them were female and patient's parent or spouse. Multivariate analyses of variance indicated that the manual-guided self-learning group reported significantly greater improvements than the usual care group in family burden [F(1,110)=6.21, p=0.006] and caregiving experience [F(1,110)=6.88, p=0.0004], and patients' psychotic symptoms [F(1,110)=6.25, p=0.0003], functioning [F(1,110)=7.01, p=0.0005] and number of
Díaz-Martín, Alicia; González-Carpio Paredes, Óscar
improve. The diagnoses with follow-up show positive results. We must increase our knowledge of psychosocial problems and communication skills in order to respond to the current demands of the population. Copyright © 2012 Elsevier España, S.L. All rights reserved.
Atzema, Clare L; Yu, Bing; Ivers, Noah M; Rochon, Paula A; Lee, Douglas S; Schull, Michael J; Austin, Peter C
Patients with cardiovascular diseases are common in the emergency department (ED), and continuity of care following that visit is needed to ensure that they receive evidence-based diagnostic tests and therapy. We examined the frequency of follow-up care after discharge from an ED with a new diagnosis of one of three cardiovascular diseases. We performed a retrospective cohort study of patients with a new diagnosis of heart failure, atrial fibrillation, or hypertension, who were discharged from 157 non-pediatric EDs in Ontario, Canada, between April 2007 and March 2014. We determined the frequency of follow-up care with a family physician, cardiologist, or internist within seven and 30 days, and assessed the association of patient, emergency physician, and family physician characteristics with obtaining follow-up care using cause-specific hazard modeling. There were 41,485 qualifying ED visits. Just under half (47.0%) had follow-up care within seven days, with 78.7% seen by 30 days. Patients with serious comorbidities (renal failure, dementia, COPD, stroke, coronary artery disease, and cancer) had a lower adjusted hazard of obtaining 7-day follow-up care (HRs 0.77-0.95) and 30-day follow-up care (HR 0.76-0.95). The only emergency physician characteristic associated with follow-up care was 5-year emergency medicine specialty training (HR 1.11). Compared to those whose family physician was remunerated via a primarily fee-for-service model, patients were less likely to obtain 7-day follow-up care if their family physician was remunerated via three types of capitation models (HR 0.72, 0.81, 0.85) or via traditional fee-for-service (HR 0.91). Findings were similar for 30-day follow-up care. Only half of patients discharged from an ED with a new diagnosis of atrial fibrillation, heart failure, and hypertension were seen within a week of being discharged. Patients with significant comorbidities were less likely to obtain follow-up care, as were those with a family
Armstrong, Kathleen; Coyte, Peter; Semple, John
Women's College Hospital (WCH) in Toronto offers specialized ambulatory surgical procedures. A feasibility study using a mobile appliciation (app) to supplement in-person follow-up care after surgery suggests that the mobile app adequately detects postoperative complications, eliminates the need for in-person follow-up care and is cost-effective. This is concordant with other postoperative telemedicine studies. The purpose of this study is to determine if we can avert in-person follow-up care through the use of mobile app compared to conventional, in-person follow-up care in the first month following surgery amongst breast reconstruction patients at WCH. This will be a pragmatic, single-centre, open, controlled, 2-arm parallel-group superiority randomized trial. Mobile app follow-up care is a novel approach to managing patients postoperatively with the potential to avert in-person follow-up and generate cost-savings for the healthcare system and patient.
Yu, Bing; Ivers, Noah; Rochon, Paula; Lee, Douglas S.; Schull, Michael J.; Austin, Peter C.
Background Continuity of care has been shown to be poor following in-hospital discharge, and there are substantially fewer resources to facilitate follow-up care arrangements after discharge from an emergency department. Our objective was to assess the frequency, timeliness and predictors for obtaining follow-up care following discharge from an emergency department in Ontario with a new diagnosis of atrial fibrillation. Methods We conducted a retrospective cohort study involving all patients discharged from the 157 nonpediatric emergency departments in Ontario, who received a new diagnosis of atrial fibrillation between 2007 and 2012. We determined the frequency of follow-up care with a family physician, cardiologist or internist within 7 (timely) and 30 days of the emergency department visit, and assessed the association of emergency and family physician characteristics, including primary care model type, with obtaining timely follow-up care. Results Among 14 907 patients discharged from Ontario emergency departments with a new, primary diagnosis of atrial fibrillation, half (n = 7473) had timely follow-up care. At 30 days, 2678 patients (18.0%) still had not obtained follow-up care. Among emergency and family physician factors, lack of a family physician had the largest independent association with acquiring timely follow-up care (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.50–0.69). Using patients with a family physician belonging to a primarily fee-for-service remuneration model as the comparison group, patients with a family physician belonging to a capitation-based Family Health Network, as part of a Family Health Team, were less likely to receive timely follow-up care (OR 0.73, 95% CI 0.62–0.86), as were those whose family physician belonged to the same model type that was not part of a Family Health Team (OR 0.77, 95% CI 0.60–0.97). Interpretation Only half of the patients who were discharged from an emergency department in Ontario with a new
Kandula, Praveena; Cook, T. S.; Boonn, W. W.; Kim, W.
With the current emphasis on healthcare reform and cost effectiveness, methods to increase healthcare efficiency while improving outcomes are paramount. With reference to breast cancer, delay in diagnosis can cause significant morbidity and mortality, as well as increased long term health care costs. Assessment with short interval mammographic follow-up of BI-RADS category 3 lesions has been shown to increase detection of a small number of breast cancers at an early stage. Because of the importance of timely follow-up for these patients, we propose a novel computer application that identifies patients due for short-term mammographic follow-up, thus reducing costly hours spent by personnel, reducing human error, and improving patient compliance. Our web-based application mines radiology reports and scheduling information to generate lists of patients due for short-term mammographic follow-up of BI-RADS category 3 results. The results can be placed in a worklist that can be used by a staff member to contact patients to schedule follow-up appointments. Additional analytic features of the application can identify referral characteristics that may serve as potential sources for improvement of patient follow-up. We believe that an automated system can be designed to improve patient care and compliance with follow-up of BI-RADS category 3 results.
Alam, Nur H.; Chisti, Mohammod J.; Salam, Mohammed A.; Ahmed, Tahmeed; Gyr, Niklaus
ABSTRACT Compliance, morbidity, mortality, and hospitalization during fortnightly follow-up were evaluated by an observational study on a cohort of children with severe and very severe pneumonia after day-care treatment at an urban clinic. The primary outcome measures were proportions of success (compliance) and failure (non-compliance) of follow-up visits at the day-care clinic. In total, 251 children were followed up, with median (IQR) age of 5.0 (3.0-9.0) months, and their compliance dropped from 92% at the first to 85% at the sixth visit. Cough (28%), fever (20%), and rapid breathing (13%) were common morbidities. Successful follow-up visits were possible in 180 (95.2%) and 56 (90.3%) of the children with severe and very severe pneumonia respectively. Eleven (4.4%) needed hospitalization, and four (1.6%) died. Majority (≈90%) of the children could be successfully followed up; some failed to attend their scheduled follow-up visits due to hospitalization and death. The common morbidities indicate the importance of follow-up for detecting medical problems and early treatment, thus reducing risk of death. PMID:25076656
Sullivan, J F; Forde, J C; Thomas, A Z; Creagh, T A
To assess the impact of a structured training programme in urethral catheterisation (UC) targeted at newly qualified junior doctors on rates of iatrogenic catheter morbidity within a tertiary care referral centre. Male UC-related morbidities were retrospectively identified from our computerised inpatient urology consultation system over a 1-year period from July 2010 to June 2011. Relevant medical records were also reviewed. Results were compared with an initial study performed between July 2006 and June 2007, prior the introduction of a structured training programme in our institution. An anonymous questionnaire was used for the subjective assessment of interns about confidence in catheterising post introduction of the programme. Of 725 urological consultations, 29 (4%) were related to complications arising from male UC during the 1 year period. This reflected a statistically significant decrease when compared to our 2007 figures, 51/864 (6%) (p < 0.05). Again, the most common indication for UC was monitoring urinary output for acute medical illness (19/29, 66%). The most common complication was urethral trauma (16/29, 55%). Of the 29 cases of UC-related morbidity, 18 (62%) resulted from interns performing UC, a decrease of 12% from our original paper. A drop of 27% was seen in the rates of UC related morbidity attributable to interns during the first 6 months of internship (July-December). Overall, 70% (vs 40% original study) of interns felt that their practical training was adequate since introduction of the programme (p < 0.01) with 53% considering theoretical training adequate (vs 16% original study (p < 0.01). When asked were they confident in performing UC, 63% said they were compared to 35% before introduction of the programme (p < 0.05). UC-related iatrogenic morbidity is not uncommon even in a tertiary-care teaching hospital. Implementation of a structured training programme in UC prior to the commencement of intern year has been shown to result
Williams, Cydni N; Kirby, Aileen; Piantino, Juan
Pediatric Neurocritical Care diagnoses account for a large proportion of intensive care admissions. Critical care survivors suffer high rates of long-term morbidity, including physical disability, cognitive impairment, and psychosocial dysfunction. To address these morbidities in Pediatric Neurocritical Care survivors, collaboration between Pediatric Neurology and Pediatric Critical Care created a multidisciplinary follow-up clinic providing specialized evaluations after discharge. Clinic referrals apply to all Pediatric Neurocritical Care patients regardless of admission severity of illness. Here, we report an initial case series, which revealed a population that is heterogenous in age, ranging from 1 month to 18 years, and in diagnoses. Traumatic brain injuries of varying severity as well as neuroinfectious and inflammatory diseases accounted for the majority of referrals. Most patients (87%) seen in the clinic had morbidities identified, requiring ongoing evaluation and expansion of the clinic. Cognitive and psychological disturbance were seen in over half of patients at the initial clinic follow-up. Sleep disturbances, daytime fatigue, headache or chronic pain, and vision or hearing concerns were also common at initial follow-up. Data from this initial population of clinic patients reiterates the need for specialized follow-up care, but also highlights the difficulties related to providing this comprehensive care and evaluating interventions to improve outcomes.
Neuman, Heather B; Rathouz, Paul J; Winslow, Emily; Weiss, Jennifer M; LoConte, Noelle K; Lin, Chee Paul; Wurm, Mike; Smith, Maureen A; Schrag, Deborah; Greenberg, Caprice C
Frequent follow-up is recommended for the more than 3 million breast cancer survivors living in the USA. Given the multidisciplinary nature of breast cancer treatment, follow-up may be provided by medical oncologists, radiation oncologists, surgeons and primary care providers. This creates the potential for significant redundancy as well as gaps in care. The objective was to examine patterns of breast cancer follow-up provided by different types of oncologists and develop a statistical means of quantifying visit distribution over time. We identified stage I-III breast cancer patients who underwent breast conservation from 2000 to 2006 (n = 12 139) within the SEER-Medicare linked database. Provider type was defined using Medicare specialty provider codes and AMA Masterfile. The coefficient of variation (CV) for time between oncologist follow-up visits was calculated. Ordinal logistic regression assessed factors associated with CV. Substantial variation in CV was observed. Sixty-seven per cent of patients with low CV (high visit regularity) received follow-up from a single oncologist type, versus 8% with high CV (low visit regularity). The number of oncologist types participating in follow-up had the greatest association with high CV (odds ratio 7.4 [6.7-8.3] and 15.4 [13.6-17.6] for two and three oncologist types). Using a novel means of quantifying follow-up visit regularity, we determined that breast cancer patients with dispersed follow-up with more than one oncologist have more disordered care. The CV could be used in electronic medical records to identify cancer survivors with more disordered. © 2016 John Wiley & Sons, Ltd.
Pekka, Nieminen; Anttila, Ahti; Bützow, Ralf; Heikkilä, Elina; Hiltunen-Back, Eija; Mäenpää, Johanna; Puistola, Ulla; Rantanen, Virpi; Rintala, Marjut; Räisänen, Ilkka; Santalahti, Anne; Talvensaari-Mattila, Anne; Vartiainen, Juhani; Vuento, Maarit; Yliskoski, Merja
Approximately 150 cervical cancer cases are diagnosed in Finland annually. Both incidence and mortality have decreased by 80% since organised screening began. Recently, screening based on primary HPV-testing with Pap-smear triage has been shown to be more sensitive and more specific among women over 35 years old in randomised studies and thus may be implemented in routine. Abnormal findings in Pap smears indicate management. Confirmed CIN1 lesions are followed up and CIN2 and worse lesions treated. Follow-up after treatment should be reliably arranged, because elevated risk of cancer remains over 20 years after treatment. Quality control is of utmost importance.
Background Individuals who have attempted suicide are at increased risk of subsequent suicidal behavior. Since 1983, a community-based suicide prevention team has been operating in the municipality of Bærum, Norway. This study aimed to test the effectiveness of the team's interventions in preventing repeated suicide attempts and suicide deaths, as part of a chain of care model for all general hospital treated suicide attempters. Methods Data has been collected consecutively since 1984 and a follow-up was conducted on all individuals admitted to the general hospital after a suicide attempt. The risk of repeated suicide attempt and suicide were comparatively examined in subjects who received assistance from the suicide prevention team in addition to treatment as usual versus those who received treatment as usual only. Logistic regression and Cox regression were used to analyze the data. Results Between January 1984 and December 2007, 1,616 subjects were registered as having attempted suicide; 197 of them (12%) made another attempt within 12 months. Compared to subjects who did not receive assistance from the suicide prevention team, individuals involved in the prevention program did not have a significantly different risk of repeated attempt within 6 months (adjusted OR = 1.08; 95% CI = 0.66-1.74), 12 months (adjusted OR = 0.86; 95% CI = 0.57-1.30), or 5 years (adjusted RR = 0.90; 95% CI = 0.67-1.22) after their first recorded attempt. There was also no difference in risk of suicide (adjusted RR = 0.85; 95% CI = 0.46-1.57). Previous suicide attempts, marital status, and employment status were significantly associated with a repeated suicide attempt within 6 and 12 months (p < 0.05). Alcohol misuse, employment status, and previous suicide attempts were significantly associated with a repeated attempt within 5 years (p < 0.05) while marital status became non-significant (p > 0.05). With each year of age, the risk of suicide increased by 3% (p < 0.05). Conclusions The
Kauppila, Timo; Seppänen, Katri; Mattila, Juho; Kaartinen, Johanna
Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor's list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors' services in collaborative parts of the health care system. An observational study. Register-based retrospective quasi-experimental longitudinal follow-up study based on a before-after setting in a Finnish city. Patients who consulted different doctors in a local health care unit. Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage. The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased. The data suggested that the reverse triage causes redistribution of the use of doctors' services rather than a true decrease in the use of these services.
Estill, Janne; Tweya, Hannock; Egger, Matthias; Wandeler, Gilles; Feldacker, Caryl; Johnson, Leigh F.; Blaser, Nello; Vizcaya, Luisa Salazar; Phiri, Sam; Keiser, Olivia
Objectives Treatment as prevention depends on retaining HIV-infected patients in care. We investigated the effect on HIV transmission of bringing patients lost to follow up (LTFU) back into care. Design Mathematical model. Methods Stochastic mathematical model of cohorts of 1000 HIV-infected patients on antiretroviral therapy (ART), based on data from two clinics in Lilongwe, Malawi. We calculated cohort viral load (CVL; sum of individual mean viral loads each year) and used a mathematical relationship between viral load and transmission probability to estimate the number of new HIV infections. We simulated four scenarios: ‘no LTFU’ (all patients stay in care); ‘no tracing’ (patients LTFU are not traced); ‘immediate tracing’ (after missed clinic appointment); and, ‘delayed tracing’ (after six months). Results About 440 of 1000 patients were LTFU over five years. CVL (million copies/ml per 1000 patients) were 3.7 (95% prediction interval [PrI] 2.9-4.9) for no LTFU, 8.6 (95% PrI 7.3-10.0) for no tracing, 7.7 (95% PrI 6.2-9.1) for immediate, and 8.0 (95% PrI 6.7-9.5) for delayed tracing. Comparing no LTFU with no tracing the number of new infections increased from 33 (95% PrI 29-38) to 54 (95% PrI 47-60) per 1000 patients. Immediate tracing prevented 3.6 (95% PrI -3.3-12.8) and delayed tracing 2.5 (95% PrI -5.8-11.1) new infections per 1000. Immediate tracing was more efficient than delayed tracing: 116 and to 142 tracing efforts, respectively, were needed to prevent one new infection. Conclusion Tracing of patients LTFU enhances the preventive effect of ART, but the number of transmissions prevented is small. PMID:24326599
Fors, Andreas; Swedberg, Karl; Ulin, Kerstin; Wolf, Axel; Ekman, Inger
To assess the long-term effect of person-centred care (PCC) in patients with acute coronary syndrome (ACS). Patients with ACS were randomly assigned to treatment as usual (control group) or an added PCC intervention for six months. The primary endpoint was a composite score of changes in general self-efficacy≥five units, return to work or to a prior activity level and re-hospitalisation or death. The composite score improved in the PCC intervention group (n=94) at a two-year follow-up compared with the control group (n=105) (18.1%, n=17 vs. 10.5%, n=11; P=0.127). In the per-protocol analysis (n=183) the improvement was significant in favour of the PCC intervention (n=78) compared with usual care (n=105) (21.8%, n=17 vs. 10.5%, n=11; P=0.039). This effect was driven by the finding that more patients in the PCC group improved their general self-efficacy score≥5units (32.2%, n=19 vs. 17.3%, n=14; P=0.046). The composite score improvement was significantly higher in the PCC intervention group without post-secondary education (n=33) in comparison with corresponding patients in the control group (n=50) (30.3%, n=10 vs. 10.0%, n=5; P=0.024). Implementation of PCC results in sustained improvements in health outcome in patients with ACS. PCC can be incorporated into conventional cardiac prevention programmes to improve equity in uptake and patient health outcomes. Swedish registry, Researchweb.org, ID NR 65791. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.
Berg, Carla J; Stratton, Erin; Esiashvili, Natia; Mertens, Ann
We examined correlates of low engagement in the healthcare system, experiences with survivorship care, barriers to follow-up care, and potential resources for promoting follow-up care among young adult survivors of childhood cancers. We conducted a mixed-method study involving surveys of 106 survivors of childhood cancer aged 18-34 recruited from a university-affiliated children's hospital and an NCI-designated cancer center in the Southeastern USA. Phone-based semistructured interviews were then conducted in a subset of 26. Assessments included health factors, psychosocial factors, healthcare system interaction, and interest in resources to promote engagement in healthcare. Survey participants were on average 22.14 (SD = 3.16) years old, 50.0 % female, and 77.4 % White. Overall, 46.0 % had attended survivorship clinic, 47.2 % reported receiving a treatment summary, 68.9 % had a primary care provider, and 17.0 % reported no interaction with healthcare in the past 2 years. Correlates of less than annual healthcare provider visits included being older (p = 0.003), being male (p < 0.001), lack of insurance (p = 0.002), and having had chemotherapy (p = 0.05). Participants reported varied experiences in terms of how health and treatment information was presented, from none or too little to overwhelming or anxiety-provoking amounts. Barriers to engaging in survivorship care included no/limited insurance, time, or transportation; major life changes; anxiety; and difficulty transitioning from pediatrics to adult care. Participants highlighted the need for educational and psychosocial resources, particularly technology-based resources. Multilevel interventions are needed to increase engagement in survivorship care among young adult cancer survivors. Technology-based resources addressing social support and mental well-being are intervention possibilities.
Stratton, Erin; Esiashvili, Natia; Mertens, Ann
We examined correlates of low engagement in the healthcare system, experiences with survivorship care, barriers to follow-up care, and potential resources for promoting follow-up care among young adult survivors of childhood cancers. We conducted a mixed-method study involving surveys of 106 survivors of childhood cancer aged 18–34 recruited from a university-affiliated children’s hospital and an NCI-designated cancer center in the Southeastern USA. Phone-based semistructured interviews were then conducted in a subset of 26. Assessments included health factors, psychosocial factors, healthcare system interaction, and interest in resources to promote engagement in healthcare. Survey participants were on average 22.14(SD=3.16) years old, 50.0 % female, and 77.4 % White. Overall, 46.0 % had attended survivorship clinic, 47.2 % reported receiving a treatment summary, 68.9 % had a primary care provider, and 17.0 % reported no interaction with healthcare in the past 2 years. Correlates of less than annual healthcare provider visits included being older (p=0.003), being male (p<0.001), lack of insurance (p=0.002), and having had chemotherapy (p=0.05). Participants reported varied experiences in terms of how health and treatment information was presented, from none or too little to overwhelming or anxiety-provoking amounts. Barriers to engaging in survivorship care included no/limited insurance, time, or transportation; major life changes; anxiety; and difficulty transitioning from pediatrics to adult care. Participants highlighted the need for educational and psychosocial resources, particularly technology-based resources. Multilevel interventions are needed to increase engagement in survivor-ship care among young adult cancer survivors. Technology-based resources addressing social support and mental well-being are intervention possibilities. PMID:25948413
Partin, Melissa R; Powell, Adam A; Burgess, Diana J; Haggstrom, David A; Gravely, Amy A; Halek, Krysten; Bangerter, Ann; Shaukat, Aasma; Nelson, David B
This study assessed whether postal follow-up to a web-based physician survey improves response rates, response quality, and representativeness. We recruited primary care and gastroenterology chiefs at 125 Veterans Affairs medical facilities to complete a 10-min web-based survey on colorectal cancer screening and diagnostic practices in 2010. We compared response rates, response errors, and representativeness in the primary care and gastroenterology samples before and after adding postal follow-up. Adding postal follow-up increased response rates by 20-25 percentage points; markedly greater increases than predicted from a third e-mail reminder. In the gastroenterology sample, the mean number of response errors made by web responders (0.25) was significantly smaller than the mean number made by postal responders (2.18), and web responders provided significantly longer responses to open-ended questions. There were no significant differences in these outcomes in the primary care sample. Adequate representativeness was achieved before postal follow-up in both samples, as indicated by the lack of significant differences between web responders and the recruitment population on facility characteristics. We conclude adding postal follow-up to this web-based physician leader survey improved response rates but not response quality or representativeness. © The Author(s) 2013.
Alam, Nur H; Chisti, Mohammod Jobayer; Salam, Mohammed Abdus; Ahmed, Tahmeed; Gyr, Niklaus
Objectives To compare the features of relapse, morbidity, mortality and re-hospitalisation following successful discharge after severe pneumonia in children between a day care group and a hospital group and to explore the predictors of failures during 3 months of follow-up. Design An observational study following two cohorts of children with severe pneumonia for 3 months after discharge from hospital/clinic. Setting Day care was provided at the Radda Clinic and hospital care at a hospital in Dhaka, Bangladesh. Participants Children aged 2–59 months with severe pneumonia attending the clinic/hospital who survived to discharge. Intervention No intervention was done except providing some medications for minor illnesses, if indicated. Primary outcome measures The primary outcome measures were the proportion of successes and failures of day care at follow-up visits as determined by estimating the OR with 95% CI in comparison to hospital care. Results The authors enrolled 360 children with a mean (SD) age of 8 (7) months, 81% were infants and 61% were men. The follow-up compliance dropped from 95% at first to 85% at sixth visit. The common morbidities during the follow-up period included cough (28%), fever (17%), diarrhoea (9%) and rapid breathing (7%). During the follow-up period, significantly more day care children (n=22 (OR 12.2 (95% CI 8.2–17.8))) required re-hospitalisation after completion of initial day care compared with initial hospital care group (n=11 (OR 6.1 (95% CI 3.4–10.6))). The predictors for failure were associated with tachycardia, tachypnoea and hypoxaemia on admission and prolonged duration of stay. Conclusions There are considerable morbidities in children discharged following treatment of severe pneumonia like cough, fever, rapid breathing and diarrhoea during 3-month period. The findings indicate the importance of follow-up for early detection of medical problems and their management to reduce the risk of death. Establishment of an
Frick, Melissa A; Vachani, Carolyn C; Bach, Christina; Hampshire, Margaret K; Arnold-Korzeniowski, Karen; Metz, James M; Hill-Kayser, Christine E
The survivorship needs of patients living with chronic cancer (CC) and their use of survivorship care plans (SCPs) have been overlooked and underappreciated. A convenience sample of 39,088 SCPs completed for cancer survivors with an Internet-based SCP tool was examined; it included 5847 CC survivors (15%; CC was defined as chronic leukemia and/or recurrent/metastatic cancer of another nature). Patient-reported treatment effects and follow-up care patterns were compared between CC survivors and survivors treated with curative intent (CI). Responses from a follow-up survey regarding SCP satisfaction and use were reviewed. CC survivors had greater odds of experiencing multiple treatment-related effects than survivors treated with CI; these effects included fatigue, cognitive changes, dyspnea, peripheral neuropathy, lymphedema, and erectile dysfunction. Nearly half of CC survivors were managed by an oncologist alone, and they were less likely than CI patients to be comanaged by a primary care provider and an oncologist. Fewer SCPs were generated by health care providers (HCPs) for CC survivors versus CI survivors. A smaller proportion of CC users versus CI users rated their experience and satisfaction with the SCP tool as very good or excellent, and CC users were less likely to share the HCP summary with their health care team. A substantial number of CC survivors, often considered incurable but treatable, seek survivorship support. Tools to facilitate participation, communication, and coordination of care are valuable for these patients, and future iterations of SCPs should be designed to address the particular circumstances of living with CC. Cancer 2017. © 2017 American Cancer Society. © 2017 American Cancer Society.
Jónasdóttir, Rannveig J; Jónsdóttir, Helga; Gudmundsdottir, Berglind; Sigurdsson, Gisli H
To compare psychological recovery of patients receiving structured nurse-led follow-up and patients receiving usual care after intensive care discharge. Quasi-experimental study. Single centre, university hospital, mixed intensive care patient population. Symptoms of post-traumatic stress disorder, anxiety and depression measured three and four times over 12 months after intensive care discharge. Disturbing memories of the intensive care stay and psychological reactions (that one's life was in danger, threat to physical integrity, intense fear, helplessness, horror) three months after intensive care. A mixed effect model tested differences between the groups over time and regression model predicted post-traumatic stress at three months. The experimental group had significantly more symptoms of post-traumatic stress and anxiety than the control group over the 12 months. Patients from both groups had severe symptoms of post-traumatic stress. Patients with post-traumatic stress at three months had disturbing memories and psychological reactions. The structured nurse-led follow-up did not improve patients' measured outcomes of psychological recovery after intensive care. Patients with severe symptoms of post-traumatic stress are of concern. Emphasis needs to be placed on disturbing memories of the intensive care stay and psychological reactions when constructing intensive care nurse-led follow-up. Copyright © 2017 Elsevier Ltd. All rights reserved.
Malik, Rena D; Wang, Chihsiung E; Lapin, Brittany; Lakeman, Justin C; Helfand, Brian T
To identify the frequencies of treatment and recommended laboratory follow-up for men with low serum testosterone levels. The Electronic Data Warehouse was queried to identify men of ages 18-85 years, who obtained a testing for serum total testosterone level from 2009 to 2012. The frequency of testosterone replacement therapy (TRT), patient demographics, and clinical characteristics were collected. The frequency of follow-up with serum total testosterone and complete blood count levels was documented. Among 9176 men who underwent testing for low testosterone levels, 3320 (36%) of them were hypogonadal with a mean serum total testosterone level of 194.3 ± 64.9 ng/dL. Of them, 17.7% men were treated with TRTs. The treatment frequency significantly increased from 8.3% in 2009 to 24% in 2012. A total of 4.8% of men of reproductive ages (age, 18-35 years) were placed on TRTs. Within 180 days of initial testing, only 40% of treated men received follow-up with liver function tests and/or complete blood count, and only 49% had a follow-up serum testosterone level. Although the frequency of TRT is increasing, only a small percentage of hypogonadal men are actively undergoing treatment. A significant proportion of men of reproductive age are being treated with significant impacts on potential fertility. Less than half of the patients treated are being monitored appropriately after testosterone replacement. This highlights the importance of further education for providers prescribing testosterone replacement. Copyright © 2015 Elsevier Inc. All rights reserved.
Sager, Solomon J; Healy, Chris; Ramireddy, Archana; Rivner, Harold; Viles Gonzalez, Juan F; Coffey, James O; Rossin, Natalia; Lo, Ka M; Goldberger, Jeffrey J; Myerburg, Robert J; Mitrani, Raul D
Differences in implantable cardioverter defibrillator (ICD) utilization based on insurance status have been described, but little is known about postimplant follow-up patterns associated with insurance status and outcomes. We collected demographic, clinical, and device data from 119 consecutive patients presenting with ICD shocks. Insurance status was classified as uninsured/Medicaid (uninsured) or private/Health Maintenance Organization /Medicare (insured). Shock frequencies were analyzed before and after a uniform follow-up pattern was implemented regardless of insurance profile. Uninsured patients were more likely to present with an inappropriate shock (63% vs 40%, p = 0.01), and they were more likely to present with atrial fibrillation (AF) as the shock trigger (37% vs 19%, p = 0.04). Uninsured patients had a longer interval between previous physician contact and index ICD shock (147 ± 167 vs 83 ± 124 days, p = 0.04). Patients were followed for a mean of 521 ± 458 days after being enrolled in a uniform follow-up protocol, and there were no differences in the rate of recurrent shocks based on insurance status. In conclusion, among patients presenting with an ICD shock, underinsured/uninsured patients had significantly longer intervals since previous physician contact and were more likely to present with inappropriate shocks and AF, compared to those with private/Medicare coverage. After the index shock, both groups were followed uniformly, and the differences in rates of inappropriate shocks were mitigated. This observation confirms the importance of regular postimplant follow-up as part of the overall ICD management standard.
Paterniti, Sabrina; Sterner, Irit; Caldwell, Christine; Bisserbe, Jean-Claude
The course of depression is poorer in clinical settings than in the general population. Several predictors have been studied and there is growing evidence that a history of childhood maltreatment consistently predicts a poorer course of depression. Between 2008 and 2012, we assessed 238 individuals suffering from a current episode of major depression. Fifty percent of these (N = 119) participated in a follow-up study conducted between 2012 and 2014 that assessed sociodemographic and clinical variables, the history of childhood abuse and neglect (using the Adverse Childhood Experience questionnaire), and the course of depression between baseline and follow-up interview (using the Life Chart method). The Structured Clinical Interview for DSM-IV-TR was used to assess diagnosis at baseline and follow-up interview. Statistical analyses used the life table survival method and Cox proportional hazard regression tests. Among 119 participants, 45.4% did not recover or remit during the follow-up period. The median time to remission or recovery was 28.9 months and the median time to the first recurrence was 25.7 months. Not being married, a chronic index depressive episode, comorbidity with an anxiety disorder, and a childhood history of physical neglect independently predicted a slower time to remission or recovery. The presence of three or more previous depression episodes and a childhood history of emotional neglect were independent predictors of depressive recurrences. Childhood emotional and physical neglect predict a less favorable course of depression. The effect of childhood neglect on the course of depression was independent of sociodemographic and clinical variables.
Bošković, L; Gašparić, M; Petrić Miše, B; Petković, M; Gugić, D; Ban, M; Jazvić, M; Dabelić, N; Belac Lovasić, I; Vrdoljak, E
The aim of this analysis was to evaluate adherence of Croatian oncologists to follow-up criteria as suggested by the current national and international guidelines for women with breast cancer receiving adjuvant endocrine therapy. The use of clinical and diagnostic methods was documented in this prospective, non-interventional, multicenter study. A total of 438 post-menopausal patients receiving adjuvant endocrine treatment with non-steroidal aromatase inhibitors were included. Average annual frequency for each clinical and diagnostic method was calculated. Median adjuvant endocrine treatment duration before study recruitment was 10.5 months (interquartile 4.7-26.6). Patients were followed up for an average 23.5 ± 4.9 months. Average number of oncological visits was 5.3. Mammograms were performed at mean annual frequency of 0.7, chest radiographs at 0.5, abdominal ultrasounds at 0.9, breast ultrasounds at 1.2, complete blood counts and chemistry panels at 1.7, carcinoembryonic antigen at 0.8, cancer antigen 15-3 at 1.6, gynaecological examination at 0.3, and densitometry at mean annual frequency of 0.3. In conclusion, among post-menopausal women with breast cancer receiving adjuvant endocrine therapy in this study, more unnecessary and unproven follow-up procedures were done compared to the guidelines' recommendations.
Ganga Devi, N Poorana; Ajay, Kumar M V; Palanivel, C; Sahu, Swaroop; Selvaraj, M; Valan, A S; Rewari, B B; Soumya, S
Information on the follow-up of HIV-infected children enrolled into preantiretroviral therapy (Pre-ART) care under routine program settings is limited in India. Knowledge on the magnitude of loss to follow-up (LFU) and its reasons will help programs to retain children in HIV care. We aimed to assess the proportion of LFU among children in Pre-ART care and its associated factors. In this retrospective cohort study, we reviewed the records of all HIV-infected children (aged <15 years) registered from 2005 to 2012 at an ART center, Madurai, South India. LFU during Pre-ART care was defined as having not visited the ART center within a year of registration. Of 426 children enrolled in Pre-ART care, 211 (49%) were females and 301 (71%) were in the 5- to 14-year age group. At 1 year of registration, 348 (82%) were lost to follow-up. Of 348, 81 returned to care after 1 year of enrollment, whereas 267 (63% of all children) were permanently lost to follow-up. The proportion of LFU remained high from 2005 to 2012. WHO staging, CD4 count, and opportunistic infection were the significant factors associated with lost to follow-up on multivariate analysis. LFU was alarmingly high indicating poor clinical and programmatic monitoring among HIV-infected children enrolled in Pre-ART care. A system for active tracing of those missing a clinic appointment intensified supervision, and monitoring along with qualitative research is urgently needed. This will help to understand the exact reasons for LFU based on which effective interventions may be planned for reducing such losses.
Hansen, Jane Møller; Wildner-Christensen, Mette; Schaffalitzky de Muckadell, Ove B
The prevalence of gastroesophageal reflux symptoms (GERS) in the population is high; however, data on long-term follow-up and incidence of GERS in the population are sparse. This study describes the long-term natural history of GERS, the related health-care use, and quality of life in a population followed up for 5 years. A total of 10,000 randomly selected inhabitants, 40-65 years old, received, as a part of a controlled trial of Helicobacter pylori screening and treatment (control group), a mailed questionnaire regarding demographic data, gastrointestinal symptoms (the Gastrointestinal Symptom Rating Scale (GSRS)), and quality of life (the Short-Form 36-Item Health Survey (SF-36)) at inclusion and after 5 years. GERS was defined as a mean score > or =2 in the reflux dimension in the GSRS. Information on use of health-care resources was drawn from the questionnaires and registers. In all, 6,781 individuals answered the first questionnaire and 5-year symptom data were complete for 5,578 (82.3%) of them. The mean age at inclusion was 52.4 years, 48% were men. At inclusion, 22% reported GERS. During follow-up, symptoms resolved in 43%, of whom 10% received acid inhibitory treatment at 5-year follow-up. The incidence of GERS was 2.2% per year. Health-care use during follow-up was significantly higher in individuals with GERS at baseline than in individuals without GERS. Quality of life at 5-year follow-up was lower in individuals with GERS at inclusion than in individuals without GERS at inclusion. GERS are prevalent, long lasting, and associated with an impaired quality of life and substantial health-care use.
Cheung, W Y; Dove, J; Lervy, B; Russell, I T; Williams, J G
The aim of this study was to ascertain GPs' views about open access to out-patient follow-up for patients with inflammatory bowel disease (IBD). Semi-structured interviews and a postal survey were carried out in general practices in West Glamorgan UK, each with at least one IBD patient taking part in a randomized trial of open access versus routine follow-up, which has been reported elsewhere. A total of 112 GPs from 53 general practices who referred the 180 study patients to specialist gastroenterological care in Neath or Swansea were included in the study. Main outcome measures were GPs' experience of the trial; preferences between methods of out-patient follow-up; and their views about enhancing open access follow-up. Sixty-nine GPs from 40 practices took part in the practice-specific data collection and 91 returned 156 patient-specific questionnaires. They expressed a strong preference for open access follow-up, for both specific patients (108/156 patients) and IBD patients in general (47/69 GPs). Preference for extending open access follow-up to other chronic conditions was not so strong (21/69 GPs). A substantial number of GPs considered their experience of the trial limited (30/69), and few GPs were aware of the shared care guideline distributed before the trial started (8/69). Few GPs encountered any problems in the management of the study patients (9/69) and <50% of the GPs used a Cumulative Encounter Form (29/69) developed for the study. Most GPs were supportive of giving patients written guidelines (56/69) and establishing a gastroenterological (GI) nurse practitioner (45/69). Open access follow-up of patients with IBD is supported by GPs. The approach would probably be improved by the distribution of written information to patients, the establishment of a GI nurse practitioner and an integrated approach between the nurse, hospital specialist, GP and patient.
Meert, Kathleen L.; Eggly, Susan; Berger, John; Zimmerman, Jerry; Anand, K. J. S.; Newth, Christopher J. L.; Harrison, Rick; Carcillo, Joseph; Michael Dean, J.; Willson, Douglas F.; Nicholson, Carol
Objective Parents of children who die in the pediatric intensive care unit (PICU) often desire a follow-up meeting with the physicians who cared for their child. Our objective is to investigate critical care physicians’ experiences and perspectives regarding follow-up meetings with parents after a child’s death in the PICU. Design Semi-structured, audio-recorded telephone interviews. Setting Six clinical centers affiliated with the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN). Participants Seventy critical care physicians (i.e., attendings and fellows) practicing or training at a CPCCRN clinical center between February 1, 2008 and June 30, 2008. Measurements and Main Results Twenty-three (33%) physicians reported never participating in a follow-up meeting with bereaved parents; 22 (31%) participated in 1-5; and 25 (36%) participated in more than 5. Of those with prior experience, 44 (94%) met with parents at the hospital and 40 (85%) met within 3 months of the death. Meeting content included discussing autopsy, parent questions, hospital course, cause of death, genetic risk, bereavement services, and legal or administrative issues; providing emotional support; and receiving parent feedback. Forty (85%) physicians perceived the meetings to be beneficial to families, and 35 (74%) to physicians. Barriers included time and scheduling, family and physician unwillingness, distance and transportation, language and cultural issues, parent anger, and lack of a system for meeting initiation and planning. Conclusions Critical care physicians have a wide range of experience conducting follow-up meetings with bereaved parents. Although physicians perceive benefits to follow-up meetings, barriers exist that interfere with their implementation in clinical practice. PMID:20581729
Sanderson, Maureen; Khabele, Dineo; Brown, Claudine L; Harbi, Khalil; Alexander, Leah R; Coker, Ann L; Fernandez, Maria E; Brandt, Heather M; Fadden, Mary K; Hull, Pamela C
A clinic-based intervention study was conducted among high-risk human papillomavirus (HPV)-infected Latinas aged 18-64 years between April 2006 and May 2008 on the Texas-Mexico border. Women were randomly assigned to receive a printed material intervention (n=186) or usual care (n=187) and were followed at three months, six months, and 12 months through telephone surveys and review of medical records. The HPV knowledge of nearly all women had increased greatly, but only two-thirds of women reported they had received follow-up care within one year of diagnosis regardless of additional health education messaging. Our findings suggest that, regardless of type of health education messaging, Latinas living on the Texas-Mexico border are aware that follow-up care is recommended, but they may not receive this care. Individual, familial and medical care barriers to receipt of follow-up care may partially account for the higher rates of cervical cancer mortality in this region.
Kabi, Shobhitendu; Panda, Baikuntha Nath; Kameswari, B.C.; Payal; Behera, Ishwar Chandra; Tripathy, Subrat Kumar; Mahanta, Seemanchana
Introduction Among the modifiable risk factors for stroke, tobacco smoking is well recognized. In some studies the use of Smokeless Tobacco (ST) has also been contributed as a risk factor for ischemic stroke. Use of ST is very common in South-East Asia. The form of ST varies according to the geographical and cultural variation. Aim To study the various clinical symptoms and radiological findings of stroke due to different types of ST. Materials and Methods This was a prospective hospital based study carried out over a period of 2 years. All the cases within age group of 16 – 60 years and with a clinical and radiological diagnosis of acute stroke were included in the study. The Fagerström Test for Nicotine Dependence for ST of more than 6 was taken as the inclusion criteria. Patients having other addictions like smoked tobacco, alcohol, etc., and with important risk factors like hypertension, diabetes, dyslipidemia were excluded. The cases were extensively investigated and followed up for at least 6 months. Analysis was done using the Statistical Package for Social Sciences (SPSS- version 16.0). Descriptive statistics like percentage, mean were used wherever appropriate. Results During a period of 2 years, a total of 54 patients were studied. Forty two (77.7%) were males and 12(22.3%) were females. The mean age at presentation was 42.72(± 8.6) years and among all 96.3% patients were diagnosed as ischemic stroke. Among ST, pan was most commonly used in 21(38.9%) patients with an average of 14.6(±3.27) years of addiction. Hemiplegia was the predominant symptom on presentation (46, 85.2%). According to Oxfordshire Stroke Classification, partial anterior circulation infarct was most common in 20(38.4%). The mean Modified Rankin scale after 5 days of hospital stay was 3.83(±1.03) and after 6 months of follow-up was 2.1(±0.8). Patients were counseled for deaddiction and after 6 months follow-up 48(88.8%) patients had quit ST. Conclusion ST is an important
... Health Care Impact Evaluation of American Recovery and Reinvestment Act (ARRA)-Funded Grants; New... of the Green Jobs and Health Care ARRA-funded training grants. This evaluation is sponsored by ETA to... impacts of the Green Jobs and Health Care (GJHC) training grants. This evaluation is sponsored by ETA for...
Aleo, C L; Murchison, A P; Dai, Y; Hark, L A; Mayro, E L; Collymore, B; Haller, J A
Patient contracts are increasingly utilized in medical practice and have the potential to improve health outcomes in high-risk populations. However, as a relatively new tool, there has been limited research regarding the efficacy of patient contracts. Diabetic retinopathy (DR) is one of the leading causes of vision impairment in adults in the US and only 50-60% of adults with diabetes adhere to annual dilated fundus exam recommendations. This study aimed to evaluate the impact of patient contracts on follow-up adherence in diabetic patients with ocular abnormalities after a free, pharmacy-based eye screening. This prospective study implemented a non-invasive, non-mydriatic fundus camera in an urban, community-based pharmacy setting to screen for ocular diseases in patients with diabetes. Patients were assigned to the contract or non-contract group. Patients who signed a contract agreed to: 1) review their results with their primary care doctor, 2) follow-up with an ophthalmologist if their results were abnormal, and 3) inform research staff if/when they completed an eye care appointment. All study participants and their primary care doctors were notified of their results via mail. Follow-up questionnaires were administered to all patients by telephone three months after the screening results. 500 patients were screened and 113 (22.6%) had abnormal results. Of the patients who had abnormal results, 83 (74.3%) were able to be contacted. Of the 83 patients who were able to be contacted, the majority of patients were African American (73.5%) and female (56.6%). The mean age was 54.7 years. Of those, 34 (41.0%) adhered to follow-up recommendations. There was no significant difference in follow-up adherence between the contract (38.1%) and non-contract group (43.9%) (P = 0.59). In addition, 70.4% of patients did not comply with at least one measure of the contract agreement. Contracts did not increase follow-up adherence to eye appointments in diabetic patients with
Diao, Kevin; Sun, Yanqing; Yoo, Stella K; Yu, Cheng; Ye, Jason C; Trakul, Nicholas; Jennelle, Richard L; Kim, Paul E; Zada, Gabriel; Gruen, John P; Chang, Eric L
Stereotactic radiosurgery (SRS) alone is an increasingly accepted treatment for brain metastases, but it requires adherence to frequently scheduled follow-up neuroimaging because of the risk of distant brain metastasis. The effect of disparities in access to follow-up care on outcomes after SRS alone is unknown. This retrospective study included 153 brain metastasis patients treated consecutively with SRS alone from 2010 through 2016 at an academic medical center and a safety-net hospital (SNH) located in Los Angeles, California. Outcomes included neurologic symptoms, hospitalization, steroid use and dependency, salvage SRS, salvage whole-brain radiotherapy, salvage neurosurgery, and overall survival. Ninety-three of the 153 patients were private hospital (PH) patients, and 60 were SNH patients. The median follow-up time was 7.7 months. SNH patients received fewer follow-up neuroimaging studies (1.5 vs 3; P = .008). In a multivariate analysis, the SNH setting was a significant risk factor for salvage neurosurgery (hazard ratio [HR], 13.65; P < .001), neurologic symptoms (HR, 3.74; P = .002), and hospitalization due to brain metastases (HR, 6.25; P < .001). More clinical visits were protective against hospitalizations due to brain metastases (HR, 0.75; P = .002), whereas more neuroimaging studies were protective against death (HR, 0.65; P < .001). SNH patients with brain metastases treated with SRS alone had fewer follow-up neuroimaging studies and were at higher risk for neurologic symptoms, hospitalization for brain metastases, and salvage neurosurgery in comparison with PH patients. Clinicians should consider the practice setting and patient access to follow-up care when they are deciding on the optimal strategy for the treatment of brain metastases. Cancer 2017;. © 2017 American Cancer Society. © 2017 American Cancer Society.
Sances, Grazia; Galli, Federica; Ghiotto, Natascia; Allena, Marta; Guaschino, Elena; Frustaci, Alessandra; Nappi, Giuseppe; Tassorelli, Cristina
To evaluate factors associated with a negative outcome in a 3-year follow-up of subjects diagnosed with medication-overuse headache (MOH) (revised-ICHD-II criteria). All consecutive patients entering the center's inpatient detoxification program were analyzed in a prospective, non-randomized fashion. All participants were assessed by a neurologist using an ad hoc patient record form. Personality was assessed using the Minnesota Multiphasic Personality Inventory (MMPI)-2, Chi-square test, one-way analysis of variance (ANOVA), and odds ratios (OR) were calculated as appropriate. One-hundred and fifty patients completed the follow-up (79.3% females, age 46.40 ± 11.31 years): 13 never stopped their drug overuse (A), 38 stopped their overuse, but relapsed at least once (B), and 99 stopped and never relapsed (C). The Group A patients differed from those in B + C as they were more frequently single (OR 0.134; P = 0.007) and unemployed (OR 3.273; P = 0.04), took a higher number of drug doses ( P < 0.001), and less frequently drank coffee (OR 3.273; P = 0.044). Personality profile: subjects in A scored higher than those in C on the following scales: Hypochondriasis ( P = 0.007), Depression ( P = 0.003), Paranoia ( P = 0.025), Fears ( P = 0.003), Obsessiveness ( P = 0.026), Bizarre Mentation ( P = 0.046), Social Discomfort ( P = 0.004), Negative Treatment Indicators ( P = 0.040), Repression ( P = 0.007), Overcontrolled Hostility ( P = 0.040), Addiction Admission ( P = 0.021), Social Responsibility ( P = 0.039), and Marital Distress ( P = 0.028). Disease outcome in MOH patients is influenced negatively by overuse severity and by specific psychological and socio-economic variables. Other possible modifier factors were voluptuary habits.
Burridge, Letitia H; Foster, Michele M; Donald, Maria; Zhang, Jianzhen; Russell, Anthony W; Jackson, Claire L
As the prevalence of type 2 diabetes continues to escalate, health system reform is seeking better patient outcomes through new models of care that aim to provide the most appropriate care when needed. Patients' experiences of service innovations can shed light on the successes and challenges of implementing change. This paper explores patients' views of a new model of integrated care for patients with type 2 diabetes. A mixed-methods, randomised control trial evaluated a beacon clinic model of care for complex type 2 diabetes led by specialist general practitioners (GPs) in primary care settings in Brisbane, Australia. In this qualitative sub-study conducted between May 2014 and January 2015, 25 consenting participants were re-interviewed after 12 months using semi-structured questions, to explore their experiences of the new model of care. Interview transcripts were analysed thematically. In the first theme, Organised for patient-centred care, patients appraised the structural elements of the clinic. For most, it was an enabling experience which included convenience, flexibility and prompt communication back to the referring GPs. The preferences of a minority were partly realised, as they tried to understand the clinical purpose in comparison with traditional care. The second theme, Positioned as partners in care, revealed the pivotal role of patient-clinician relationships in patients' engagement with advice and self-care. Most found clinicians' collaborative approach engaging and motivating. A small minority with contextual concerns were disappointed with the focus on diabetes and struggled to engage fully with the model. Most participants valued this model of care, which reflects a capacity to manage the variable and complex needs of most patients referred for care. However, multi-level strategies are also needed to enhance patients' engagement with care and the sustainability of integrated diabetes care.
Barkow, Katrin; Maier, Wolfgang; Ustün, T Bedirhan; Gänsicke, Michael; Wittchen, Hans-Ulrich; Heun, Reinhard
The aim of this study was to identify internationally relevant risk factors for the persistence of depression in primary care. None of the previous studies examining primary care patients could examine an equivalently large international sample. The findings from the WHO Collaborative Study on 'Psychological Problems in General Health Care' might be generalised to different cultural environments. A primary care sample of depressed subjects (ICD-10) (n=725) from 15 centres from all over the world was reinvestigated for the presence of depression after 12 months. Logistic regression analysis was used to determine the relationship of sociodemographic variables, characteristics of mental illness, and social disability with depression at follow-up. 33.5% of the subjects met ICD-10 criteria for a current depressive episode at the 12-month follow-up. Logistic regression analysis revealed that years of formal education, unemployment, depression severity, antidepressant use, abdominal pain as the main reason for consulting the general practitioner, and 'Repeated suicidal thoughts' were related to depression after 1 year. We have only poor information about details of the actual course of patients between the two assessments. Our findings of significant variables are generally comparable to results of previously conducted studies. Sociodemographic and disease-specific variables play an important role in the prediction of depression at the 12-month follow-up. General practitioners must be careful in the consideration of these variables but also of individual patient characteristics.
Espehaug, Birgitte; Hausken, Marie F; Graue, Marit; Østbye, Truls; Skeie, Svein; Cooper, John G; Tell, Grethe S; Günther, Bodo Erhardt; Dale, Håvard; Smith-Strøm, Hilde; Kolltveit, Beate-Christin H; Kirkevold, Marit; Rokne, Berit
Background This paper presents the protocol for an ongoing study to evaluate a telemedicine follow-up intervention for patients with diabetes-related foot ulcers. Diabetes-related foot ulcers represent challenges for patients and the health services. The large increase in the prevalence of diabetes, combined with the aging population, means that the absolute number of patients with diabetes-related foot ulcers is likely to continue to increase. Health care services therefore need to provide close clinical follow-up care for people with diabetes both in primary and specialist care. Information and communication technologies may enable more integrated treatment and care pathways across organizational boundaries. However, we lack knowledge about the effect of telemedicine follow-up and how such services can be optimally organized. Objective To present the design and methods of a study evaluating a telemedicine follow-up intervention for patients with diabetes-related foot ulcers. Methods The study is designed as a cluster randomized controlled trial (noninferiority trial) involving municipalities or municipality districts (clusters) belonging to one clinical site in Western Norway. The study includes patients with type 1 and type 2 diabetes presenting with a new foot ulcer at the initial visit to the clinic. Patients in the intervention group receive telemedicine follow-up care in the community. The key ingredient in the intervention is the close integration between health care levels. The intervention is facilitated by the use of an interactive wound platform consisting of a Web-based ulcer record combined with a mobile phone, enabling counseling and communication between nurses in the community and specialist health care. Patients in the control group receive standard hospital outpatient care. The primary endpoint in the trial is healing time; secondary outcomes include amputation and death, patient-reported outcome measures, and follow-up data on the recurrence of
Muta, Rieko; Sanjo, Makiko; Miyashita, Mitsunori; Wakabayashi, Rieko; Ando, Etsuko; Morita, Tatsuya; Tsuneto, Satoru; Shima, Yasuo
There is no standardized method by which bereavement care is offered by hospice/palliative care units (PCUs) in Japan. To evaluate bereavement services provided by hospice/PCUs and clarify demands for bereavement care. Qualitative design based on semistructured interviews and content analysis. Forty-four bereaved family members of patients with cancer who died in 9 PCUs in 4 regions. Memorial services were positively evaluated for the following variables: reunion and interaction with staff; the service's relaxed atmosphere; staff attentiveness; suitable location; suitable timing; program content; and interaction with other bereaved families. Memorial cards were positively evaluated regarding the level of concern shown by the staff and the personalized card. Respondents indicated their desire for a care system, a bereaved family care program, and information services. © The Author(s) 2013.
Li-Tsang, Cecilia W. P.; Lee, Maggie Y. F.; Yeung, Susanna S. S.; Siu, Andrew M. H.; Lam, C. S.
We investigated the long-term effects of an information and communication technology (ICT) training programme for people with intellectual disabilities (ID). A community-based ICT training programme was designed to enhance the computer skills of people with ID and prepare them to make use of ICT in their daily life. Of the 100 who had participated…
Li-Tsang, Cecilia W. P.; Lee, Maggie Y. F.; Yeung, Susanna S. S.; Siu, Andrew M. H.; Lam, C. S.
We investigated the long-term effects of an information and communication technology (ICT) training programme for people with intellectual disabilities (ID). A community-based ICT training programme was designed to enhance the computer skills of people with ID and prepare them to make use of ICT in their daily life. Of the 100 who had participated…
Dieluweit, U; Seitz, D C M; Besier, T; Debatin, K-M; Grabow, D; Kaatsch, P; Goldbeck, L
Survivors of pediatric cancer are at increased risk for medical and psychosocial late effects. This study retrospectively investigated the utilization of oncological and psychosocial care by former adolescent cancer patients (≥ 5 years since cancer diagnosis) in Germany. Based on data of the German Childhood Cancer Registry (N=1 876 survivors of cancer with an age at diagnosis between 15 and 18 years), the study cohort comprised 820 survivors of adolescent cancer (time since diagnosis: M=13.7, SD=6.0, age at follow-up: M=30.4, SD=6.0 years). Survivors of adolescent cancer completed standardized questionnaires measuring symptoms of posttraumatic stress, depression and anxiety as well as items on their utilization of medical and psychosocial care. More than a quarter (26.2%) of the survivors was no longer attending regular oncological follow-up assessments. Less than half of the survivors (44.4%) had received psychosocial care, mostly during their in-patient cancer treatment and their post-acute rehabilitation phase. Out of 184 survivors showing clinically relevant symptoms of posttraumatic stress, anxiety and/or depression at time of the study, 12.0% received psychosocial care and 13.6% took psychotropic medication. It should be studied further why only a small proportion of the survivors showing clinically relevant symptoms received psychosocial or psychopharmacological treatment. Systematic oncological follow-up assessments should take psychological late effects into greater account. © Georg Thieme Verlag KG Stuttgart · New York.
Sances, G; Ghiotto, N; Galli, F; Guaschino, E; Rezzani, C; Guidetti, V; Nappi, G
To investigate factors influencing prognosis in medication-overuse headache (MOH), we conducted a 12-month follow-up of patients with probable MOH. We recruited 215 patients consecutively admitted to our headache centre for an inpatient detoxification treatment. We analysed likely predictor factors for headache resolution (sex, age, primary headache, psychiatric comorbidity, type and timing of overuse). Mann-Whitney U-test and chi-squared test were used. One year after withdrawal, we had complete data on 172 patients (80%): 38 of these patients (22%) had relapsed into overuse and 134 (78%) had not. The negative prognostic factors for relapse were: intake of more than 30 doses/month (P = 0.004), smoking (P = 0.012), alcohol consumption (P = 0.037), non-confirmation of MOH diagnosis 2 months after detoxification (P = 0.000), and return to overused drug(s) (P = 0.000). The 1-year relapse rate was 22%. The existence of sub-groups of MOH patients with such risk factors could influence treatment strategies.
Cauley, Keith A; Linnell, Grant J; Braff, Steven P; Filippi, Christopher G
The purpose of this study was to retrospectively assess the outcomes of temporal MRI follow-up of indeterminate cystic lesions of the pineal region. Cases of indeterminate pineal lesions were identified by a computerized search of radiology reports at our institution from 1998 to 2007. Twenty-six indeterminate pineal lesions, one each in 26 patients (six males and 20 females), were followed in the current study. Cases were included in the study if the radiology report detailed an incidentally noted but indeterminate or worrisome cystic lesion of the pineal region and if temporal follow-up MRI was recommended by the interpreting neuroradiologist. For a case to be included in our data set, a follow-up MRI study must have been obtained at least 6 months after the initial study. Follow-up imaging ranged from 7 months to 8 years. Lesions ranged in description and appearance from "probable benign cyst" with typical cystic imaging features to "pineal mass" with features of solid enhancement. We found that, within the limitations of the technique, there were no significant changes in the size or character of any indeterminate pineal region lesion followed at our institution over the time interval of 1998-2007. In our study, all pineal lesions found incidentally and for which follow-up imaging had been recommended were stable over time. These data suggest that neoplastic lesions of the pineal region either are too rare or grow too slowly to be identified by traditional temporal imaging follow-up. With increasing interest in optimal allocation of health care resources, our findings suggest that incidentally identified pineal region cystic lesions, both typical and atypical, can be followed clinically.
Trojahn, Melina Maria; Ruschel, Karen Brasil; Nogueira de Souza, Emiliane; Mussi, Cláudia Motta; Naomi Hirakata, Vânia; Nogueira Mello Lopes, Alexandra; Rabelo-Silva, Eneida Rejane
This study aimed to examine the predictors of better self-care behavior in patients with heart failure (HF) in a home visiting program. This is a longitudinal study nested in a randomized controlled trial (ISRCTN01213862) in which the home-based educational intervention consisted of a six-month followup that included four home visits by a nurse, interspersed with four telephone calls. The self-care score was measured at baseline and at six months using the Brazilian version of the European Heart Failure Self-Care Behaviour Scale. The associations included eight variables: age, sex, schooling, having received the intervention, social support, income, comorbidities, and symptom severity. A simple linear regression model was developed using significant variables (P ≤ 0.20), followed by a multivariate model to determine the predictors of better self-care. One hundred eighty-eight patients completed the study. A better self-care behavior was associated with patients who received intervention (P < 0.001), had more years of schooling (P = 0.016), and had more comorbidities (P = 0.008). Having received the intervention (P < 0.001) and having a greater number of comorbidities (P = 0.038) were predictors of better self-care. In the multivariate regression model, being in the intervention group and having more comorbidities were a predictor of better self-care. PMID:24083023
Armor, Becky L; Wight, Avery J; Carter, Sandra M
Approximately two-thirds of adverse events posthospital discharge are due to medication-related problems. Medication reconciliation is a strategy to reduce medication errors and improve patient safety. To evaluate adverse drug events (ADEs), potential ADEs (pADEs), and medication discrepancies occurring between hospital discharge and primary care follow-up in an academic family medicine clinic. Adult patients recently discharged from the hospital were seen by a pharmacist for medication reconciliation between September 1, 2011, and November 30, 2012. The pharmacist identified medication discrepancies and pADEs or ADEs from a best possible medication history obtained from the electronic medical record (EMR) and hospital medication list. In 43 study participants, an average of 2.9 ADEs or pADEs was identified (N = 124). The most common ADEs/pADEs identified were nonadherence/underuse (18%), untreated medical problems (15%), and lack of therapeutic monitoring (13%). An average of 3.9 medication discrepancies per participant was identified (N = 171), with 81% of participants experiencing at least 1 discrepancy. The absence of a complete and accurate medication list at hospital discharge is a barrier to comprehensive medication management. Strategies to improve medication management during care transitions are needed in primary care. © The Author(s) 2014.
Meert, Kathleen L.; Eggly, Susan; Berg, Robert A.; Wessel, David L.; Newth, Christopher J.L.; Shanley, Thomas P.; Harrison, Rick; Dalton, Heidi; Clark, Amy E.; Dean, J. Michael; Doctor, Allan; Nicholson, Carol E.
Objective To evaluate the feasibility and perceived benefits of conducting physician-parent follow-up meetings after a child’s death in the PICU according to a framework developed by the Collaborative Pediatric Critical Care Research Network (CPCCRN). Design Prospective observational study. Setting Seven CPCCRN affiliated children’s hospitals. Subjects Critical care attending physicians, bereaved parents, and meeting guests (i.e., parent support persons, other health professionals). Interventions: Physician-parent follow-up meetings using the CPCCRN framework. Measurements and Main Results Forty-six critical care physicians were trained to conduct follow-up meetings using the framework. All meetings were video recorded. Videos were evaluated for the presence or absence of physician behaviors consistent with the framework. Present behaviors were evaluated for performance quality using a 5-point scale (1=low, 5=high). Participants completed meeting evaluation surveys. Parents of 194 deceased children were mailed an invitation to a follow-up meeting. Of these, one or both parents from 39 families (20%) agreed to participate, 80 (41%) refused, and 75 (39%) could not be contacted. Of 39 who initially agreed, three meetings were canceled due to conflicting schedules. Thirty-six meetings were conducted including 54 bereaved parents, 17 parent support persons, 23 critical care physicians and 47 other health professionals. Physician adherence to the framework was high; 79% of behaviors consistent with the framework were rated as present with a quality score of 4.3±0.2. Of 50 evaluation surveys completed by parents, 46 (92%) agreed or strongly agreed the meeting was helpful to them and 40 (89%) to others they brought with them. Of 36 evaluation surveys completed by critical care physicians (i.e., one per meeting), 33 (92%) agreed or strongly agreed the meeting was beneficial to parents and 31 (89%) to them. Conclusions Follow-up meetings using the CPCCRN framework are
Hansen, Vibeke Brogaard; Maindal, Helle Terkildsen
In Denmark, the local and regional health authorities share responsibility for cardiac rehabilitation (CR). The objective was to assess effectiveness of CR across sectors coordinated by a nurse case manager (NCM). A one-year follow-up study. A CR programme (GoHeart) was evaluated in a cohort at Lillebaelt Hospital Vejle, DK from 2010 to 2011. Consecutive patients admitted to CR were included. The inclusion criteria were the event of acute myocardial infarction or stable angina and invasive revascularization (left ventricular ejection fraction (LVEF) ≥45%). Cardiac risk factors, stratified self-care and self-reported psychosocial factors (SF12 and Hospital Anxiety and Depression Scale (HADS)) were assessed at admission (phase IIa), at three months at discharge (phase IIb) and at one-year follow-up (phase III). Intention-to-treat and predefined subgroup analysis on sex was performed. Of 241 patients, 183 (75.9%) were included (mean age 63.8 years). At discharge improvements were found in total-cholesterol (p < 0.001), low density lipoprotein (LDL; p < 0.001), functional capacities (metabolic equivalent of tasks (METS), p < 0.01), self-care management (p < 0.001), Health status Short Form 12 version (SF12; physical; p < 0.001 and mental; p < 0.01) and in depression symptoms (p < 0.01). At one-year follow-up these outcomes were maintained; additionally there was improvement in body mass index (BMI; p < 0.05), and high density lipoprotein (HDL; p < 0.05). There were no sex differences. CR shared between local and regional health authorities led by a NCM (GoHeart) improves risk factors, self-care and psychosocial factors. Further improvements in most variables were at one-year follow-up.
Lagerström, Lennart; Fornell, Ann-Charlott; Stenvik, Arild
Changes in the occlusion after orthodontic treatment have in several studies been analyzed by the use of the PAR Index developed by Shaw & Richmond. The use of the PAR Index has been shown by O'Brien & Shaw to be a reliable and reproducible method to evaluate orthodontic treatment results. The purpose of the study was to examine the long-range orthodontic treatment outcome by following a group of patients into adulthood to the age of 31 years. For the study 115 individuals from a previous randomized study were invited for follow-up examination at age 31 years. Seventy-two individuals, 32 males (44.4%) and 40 females (55.6%) of the original sample attended for clinical examination. Study casts were obtained and questionnaires addressing the patient's awareness and opinion of the treatment were distributed. In addition twenty-four subjects responded by returning filled-in questionnaires. The mean change in wPAR scores from start to retention represents a mean relative improvement in occlusion of 78.7%. The mean wPar score improvement from age 19 to 31 years was 11.9%. The relative mean wPar score change dropped to 53.5% at age 31 years. The differences in wPAR recordings between the recorded stages were all statistically significant. The treatment outcome as expressed by mean wPAR scores at age 31 years was significantly better among individuals treated with extractions compared to those treated without extractions. The mean wPAR scores of the individuals with retainers at age 31 years were significantly lower when compared to the mean score for those without retainers (unpaired t-test, p = 0.020). This clearly indicates the benefit of long-term retention. The changes in the concern scores from 19 to 31 years of age were small. At age 31 years only 8 of the 96 respondents (8.3%) expressed concern about the treatment outcome.
Pigrau-Serrallach, Carlos; Cabral-Galeano, Evelyn; Almirante-Gragera, Benito; Sordé-Masip, Roger; Rodriguez-Pardo, Dolors; Fernandez-Hidalgo, Nuria; Larrosa-Escartín, Nieves; Bescos-Atín, Socorro; Pahissa-Berga, Albert
This study reviews our experience in bisphosphonate-associated jaw osteomyelitis (BJOM), focusing on the incidence, etiology, treatment, and long-term outcome. Retrospective review of the clinical histories adult patients diagnosed with BJOM (1995-2008) in a tertiary hospital. BJOM was found in 30 of 132 (22.7%) consecutive patients with jaw osteomyelitis. The percentage of BJOM cases increased from 8.7% (4/46) in 1995-2005 to 30.2% (26/86) in 2005-2008. Symptoms appeared in a median of 2.5 years after intravenous use, and 4.5 years after oral exposure. Viridans group streptococci were isolated in 83.3% of cases. Actinomyces spp. was found in 16 (39.0%) of 41 bone histologies. All included patients received a median of 6 months of appropiate antibiotic therapy and a surgical procedure (debridament and/or sequestrectomy). Thirteen of 27 cases (48.1%) with long-term follow-up (median 22 months, IQR 25-75 17-28) failed. Clinical failure defined as, persistent infection or relapse, was more frequent in patients receiving intravenous than oral bisphosphonates (11/16 [68.8%] vs. 2/11 [18.2%]; P < .05) and in cases with Actinomyces spp. (7/10 [70.0%] vs6/17 [35.3%]; P = .08). Bisphosphonate therapy is now a frequent cause of JO. BJOM is difficult to cure and relapses are common, particularly in patients exposed to intravenous bisphosphonates. Copyright © 2012 Elsevier España, S.L. All rights reserved.
Grimmsmann, Thomas; Himmel, Wolfgang
To study drug persistence for antihypertensive treatment considering typical patient behaviour including extended drug holidays or irregular repeat prescriptions. We used prescription data from a German statutory health insurance to follow up patients for 4 years. Medication persistence was defined as the continued use of a specific drug class, therapy persistence as the continued use of any antihypertensive drug. We applied 2 different interval criteria within which a repeat prescription had to be issued: 180 and 360 days. A total of 9,513 patients started an antihypertensive therapy between 2006 and 2008. Applying the 180-day (360-day) interval criterion, 28 % (66 %) of the patients starting therapy with a beta-blocker were still medication-persistent after 4 years. The rates were similar for angiotensin-II receptor blockers (ARBs; 30 % and 69 % respectively) or angiotensin-converting enzyme (ACE) inhibitors (28 % and 61 % respectively). Looking at therapy persistence, these rates were 44 % (79 %) when an ACE inhibitor was the initial drug, 46 % (82 %) for ARBs. On average, even of those who were defined as therapeutically persistent with the 360 days criterion, half received a repeat prescription within 96 days, three quarters within 131 days-with a median supply of 1.2 units per day and 1.25 defined daily doses. By applying more patient-orientated criteria, we found that many patients were therapy-persistent and received a prescription at the appropriate time. Therapy persistence was nearly independent of the initial agent; thus, drug persistence may not be an argument in favour of choosing a certain drug as a first-line option.
Tsai, Ming-Hsien; Fang, Yu-Weil; Wang, Li Hui; You, Xiang Gin; Leu, Jyh-Gang
Abstract Multidisciplinary predialysis education and team care (MDC) may slow the decline in renal function in patients with chronic kidney disease (CKD). However, associations between unexpected return during MDC and progression of renal dysfunction have not been characterized in patients with CKD. Our study aimed to determine the association between exacerbation of renal dysfunction and the frequency of unexpected return during follow-up. A total of 437 patients with CKD receiving multidisciplinary care between January 2009 and June 2013 at the Shin-Kong Wu Ho-Su Memorial Hospital were included in this retrospective observational cohort study, and multiple imputations were performed for missing data. The predictor was the frequency of unexpected return for follow-up during the first year after entering MDC. Main outcome was monthly declines in estimated glomerular filtration rates (eGFR). Moreover, the demographic data, comorbidities, history of medication, and routine laboratory data for patients with CKD were collected. Among all patients, 59.7% were male, the mean age at initiation of MDC was 69.4 ± 13.2 years, and the duration of follow-up was 21.4 ± 3.3 months. The subjects were divided into 2 groups according to frequencies of follow-up (≤4 and > 4 visits) during the 1st year of MDC. The patients with CKD were regularly followed up every 3 months as a part of MDC in our hospital, and patients who returned for more than 4 follow-up visits were included in the unexpected return group. In crude regression analyses, unexpected return was significantly associated with higher monthly declines of eGFR (β = 0.092, 95% confidence interval, 0.014–0.170). This association remained after adjustments for multiple variables, and subgroup analyses of unexpected return showed that male gender, older age, CKD stage 1 to 3, hypertension, history of coronary artery disease, and use of renin–angiotensin system blockade were significantly associated with
Tsai, Ming-Hsien; Fang, Yu-Weil; Wang, Li Hui; You, Xiang Gin; Leu, Jyh-Gang
Multidisciplinary predialysis education and team care (MDC) may slow the decline in renal function in patients with chronic kidney disease (CKD). However, associations between unexpected return during MDC and progression of renal dysfunction have not been characterized in patients with CKD. Our study aimed to determine the association between exacerbation of renal dysfunction and the frequency of unexpected return during follow-up.A total of 437 patients with CKD receiving multidisciplinary care between January 2009 and June 2013 at the Shin-Kong Wu Ho-Su Memorial Hospital were included in this retrospective observational cohort study, and multiple imputations were performed for missing data. The predictor was the frequency of unexpected return for follow-up during the first year after entering MDC. Main outcome was monthly declines in estimated glomerular filtration rates (eGFR). Moreover, the demographic data, comorbidities, history of medication, and routine laboratory data for patients with CKD were collected.Among all patients, 59.7% were male, the mean age at initiation of MDC was 69.4 ± 13.2 years, and the duration of follow-up was 21.4 ± 3.3 months. The subjects were divided into 2 groups according to frequencies of follow-up (≤4 and > 4 visits) during the 1st year of MDC. The patients with CKD were regularly followed up every 3 months as a part of MDC in our hospital, and patients who returned for more than 4 follow-up visits were included in the unexpected return group. In crude regression analyses, unexpected return was significantly associated with higher monthly declines of eGFR (β = 0.092, 95% confidence interval, 0.014-0.170). This association remained after adjustments for multiple variables, and subgroup analyses of unexpected return showed that male gender, older age, CKD stage 1 to 3, hypertension, history of coronary artery disease, and use of renin-angiotensin system blockade were significantly associated with declines in
Martikainen, Kirsti K; Seppä, Kaija; Viita, Paula M; Rajala, Sulo A; Luukkaala, Tiina H; Keränen, Tapani
The prognosis of transient loss of consciousness (LOC) was studied in a one-year follow-up survey. Included were adult patients referred by primary health care physicians for a non-acute specialist consultation during the 2-year period from 01.10.1999 to 30.9.2001. The main outcome measures were recurrence of LOCs during the follow-up, fear of recurrence, injuries, and employment. Altogether, 109 consecutive patients were followed and 39 (36%) suffered a recurrence during the one-year follow-up: 17 (30%) with syncope, 16 (43%) with seizure and six (38%) with uncertain type of LOC. The first ever seizure recurred in 5/9 (56%) during the first year, but only 1 of 17 (6%) first syncope attacks. There was no difference in the recurrence rate if the patient had had previous attacks prior to the index LOC. Injuries, mainly minor, were associated with LOCs in 56% of patients. The risk of injury was highest (83%) with alcohol-related seizures. The unemployment rate was especially high in the seizure group. Fear of recurrence was more common at the beginning than at the end of the follow-up. Seizures recur relatively often, but also recurrent syncope needs more attention--both may cause fear and lead to injuries.
Gil, Karen M.; And Others
Studied adults with sickle cell disease (SCD) participating in longitudinal study of pain-coping strategies. Eighty-nine subjects completed baseline assessment of pain-coping strategies and structured pain interviews assessing health care use and activity reduction during painful episodes. Baseline Negative Thinking and Passive Adherence were…
Gil, Karen M.; And Others
Studied adults with sickle cell disease (SCD) participating in longitudinal study of pain-coping strategies. Eighty-nine subjects completed baseline assessment of pain-coping strategies and structured pain interviews assessing health care use and activity reduction during painful episodes. Baseline Negative Thinking and Passive Adherence were…
Dale, Jeremy; Martin, Steven; Gadsby, Roger
To evaluate the 3-year impact of initiating basal insulin on glycaemic control (HbA1c) and weight gain in patients with poorly controlled type 2 diabetes registered with UK general practices that volunteered to participate in an insulin initiation training programme. Audit utilising data collected from practice record systems, which included data at baseline, 3, 6 months and subsequent six-monthly intervals post-insulin initiation for up to 10 patients per participating practice. Of 115 eligible practices, 55 (47.8%) contributed data on a total of 516 patients. The mean improvement in HbA1c levels in the first 6 months was 1.4% (range -3.8% to 8.2%, median=1.40%). Thereafter, there was no overall change in HbA1c levels, although the change for individual patients ranged from -4.90% to +7.50%. At 36 months, 141 (41%) patients for whom data were provided had achieved the pre-2006/2007 UK Quality and Outcomes Framework (QOF) target of 7.4% or less, including 98 (29%) who had achieved an HbA1c of 7% or less. Patients who achieved target had a lower HbA1c at baseline (mean 9.1% compared to 9.7%; p<0.001); had a lower weight at 36 months (mean 88.0kg compared to 93.5kg; p=0.05); were more likely to be on basal insulin alone (88, 47.1% compared to 46, 34.6%; p<0.05); and were slightly older (mean 64.5 years compared to 61.7 years; p<0.05). Attending an insulin initiation training programme may successfully prepare primary healthcare professionals to initiate insulin therapy as part of everyday practice for patients with poorly controlled type 2 diabetes. The impact on glycaemic control is maintained over a 3-year period. Although intensification of treatment occurred during this period, the findings suggest scope for further intensification of insulin therapy in order to improve on the glycaemic control achieved during the first 6 months post-insulin initiation.
Sondo, B; Testa, J; Kone, B
Our aim was to analyze the financial costs of health care for women in labor transferred to primary referral maternity units in childbirth at risk. Another aim was to consider the willingness of women and their husbands to financially save and support the increasing costs of health care. For 15 consecutive days, medical students interviewed all women transferred for a risky delivery in 12 of the 17 primary referral maternity units in Burkina Faso. The median cost for transferring the women and their necessary health care was approximately 30,500 CFA. The median cost for the kit of surgical supplies was 15,000 CFA; the costs of medicine and transportation fare for the woman and her husband were 14,000 CFA and 9,800 CFA, respectively. The median cost for the health care of the newborn was 2,400 CFA. When the decision for the transfer was made, the necessary money to pay for the expenses was available for only 40 out of 79 women. Women and their husbands were willing to save for health care either through existing community institutions such as groups of villagers and popular savings developments (69 women and men); or through annuity schemes to be created (33 women and men); or through banks (4 women and men). Four women and 6 men refused to contribute because of previous experiences of poor management of collective funds. The average savings were low and insufficient to cover the expected expenses for the transfer and care of the women. The savings were reserved for payment of the transportation fare for the women and their husbands to the referral units (21 women and 20 men), prescriptions (9 women and 5 men), the medical consultation (1 woman), and to provide for both (37 women and 39 men). The costs of health care are expensive. The poverty of the couple facing an urgent problem of life or death made them discover new options for investing in their available community associations such as groups of villagers and popular savings developments and other options such
Lundqvist, Stefan; Börjesson, Mats; Larsson, Maria E H; Hagberg, Lars; Cider, Åsa
There is strong evidence that inadequate physical activity (PA) leads to an increased risk of lifestyle-related diseases and premature mortality. Physical activity on prescription (PAP) is a method to increase the level of PA of patients in primary care, but needs further evaluation. The aim of this observational study was to explore the association between PAP-treatment and the PA level of patients with metabolic risk factors and the relationship between changes in the PA level and health outcomes at the 6 month follow-up. This study included 444 patients in primary care, aged 27-85 years (56% females), who were physically inactive with at least one component of metabolic syndrome. The PAP-treatment model included: individualized dialogue concerning PA, prescribed PA, and a structured follow-up. A total of 368 patients (83%) completed the 6 months of follow-up. Of these patients, 73% increased their PA level and 42% moved from an inadequate PA level to sufficient, according to public health recommendations. There were significant improvements (p≤ 0.05) in the following metabolic risk factors: body mass index, waist circumference, systolic blood pressure, fasting plasma glucose, cholesterol, and low density lipoprotein. There were also significant improvements regarding health-related quality of life, assessed by the Short Form 36, in: general health, vitality, social function, mental health, role limitation-physical/emotional, mental component summary, and physical component summary. Regression analysis showed a significant association between changes in the PA level and health outcomes. During the first 6-month period, the caregiver provided PAP support 1-2 times. This study indicates that an individual-based model of PAP-treatment has the potential to change people's PA behavior with improved metabolic risk factors and self-reported quality of life at the 6 month follow-up. Thus, PAP seems to be feasible in a clinical primary care practice, with minimum effort
Börjesson, Mats; Larsson, Maria E. H.; Hagberg, Lars; Cider, Åsa
There is strong evidence that inadequate physical activity (PA) leads to an increased risk of lifestyle-related diseases and premature mortality. Physical activity on prescription (PAP) is a method to increase the level of PA of patients in primary care, but needs further evaluation. The aim of this observational study was to explore the association between PAP-treatment and the PA level of patients with metabolic risk factors and the relationship between changes in the PA level and health outcomes at the 6 month follow-up. This study included 444 patients in primary care, aged 27–85 years (56% females), who were physically inactive with at least one component of metabolic syndrome. The PAP-treatment model included: individualized dialogue concerning PA, prescribed PA, and a structured follow-up. A total of 368 patients (83%) completed the 6 months of follow-up. Of these patients, 73% increased their PA level and 42% moved from an inadequate PA level to sufficient, according to public health recommendations. There were significant improvements (p≤ 0.05) in the following metabolic risk factors: body mass index, waist circumference, systolic blood pressure, fasting plasma glucose, cholesterol, and low density lipoprotein. There were also significant improvements regarding health-related quality of life, assessed by the Short Form 36, in: general health, vitality, social function, mental health, role limitation-physical/emotional, mental component summary, and physical component summary. Regression analysis showed a significant association between changes in the PA level and health outcomes. During the first 6-month period, the caregiver provided PAP support 1–2 times. This study indicates that an individual-based model of PAP-treatment has the potential to change people’s PA behavior with improved metabolic risk factors and self-reported quality of life at the 6 month follow-up. Thus, PAP seems to be feasible in a clinical primary care practice, with minimum
Johnson, Jeffrey A; Al Sayah, Fatima; Wozniak, Lisa; Rees, Sandra; Soprovich, Allison; Qiu, Weiyu; Chik, Constance L; Chue, Pierre; Florence, Peter; Jacquier, Jennifer; Lysak, Pauline; Opgenorth, Andrea; Katon, Wayne; Majumdar, Sumit R
Depressive symptoms are common and, when coexisting with diabetes, worsen outcomes and increase health care costs. We evaluated a nurse case-manager-based collaborative primary care team model to improve depressive symptoms in diabetic patients. We conducted a controlled implementation trial in four nonmetropolitan primary care networks. Eligible patients had type 2 diabetes and screened positive for depressive symptoms, based on a Patient Health Questionnaire (PHQ) score of ≥10. Patients were allocated using an "on-off" monthly time series. Intervention consisted of case-managers working 1:1 with patients to deliver individualized care. The main outcome was improvement in PHQ scores at 12 months. A concurrent cohort of 71 comparable patients was used as nonscreened usual care control subjects. Of 1,924 patients screened, 476 (25%) had a PHQ score >10. Of these, 95 were allocated to intervention and 62 to active control. There were no baseline differences between groups: mean age was 57.8 years, 55% were women, and the mean PHQ score was 14.5 (SD 3.7). Intervention patients had greater 12-month improvements in PHQ (7.3 [SD 5.6]) compared with active-control subjects (5.2 [SD 5.7], P = 0.015). Recovery of depressive symptoms (i.e., PHQ reduced by 50%) was greater among intervention patients (61% vs. 44%, P = 0.03). Compared with trial patients, nonscreened control subjects had significantly less improvement at 12 months in the PHQ score (3.2 [SD 4.9]) and lower rates of recovery (24%, P < 0.05 for both). In patients with type 2 diabetes who screened positive for depressive symptoms, collaborative care improved depressive symptoms, but physician notification and follow-up was also a clinically effective initial strategy compared with usual care. © 2014 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
Magee, Catherine G.; Hult, Jen R.; Turalba, Ruby; McMillan, Shelby
Growing evidence indicates that women in prison are particularly vulnerable to many negative health outcomes, including cervical cancer. The Papanicolaou (Pap) test is an effective tool to screen for this disease. To determine what is and is not working with the Pap test and follow-up treatment, we performed qualitative interviews with women prisoners and key informants at a California state women’s prison. Our assessment revealed that the process of administering Pap tests at this institution was not meeting the health care needs of the women interviewed. Women reported having negative experiences during the test and with their health care providers. Additionally the prison’s culture and infrastructure create obstacles that hinder prisoners from receiving quality care and providers from delivering that care. In response, women prisoners use self-and community advocacy to meet their health care needs and cope with these challenges. PMID:16186450
Sackey, Peter V; Martling, Claes-Roland; Carlswärd, Christine; Sundin, Orjan; Radell, Peter J
To compare memories from the intensive care unit (ICU) and short- and long-term psychological morbidity in patients after sedation with intravenous midazolam or inhaled isoflurane. Prospective long-term follow-up after randomized controlled trial. General ICU at Karolinska University Hospital, Solna, Stockholm. Forty patients in need of sedation during ventilator treatment. Patients were randomized to receive isoflurane or midazolam for goal-directed sedation until extubation or for a maximum of 96 hrs. For short-term follow-up, doctors', nurses', and physiotherapists' notes from the 4 days following exposure to the study drugs were reviewed for words indicating adequate or pathologic cognitive and psychological recovery. For long-term follow-up, all 6-month survivors received questionnaires including the ICU Memory Tool (ICU-MT), Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), and Well-Being Index. Additionally, several screening questions for previous posttraumatic stress symptoms were included. In the short term follow-up, no significant differences were found between groups. In the long-term follow-up, a trend toward fewer hallucinations/delusions after isoflurane sedation than after midazolam (two of ten isoflurane patients vs. five of seven midazolam patients) was found (p = .06). None of the five solely isoflurane-sedated patients reported hallucinations/delusions from the ICU. There was no difference in groups in long-term psychological morbidity as measured with HADS and IES. Memories of negative feelings in the ICU (ICU-MT) were associated with high HADS and IES scores (Fisher's exact test, p = .02 and p = .01, respectively). Sedation of ICU patients with isoflurane may result in fewer delusional memories or hallucinations from the ICU compared with more commonly used intravenous sedation. Memories of negative feelings from the ICU were associated with symptoms of depression or anxiety or symptoms indicating posttraumatic stress
Jani, Bhautesh Dinesh; Purves, David; Barry, Sarah J. E.; McCowan, Colin; Cavanagh, Jonathan; Mair, Frances S.
Background: Evidence on the long-term usefulness of anti-depressants in managing depression in cardiometabolic disease is limited. Aim: We examined the effects of anti-depressant prescribing on depressive symptoms at 12 months follow-up in patients with cardiometabolic disease and a positive depression screening result at baseline. Design and Setting: We retrospectively reviewed routine UK primary care data for patients with coronary heart disease, diabetes and previous stroke for the year 2008–2009. 35,537 patients with one of the three above diseases underwent depression screening using the Hospital Anxiety and Depression Scale (HADS-D). Of 7080 patients with a positive screening result (HADS-D ≥ 8), 3933 (55.5%) patients had a repeat HADS-D recorded at 12 months follow-up. Methods: We compared the change in HADS-D at follow-up and remission rate in those who were prescribed anti-depressants (n = 223) against those who were not (n = 3710). Results: The mean change in HADS-D from baseline, for the nonprescribed group was similar to the reduction observed in patients who were continuously prescribed (n = 93) with anti-depressants during follow-up. Patients who were prescribed intermittently (n = 72) or only one (n = 58) prescription during follow-up had a lower reduction in HADS-D compared to the nonprescribed group. There was no difference in remission rates between continuously prescribed and the nonprescribed group, but remission was lower in patients prescribed intermittently and single prescription. Conclusion: Improvement in depressive symptoms in patients with cardiometabolic disease at 12 months was not any better in patients prescribed with anti-depressants compared to the nonprescribed group. The role of anti-depressants in the management of depression in cardiometabolic disease merits further investigation. PMID:26286616
Lingard, Heide; Zehetmayer, Sonja; Maier, Manfred
Objective The aim of this study was to estimate the rate of bacterial superinfection in patients with URTI by using on-site determination of C-reactive protein (CRP). Design A prospective cohort study. Setting A total of 30 primary care practices. Subjects Patients with URTI. Intervention The CRP value was determined at the first consultation and at a follow-up within 3–5 days. CRP values of 30 units (mg) or higher were considered to be an indication of bacterial involvement. Main outcome measures CRP values during follow-up and duration of illness. Results Among the 506 patients included, 73.1% exhibited a CRP value below the defined limit at their first visit and were considered to suffer from URTI of viral origin. The rate of subsequent bacterial superinfection was 8.1%. Compared with patients suffering from URTI of bacterial or viral origin the duration of illness in patients with bacterial superinfection was significantly longer. Conclusion During follow-up of patients with URTI, the prevalence of bacterial superinfection detected by using a near patient CRP determination is surprisingly low. This result should help to reduce the prescription rate of antibiotics in primary care. PMID:18615361
Describes a follow-up program for enrolling day care center prospects. Follow-up within the center utilizes contact management software and a prospect profile system to record information about potential customers. External follow-up includes a telephone call to confirm an appointment to the center or to provide additional information to the…
Describes a follow-up program for enrolling day care center prospects. Follow-up within the center utilizes contact management software and a prospect profile system to record information about potential customers. External follow-up includes a telephone call to confirm an appointment to the center or to provide additional information to the…
Goetz, Katja; Loew, Thomas; Hornung, Regina; Cojocaru, Laura; Lahmann, Claas; Tritt, Karin
Background. Early retirement of teachers due to burnout is frequent in Germany. In this study short- and medium-term effects of AFA breathing therapy were evaluated. Methods. This study was designed as a longitudinal controlled intervention design with four points of measurements: before assessment (T1), after intervention (T2), three months (follow up 1) (T3) after intervention, and six months (follow up 2) after intervention (T4). The intervention lasted a total of 11 weeks (weekly group therapy for eight weeks and three weeks of individual breathing session). The effects of intervention were measured with the questionnaire "work-related behaviour and experience Patterns" (AVEM) at four times. Results. In the intervention group 64 teachers and in the self-selected control group 27 teachers were included. The AVEM scales "subjective significance of work" and "professional ambition" changed over time and within both groups (interaction effect). Significant improvements over the four measurements were observed in the intervention group in two AVEM scales: "emotional distancing" (F = 6.3; P < 0.01) and "balance and mental stability" (F = 4.4; P < 0.02). Conclusions. AFA breathing therapy showed short- and medium-term effects in the intervention group over four points of measurements. It may be assumed that breath therapy supports teachers in resisting occupational demand.
Loew, Thomas; Hornung, Regina; Cojocaru, Laura; Lahmann, Claas; Tritt, Karin
Background. Early retirement of teachers due to burnout is frequent in Germany. In this study short- and medium-term effects of AFA breathing therapy were evaluated. Methods. This study was designed as a longitudinal controlled intervention design with four points of measurements: before assessment (T1), after intervention (T2), three months (follow up 1) (T3) after intervention, and six months (follow up 2) after intervention (T4). The intervention lasted a total of 11 weeks (weekly group therapy for eight weeks and three weeks of individual breathing session). The effects of intervention were measured with the questionnaire “work-related behaviour and experience Patterns” (AVEM) at four times. Results. In the intervention group 64 teachers and in the self-selected control group 27 teachers were included. The AVEM scales “subjective significance of work” and “professional ambition” changed over time and within both groups (interaction effect). Significant improvements over the four measurements were observed in the intervention group in two AVEM scales: “emotional distancing” (F = 6.3; P < 0.01) and “balance and mental stability” (F = 4.4; P < 0.02). Conclusions. AFA breathing therapy showed short- and medium-term effects in the intervention group over four points of measurements. It may be assumed that breath therapy supports teachers in resisting occupational demand. PMID:24069056
Effectiveness of the Austrian disease management programme "Therapie Aktiv" for type 2 diabetes regarding the improvement of metabolic control, risk profile and guideline adherence: 2 years of follow up.
Flamm, Maria; Panisch, Sigrid; Winkler, Henrike; Johansson, Tim; Weitgasser, Raimund; Sönnichsen, Andreas C
We evaluated the disease management programme (DMP) "Therapie Aktiv" for diabetes mellitus type 2 during the first year of implementation in a cluster-randomised controlled trial (RCT), which revealed an improvement of process quality, but only insignificant effects on HbA1c. To further analyse the effects of the DMP we followed up participants of the RCT for another year. After completion of the RCT, the study was continued as an open observational trial. By patient's choice, three groups were formed. Group 1 (DMP/DMP): interventions of the RCT (DMP), who remained in the DMP; group 2 (Control/DMP): controls of the RCT (usual care), who participated in the DMP during the second year; group 3 (Control/Control): controls of the RCT (usual care), who remained as controls. HbA1c. BMI, lipids, blood pressure and measures of process quality. Only 801 of 1,489 RCT participants completed the study (53.8 %). Group 1: n = 355; group 2: n = 335; group 3: n = 111. After 2 years, pre-post-analysis revealed a significant reduction of HbA1c (0.37 %, p < 0.001) in both DMP groups, and a reduction of only 0.03 % (p = 0.975) in the control group. However, the difference between the groups was not significant (p = 0.065). There was a significant improvement of process quality in the DMP groups compared with controls. The DMP clearly enhances process quality. Furthermore, the DMP yields a reduction of HbA1c within groups after 2 years, but significance is lost in between-group analysis. We conclude that the DMP has only a minor effect on metabolic control.
Thomas, G. R.; Kerr, M. P.
Background: Obesity has been identified as a major health concern in adults with intellectual disabilities. This study evaluates a health promotion programme delivered by a NHS department for adults with intellectual disabilities. Method: Routine NHS data were collated and analysed descriptively. One hundred and ninety one adults with intellectual…
Miller, Sarah; Connolly, Paul; Maguire, Lisa K
This article presents the findings of a randomized controlled trial evaluation of the effects of a revised version of the volunteer mentoring programme, "Time to Read." Participating children received two 30-minute mentoring sessions per week from volunteer mentors who carried out paired reading activities with the children. The current…
Havrdova, Eva; Arnold, Douglas L; Cohen, Jeffrey A; Hartung, Hans-Peter; Fox, Edward J; Giovannoni, Gavin; Schippling, Sven; Selmaj, Krzysztof W; Traboulsee, Anthony; Compston, D Alastair S; Margolin, David H; Thangavelu, Karthinathan; Rodriguez, Claudio E; Jody, Darlene; Hogan, Richard J; Xenopoulos, Panos; Panzara, Michael A; Coles, Alasdair J
To evaluate 5-year efficacy and safety of alemtuzumab in treatment-naive patients with active relapsing-remitting MS (RRMS) (CARE-MS I; NCT00530348). Alemtuzumab-treated patients received treatment courses at baseline and 12 months later; after the core study, they could enter an extension (NCT00930553) with as-needed alemtuzumab retreatment for relapse or MRI activity. Assessments included annualized relapse rate (ARR), 6-month confirmed disability worsening (CDW; ≥1-point Expanded Disability Status Scale [EDSS] score increase [≥1.5 if baseline EDSS = 0]), 6-month confirmed disability improvement (CDI; ≥1-point EDSS decrease [baseline score ≥2.0]), no evidence of disease activity (NEDA), brain volume loss (BVL), and adverse events (AEs). Most alemtuzumab-treated patients (95.1%) completing CARE-MS I enrolled in the extension; 68.5% received no additional alemtuzumab treatment. ARR remained low in years 3, 4, and 5 (0.19, 0.14, and 0.15). Over years 0-5, 79.7% were free of 6-month CDW; 33.4% achieved 6-month CDI. Most patients (61.7%, 60.2%, and 62.4%) had NEDA in years 3, 4, and 5. Median yearly BVL improved over years 2-4, remaining low in year 5 (years 1-5: -0.59%, -0.25%, -0.19%, -0.15%, and -0.20%). Exposure-adjusted incidence rates of most AEs declined in the extension relative to the core study. Thyroid disorder incidences peaked at year 3 and subsequently declined. Based on these data, alemtuzumab provides durable efficacy through 5 years in the absence of continuous treatment, with most patients not receiving additional courses. NCT00530348; NCT00930553. This study provides Class III evidence that alemtuzumab durably improves efficacy outcomes and slows BVL in patients with RRMS. Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
Murtaugh, Christopher M; Deb, Partha; Zhu, Carolyn; Peng, Timothy R; Barrón, Yolanda; Shah, Shivani; Moore, Stanley M; Bowles, Kathryn H; Kalman, Jill; Feldman, Penny H; Siu, Albert L
To compare the effectiveness of two "treatments"-early, intensive home health nursing and physician follow-up within a week-versus less intense and later postacute care in reducing readmissions among heart failure (HF) patients discharged to home health care. National Medicare administrative, claims, and patient assessment data. Patients with a full week of potential exposure to the treatments were followed for 30 days to determine exposure status, 30-day all-cause hospital readmission, other health care use, and mortality. An extension of instrumental variables methods for nonlinear statistical models corrects for nonrandom selection of patients into treatment categories. Our instruments are the index hospital's rate of early aftercare for non-HF patients and hospital discharge day of the week. All hospitalizations for a HF principal diagnosis with discharge to home health care between July 2009 and June 2010 were identified from source files. Neither treatment by itself has a statistically significant effect on hospital readmission. In combination, however, they reduce the probability of readmission by roughly 8 percentage points (p < .001; confidence interval = -12.3, -4.1). Results are robust to changes in implementation of the nonlinear IV estimator, sample, outcome measure, and length of follow-up. Our results call for closer coordination between home health and medical providers in the clinical management of HF patients immediately after hospital discharge. © Health Research and Educational Trust.
Fens, Manon; van Heugten, Caroline M; Beusmans, George; Metsemakers, Job; Kester, Arnold; Limburg, Martien
To evaluate the effectiveness of a stroke-specific follow-up care model on quality of life for stroke patients, being discharged home, and their caregivers. A non-randomized, controlled trial, comparing an intervention group with a control group (usual care). Stroke patients and their caregivers. Intervention involved 5 home visits by a stroke care coordinator over a period of 18 months, using a structured assessment tool. Outcome measures were conducted at baseline (T0) and every 6 months thereafter (T6, T12 and T18) in the domains of quality of life (primary), activities of daily living, social activities, depression, anxiety and caregiver strain. The intervention group (n = 62) had significantly increased its social activities after 18 months, whereas the control group (n = 55) showed significantly decreased levels of social activities. In the first 6 months, levels of depression decreased significantly in caregivers of the intervention group. No differences were found for quality of life and the other outcome measures. The intervention was not effective in improving quality of life, but was effective in improving levels of social activities. The intervention may have focussed too much on screening for stroke-related problems and not as much on adequate follow-up care and referral.
Packness, Aake; Waldorff, Frans Boch; Christensen, René dePont; Hastrup, Lene Halling; Simonsen, Erik; Vestergaard, Mogens; Halling, Anders
To determine the impact of socioeconomic position (SEP) and distance to provider on outpatient mental health care utilization among incident users of antidepressants. A nationwide register-based cohort study of 50,374 person-years. Persons in low SEP were more likely to have outpatient psychiatrist contacts [odds ratio (OR) 1.25; confidence interval (CI) 1.17-1.34], but less likely to consult a co-payed psychologist (OR 0.49; CI 0.46-0.53) and to get mental health service from a GP (MHS-GP) (OR 0.81; CI 0.77-0.86) compared to persons in high SEP after adjusting for socio-demographics, comorbidity and car ownership. Furthermore, persons in low SEP who had contact to any of these therapists tended to have lower rates of visits compared to those in high SEP. When distance to services increased by 5 km, the rate of visits to outpatient psychiatrist tended to decrease by 5% in the lowest income group (IRR 0.95; CI 0.94-0.95) and 1% in the highest (IRR 0.99; CI 0.99-1.00). Likewise, contact to psychologists decreased by 11% in the lowest income group (IRR 0.89; CI 0.85-0.94), whereas rate of visits did not interact. Patients in low SEP have relatively lower utilization of mental health services even when services are free at delivery; co-payment and distance to provider aggravate the disparities in utilization between patients in high SEP and patients in low SEP.
Fernald, Lia C H; Gertler, Paul J; Neufeld, Lynnette M
Mexico's conditional cash transfer programme, Oportunidades, was started to improve the lives of poor families through interventions in health, nutrition, and education. We investigated the effect of Oportunidades on children almost 10 years after the programme began. From April, 1998, to October, 1999, low-income communities were randomly assigned to be enrolled in Oportunidades immediately (early treatment, n=320) or 18 months later (late treatment, n=186). In 2007, when 1093 children receiving early treatment and 700 late treatment in these communities were aged 8-10 years, they were assessed for outcomes including physical growth, cognitive and language development, and socioemotional development. The primary objective was to investigate outcomes associated with an additional 18 months in the programme. We used cluster-adjusted t tests and multivariate regressions to compare effects of programme participation for height-for-age, body-mass index (BMI), and cognitive language and behavioural assessment scores in early versus late treatment groups. Early enrolment reduced behavioural problems for all children in the early versus late treatment group (mean behaviour problem score -0.09 [SD 0.97] vs 0.13 [1.03]; p=0.0024), but we identified no difference between groups for mean height-for-age Z scores (-1.12 [0.96] vs -1.14 [0.97]; p=0.88), BMI-for-age Z scores (0.14 [0.99] vs 0.17 [1.06]; p=0.58), or assessment scores for language (98.8 [13.8] vs 98.4 [14.6] p=0.90) or cognition (98.8 [12.9] vs 100.2 [13.2]; p=0.26). An additional 18 months of the programme before age 3 years for children aged 8-10 years whose mothers had no education resulted in improved child growth of about 1.5 cm assessed as height-for-age [corrected] Z score (beta 0.23 [0.023-0.44] p=0.029), independently of cash received. An additional 18 months in the Oportunidades programme has independent beneficial effects other than money, especially for women with no formal education. The money itself
Clemenzi, Alessandro; Formisano, Rita; Matteis, Maria; Gallinacci, Luciano; Cochi, Giulio; Savina, Paola; Cicinelli, Paola
To evaluate the efficacy and the safety of repeated botulinum toxin type A (BT-A) injections in patients with severe acquired brain injury (ABI) and to gain a better knowledge of possible clinical or demographic characteristics associated with a better rehabilitation outcome. Prospective study with a 1-year follow-up period. Twenty-one patients with spasticity due to severe ABI and no further improving with rehabilitation treatment and oral anti-spastic drugs. Repeated BT-A injections associated to a rehabilitation programme. Barthel Index (BI), Modified Ashworth Score (MAS) and VAS score for pain subjective perception were recorded. At the end of the follow-up study, MAS, BI and VAS significantly improved. Despite the number of BT-A injections, a shorter interval between severe ABI onset and first BT-A treatment correlated to a better BI improvement. None of the patients experienced adverse events attributable to BT-A. BT-A was effective and safe in the treatment of spasticity in severe ABI patients, with a better functional outcome in those subjects treated earlier after spasticity onset. The lack of correlation between clinical outcome and number of injections suggests, in addition to a direct inhibition at the neuromuscular junction, a more distant BT-A long-term effect.
Sameer, Moideen; Chandrasekaran, Ramamurthy
Background Very little is known about the long term diagnostic stability of Dhat (semen loss) syndrome owing to a dearth of follow up studies on this condition. Aim The aim of the study was to assess the diagnostic stability and naturalistic long term outcomes in a group of pure Dhat syndrome cases. Materials and Methods The study was carried out in the outpatient psychiatry department of a tertiary care hospital in South India, using a retrospective cohort design. Forty one cases of ‘pure’ Dhat syndrome (with no other concurrent diagnosis) were selected by a chart review of patients attending the outpatient Psychiatry department. Out of this initial cohort, follow up interviews were held for 36 patients. Direct clinical interviews were held with all participants to assess change in diagnosis. Those who no longer qualified for Dhat syndrome were interviewed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to generate other diagnoses. For analysis, the patients were divided into two groups – those who positively endorsed symptoms of Dhat syndrome at follow up (DSP group) and those who no longer did (DSN group). These groups were compared using chi-square test for categorical variables and student t-test for continuous variables to look for significant differences. Frequencies and percentages were used to depict socio-demographic data and the follow up diagnoses. Statistical Analysis Data was analysed using SPSS for Windows, Version 16.0 (Chicago, SPSS Inc.) Results The mean duration of follow up was 6±3.5 years. Nearly two-thirds of the sample no longer fulfilled criteria for Dhat syndrome in follow up. The most common revisional diagnosis in these patients was somatoform disorders. Age, marital status and literacy distinguished the two groups. About a quarter of the sample (26.07%) was in complete remission. Conclusion Even the purest variety of Dhat syndrome is not a stable diagnosis in the majority of patients. The condition may
Lainiala, O; Eskelinen, A; Elo, P; Puolakka, T; Korhonen, J; Moilanen, T
We conducted a retrospective study to assess the prevalence of adverse reactions to metal debris (ARMD) in patients operated on at our institution with metal-on-metal (MoM) total hip replacements with 36 mm heads using a Pinnacle acetabular shell. A total of 326 patients (150 males, 175 hips; 176 females, 203 hips) with a mean age of 62.7 years (28 to 85) and mean follow-up of 7.5 years (0.1 to 10.8) participating in our in-depth modern MoM follow-up programme were included in the study, which involved recording whole blood cobalt and chromium ion measurements, Oxford hip scores (OHS) and plain radiographs of the hip and targeted cross-sectional imaging. Elevated blood metal ion levels (> 5 parts per billion) were seen in 32 (16.1%) of the 199 patients who underwent unilateral replacement. At 23 months after the start of our modern MoM follow-up programme, 29 new cases of ARMD had been revealed. Hence, the nine-year survival of this cohort declined from 96% (95% CI 95 to 98) with the old surveillance routine to 86% (95% CI 82 to 90) following the new protocol. Although ARMD may not be as common in 36 mm MoM THRs as in those with larger heads, these results support the Medicines and Healthcare Products Regulatory Agency guidelines on regular reviews and further investigations, and emphasise the need for specific a follow-up programme for patients with MoM THRs. ©2014 The British Editorial Society of Bone & Joint Surgery.
Cotton, Seonaidh; Sharp, Linda; Cochran, Claire; Gray, Nicola; Cruickshank, Maggie; Smart, Louise; Thornton, Alison; Little, Julian
Background Although it is recognised that some women experience pain or bleeding during a cervical cytology test, few studies have quantified physical after-effects of these tests. Aim To investigate the frequency, severity, and duration of after-effects in women undergoing follow-up cervical cytology tests, and to identify subgroups with higher frequencies in Grampian, Tayside, and Nottingham. Design Cohort study nested with a multi-centre individually randomised controlled trial. Method The cohort included 1120 women, aged 20–59 years, with low-grade abnormal cervical cytology who completed a baseline sociodemographic questionnaire and had a follow-up cervical cytology test in primary care 6 months later. Six weeks after this test, women completed a postal questionnaire on pain, bleeding, and discharge experienced after the test, including duration and severity. The adjusted prevalence of each after-effect was computed using logistic regression. Results A total of 884 women (79%) completed the after-effects questionnaire; 30% of women experienced one or more after-effect: 15% reported pain, 16% bleeding, and 7% discharge. The duration of discharge was ≤2 days for 66%, 3–6 days for 22%, and ≥7 days for 11% of women. Pain or bleeding lasted ≤2 days in more than 80% of women. Severe after-effects were reported by <1% of women. The prevalence of pain decreased with increasing age. Bleeding was more frequent among nulliparous women. Discharge was more common among oral contraceptive users. Conclusion Pain, bleeding, and discharge are not uncommon in women having follow-up cervical cytology tests. Informing women about possible after-effects could better prepare them and provide reassurance, thereby minimising potential non-adherence with follow-up or non-participation with screening in the future. PMID:21801512
Cotton, Seonaidh; Sharp, Linda; Cochran, Claire; Gray, Nicola; Cruickshank, Maggie; Smart, Louise; Thornton, Alison; Little, Julian
Although it is recognised that some women experience pain or bleeding during a cervical cytology test, few studies have quantified physical after-effects of these tests. To investigate the frequency, severity, and duration of after-effects in women undergoing follow-up cervical cytology tests, and to identify subgroups with higher frequencies in Grampian, Tayside, and Nottingham. Cohort study nested with a multi-centre individually randomised controlled trial. The cohort included 1120 women, aged 20-59 years, with low-grade abnormal cervical cytology who completed a baseline sociodemographic questionnaire and had a follow-up cervical cytology test in primary care 6 months later. Six weeks after this test, women completed a postal questionnaire on pain, bleeding, and discharge experienced after the test, including duration and severity. The adjusted prevalence of each after-effect was computed using logistic regression. A total of 884 women (79%) completed the after-effects questionnaire; 30% of women experienced one or more after-effect: 15% reported pain, 16% bleeding, and 7% discharge. The duration of discharge was ≤2 days for 66%, 3-6 days for 22%, and ≥7 days for 11% of women. Pain or bleeding lasted ≤2 days in more than 80% of women. Severe after-effects were reported by <1% of women. The prevalence of pain decreased with increasing age. Bleeding was more frequent among nulliparous women. Discharge was more common among oral contraceptive users. Pain, bleeding, and discharge are not uncommon in women having follow-up cervical cytology tests. Informing women about possible after-effects could better prepare them and provide reassurance, thereby minimising potential non-adherence with follow-up or non-participation with screening in the future.
Biese, Kevin; Lamantia, Michael; Shofer, Frances; McCall, Brenda; Roberts, Ellen; Stearns, Sally C; Principe, Stephanie; Kizer, John S; Cairns, Charles B; Busby-Whitehead, Jan
Older patients discharged from the emergency department (ED) have difficulty comprehending discharge plans and are at high risk of adverse outcomes. The authors investigated whether a postdischarge telephone call-mediated intervention by a nurse would improve discharge care plan adherence, specifically by expediting post-ED visit physician follow-up appointments and/or compliance with medication changes. The second objectives were to determine if this telephone call intervention would reduce return ED visits and/or hospitalizations within 35 days of the index ED visit and to determine potential cost savings of this intervention. This was a 10-week randomized, controlled trial among patients aged 65 and older discharged to home from an academic ED. At 1 to 3 days after each patient's index ED visit, a trained nurse called intervention group patients to review discharge instructions and assist with discharge plan compliance; placebo call group patients received a patient satisfaction survey call, while the control group patients were not called. Data collection calls occurred at 5 to 8 days and 30 to 35 days after the index ED visits for all three groups. Chi-square or Fisher's exact tests were performed for categorical data and the Kruskal-Wallis test examined group differences in time to follow-up. A total of 120 patients completed the study. Patients were 60% female and 72% white, with a mean age of 75 years (standard deviation [SD] ± 7.58 years). Intervention patients were more likely to follow up with medical providers within 5 days of their ED visits than either the placebo or the control group patients (54, 20, and 37%, respectively; p = 0.04). All groups performed well in medication acquisition and comprehension of medication indications and dosage. There were no differences in return visits to the ED or hospital within 35 days of the index ED visit for intervention patients, compared to placebo or control group patients (22, 33, and 27
Humphreys, Kathryn L; Gleason, Mary Margaret; Drury, Stacy S; Miron, Devi; Nelson, Charles A; Fox, Nathan A; Zeanah, Charles H
Early social deprivation can negatively affect domains of functioning. We examined psychopathology at age 12 years in a cohort of Romanian children who had been abandoned at birth and placed into institutional care, then assigned either to be placed in foster care or to care as usual. We used follow-up data from the Bucharest Early Intervention Project (BEIP), a randomised controlled trial of abandoned children in all six institutions for young children in Bucharest, Romania. In the initial trial, 136 children, enrolled between ages 6-31 months, were randomly assigned to either care as usual or placement in foster care. In this study we followed up these children at age 12 years to assess psychiatric symptoms using the Diagnostic Interview Schedule for Children (4th edition; DISC-IV). We also recruited Romanian children who had never been placed in an institution from paediatric clinics and schools in Bucharest as a comparator group who had never been placed in an institution. The primary outcome measure was symptom counts assessed through DISC-IV scores for three domains of psychopathology: internalising symptoms, externalising symptoms, and attention-deficit hyperactivity disorder (ADHD). We compared mean DISC-IV scores between trial participants and comparators who had never been placed in an institution, and those assigned to care as usual or foster care. Analyses were done by modified intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00747396. We followed up 110 children from the BEIP trial between Jan 27, 2011, and April 11, 2014, and 49 children as comparators who had never been placed in an institution. The 110 children who had ever been placed in an institution had higher symptom counts for internalising disorders (mean 0·93 [SD 1·68] vs 0·45 [0·84], difference 0·48 [95% CI 0·14-0·82]; p=0·0127), externalising disorders (2·31 [2·86] vs 0·65 [1·33], difference 1·66 [1·06-2·25]; p<0·0001), and ADHD (4·00 [5·01
Humphreys, Kathryn L; Gleason, Mary Margaret; Drury, Stacy S; Miron, Devi; Nelson, Charles A; Fox, Nathan A; Zeanah, Charles H
Summary Background Early social deprivation can negatively affect domains of functioning. We examined psychopathology at age 12 years in a cohort of Romanian children who had been abandoned at birth and placed into institutional care, then assigned either to be placed in foster care or to care as usual. Methods We used follow-up data from the Bucharest Early Intervention Project (BEIP), a randomised controlled trial of abandoned children in all six institutions for young children in Bucharest, Romania. In the initial trial, 136 children, enrolled between ages 6–31 months, were randomly assigned to either care as usual or placement in foster care. In this study we followed up these children at age 12 years to assess psychiatric symptoms using the Diagnostic Interview Schedule for Children (4th edition; DISC-IV). We also recruited Romanian children who had never been placed in an institution from paediatric clinics and schools in Bucharest as a comparator group who had never been placed in an institution. The primary outcome measure was symptom counts assessed through DISC-IV scores for three domains of psychopathology: internalising symptoms, externalising symptoms, and attention-deficit hyperactivity disorder (ADHD). We compared mean DISC-IV scores between trial participants and comparators who had never been placed in an institution, and those assigned to care as usual or foster care. Analyses were done by modified intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00747396. Findings We followed up 110 children from the BEIP trial between Jan 27, 2011, and April 11, 2014, and 49 children as comparators who had never been placed in an institution. The 110 children who had ever been placed in an institution had higher symptom counts for internalising disorders (mean 0.93 [SD 1.68] vs 0.45 [0.84], difference 0.48 [95% CI 0.14–0.82]; p=0.0127), externalising disorders (2.31 [2.86] vs 0.65 [1.33], difference 1.66 [1.06–2.25]; p<0
de Souza, Jacqueline; de Almeida, Letícia Yamawaka; Moll, Marciana Fernandes; Silva, Lucas Duarte; Ventura, Carla Aparecida Arena
The objective of this study is to analyze the characteristics of social support networks of patients with psychiatric disorders at follow-up to primary care. This is a cross-sectional qualitative research study. Forty-five interviews were held with patients and their supporters. The results showed small and dense networks, with a strong emphasis on the bonds with formal supporters and a scant network of informal supporters. It is recommended to develop strategies to improve social support networks and use this as an outcome indicator related to social integration of these patients and to the quality of services involved with outpatient healthcare. Copyright © 2015 Elsevier Inc. All rights reserved.
Teagle, S E; Brindis, C D
To compare perceptions of the motivators and barriers to obtaining public prenatal care from the perspectives of pregnant adolescents coming for first-time and follow-up appointments, as well as among those of their prenatal care providers. The patient sample consisted of 250 consecutive, adolescent, public prenatal patients coming to one of the 5 prenatal clinics in one county in Arkansas. Patient responses were analyzed by appointment status (first-time vs. follow-up visitors). Sixteen providers at the same public prenatal clinics were also interviewed using the same survey instrument. We observed striking differences between patients and providers with respect to their perceptions of both the motivators and barriers to prenatal care. Adolescents reported "concern over the health of their baby" as a primary motivation, while providers identified adolescents' "concern over their own health" as the most important reason. With regard to barriers, adolescents were more likely to identify system-related barriers (e.g., lack of finances and transportation, and waiting time for appointments), while providers were more likely to identify personal barriers (e.g., feeling depressed, fear of procedures, and needing time to deal with problems at home). Patients and providers agreed, however, that fear of procedures and not wanting to be pregnant were important barriers to care. The differences in perceptions between adolescents and their prenatal care providers suggest that poor patient-provider communication may represent one of the single most important nonfinancial barriers to care. Possible explanations for inadequate patient-provider communication as well as solutions to improve their clinic interactions are discussed.
Pedersen, Charlotte Gjørup; Olrik Wallenstein Jensen, Signe; Johnsen, Søren Paaske; Nordentoft, Merete; Mainz, Jan
It is unknown whether evidence-based, in-hospital processes of care may influence the risk of criminal behaviour among patients with schizophrenia. Our study aimed to examine the association between guideline recommended in-hospital psychiatric care and criminal behaviour among patients with schizophrenia. Danish patients with schizophrenia (18 years or older) discharged from a psychiatric ward between January 2004 and March 2009 were identified using a national population-based schizophrenia registry (n = 10 757). Data for in-hospital care and patient characteristics were linked with data on criminal charges obtained from the Danish Crime Registry until November 2010. Twenty per cent (n = 2175) of patients were charged with a crime during follow-up (median = 428 days). Violent crimes accounted for 59% (n = 1282) of the criminal offences. The lowest risk of crime was found among patients receiving the most processes of in-hospital care (top quartile of received recommended care, compared with bottom quartiles, adjusted hazard ratio = 0.86, 95% CI 0.75 to 0.99). The individual processes of care associated with the lowest risk of criminal behaviour were antipsychotic treatment and staff contact with relatives. High-quality, in-hospital psychiatric care was associated with a lower risk of criminal behaviour after discharge among patients with schizophrenia.
Gustavsson, Catharina; von Koch, Lena
Background and objective In previous short-term and 2-year follow-ups, a pain and stress self-management group intervention (PASS) had better effect on pain-related disability, self-efficacy, catastrophizing, and perceived pain control than individually administered physiotherapy (IAPT) for patients with persistent tension-type neck pain. Studies that have evaluated long-term effects of self-management approaches toward persistent neck pain are sparse. The objective of this study was to compare pain-related disability, self-efficacy for activities of daily living (ADL), catastrophizing, pain, pain control, use of analgesics, and health care utilization in people with persistent tension-type neck pain 9 years after they received the PASS or IAPT. Materials and methods Of 156 people (PASS, n = 77; IAPT, n = 79) originally included in a randomized controlled trial, 129 people (PASS, n = 63; IAPT, n = 66) were eligible and were approached for the 9-year follow-up. They were sent a self-assessment questionnaire, comprising the Neck Disability Index, the Self-Efficacy Scale, the Coping Strategies Questionnaire, and questions regarding pain, analgesics, and health care utilization. Mixed linear models for repeated measures analysis or generalized estimating equations were used to evaluate the differences between groups and within groups over time (baseline, previous follow-ups, and 9-year follow-up) and the interaction effect of “time by group”. Results Ninety-four participants (73%) responded (PASS, n = 48; IAPT, n = 46). At 9 years, PASS participants reported less pain-related disability, pain at worst, and analgesics usage, and a trend toward better self-efficacy compared to IAPT participants. There was a difference between groups in terms of change over time for disability, self-efficacy for ADL, catastrophizing, perceived pain control, and health care visits in favor of PASS. Analyses of simple main effects at 9 years showed that the PASS group had less
El-Helaly, Mohamed; Balkhy, Hanan H; Waseem, Khan; Khawaja, Sahdia
Previous cross-sectional studies have shown that exposure to cleaning chemicals among health-care workers (HCWs) is associated with respiratory disorders and ventilatory function changes. This study aimed to further explore this association using a longitudinal approach. A prospective 2-year follow-up study was carried out at a tertiary care hospital in Saudi Arabia from June 2012 to June 2014 among 56 nurses who were responsible for disinfection and sterilization of medical instruments and equipment. The workplaces of the participants were assessed for engineering, environmental, and safety control measures. Self-administered questionnaires were distributed to all participants to assess their exposure to cleaning chemicals and their medical history. Spirometric parameters were measured for all nurses in 2012 (baseline) and again in 2014 (follow-up). The prevalence of work-related respiratory symptoms did not increase significantly over this time. Among all the spirometric parameters, only forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio decreased significantly, and only 10.7% of participants who were exposed to cleaning chemicals for more than 10 years had FEV1 and FVC less than their longitudinal normal limits at the end of the study. Smoking and gender were associated with statistically significant decreases in some of the spirometric parameters. Our 2-year follow-up study did not demonstrate significant association between exposure to cleaning chemicals among HCWs and changes in the prevalence of work-related respiratory symptoms, but indicated early effects on ventilatory function among them. The study highlights the importance of periodic spirometry, proper work practices, and effective control measures to protect HCWs against potentially harmful workplace chemicals for disinfection and sterilization.
Chenoweth, Lynn; Stein-Parbury, Jane; White, Danielle; McNeill, Georgene; Jeon, Yun-Hee; Zaratan, Beverley
Maintaining the health and well-being of family carers of people with dementia is vital, given their potential for experiencing burden associated with the role. The study aimed to help dementia carers develop self-efficacy, be less hassled by the caring role and improve their health and well-being with goal-directed behaviour, by participating in an eight module carer coaching program. The study used mixed methods in a pre/post-test/follow-up design over 24 months, with assignment of consented dementia carers to either individualised (n = 16) or group coaching (n = 32), or usual carer support services (n = 43), depending on preference. Care-giving self-efficacy and hassles, carer health, well-being and goal-directed behaviours were assessed over time. Analysis of Variance (ANOVA) was used to compare changes over time and the effects of coaching on carer self-efficacy, hassles and health, using the Univariate General Linear Model (GLM). All carers were hassled by many aspects of caring at baseline. Participants receiving coaching reported non-significant improvements in most areas of self-efficacy for caring, hassles associated with caring and self-reported health at post-test and follow-up, than did carers receiving usual carer support. Group coaching had greater success in helping carers to achieve their goals and to seek help from informal and formal support networks and services. The study outcomes were generally positive, but need to be interpreted cautiously, given some methodological limitations. It has been shown, however, that health staff can assist dementia carers to develop self-efficacy in better managing their family member's limitations and behaviour, seek help from others and attend to their health. Teaching carers to use goal-directed behaviour may help them achieve these outcomes.
Vijay, Sophia; Kumar, Prahlad; Chauhan, Lakbir Singh; Narayan Rao, Saroja Vadigepalli; Vaidyanathan, Preetish
Background There is paucity of data from India on the impact of HIV related immunosuppression in response to TB treatment and mortality among HIV infected TB patients. We assessed the TB treatment outcome and mortality in a cohort of HIV infected TB patients treated with intermittent short course chemotherapy under TB control programme in a high HIV prevalent district of south India. Methodology/ Findings Among 3798 TB patients registered for treatment in Mysore district from July 2007 to June 2008, 281 HIV infected patients formed the study group. The socio-demographic and treatment related data of these patients was obtained from TB and HIV programme records and patient interviews 19 months after TB treatment initiation by field investigators. Treatment success rate of 281 patients was 75% while in smear positive pulmonary tuberculosis cases it was 62%, attributable to defaults (16%) and deaths (19%). Only 2 patients had treatment failure. Overall, 83 (30%) patients were reported dead; 26 while on treatment and 57 after TB treatment. Association of treatment related factors with treatment outcome and survival status was studied through logistic regression analysis. Factors significantly associated with ‘unfavourable outcome’ were disease classification as Pulmonary [aOR-1.96, CI (1.02–3.77)], type of patient as retreatment [aOR-4.78, CI (2.12–10.76)], and non initiation of ART [aOR-4.90, CI (1.85–12.96)]. Factors associated with ‘Death’ were non initiation of ART [aOR-2.80, CI (1.15–6.81)] and CPT [aOR-3.46, CI (1.47–8.14)]. Conclusion Despite the treatment success of 75% the high mortality (30%) in the study group is a matter of concern and needs immediate intervention. Non initiation of ART has emerged as a high risk factor for unfavourable treatment outcome and mortality. These findings underscore the importance of expanding and improving delivery of ART services as a priority and reconsideration of the programme guidelines for ART initiation
Eggly, Susan; Meert, Kathleen L; Berger, John; Zimmerman, Jerry; Anand, K J S; Newth, Christopher J L; Harrison, Rick; Carcillo, Joseph; Dean, J Michael; Willson, Douglas F
We examined physicians' conceptualization of closure as a benefit of follow-up meetings with bereaved parents. The frequency of use and the meaning of the word "closure" were analyzed in transcripts of interviews with 67 critical care physicians affiliated with the Collaborative Pediatric Critical Care Research Network. In all, 38 physicians (57 percent) used the word "closure" at least once (median: 2; range: 1 to 7), for a total of 86 times. Physicians indicated that closure is a process or trajectory rather than an achievable goal. They also indicated that parents and physicians can move toward closure by gaining a better understanding of the causes and circumstances of the death and by reconnecting with, or resolving relationships between, parents and health professionals. Physicians suggested that a primary reason to conduct follow-up meetings is that such meetings offer parents and physicians an opportunity to move toward closure. Future research should attempt to determine whether followup meetings reduce the negative effects of bereavement for parents and physicians.
Tweya, Hannock; Gugsa, Salem; Hosseinipour, Mina; Speight, Colin; Ng'ambi, Wingston; Bokosi, Mphatso; Chikonda, Janet; Chauma, Annie; Khomani, Patricia; Phoso, Malocho; Mtande, Tiwonge; Phiri, Sam
To assess factors, outcomes and reasons for loss to follow-up (LTFU) among pregnant and breastfeeding women initiated on a lifelong antiretroviral therapy (ART) for PMTCT in a large antenatal clinic in Malawi. We identified all pregnant and breastfeeding women who were initiated on ART between September 2011 and September 2013 and had missed their clinic appointment by at least 3 weeks at Bwaila Hospital, the largest antenatal clinic in Malawi. These women were traced by phone or home visits. Their true status and reasons for ART discontinuation were documented during tracing. A total of 2930 women started ART for PMTCT; 2458 (84%) pregnant and 472 (16%) breastfeeding, of which, 577 (20%) missed a scheduled clinic appointment. LTFU was associated with younger age, being pregnant, and earlier year of ART initiation. We successfully traced 229 (40%), of whom, 10 (4%) had died. Of the 219 women found alive, 118 (54%) had stopped taking ARV drugs, 67 (30%) had self-transferred to another ART clinic, 13 (6%) had collected drugs from other sources, 9 (4%) had treatment interruptions and 12 (5%) had other outcomes. Reasons cited for stopping ART were travel (38%), lack of transport money (16%), not understanding the initial ARV education session (10%), being too weak/sick (10%), ARV side effects (10%) and other reasons. Approximately half of the women who were traced were taking ARVs. The study emphasises the need for enhanced post-test counselling strategies, ongoing psychosocial support, provision of incentives and further decentralisation efforts of PMTCT services. © 2014 John Wiley & Sons Ltd.
This paper describes the genesis, design and implementation of a leadership programme for critical care. This was an initiative funded by the National Health Service (NHS) Nursing Leadership Project and had at the core of its design flexibility to meet the needs of the individual hospitals, which took part in it. Participation was from the multi-disciplinary critical care team. Six NHS hospitals took part in the programme which was of 20 days duration and took place on hospital sites. The programme used the leadership model of as its template and had a number of distinct components; a baseline assessment, personal development, principles of leadership and critical case reviews. The programme was underpinned by three themes; working effectively in multi-professional teams to provide patient focussed care, managing change through effective leadership and developing the virtual critical care service. Each group set objectives pertinent to their own organisation's needs. The programme was evaluated by a self-reporting questionnaire; group feedback and feedback from stakeholders. Programme evaluation was positive from all the hospitals but it was clear that the impact of the programme varied considerably between the groups who took part. It was noted that there was some correlation between the success of the programme and organisational 'buy in' as well as the organisational culture within which the participants operated. A key feature of the programme success was the critical case reviews, which were considered to be a powerful learning tool and medium for group learning and change management.
Singh–Carlson, S.; Wong, F.; Martin, L.; Nguyen, S.K.A.
Background and Objectives As more treatment options become available and supportive care improves, a larger number of people will survive after treatment for breast cancer. In the present study, we explored the experiences and concerns of female South Asian (sa) breast cancer survivors (bcss) from various age groups after treatment to determine their understanding of follow-up care and to better understand their preferences for a survivorship care plan (scp). Methods Patients were identified by name recognition from BC Cancer Agency records for sa patients who were 3–60 months post treatment, had no evidence of recurrence, and had been discharged from the cancer centre to follow-up. Three focus groups and eleven face-to-face semistructured interviews were audio-recorded, transcribed verbatim, cross-checked for accuracy, and analyzed using thematic and content analysis. Participants were asked about their survivorship experiences and their preferences for the content and format of a scp. Results Fatigue, cognitive changes, fear of recurrence, and depression were the most universal effects after treatment. “Quiet acceptance” was the major theme unique to sa women, with a unique cross-influence between faith and acceptance. Emphasis on a generalized scp with individualized content echoed the wide variation in breast cancer impacts for sa women. Younger women preferred information on depression and peer support. Conclusions For sa bcss, many of the psychological and physical impacts of breast cancer diagnosis and treatment may be experienced in common with bcss of other ethnic backgrounds, but the present study also suggests the presence of unique cultural nuances such as spiritual and language-specific support resource needs. The results provide direction for designing key content and format of scps, and information about elements of care that can be customized to individual patient needs. PMID:23559888
Kim, Hyoun K.; Leve, Leslie D.
Objective The present study evaluated the efficacy of the Middle School Success intervention (MSS) for reducing substance use and delinquency among girls in foster care, using a randomized controlled trial (RCT) design. The program was designed to fill a service gap during the summer prior to the middle school transition and to prevent delinquency, substance use, and related problems. Method One hundred girls in foster care and their caregivers were randomly assigned either to the intervention (n = 48) or to a regular foster care control (n = 52) condition. The girls completed a baseline (T1) assessment and follow-up assessments at 6 months (T2), 12 months (T3), 24 months (T4), and 36 months (T5) postbaseline. Caregivers participated in assessments from T1 through T4. This study is a follow up to Smith et al. (2011)’s study, which examined immediate outcomes at T2. Results Girls in the intervention condition showed significantly lower levels of substance use than did girls in the control condition at 36-months postbaseline. The group difference was only marginally significant for delinquency. Further analyses indicated significant indirect effects of the intervention through increased prosocial behaviors which led to decreased internalizing and externalizing symptoms and then to lower levels of substance use. The direct effect of the intervention on substance use remained significant in the presence of the indirect effects. For delinquency, the intervention had positive effects mainly through increased prosocial skills. Conclusions Findings highlight the importance of providing preventive intervention services for early adolescent girls in foster care. PMID:22004305
Schäfer, Ingmar; Küver, Claudia; Gedrose, Benjamin; Hoffmann, Falk; Russ-Thiel, Barbara; Brose, Hans-Peter; van den Bussche, Hendrik; Kaduszkiewicz, Hanna
In summer 2003 a disease management program (DMP) for type 2 diabetes was introduced on a nationwide basis in Germany. Patient participation and continuity of care within the DMP are important factors to achieve long-term improvements in clinical endpoints. Therefore it is of interest, if patients experience any positive or negative effects of the DMP on their treatment that would support or hamper further participation. The main objective of the study was to find out if the German Disease Management Program (DMP) for type 2 diabetes improves process and outcome quality of medical care for patients in the light of their subjective experiences over a period of one year. Cohort study with a baseline interview and a follow-up after 10.4 +/- 0.64 months. Data on process and outcome measures were collected by telephone interviews with 444 patients enrolled and 494 patients not enrolled in the German DMP for type 2 diabetes. Data were analyzed by multivariate logistic regression analyses. DMP enrolment was significantly associated with a higher process quality of care. At baseline enrolled patients more often reported that they had attended a diabetes education course (OR = 3.4), have > or = 4 contacts/year with the attending physician (OR = 3.3), have at least one annual foot examination (OR = 3.1) and one referral to an ophthalmologist (OR = 3.4) and possess a diabetes passport (OR = 2.4). Except for the annual referral to an ophthalmologist these parameters were also statistically significant at follow-up. In contrast, no differences between enrolled and not enrolled patients were found concerning outcome quality indicators, e.g. self-rated health, Glycated hemoglobin (GHb) and blood pressure. However, 16-36% of the DMP participants reported improvements of body weight and/or GHb and/or blood pressure values due to enrolment - unchanged within one year of follow-up. In the light of patient's experiences the DMP enhances the process quality of medical care for type 2
Background In summer 2003 a disease management program (DMP) for type 2 diabetes was introduced on a nationwide basis in Germany. Patient participation and continuity of care within the DMP are important factors to achieve long-term improvements in clinical endpoints. Therefore it is of interest, if patients experience any positive or negative effects of the DMP on their treatment that would support or hamper further participation. The main objective of the study was to find out if the German Disease Management Program (DMP) for type 2 diabetes improves process and outcome quality of medical care for patients in the light of their subjective experiences over a period of one year. Methods Cohort study with a baseline interview and a follow-up after 10.4 ± 0.64 months. Data on process and outcome measures were collected by telephone interviews with 444 patients enrolled and 494 patients not enrolled in the German DMP for type 2 diabetes. Data were analyzed by multivariate logistic regression analyses. Results DMP enrolment was significantly associated with a higher process quality of care. At baseline enrolled patients more often reported that they had attended a diabetes education course (OR = 3.4), have ≥ 4 contacts/year with the attending physician (OR = 3.3), have at least one annual foot examination (OR = 3.1) and one referral to an ophthalmologist (OR = 3.4) and possess a diabetes passport (OR = 2.4). Except for the annual referral to an ophthalmologist these parameters were also statistically significant at follow-up. In contrast, no differences between enrolled and not enrolled patients were found concerning outcome quality indicators, e.g. self-rated health, Glycated hemoglobin (GHb) and blood pressure. However, 16-36% of the DMP participants reported improvements of body weight and/or GHb and/or blood pressure values due to enrolment - unchanged within one year of follow-up. Conclusions In the light of patient's experiences the DMP enhances the process
Ashworth, Julie; Green, Daniel J; Dunn, Kate M; Jordan, Kelvin P
Opioid prescribing for chronic noncancer pain is increasing, but there is limited knowledge about longer-term outcomes of people receiving opioids for conditions such as back pain. This study aimed to explore the relationship between prescribed opioids and disability among patients consulting in primary care with back pain. A total of 715 participants from a prospective cohort study, who gave consent for review of medical and prescribing records and completed baseline and 6month follow-up questionnaires, were included. Opioid prescription data were obtained from electronic prescribing records, and morphine equivalent doses were calculated. The primary outcome was disability (Roland-Morris Disability Questionnaire [RMDQ]) at 6months. Multivariable linear regression was used to examine the association between opioid prescription at baseline and RMDQ score at 6months. Analyses were adjusted for potential confounders using propensity scores reflecting the probability of opioid prescription given baseline characteristics. In the baseline period, 234 participants (32.7%) were prescribed opioids. In the final multivariable analysis, opioid prescription at baseline was significantly associated with higher disability at 6-month follow-up (P<.022), but the magnitude of this effect was small, with a mean RMDQ score of 1.18 (95% confidence interval: 0.17 to 2.19) points higher among those prescribed opioids compared to those who were not. Our findings indicate that even after adjusting for a substantial number of potential confounders, opioids were associated with slightly worse functioning in back pain patients at 6-month follow-up. Further research may help us to understand the mechanisms underlying these findings and inform clinical decisions regarding the usefulness of opioids for back pain.
Ashworth, Julie; Green, Daniel J.; Dunn, Kate M.; Jordan, Kelvin P.
Opioid prescribing for chronic noncancer pain is increasing, but there is limited knowledge about longer-term outcomes of people receiving opioids for conditions such as back pain. This study aimed to explore the relationship between prescribed opioids and disability among patients consulting in primary care with back pain. A total of 715 participants from a prospective cohort study, who gave consent for review of medical and prescribing records and completed baseline and 6 month follow-up questionnaires, were included. Opioid prescription data were obtained from electronic prescribing records, and morphine equivalent doses were calculated. The primary outcome was disability (Roland-Morris Disability Questionnaire [RMDQ]) at 6 months. Multivariable linear regression was used to examine the association between opioid prescription at baseline and RMDQ score at 6 months. Analyses were adjusted for potential confounders using propensity scores reflecting the probability of opioid prescription given baseline characteristics. In the baseline period, 234 participants (32.7%) were prescribed opioids. In the final multivariable analysis, opioid prescription at baseline was significantly associated with higher disability at 6-month follow-up (P < .022), but the magnitude of this effect was small, with a mean RMDQ score of 1.18 (95% confidence interval: 0.17 to 2.19) points higher among those prescribed opioids compared to those who were not. Our findings indicate that even after adjusting for a substantial number of potential confounders, opioids were associated with slightly worse functioning in back pain patients at 6-month follow-up. Further research may help us to understand the mechanisms underlying these findings and inform clinical decisions regarding the usefulness of opioids for back pain. PMID:23688575
Delaney, E K; Murchie, P; Lee, A J; Ritchie, L D; Campbell, N C
To evaluate the effects of nurse-led secondary prevention clinics for coronary heart disease (CHD) in primary care on total mortality and coronary event rates after 10 years. Follow-up of a randomised controlled trial by review of national datasets. Stratified random sample of 19 general practices in northeast Scotland. Original study cohort of 1343 patients, aged <80 years, with a working diagnosis of CHD, but without dementia or terminal illness and not housebound. Nurse-led secondary prevention clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow-up for 1 year, Total mortality and coronary events (non-fatal myocardial infarctions (MIs) and coronary deaths). Mean (SD) follow-up was at 10.2 (0.19) years. No significant differences in total mortality or coronary events were found at 10 years. 254 patients in the intervention group and 277 patients in the control group had died: cumulative death rates were 38% and 41%, respectively (p = 0.177). 196 coronary events occurred in the intervention group and 195 in the control group: cumulative event rates were 29.1% and 29.1%, respectively (p = 0.994). When Kaplan-Meier survival analysis, adjusted for age, sex and general practice, was used, proportional hazard ratios were 0.88 (0.74 to 1.04) for total mortality and 0.96 (0.79 to 1.18) for coronary death or non-fatal MI. No significant differences in the distribution of cause of death classifications was found at either 4 or 10 years. After 10 years, differences between groups were no longer significant. Total mortality survival curves for the intervention and control groups had not converged, but the coronary event survival curves had. Possibly, therefore, the earlier that secondary prevention is optimised, the less likely a subsequent coronary event is to prove fatal.
Kitajima, K; Kuroda, K; Tatara, K
In order to investigate social functioning, a self-administered questionnaire was distributed to 66 participants (30 men and 36 women) in a group rehabilitation programme for the mentally ill at public health centers, and followed for 1 year to investigate their employability as an indicator of social participation. The survey included 20 items related to 5 aspects of daily life: diurnal routine, basic personal management, social activities, personal relationships, and management of illness. The major findings were as follows: 1. The group who had become employed showed significantly higher positive responses to questions concerning self-management such as conversation with others, consultation with others and when condition worsened than the unemployed group. Also the employed showed a tendency for higher positive responses to such items as cooking, keeping appointments, taking medicine, taking an active role in managing medications. 2. According to discriminant analysis by Hayashi's quantification method II, factors distinguishing 17 participants who had become employed within the year and those who remained unemployed included the following: ability to converse with others, taking an active role in managing medications, and ability to cook, male gender, co-residence with family, and a period of 3 years or less since hospital discharge. These results suggest that a public health rehabilitation program aimed at improving interpersonal skills, self-management of illness and other skills of daily living may be useful in helping the mentally ill participate socially.
Rayner, Lauren; Lee, William; Price, Annabel; Monroe, Barbara; Sykes, Nigel; Hansford, Penny; Higginson, Irene J; Hotopf, Matthew
This cross-sectional survey aimed to determine the prevalence and remission of depression in patients receiving palliative care and to ascertain the predictive value of somatic symptoms in making the diagnosis. Three hundred consecutive patients were interviewed within one week of their initial assessment by a specialist nurse at a palliative care service with in-patient and homecare facilities in south London, UK. Depression was assessed using the PRIME-MD PHQ-9. Presence of somatic symptoms (fatigue, sleep disturbance, poor appetite) was determined using the EORTC-QLQ-C30 quality of life questionnaire. Fifty-eight (19.3% [15.3 to 23.3]) patients met criteria for Major Depressive Disorder; 109 (36.3% [32.3 to 40.3]) met criteria for 'Any depressive syndrome'. Patients with Major Depressive Disorder were more likely to be male, and to have non-malignant disease, pain, poor performance status and desire for an early death. Of those patients with Major Depressive Disorder at baseline, 69% (27/39) had remitted four weeks later. Of those not depressed at baseline, 11% (19/174) met criteria for depression at follow-up. The positive predictive values of sleep disturbance, poor appetite and fatigue were low (<24%), whereas the negative predictive values of these symptoms were high (>89%). The high prevalence of depression in palliative care attests to the need for psychological assessment and support. Depression in patients receiving palliative care is unstable, suggesting that symptoms should be carefully monitored.
Kilbourne, Amy M.; Blow, Frederic C.; Pierce, John R.; Winkel, Bernard M.; Huycke, Edward; Langberg, Robert; Lyle, David; Phillips, Yancy; Visnic, Stephanie
Objectives. We determined whether contacting Department of Veterans Affairs (VA) patients with schizophrenia or bipolar disorders (serious mental illness [SMI]) who had dropped out of care for prolonged periods resulted in reengagement with VA services and decreased mortality. Methods. We developed a list of patients with SMI who were last treated in fiscal years 2005 to 2006, and were lost to follow-up care for at least 1 year. VA medical centers used our list to contact patients and schedule appointments. Additional VA administrative data on patient utilization and mortality through May 2009 were analyzed. Results. About 72% (2375 of 3306) of the patients who VA staff attempted to contact returned for VA care. The mortality rate of returning patients was significantly lower than that for patients not returning (0.5% vs 3.9%; adjusted odds ratio = 5.8; P < .001), after demographic and clinical factors were controlled. Conclusions. The mortality rate for returning patients with SMI was almost 6 times less than for those who did not return for medical care. Proactive outreach might result in patients returning to care and should be implemented to reengage this vulnerable group. PMID:22390607
O'Brien, B P; Murphy, D; Conrick-Martin, I; Marsh, B
Patients who have overdosed on drugs commonly present to emergency departments, with only the most severe cases requiring intensive care unit (ICU) admission. Such patients typically survive hospitalisation. We studied their longer term functional outcomes and recovery patterns which have not been well described. All patients admitted to the 18-bed ICU of a university-affiliated teaching hospital following drug overdoses between 1 January 2004 and 31 December 2006 were identified. With ethical approval, we evaluated the functional outcome and recovery patterns of the surviving patients 31 months after presentation, by telephone or personal interview. These were recorded as Glasgow outcome score, Karnofsky performance index and present work status. During the three years studied, 43 patients were identified as being admitted to our ICU because of an overdose. The average age was 34 years, 72% were male and the mean APACHE II score was 16.7. Of these, 32 were discharged from hospital alive. Follow-up data was attained on all of them. At a median of 31 months follow-up, a further eight had died. Of the 24 surviving there were 13 unemployed, seven employed and four in custody. The median Glasgow outcome score of survivors was 4.5, their Karnofsky score 80. Admission to ICU for treatment of overdose is associated with a very high risk of death in both the short- and long-term. While excellent functional recovery is achievable, 16% of survivors were held in custody and 54% unemployed.
Cárdenas-Valladolid, Juan; Salinero-Fort, Miguel A; Gómez-Campelo, Paloma; de Burgos-Lunar, Carmen; Abánades-Herranz, Juan C; Arnal-Selfa, Rosa; Andrés, Ana López-
Implementation of a standardized language in Nursing Care Plans (SNCP) allows for increased efficiency in nursing data management. However, the potential relationship with patientś health outcomes remains uncertain. The aim of this study was to evaluate the effectiveness of SNCP implementation, based on North American Nursing Diagnosis Association (NANDA) and Nursing Interventions Classification (NIC), in the improvement of metabolic, weight, and blood pressure control of Type 2 Diabetes Mellitus (T2DM) patients. A two-year prospective follow-up study, in routine clinical practice conditions. 31 primary health care centers (Spain) participated with 24,124 T2DM outpatients. Data was collected from Computerized Clinical Records; SNCP were identified using NANDA and NIC taxonomies. Descriptive and ANCOVA analyses were conducted. 18,320 patients were identified in the Usual Nursing Care (UNC) group and 5,168 in the SNCP group. At the two-year follow-up, the SNCP group improved all parameters except LDL cholesterol and diastolic blood pressure. We analyzed data adjustming by the baseline value for these variables and variables with statistically significant differences between groups at baseline visit. Results indicated a lowering of all parameters except HbA1c, but a statistically significant reduction was only observed with diastolic blood pressure results. However, the adjusted reduction of diastolic blood pressure is of little clinical relevance. Greater differences of control values for diastolic blood pressure, HbA1c, LDL-cholesterol and Body Mass Index were found in the SNCP group, but only reached statistical significance for HbA1c. A greater proportion of patients with baseline HbA1c ≥7 decreased to <7% at the two-year follow-up in the SNCP group than in the UNC group (16.9% vs. 15%; respectively; p = 0.01). Utilization of SNCP was helpful in achieving glycemic control targets in poorly controlled patients with T2DM (HbA1c ≥7%). Diastolic blood pressure
Cárdenas-Valladolid, Juan; Salinero-Fort, Miguel A.; Gómez-Campelo, Paloma; de Burgos-Lunar, Carmen; Abánades-Herranz, Juan C.; Arnal-Selfa, Rosa; Andrés, Ana López-
Background Implementation of a standardized language in Nursing Care Plans (SNCP) allows for increased efficiency in nursing data management. However, the potential relationship with patientś health outcomes remains uncertain. The aim of this study was to evaluate the effectiveness of SNCP implementation, based on North American Nursing Diagnosis Association (NANDA) and Nursing Interventions Classification (NIC), in the improvement of metabolic, weight, and blood pressure control of Type 2 Diabetes Mellitus (T2DM) patients. Methods A two-year prospective follow-up study, in routine clinical practice conditions. 31 primary health care centers (Spain) participated with 24,124 T2DM outpatients. Data was collected from Computerized Clinical Records; SNCP were identified using NANDA and NIC taxonomies. Descriptive and ANCOVA analyses were conducted. Results 18,320 patients were identified in the Usual Nursing Care (UNC) group and 5,168 in the SNCP group. At the two-year follow-up, the SNCP group improved all parameters except LDL cholesterol and diastolic blood pressure. We analyzed data adjustming by the baseline value for these variables and variables with statistically significant differences between groups at baseline visit. Results indicated a lowering of all parameters except HbA1c, but a statistically significant reduction was only observed with diastolic blood pressure results. However, the adjusted reduction of diastolic blood pressure is of little clinical relevance. Greater differences of control values for diastolic blood pressure, HbA1c, LDL-cholesterol and Body Mass Index were found in the SNCP group, but only reached statistical significance for HbA1c. A greater proportion of patients with baseline HbA1c ≥7 decreased to <7% at the two-year follow-up in the SNCP group than in the UNC group (16.9% vs. 15%; respectively; p = 0.01). Conclusions Utilization of SNCP was helpful in achieving glycemic control targets in poorly controlled patients with T2DM
Meyer, Saskia; Gräske, Johannes; Worch, Andreas; Wolf-Ostermann, Karin
Malnutrition in the elderly is an important nursing challenge. Persons with dementia disease are often affected by malnutrition. During recent years, shared-housing arrangements (SHA) for older care-dependent people, frequently with dementia disease, have evolved in Germany. SHA can be an alternative to traditional residential care in nursing homes. The prevalence of malnutrition in SHA is compared to the prevalence in community dwellings and lower than the prevalence of malnutrition in nursing homes. There are no scientific data about the development of the nutritional status of older care-dependent people in SHA over one year. The aim of this study is to describe the nutritional status of care-dependent people with dementia disease living in SHA and to investigate changes over a period of one year. A longitudinal study with a one-year follow-up was performed. Standardised interviews with nurses were conducted concerning nutritional status (Mini Nutritional Assessment--MNA), cognitive capacities (Mini Mental State Examination--MMSE), activities of daily living (Extended Barthel-Index--EBI) and socio-demographic characteristics. Nutritional data were available for 45 residents at baseline and 36 residents at follow-up. At baseline, 45 residents with an average age of 78.4 years living in SHA in the state of Berlin, Germany, were included in the study. Predominantly, residents were female (73.3%) and diagnosed with dementia (88.9%), with a moderate to severe cognitive impairment (MMSE: 10.8) and low daily living abilities (EBI: 33.7). Most residents (80.6%) have a risk of malnutrition regarding the MNA. The average MNA score did decline slightly within one year (t0 = 20.8 vs. t1 = 19.7). Regular screenings for malnutrition using validated standardised assessments, which are easy to apply, should be implemented in SHA to avoid nutritional and health-related problems arising from malnutrition. Flexible structures for care, as in SHA, can facilitate coping with
Background Comprehensive rehabilitation, involving health professionals from various disciplines, is widely used as an adjunct to pharmacological and surgical treatment in people with rheumatic diseases. However, the evidence for the clinical- and cost-effectiveness of such interventions is limited, and the majority of those who receive rehabilitation are back to their initial health status six to 12 months after discharge. Methods/design To evaluate the goal attainment, health effects and cost-effectiveness of a new rehabilitation programme compared to current traditional rehabilitation programmes for people with rheumatic diseases, a stepped-wedge cluster randomized trial will be performed. Patients admitted for rehabilitation at six centres in the south-eastern part of Norway will be invited to participate. In the trial, six participating centres will switch from a control (current rehabilitation programme) to an intervention phase (the new rehabilitation programme) in a randomized order. Supported by recent research, the new programme will be a supplement to the existing programme at each centre, and will comprise four elements designed to enhance and support lifestyle changes introduced in the rehabilitation period: structured goal-planning, motivational interviewing, a self-help booklet and four follow-up telephone calls during the first five months following discharge. The primary outcome will be health-related quality of life and goal attainment, as measured by the Patient Generated Index directly before and after the rehabilitation stay, as well as after six and 12 months. Secondary outcomes will include self-reported pain, fatigue, a global assessment of disease activity and motivation for change (measured on 11-point numeric ratings scales), health-related quality of life as measured by the Short Form 36 Health Survey (SF-36) and utility assessed by the SF6D utility index. The main analysis will be on an intention to treat basis and will assess the
Gregory, Robert J; DeLucia-Deranja, Evan; Mogle, Jacqueline A
Patients having co-occurring borderline personality disorder and alcohol use disorders represent a common, but particularly severe and refractory subgroup. An individual, time-limited treatment, dynamic deconstructive psychotherapy (DDP), has been shown to be effective for this subgroup, but long-term outcomes are not known. Participants were recruited from a sample of 30 patients enrolled in a 12-month randomized controlled trial of DDP versus optimized community care (OCC). Outcomes were assessed after an additional 18 months of naturalistic follow-up. DDP participants received an equivalent amount of individual treatment and less group therapy than those receiving OCC, but demonstrated large, sustained treatment effects over a broad range of outcomes and achieved significantly greater improvement in core BPD symptoms, depression, parasuicide, and recreational drug use over the 30-month study. These results suggest that DDP is a cost-effective treatment that can lead to broad and sustained improvement for the dually diagnosed subgroup.
Cornillon, J; Peffault de Latour, R; Apaza, S; Bourg, M-A; Courbon, C; Evard, S; Guiraud, M; Le Bars, L; Petit, S; Magro, L; Schmitt, S; Tardieu, L; Samsonova, O; Tipton, R; Yakoub-Agha, I
The number of Hematopoietic Stem Cell Transplantations has globally taken off in the past decade. However, this increase in transplantation activity has put in the spotlight the need to create a special transplantation-skilled population of nurses. This type of specialisation allocated solely to this activity has not existed within the French nursing community until now. In the attempt to harmonize clinical practices between different French transplantation centers, the French Society of Bone Marrow Transplantation and Cell Therapy (SFGM-TC) sets up its forth annual series of workshops which brought together practitioners from all member centers and took place in September 2013 in Lille. Here we report our results and recommendations regarding the implementation of a transplant nurse status for post-transplant follow-up care.
Poole, G E; Galpin, Grant
New Zealand annually accepts approximately 750 quota refugees from around the world for resettlement in New Zealand. The humanitarian nature of the quota composition consists of those who are determined by the United Nations refugee agency to be in high need of immediate protection, a large proportion of medical and disability cases, and women and children at risk. Quota refugees arrive in group intakes and participate in assessment and orientation for the first 6 weeks at the national Mangere Refugee Resettlement Centre in South Auckland. This paper describes the findings of screening for refugees with a history of torture during 2007-2008. There were 144 refugees or 19.2% of the new arrivals found to have histories of torture during this period. The implications for future research, and follow-up care of people who have survived torture are discussed.
Mental health and functional impairment outcomes following a 6-week intensive treatment programme for UK military veterans with post-traumatic stress disorder (PTSD): a naturalistic study to explore dropout and health outcomes at follow-up
Murphy, Dominic; Hodgman, Georgina; Carson, Carron; Spencer-Harper, Lucy; Hinton, Mark; Wessely, Simon; Busuttil, Walter
Objective Combat Stress, a UK national charity for veterans with mental health problems, has been funded by the National Health Service (NHS) to provide a national specialist service to deliver treatment for post-traumatic stress disorder (PTSD). This paper reports the efficacy of a PTSD treatment programme for UK veterans at 6 months follow-up. Design A within subject design. Setting UK veterans with a diagnosis of PTSD who accessed Combat Stress. Participants 246 veterans who received treatment between late 2012 and early 2014. Intervention An intensive 6-week residential treatment programme, consisting of a mixture of individual and group sessions. Participants were offered a minimum of 15 individual trauma-focused cognitive behavioural therapy sessions. In addition, participants were offered 55 group sessions focusing on psychoeducational material and emotional regulation. Main outcome measures Clinicians completed measures of PTSD and functional impairment and participants completed measures of PTSD, depression, anger and functional impairment. Results We observed significant reductions in PTSD scores following treatment on both clinician completed measures (PSS-I: −13.0, 95% CI −14.5 to −11.5) and self-reported measures (Revised Impact of Events Scale (IES-R): −16.5, 95% CI −19.0 to −14.0). Significant improvements in functional impairment were also observed (eg, Health of the Nation Outcome Scales (HONOS): −6.85, 95% CI −7.98 to −5.72). There were no differences in baseline outcomes between those who completed and those who did not complete the programme, or post-treatment outcomes between those we were able to follow-up at 6 months and those lost to follow-up. Conclusions In a naturalistic study we observed a significant reduction in PTSD scores and functional impairment following treatment. These improvements were maintained at 6 month follow-up. Our findings suggest it may be helpful to take a closer look at combining individual
Mental health and functional impairment outcomes following a 6-week intensive treatment programme for UK military veterans with post-traumatic stress disorder (PTSD): a naturalistic study to explore dropout and health outcomes at follow-up.
Murphy, Dominic; Hodgman, Georgina; Carson, Carron; Spencer-Harper, Lucy; Hinton, Mark; Wessely, Simon; Busuttil, Walter
Combat Stress, a UK national charity for veterans with mental health problems, has been funded by the National Health Service (NHS) to provide a national specialist service to deliver treatment for post-traumatic stress disorder (PTSD). This paper reports the efficacy of a PTSD treatment programme for UK veterans at 6 months follow-up. A within subject design. UK veterans with a diagnosis of PTSD who accessed Combat Stress. 246 veterans who received treatment between late 2012 and early 2014. An intensive 6-week residential treatment programme, consisting of a mixture of individual and group sessions. Participants were offered a minimum of 15 individual trauma-focused cognitive behavioural therapy sessions. In addition, participants were offered 55 group sessions focusing on psychoeducational material and emotional regulation. Clinicians completed measures of PTSD and functional impairment and participants completed measures of PTSD, depression, anger and functional impairment. We observed significant reductions in PTSD scores following treatment on both clinician completed measures (PSS-I: -13.0, 95% CI -14.5 to -11.5) and self-reported measures (Revised Impact of Events Scale (IES-R): -16.5, 95% CI -19.0 to -14.0). Significant improvements in functional impairment were also observed (eg, Health of the Nation Outcome Scales (HONOS): -6.85, 95% CI -7.98 to -5.72). There were no differences in baseline outcomes between those who completed and those who did not complete the programme, or post-treatment outcomes between those we were able to follow-up at 6 months and those lost to follow-up. In a naturalistic study we observed a significant reduction in PTSD scores and functional impairment following treatment. These improvements were maintained at 6 month follow-up. Our findings suggest it may be helpful to take a closer look at combining individual trauma-focused cognitive behaviour therapy and group sessions when treating veterans with PTSD. This is the first
Morténius, Helena; Fridlund, Bengt; Marklund, Bertil; Palm, Lars; Baigi, Amir
To evaluate the long-term utilisation of strategic communication as a factor of importance when changing work practices among primary care staff. In many health care organisations, there is a gap between theory and practice. This gap hinders the provision of optimal evidence-based practice and, in the long term, is unfavourable for patient care. One way of overcoming this barrier is systematically structured communication between the scientific theoretical platform and clinical practice. This longitudinal evaluative study was conducted among a primary care staff cohort. Strategic communication was considered to be the intervention platform and included a network of ambassadors who acted as a component of the implementation. Measurements occurred 7 and 12 years after formation of the cohort. A questionnaire was used to obtain information from participants. In total, 846 employees (70%) agreed to take part in the study. After 12 years, the 352 individuals (60%) who had remained in the organisation were identified and followed up. Descriptive statistics and multivariate analysis were used to analyse the data. Continuous information contributed to significant improvements over time with respect to new ideas and the intention to change work practices. There was a statistically significant synergistic effect on the new way of thinking, that is, willingness to change work practices. During the final two years, the network of ambassadors had created a distinctive image for itself in the sense that primary care staff members were aware of it and its activities. This awareness was associated with a positive change with regard to new ways of thinking. More years of practice was inversely associated with willingness to change work practices. Strategic communication may lead to a scientific platform that promotes high-quality patient care by means of new methods and research findings.
Kuuppelomäki, Merja; Utriainen, Pekka
The purpose of the study was to describe the sense of coherence (SOC) of three groups of Finnish polytechnic students (n=287) at the beginning of their studies and to follow it during a period of 3 year amongst the health care students (n=63) of this group. The associations between SOC and smoking, drinking and physical exercise were also studied. The data were collected with a questionnaire which included Antonovsky's (Adv. Nurs. Sci. 1(1983)37) SOC scale. Data analysis was with SPSS statistical software. The students showed a strong sense of coherence at the beginning of their studies. Physical activity was related to the strength of SOC, but no association was found with smoking and drinking. Health care students showed a stronger SOC at the beginning of their studies than the two other groups. During the follow-up focused on the health care students, SOC weakened in 6%, remained unchanged in 65% and strengthened in 32% of the participants. Smoking, drinking and physical exercise showed no association with these changes. Future research should be focused on identifying factors that are related to SOC during education.
Hellstrand, Mats; Simonsson, Bo; Engström, Sevek; Nilsson, Kent W; Molarius, Anu
The total number of cardiovascular (CVD) deaths accounted for almost a third of all deaths globally in 2013. Population based randomised controlled trials, managed within primary care, on CVD risk factor interventions are scarce. The aim of the study was to evaluate the effects of a health dialogue intervention in a primary care setting offered to a population at the age of 55 years, focusing on CVD risk factors. The study was performed in five primary health care centres in the county of Västmanland, Sweden between April 2011 and December 2012. Men and women were randomly assigned to intervention (n = 440) and control groups (n = 440). At baseline, both groups filled in a health questionnaire and serum cholesterol, fasting plasma glucose, glycated haemoglobin (HbA1c), weight, height, waist (WC) and hip circumference, waist hip ratio (WHR) and systolic/diastolic blood pressure were measured. Intervention group attended a health dialogue, supported by a visualised health profile, with a possibility for further activities. Participation rates at baseline were 53% and 52% respectively. A 1-year follow-up was carried out. The intervention group (n = 165) showed reductions compared to the control group (n = 177) concerning body mass index (BMI) (0.3 kg/m(2), p = .031), WC (2.1 cm, p ≤ .001) and WHR (.002, p ≤ .001) at the 1-year follow-up. No differences between the intervention and control groups were found in other variables. Intervention group, compared to baseline, had reduced weight, BMI, WC, WHR, HbA1c, and diet, while the men in the control group had reduced their alcohol consumption. A health dialogue intervention at the age of 55 years, conducted in ordinary primary care, showed a moderate effect on CVD risk factor levels, in terms of BMI, WC and WHR. BioMed Central, ISRCTN22586871 , date assigned; 10/12/2015.
von Bonsdorff, Mikaela Birgitta; von Bonsdorff, Monika; Kulmala, Jenni; Törmäkangas, Timo; Seitsamo, Jorma; Leino-Arjas, Päivi; Nygård, Clas-Håkan; Ilmarinen, Juhani; Rantanen, Taina
high job strain increases the risk of health decline, but little is known about the specific consequences and long-term effects of job strain on old age health. purpose was to investigate whether physical and mental job strain in midlife was associated with hospital care use in old age. study population included 5,625 Finnish public sector employees aged 44-58 years who worked in blue- and white-collar professions in 1981. The number of in-patient hospital care days was collected from the Finnish Hospital Discharge Register for the 28-year follow-up period. rates of hospital care days per 1,000 person-years for men were 7.78 (95% confidence interval [CI] 7.71-7.84) for low, 9.68 (95% CI 9.50-9.74) for intermediate and 12.56 (95% CI 12.47-12.66) for high physical job strain in midlife. The corresponding rates for women were 6.63 (95% CI 6.57-6.68), 7.91 (95% CI 7.87-7.95) and 10.35 (95% CI 10.25-10.42), respectively. Rates were parallel but lower for mental job strain. Reporting high physical job strain in midlife increased the risk of hospital care in old age compared with those who reported low job strain, fully adjusted incidence rate ratio 1.17 (95% CI 1.00-1.38) for men and 1.42 (95% CI 1.25-1.61) for women. These associations were robust in analyses confined to hospital care that took place after the employees had turned 65 years. exposure to high mental and, particularly, high physical job strain in midlife may set employees on a higher healthcare use trajectory which persists into old age.
Casanova, Ludovic; Bocquier, Aurélie; Cortaredona, Sébastien; Nauleau, Stève; Sauze, Laurent; Sciortino, Vincent; Villani, Patrick; Verger, Pierre
To assess whether private general practitioners (GPs) belonging to a diabetes-care network adhered more closely to clinical practice guidelines for diabetes care than GPs not in such a network, for all their patients with type 2 diabetes treated with medication (patients with diabetes), regardless of whether they received care through a network (that is, whether a halo effect occurred). The study, based on health insurance reimbursement databases in southeastern France, included 468 GPs in two networks and 468 non-network GPs in the same geographical area, matched one-to-one by propensity scores. We followed up their patients with diabetes (n=22,808) from 2008 through 2011, conducting multivariate time-to-event analyses (Cox models) that took the matching design into account to evaluate time from inclusion until performance of the given number of each of six recommended examinations/tests. GPs belonging to a diabetes-care network adhered more closely to clinical practice guidelines but our result were slightly pronounced. Hazard ratios (HR) were significantly higher for patients of network GPs for the implementation of 3 HbA1C assays (HRa=1.13; [95%CI=1.10-1.16]), or 1 microalbuminuria assay (1.4 [1.35-1.45]); they were lower for LDL-cholesterol assays (1.04 [1.01-1.07]) and ophthalmological checkups (1.07 [1.04-1.10]), and not significant for creatinemia or cardiac monitoring. Network GPs had better diabetes monitoring practices for all their patients with diabetes than the other GPs, especially for the most diabetes-specific tests. Further research is needed in other settings to confirm the existence of this halo effect. Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Bowman, Kirsty; Delgado, João; Henley, William E.; Masoli, Jane A.; Kos, Katarina; Brayne, Carol; Thokala, Praveen; Lafortune, Louise; Kuchel, George A.; Ble, Alessandro
Background: Moderate obesity in later life may improve survival, prompting calls to revise obesity control policies. However, this obesity paradox may be due to confounding from smoking, diseases causing weight-loss, plus varying follow-up periods. We aimed to estimate body mass index (BMI) associations with mortality, incident type 2 diabetes, and coronary heart disease in older people with and without the above confounders. Methods: Cohort analysis in Clinical Practice Research Datalink primary care, hospital and death certificate electronic medical records in England for ages 60 to more than 85 years. Models were adjusted for age, gender, alcohol use, smoking, calendar year, and socioeconomic status. Results: Overall, BMI 30–34.9 (obesity class 1) was associated with lower overall death rates in all age groups. However, after excluding the specific confounders and follow-up less than 4 years, BMI mortality risk curves at age 65–69 were U-shaped, with raised risks at lower BMIs, a nadir between 23 and 26.9 and steeply rising risks above. In older age groups, mortality nadirs were at modestly higher BMIs (all <30) and risk slopes at higher BMIs were less marked, becoming nonsignificant at age 85 and older. Incidence of diabetes was raised for obesity-1 at all ages and for coronary heart disease to age 84. Conclusions: Obesity is associated with shorter survival plus higher incidence of coronary heart disease and type 2 diabetes in older populations after accounting for the studied confounders, at least to age 84. These results cast doubt on calls to revise obesity control policies based on the claimed risk paradox at older ages. PMID:27492450
Hooker, Leesa; Small, Rhonda; Taft, Angela
To investigate factors contributing to the sustained domestic violence screening and support practices of Maternal and Child Health nurses 2 years after a randomized controlled trial. Domestic violence screening by healthcare professionals has been implemented in many primary care settings. Barriers to screening exist and screening rates remain low. Evidence for longer term integration of nurse screening is minimal. Trial outcomes showed sustained safety planning behaviours by intervention group nurses. Process evaluation in 2-year follow-up of a cluster randomized controlled trial. Evaluation included a repeat online nurse survey and 14 interviews (July-September 2013). Survey analysis included comparison of proportionate group difference between arms and between trial baseline and 2 year follow-up surveys. Framework analysis was used to assess qualitative data. Normalization Process Theory informed evaluation design and interpretation of results. Survey response was 77% (n = 123/160). Sustainability of nurse identification of domestic violence appeared to be due to greater nurse discussion and domestic violence disclosure by women, facilitated by use of a maternal health and well-being checklist. Over time, intervention group nurses used the maternal checklist more at specific maternal health visits and found the checklist the most helpful resource assisting their domestic violence work. Nurses' spoke of a degree of 'normalization' to domestic violence screening that will need constant investment to maintain. Sustainable domestic violence screening and support outcomes can be achieved in an environment of comprehensive, nurse designed and theory driven implementation. Continuing training, discussion and monitoring of domestic violence work is needed to retain sustainable practices. © 2015 John Wiley & Sons Ltd.
Gantner, Pierre; Treger, Michele; De Miscault, Constance; Batard, Marie-Laure; Bernard-Henry, Claudine; Cheneau, Christine; De Mautort, Erik; Partisani, Marialuisa; Priester, Michele; Rey, David
Objectives The care of exposed individuals to HIV remains a challenge regarding follow-up completion and HIV-testing of the partner. Identifying patients with risk of not fulfilling HIV-testing follow-up completion (FC), among patients demanding non-occupational post-exposure prophylaxis (nPEP), may improve clinical practice. Methods A retrospective chart review was conducted in a single French HIV-infection care center. FC predictors were assessed in a multivariate logistic regression model (Likelihood ratios test). Results Between 2009 and 2013, 646 sexual exposures to HIV were evaluated for nPEP, of which 507 effectively received nPEP (78%). FC rate was 30% (194/646). In the multivariate analysis, FC rates rose with age of exposed individuals (OR, 1.04 [0.25–4.28]; p<0.001) and decreased with the year of sexual exposure (OR, 0.74 [0.65–0.85]; p<0.001). FC was associated with sexual encounter with a sex worker (OR, 4.07 [0.98–16.82]; p<0.001) and nPEP use (OR, 2.69 [2.37–3.06]; p<0.001). nPEP early discontinuation was associated with decreased FC rates (OR, 0.18 [0.08–0.39]; p<0.001). No documented nPEP failure was identified. However, five Men who have Sex with Men (MSM) nPEP recipients for unprotected anal receptive intercourse subsequently seroconverted to HIV more than 6 months after nPEP. Seroconversion to HIV was associated with the lack of FC (p = 0.04) and multiple presentations for nPEP over the study period (p = 0.002). Conclusions We identified significant predictors of not fulfilling sequential HIV-testing. They appear to be linked with a self-perceived HIV risk, especially in young adults recently exposed. Enhanced counseling in targeted individuals with high risk behaviors and using smartphone and internet-based strategies may be interesting retention in care options. PMID:26696009
Nishi, Daisuke; Kawashima, Yuzuru; Noguchi, Hiroko; Usuki, Masato; Yamashita, Akihiro; Koido, Yuichi; Matsuoka, Yutaka J
Objectives: Although attention has been paid to post-traumatic stress disorder (PTSD) among health care professionals after disasters, the impact of traumatic events on their work has not been elucidated. The aim of this study was to examine whether disaster-related distress, resilience, and post-traumatic growth (PTG) affect work engagement among health care professionals who had been deployed to the areas affected by the Great East Japan Earthquake that occurred on March 11, 2011. Methods: We recruited disaster medical assistance team members who were engaged in rescue activities after the earthquake. The short version of the Resilience Scale (RS-14) and Peritraumatic Distress Inventory (PDI) were administered one month after the earthquake, and the short form of Posttraumatic Growth Inventory (SF-PTGI) and Utrecht Work Engagement Scale (UWES) were administered four years after the earthquake. Work engagement is composed of vigor, dedication, and absorption. Regression analyses were used to examine the relationship of UWES with RS-14, PDI, and SF-PTGI. Results: We obtained baseline data of 254 participants in April 2011, and 191 (75.2%) completed the follow-up assessment between December 2014 and March 2015. The results showed that RS-14 predicted vigor, dedication, and absorption; in addition, SF-PTGI was positively related with these three parameters (p<0.01 for all). Conclusions: Resilience at baseline and PTG after rescue activities may increase work engagement among health care professionals after disasters. These findings could be useful for establishing a support system after rescue activities during a large-scale disaster and for managing work-related stress among health care professionals. PMID:27265533
Viana, Renata Cristina Teixeira Pinto; Pincelli, Mariangela Pimentel; Pizzichini, Emílio; Silva, André Pacheco; Manes, Joice; Marconi, Tatiana Dias; Steidle, Leila John Marques
Objective The purpose of this study was to evaluate the clinical/functional aspects and quality of life of chronic obstructive pulmonary disease patients who were discharged after an intensive care unit admission for acute respiratory failure. Methods This prospective study included chronic obstructive pulmonary disease patients who were admitted to two intensive care units between December of 2010 and August of 2011 and evaluated over three visits after discharge. Thirty patients were included, and 20 patients completed the three-month follow up. Results There was a significant improvement in the following: forced expiratory flow in one second (L) (1.1/1.4/1.4; p = 0.019), six-minute walk test (m) (- /232.8 /272.6; p = 0.04), BODE score (7.5/5.0/3.8; p = 0.001), cognition measured by the Mini Mental State Examination (21/23.5/23.5; p = 0.008) and quality of life measured by the total Saint George Respiratory Questionnaire score (63.3/56.8/51, p = 0.02). The mean difference in the total score was 12.3 (between visits 1 and three). Important clinical differences were observed for the symptom score (18.8), activities score (5.2) and impact score (14.3). The majority of participants (80%) reported they would be willing to undergo a new intensive care unit admission. Conclusion Despite the disease severity, there was a significant clinical, functional and quality of life improvement at the end of the third month. Most patients would be willing to undergo a new intensive care unit admission. PMID:28444072
Viana, Renata Cristina Teixeira Pinto; Pincelli, Mariangela Pimentel; Pizzichini, Emílio; Silva, André Pacheco; Manes, Joice; Marconi, Tatiana Dias; Steidle, Leila John Marques
The purpose of this study was to evaluate the clinical/functional aspects and quality of life of chronic obstructive pulmonary disease patients who were discharged after an intensive care unit admission for acute respiratory failure. This prospective study included chronic obstructive pulmonary disease patients who were admitted to two intensive care units between December of 2010 and August of 2011 and evaluated over three visits after discharge. Thirty patients were included, and 20 patients completed the three-month follow up. There was a significant improvement in the following: forced expiratory flow in one second (L) (1.1/1.4/1.4; p = 0.019), six-minute walk test (m) (- /232.8 /272.6; p = 0.04), BODE score (7.5/5.0/3.8; p = 0.001), cognition measured by the Mini Mental State Examination (21/23.5/23.5; p = 0.008) and quality of life measured by the total Saint George Respiratory Questionnaire score (63.3/56.8/51, p = 0.02). The mean difference in the total score was 12.3 (between visits 1 and three). Important clinical differences were observed for the symptom score (18.8), activities score (5.2) and impact score (14.3). The majority of participants (80%) reported they would be willing to undergo a new intensive care unit admission. Despite the disease severity, there was a significant clinical, functional and quality of life improvement at the end of the third month. Most patients would be willing to undergo a new intensive care unit admission.
Dawes, Jo; Deaton, Stuart; Greenwood, Nan
The purpose of this study was to appraise referrals of homeless patients to physiotherapy services and explore perceptions of barriers to access. This exploratory mixed-method study used a follow-up qualitative extension to core quantitative research design. Over 9 months, quantitative data were gathered from the healthcare records of homeless patients referred to physiotherapy by a general practitioner (GP) practice, including the number of referrals and demographic data of all homeless patients referred. Corresponding physiotherapy records of those people referred to physiotherapy were searched for the outcome of their care. Qualitative semi-structured telephone interviews, based on the quantitative findings, were carried out with staff involved with patient care from the referring GP practice and were used to expand insight into the quantitative findings. Two primary care sites provided data for this study: a GP practice dedicated exclusively to homeless people and the physiotherapy department receiving their referrals. Quantitative data from the healthcare records of 34 homeless patient referrals to physiotherapy were collected and analysed. In addition, five staff involved in patient care were interviewed. 34 referrals of homeless people were made to physiotherapy in a 9-month period. It was possible to match 25 of these to records from the physiotherapy department. Nine (36%) patients did not attend their first appointment; seven (28%) attended an initial appointment, but did not attend a subsequent appointment and were discharged from the service; five (20%) completed treatment and four patients (16%) had ongoing treatment. Semi-structured interviews revealed potential barriers preventing homeless people from accessing physiotherapy services, the complex factors being faced by those making referrals and possible ways to improve physiotherapy access. Homeless people with musculoskeletal problems may fail to access physiotherapy treatment, but opportunities
Nishi, Daisuke; Kawashima, Yuzuru; Noguchi, Hiroko; Usuki, Masato; Yamashita, Akihiro; Koido, Yuichi; Matsuoka, Yutaka J
Although attention has been paid to post-traumatic stress disorder (PTSD) among health care professionals after disasters, the impact of traumatic events on their work has not been elucidated. The aim of this study was to examine whether disaster-related distress, resilience, and post-traumatic growth (PTG) affect work engagement among health care professionals who had been deployed to the areas affected by the Great East Japan Earthquake that occurred on March 11, 2011. We recruited disaster medical assistance team members who were engaged in rescue activities after the earthquake. The short version of the Resilience Scale (RS-14) and Peritraumatic Distress Inventory (PDI) were administered one month after the earthquake, and the short form of Posttraumatic Growth Inventory (SF-PTGI) and Utrecht Work Engagement Scale (UWES) were administered four years after the earthquake. Work engagement is composed of vigor, dedication, and absorption. Regression analyses were used to examine the relationship of UWES with RS-14, PDI, and SF-PTGI. We obtained baseline data of 254 participants in April 2011, and 191 (75.2%) completed the follow-up assessment between December 2014 and March 2015. The results showed that RS-14 predicted vigor, dedication, and absorption; in addition, SF-PTGI was positively related with these three parameters (p<0.01 for all). Resilience at baseline and PTG after rescue activities may increase work engagement among health care professionals after disasters. These findings could be useful for establishing a support system after rescue activities during a large-scale disaster and for managing work-related stress among health care professionals.
Soltani, Jafar; Jamil Amjadi, Mohamad
We studied the safety of a trivalent inactivated surface antigen (split virion, inactivated) influenza vaccine, Begrivac® (Novartis Company), widely used in health care workers in Kurdistan. A longitudinal follow-up study was performed in Sanandaj city, west of Iran, recruiting 936 people. A questionnaire was completed for each participant, and all symptoms or abnormal physical findings were recorded. In part 1 of the study, the post-vaccination complaints were headache (5.3%), fever (7.9%), weakness (9.6%), chills (10.1%), sweating (10.5%), arthralgia (20.2%), and malaise (21.5%). Swelling of the injection site was seen in 267 (30.3%) participants, and pruritus of the injection site was seen in 290 (32.9%) participants. Redness and induration were also reported in 42.5% of the participants. Local reactions were mainly mild and lasted for 1-2 days. No systemic reactions were reported in the second part of the study. None of the participants experienced any inconvenience. We concluded that local adverse reactions after the trivalent inactivated split influenza vaccine, Begrivac®, in health care workers were far more common than expected. Continuous surveillance is needed to assess the potential risks and benefits of newly produced influenza vaccines.
Spinks, Tracy; Albright, Heidi W.; Feeley, Thomas W.; Walters, Ron; Burke, Thomas W.; Aloia, Thomas; Bruera, Eduardo; Buzdar, Aman; Foxhall, Lewis; Hui, David; Summers, Barbara; Rodriguez, Alma; DuBois, Raymond; Shine, Kenneth I.
Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US healthcare system in the late 1990s. The National Cancer Policy Board (NCPB), a twenty-member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system, where patients would have equitable access to coordinated, guideline-based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. This report outlined ten recommendations, which, when implemented, would: 1) improve the quality of cancer care; 2) increase our understanding of quality cancer care; and, 3) reduce or eliminate access barriers to quality cancer care. Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating healthcare costs, has prompted national efforts to reform the healthcare system. These efforts by healthcare providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States. PMID:22045610
Spinks, Tracy; Albright, Heidi W; Feeley, Thomas W; Walters, Ron; Burke, Thomas W; Aloia, Thomas; Bruera, Eduardo; Buzdar, Aman; Foxhall, Lewis; Hui, David; Summers, Barbara; Rodriguez, Alma; Dubois, Raymond; Shine, Kenneth I
Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US health care system in the late 1990s. The National Cancer Policy Board (NCPB), a 20-member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system in which patients would have equitable access to coordinated, guideline-based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. The report outlined 10 recommendations, which, when implemented, would: 1) improve the quality of cancer care, 2) increase the current understanding of quality cancer care, and 3) reduce or eliminate access barriers to quality cancer care. Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating health care costs, has prompted national efforts to reform the health care system. These efforts by health care providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States.
De Regge, Melissa; De Pourcq, Kaat; Meijboom, Bert; Trybou, Jeroen; Mortier, Eric; Eeckloo, Kristof
Multiple studies have investigated the outcome of integrated care programs for chronically ill patients. However, few studies have addressed the specific role hospitals can play in the downstream collaboration for chronic disease management. Our objective here is to provide a comprehensive overview of the role of the hospitals by synthesizing the advantages and disadvantages of hospital interference in the chronic discourse for chronically ill patients found in published empirical studies. Systematic literature review. Two reviewers independently investigated relevant studies using a standardized search strategy. Thirty-two articles were included in the systematic review. Overall, the quality of the included studies is high. Four important themes were identified: the impact of transitional care interventions initiated from the hospital's side, the role of specialized care settings, the comparison of inpatient and outpatient care, and the effect of chronic care coordination on the experience of patients. Our results show that hospitals can play an important role in transitional care interventions and the coordination of chronic care with better outcomes for the patients by taking a leading role in integrated care programs. Above that, the patient experiences are positively influenced by the coordinating role of a specialist. Specialized care settings, as components of the hospital, facilitate the coordination of the care processes. In the future, specialized care centers and primary care could play a more extensive role in care for chronic patients by collaborating.
American Educational Research Journal, 2005
Associations between early child care and children's functioning though the end of third grade were examined. Some of the relations that had been detected before children's school entry were maintained. Higher-quality child care continued to be linked to higher scores in math, reading, and memory. More time spent in center care was associated with…
Mamas, Mamas A; Sperrin, Matthew; Watson, Margaret C; Coutts, Alasdair; Wilde, Katie; Burton, Christopher; Kadam, Umesh T; Kwok, Chun Shing; Clark, Allan B; Murchie, Peter; Buchan, Iain; Hannaford, Philip C; Myint, Phyo K
This study was designed to evaluate whether survival rates in patients with heart failure (HF) are better than those in patients with diagnoses of the four most common cancers in men and women, respectively, in a contemporary primary care cohort in the community in Scotland. Data were obtained from the Primary Care Clinical Informatics Unit from a database of 1.75 million people registered with 393 general practices in Scotland. Sex-specific survival modelling was undertaken using Cox proportional hazards models, adjusted for potential confounders. A total of 56 658 subjects were eligible for inclusion in the study. These represented a total of 147 938 person-years of follow-up (median follow-up: 2.04 years). In men, HF (reference group; 5-year survival: 55.8%) had worse mortality outcomes than prostate cancer [hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.57-0.65; 5-year survival: 68.3%], and bladder cancer (HR 0.88, 95% CI 0.81-0.96; 5-year survival: 57.3%), but better outcomes than lung cancer (HR 3.86, 95% CI 3.65-4.07; 5-year survival: 8.4%) and colorectal cancer (HR 1.23, 95% CI 1.16-1.31; 5-year survival: 48.9%). In women, HF (reference group; 5-year survival: 49.5%) had worse mortality outcomes than breast cancer (HR 0.55, 95% CI 0.51-0.59; 5-year survival 77.7%), but better outcomes than colorectal cancer (HR 1.21, 95% CI 1.13-1.29; 5-year survival 51.5%), lung cancer (HR 3.82, 95% CI 3.60-4.05; 5-year survival 10.4%), and ovarian cancer (HR 1.98, 95% CI 1.80-2.17; 5-year survival 38.2%). Despite advances in management, HF remains as 'malignant' as some of the common cancers in both men and women. © 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.
Claveria Guiu, Isabel; Caro Mendivelso, Johanna; Ouaarab Essadek, Hakima; González Mestre, Maria Asunción; Albajar-Viñas, Pedro; Gómez I Prat, Jordi
The Catalonian Expert Patient Programme on Chagas disease is a initiative, which is part of the Chronic Disease Programme. It aims to boost responsibility of patients for their own health and to promote self-care. The programme is based on nine sessions conducted by an expert patient. Evaluation was focusing in: habits and lifestyle/self-care, knowledge of disease, perception of health, self-esteem, participant satisfaction, and compliance with medical follow-up visits. Eighteen participants initiated the programme and 15 completed it. The participants were Bolivians. The 66.7 % of them had been diagnosed with chagas disease in Spain. The 100 % mentioned that they would participate in this activity again and would recommend it to family and friends. The knowledge about disease improve after sessions. The method used in the programme could serve as a key strategy in the field of comprehensive care for individuals with this disease.
Vicens, Caterina; Sempere, Ermengol; Bejarano, Ferrán; Socias, Isabel; Mateu, Catalina; Fiol, Francisca; Palop, Vicente; Mengual, Marta; Folch, Silvia; Lera, Guillem; Basora, Josep; Leiva, Alfonso
Background Primary care interventions that promote cessation of benzodiazepine (BZD) use in long-term users are effective at 1 year, but their efficacy at 3 years is uncertain. Aim To assess the 3-year efficacy of two primary care interventions delivered by GPs on cessation of BZD use in long-term users. Design and setting Multicentre, three-arm, cluster randomised, controlled trial, with random allocation at the GP level. Method Seventy-five GPs and 532 patients were randomly allocated to three groups: usual care (control), structured intervention with stepped-dose reduction and follow-up visits (SIF), or structured intervention with written stepped-dose reduction (SIW). The primary outcome was BZD use at 36 months. Results At 36 months, 66/168 patients (39.2%) in the SIW group, 79/191 patients (41.3%) in the SIF group, and 45/173 patients (26.0%) in the control group had discontinued BZD use. The relative risks (RR) adjusted by cluster were 1.51 (95% CI = 1.10 to 2.05; P = 0.009) in the SIW group and 1.59 (95% CI = 1.15 to 2.19; P = 0.005) in the SIF group. A total of 131/188 patients (69.7%) who successfully discontinued BZD use at 12 months remained abstinent at 36 months. The groups showed no significant differences in anxiety, depression, or sleep dissatisfaction at 36 months. Conclusion The interventions were effective on cessation of BZD use; most patients who discontinued at 12 months remained abstinent at 3 years. Discontinuation of BZD use did not have a significant effect on anxiety, depression, or sleep quality. PMID:26823269
Njuguna, Christine; Stewart, Annemie; Mouton, Johannes P.; Blockman, Marc; Maartens, Gary; Swart, Annoesjka; Chisholm, Briony; Jones, Jackie; Dheda, Mukesh; Igumbor, Ehimario U.
Introduction The National HIV & Tuberculosis Health Care Worker (HCW) Hotline provides advice on the management of suspected adverse drug reactions (ADRs). We describe suspected ADRs reported to the hotline by HCWs, concordance with advice, and patient outcomes. Methods We reviewed suspected ADRs in HIV-infected patients, patients taking antiretrovirals and patients taking anti-tuberculosis therapy reported from May 2013 to October 2014. We performed causality assessment using the World Health Organization Uppsala Monitoring Centre (WHO-UMC) criteria. We included suspected ADRs categorized as certain, probable or possible in further analysis. Results We received 772 ADR reports, of which 87/772 (11.3 %) were classified as certain, 176/772 (22.8 %) as probable, 361/772 (46.8 %) as possible, and 148/772 (19.2 %) as unlikely or unassessable. The most frequent ADRs were rash, drug-induced liver injury (DILI) and kidney injury, comprising 110/624 (17.6 %), 87/624 (13.9 %), and 77/624 (12.3 %), respectively. The ADR was severe in 27.3 % of rashes, 36.4 % of kidney injury reports and 88.5 % of DILI reports. Most frequently implicated drugs, either alone or in combination with other potentially causative drugs, were efavirenz (rashes), efavirenz and anti-tuberculosis drugs (DILI) and tenofovir (kidney injury). In 383 cases with HCW follow-up, 254 (66.3 %) improved, 9 (2.3 %) had complete resolution, 32 (8.4 %) remained unchanged, 6 (1.6 %) deteriorated, 10 (2.6 %) died and 72 (18.8 %) had unknown outcome. Advice provided was followed in 93.2 % of these cases. Of 223 ADRs with preventability data, 40 (17.9 %) were preventable. Conclusion Queries about rashes, DILIs and kidney injuries were common. Detection and management of these ADRs should be included in HCW training. In cases with follow-up, concordance with advice was high, and HCWs reported improvement in the majority. PMID:26547719
Barbosa, Ana; Nolan, Mike; Sousa, Liliana; Marques, Alda; Figueiredo, Daniela
This study aimed to assess the effects of a psychoeducational intervention, designed to improve direct care workers' stress, burnout and job satisfaction, and person-centered communicative behavior in people with dementia. A pretest-posttest control group design was conducted in 4 aged-care facilities. Two experimental facilities received a psychoeducational intervention, and 2 control facilities received an education only. Data were gathered from 53 care workers at baseline, immediately, and 6 months after the intervention, through self-administrated instruments and video-recorded morning care sessions. The experimental group showed a significant decrease in care workers' burnout and a significant improvement in several communicative behaviors (e.g., involvement). Stress levels deteriorated at 6 months, and no intervention effects were found for job satisfaction. The findings highlight the importance of providing care workers with both technical competences and tools for stress management, as this might be associated with a reduction in their levels of exhaustion and improved communicative behaviors. © The Author(s) 2015.
Prognosis and treatment of atrial fibrillation patients by European cardiologists: one year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot registry).
Lip, Gregory Y H; Laroche, Cécile; Ioachim, Popescu Mircea; Rasmussen, Lars Hvilsted; Vitali-Serdoz, Laura; Petrescu, Lucian; Darabantiu, Dan; Crijns, Harry J G M; Kirchhof, Paulus; Vardas, Panos; Tavazzi, Luigi; Maggioni, Aldo P; Boriani, Giuseppe
The EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot) provides systematic collection of contemporary data regarding the management and treatment of 3119 subjects with AF from 9 member European Society of Cardiology (ESC) countries. In this analysis, we report the development of symptoms, use of antithrombotic therapy and rate vs. rhythm strategies, as well as determinants of mortality and/or stroke/transient ischaemic attack (TIA)/peripheral embolism during 1-year follow-up in this contemporary European registry of AF patients. The registry population comprised consecutive in- and out-patients with AF presenting to cardiologists in participating ESC countries. Consecutive patients with AF documented by ECG were enrolled. Follow-up was performed by the local investigator, initially at 1 year, as part of a long-term cohort study. At the follow-up, patients were frequently asymptomatic (76.8%), but symptoms are nevertheless common among paroxysmal and persistent AF patients, especially palpitations, fatigue, and shortness of breath. Oral anticoagulant (OAC) use remains high, ∼78% overall at follow-up, and of those on vitamin K antagonist (VKA), 84% remained on VKA during the follow-up, while of those on non-VKA oral anticoagulant (NOAC) at baseline, 86% remained on NOAC, and 11.8% had changed to a VKA and 1.1% to antiplatelet therapy. Digitalis was commonly used in paroxysmal AF patients. Of rhythm control interventions, electrical cardioversion was performed in 9.7%, pharmacological cardioversion in 5.1%, and catheter ablation in 4.4%. Despite good adherence to anticoagulation, 1-year mortality was high (5.7%), with most deaths were cardiovascular (70%). Hospital readmissions were common, especially for atrial tachyarrhythmias and heart failure. On multivariate analysis, independent baseline predictors for mortality and/or stroke/TIA/peripheral embolism were age, AF as primary presentation, previous TIA, chronic
Poorgholami, Farzad; Mansoori, Parisa; Montaseri, Zohreh; Najafi, Kazem
Various strategies such as teaching self care to hemodialysis patients have been employed to increase the level of their hope. This study aimed at examining the effects of a telephone follow-up program on the level of hope in a self care education program. In this single-blind randomized controlled clinical trial, 75 hemodialysis patients, selected by convenient sampling, were randomly assigned to 3 groups (n=25 each) including a control, a self care education, or a self care education with telephone follow-up. The control group received the routine care. The self care education group received 5 instruction sessions. The telephone follow-up group had similar instructional sessions followed by telephone calls during the subsequent 2 months. Data, collected using demographic information list and Miller's hope questionnaire, were analyzed using Chi-Square, t-test, and one-way ANOVA followed by Scheffee test. There was no significant difference among the scores of hope in the three groups before the intervention (P=0.40). However, after the intervention, the level of hope in the self care education group and self care education plus telephone follow-up groups were significantly higher than that of the control group (P=0.001). Moreover, the level of hope in the group with self care education plus telephone follow-up was significantly (P=0.001) more than that of the self care education group. Our findings indicated that teaching followed by telephone follow-up was associated with higher levels of hope. Therefore, such a strategy may be employed to improve the quality of life of patients with renal dialysis. IRCT2014042617440N1.
Poorgholami, Farzad; Mansoori, Parisa; Montaseri, Zohreh; Najafi, Kazem
Background: Various strategies such as teaching self care to hemodialysis patients have been employed to increase the level of their hope. This study aimed at examining the effects of a telephone follow-up program on the level of hope in a self care education program. Methods: In this single-blind randomized controlled clinical trial, 75 hemodialysis patients, selected by convenient sampling, were randomly assigned to 3 groups (n=25 each) including a control, a self care education, or a self care education with telephone follow-up. The control group received the routine care. The self care education group received 5 instruction sessions. The telephone follow-up group had similar instructional sessions followed by telephone calls during the subsequent 2 months. Data, collected using demographic information list and Miller’s hope questionnaire, were analyzed using Chi-Square, t-test, and one-way ANOVA followed by Scheffee test. Results: There was no significant difference among the scores of hope in the three groups before the intervention (P=0.40). However, after the intervention, the level of hope in the self care education group and self care education plus telephone follow-up groups were significantly higher than that of the control group (P=0.001). Moreover, the level of hope in the group with self care education plus telephone follow-up was significantly (P=0.001) more than that of the self care education group. Conclusion: Our findings indicated that teaching followed by telephone follow-up was associated with higher levels of hope. Therefore, such a strategy may be employed to improve the quality of life of patients with renal dialysis. Trial Registration Number: IRCT2014042617440N1 PMID:27382592
Mental disorders rank first amongst all causes for disability pensions and second in the field of medical rehabilitation. Especially alarming is the significantly lower age of entry of the mentally ill disability pensioners, compared to those with other indications. Mentally ill people often look back at a long history of diseases before getting in contact with the German pension insurance. In this regard the German pension insurance, which is obligated to effectively support people in order to keep them in working life until reaching the regular retirement age, is facing a big challenge, which stands right next to further demands, due to the demographic change, the increase of chronic diseases, multimorbidity, retirement age of 67 and changes in the working environment.With their activities in the field of medical rehabilitation the German pension insurance is aiming at the reintegration of people whose working capacity is endangered or reduced into the labor force or to prevent them from leaving it early. One of the main challenges notably in the field of mental diseases is to keep the success of the medical rehabilitation long-lasting. In this regard the post-rehabilitation provisions of the German pension insurances offer support according to § 31 I 1 Nr. 1 Social Insurance Code VI, if so required.On January 1st, 2016 the German pension insurance has adopted a new conceptual framework in the field of post rehabilitation which is presented in the following article, covering the range of psychosomatic indications. The aim of the new conceptual framework, which has to be implemented within the next three years, is to establish a nationwide, uniformed and preferably comprehensive follow-up care concept, which can be referred to by everyone, regardless which agency of the German pension insurance is in charge.
Purran, Ashutosh; Weller, Gordon; Kerr, Catherine
An integrated care organisation requires a flexible workforce with a variable skill mix in all care settings. Organisations should ensure that education and training are maintained to support safe, high quality care that provides value for money, promotes flexibility, and increases workforce participation in achieving organisation objectives and the expansion of services. Peripherally inserted central catheter (PICC) care was identified as a challenging area for the nursing workforce in acute care and community services, following the integration and service enlargement of the Whittington Health NHS Trust. This article describes the evaluation of a new PICC care training programme that was developed and implemented to increase knowledge and awareness. The evaluation provides the clinical education team with information to help identify additional training needs to facilitate the integration of care.
Nimbalkar, Archana Somashekhar; Patel, Dipen Vasudev; Patel, Vijay Karshanbhai; Patel, Dhaval Nileshbhai; Phatak, Ajay Gajanan
Introduction Skin to Skin Care (SSC) in neonatal period influences immediate breastfeeding outcomes in early childhood, especially the duration of exclusive breastfeeding. Aim We investigated influence of 17 hours of SSC given from day one of life on Infant and Young Child Feeding (IYCF) practices through one year of life. Materials and Methods Follow-up of a Superiority Randomized Control Trial (RCT) (CTRI/2013/06/003790) conducted in a teaching hospital located in central Gujarat. Mothers of 100 neonates (48 girls, 52 boys) from previous study cohort of RCT on SSC were followed. A survey on IYCF practices during the first year of life was administered after the end of infancy. In RCT, 50 neonates had received SSC beginning of 30 min- 1 hour after birth for average 17 hours on day 1 of life. In the control group, 50 newborn were placed next to the mother and conventional care was provided. There was a significant difference between hypothermia incidences in these groups in the first two days of life. Results There was no difference in the groups as far as the duration of exclusive breastfeeding, number of times breastfed per day, or stoppage of night feeds. No baby in either group received bottled feeds but about 53 received some form of extra lacteal feeds in the first 6 months without significant group difference. Fewer SSC mothers reported difficulties with breastfeeding or extra lacteal supplementation. All mothers who faced problems contacted physicians for advice and 20 were advised top milk and 6 given other foods. At one year of life 66% mothers were giving less than the recommended five food servings. There was no difference in practices related to hand washing, food preparation and storage, feeding habits of child and illness episodes in the children. Conclusion IYCF practices in this small group were not as per guidelines. Few positive trends were seen with fewer SSC mothers facing problems related to breastfeeding. The study was underpowered to detect
Plourdeau, Ludivine; Huez, Jean-François; Connan, Laurent
To assess the taking charge of the patients requiring a follow-up with the long course by the trainees during the Saspas, to identify the obstacles to its setting up and to propose prospects of improvement are the main objectives of this work. The trainees of Angers carried out a collection concerning each patient seen three times or more during the semester of winter 2006-2007. At the end of semester, they answered a questionnaire and participated in a focus group. There were great inequalities between the trainees. They had seen between 13 and 51 patients three times or more (average=22). The proportion of chronic disease varied from 24 to 68%. Most frequently met were those of the 50 first results of consultation of the SFMG. Four of the 11 trainees made a follow-up of pregnancy, three a follow-up of infant. When the first consultation concerned a situation requiring a follow-up with the long course, the trainees had proposed a new appointment in 38.6% of the cases, 95% of the patient had it honoured. The obstacles identified were inherent in the organization of the training course, the secretariat, the Masters of training course, the trainees and the patients. These obstacles are perfectible by a work on the appointement management privileging the patients concerned with a follow-up to the long course, on the organization of the training courses, on the invesment of the trainees and the masters of training course.
Kitterick, Padraig; DeBold, Lisa; Weal, Mark; Clarke, Nicholas; Newberry, Eva; Aubert, Lisa
Introduction Many resources are required to provide postoperative care to patients who receive a cochlear implant. The implant service commits to lifetime follow-up. The patient commits to regular adjustment and rehabilitation appointments in the first year and annual follow-up appointments thereafter. Offering remote follow-up may result in more stable hearing, reduced patient travel expense, time and disruption, more empowered patients, greater equality in service delivery and more freedom to optimise the allocation of clinic resources. Methods and analysis This will be a two-arm feasibility randomised controlled trial (RCT) involving 60 adults using cochlear implants with at least 6 months device experience in a 6-month clinical trial of remote care. This project will design, implement and evaluate a person-centred long-term follow-up pathway for people using cochlear implants offering a triple approach of remote and self-monitoring, self-adjustment of device and a personalised online support tool for home speech recognition testing, information, self-rehabilitation, advice, equipment training and troubleshooting. The main outcome measure is patient activation. Secondary outcomes are stability and quality of hearing, stability of quality of life, clinic resources, patient and clinician experience, and any adverse events associated with remote care. We will examine the acceptability of remote care to service users and clinicians, the willingness of participants to be randomised, and attrition rates. We will estimate numbers required to plan a fully powered RCT. Ethics and dissemination Ethical approval was received from North West—Greater Manchester South Research Ethics Committee (15/NW/0860) and the University of Southampton Research Governance Office (ERGO 15329). Results Results will be disseminated in the clinical and scientific communities and also to the patient population via peer-reviewed research publications both online and in print, conference and
Honkasalo, Mikko T; Linna, Miika; Sane, Timo; Honkasalo, Atte; Elonheimo, Outi
In Finland diabetologists have long been concerned about the level of diabetes care as the incidence of type 1 diabetes and complicated type 2 diabetes is exceeding the capacity of specialist clinics. We compared the outcome of diabetes care in two middle-sized Finnish municipalities with different models of diabetes care organisation in public primary health care. In Kouvola the primary health care of all diabetic patients is based on general practitioners, whereas in Nurmijärvi the follow-up of type 1 and most complicated type 2 diabetic patients is assigned to a general practitioner specialised in diabetes care. Our study population consisted of all adult diabetic patients living in the municipalities under review.We compared the use and costs of public diabetes care, glycemic control, blood pressure, LDL-cholesterol level, the application of the national guidelines and patient satisfaction. The main outcome measures were the costs and use of health care services due to diabetes and its complications. In Nurmijärvi, where diabetes care was centralised, more type 1 diabetic patients were followed up in primary health care than in Kouvola, where general practitioners need more specialist consultations. The centralisation resulted in cost savings in the diabetes care of type 1 diabetic patients. Although the quality of care was similar, type 1 diabetic patients were more satisfied with their follow-up in the centralised system. In the care of type 2 diabetic patients the centralised system required fewer specialist consultations, but the quality and costs were similar in both models. The follow-up of most diabetic patients - including type 1 diabetes - can be organised in primary health care with the same quality as in secondary care units. The centralised primary care of type 1 diabetes is less costly and requires fewer specialist consultations.
Gadallah, Mohsen Abdel Hamid; Aboul Fotouh, Aisha Mohamed; Habil, Ihab Shehad; Imam, Safaa Shafik; Wassef, Ghada
Reported rates of neonatal health care-associated infections (HAIs) in neonatal intensive care units (NICUs) have risen rapidly in recent years. Little data are available in Egypt, however. The aim of the present study was to determine the incidence of and risk factors for HAIs in the NICU of Ain Shams University Hospital of Obstetrics and Gynecology. A prospective study was carried out on all neonates admitted in the NICU of Ain Shams University Hospital of Obstetrics and Gynecology in 2012. Centers for Disease Control and Prevention criteria were followed for identifying HAIs. A total of 434 neonates were enrolled in the study. The cumulative incidence of HAIs in the NICU was 28%. Bloodstream infections accounted for 85% of HAI episodes; pneumonia, for 10%. The most common organism isolated was Klebsiella spp. The main risk factors identified on multivariable analysis were gestational age <38 weeks (relative risk [RR], 1.63), birth weight <1,500 g (RR, 1.39), mechanical ventilation (RR, 1.74), and surgical procedures (RR, 1.65). The mortality rate attributed to HAIs was 11.75%, and the extra hospital length of stay attributed to HAIs was 8 days. The high incidence of HAI identified in the study NICU mandates more vigorous infection control interventions. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Bessen, T; Chen, G; Street, J; Eliott, J; Karnon, J; Keefe, D; Ratcliffe, J
Background: Early diagnosis and improved treatment outcomes have increased breast cancer survival rates that, in turn, have led to increased numbers of women undergoing follow-up after completion of primary treatment. The current workload growth is unsustainable for breast cancer specialists who also provide care for women newly diagnosed or with a recurrence. Appropriate and acceptable follow-up care is important; yet, currently we know little about patient preferences. The aim of this study was to explore the preferences of Australian breast cancer survivors for alternative modes of delivery of follow-up services. Methods: A self-administered questionnaire (online or paper) was developed. The questionnaire contained a discrete choice experiment (DCE) designed to explore patient preferences with respect to provider, location, frequency and method of delivery of routine follow-up care in years 3, 4 and 5 after diagnosis, as well as the perceived value of ‘drop-in' clinics providing additional support. Participants were recruited throughout Australia over a 6-month period from May to October 2012. Preference scores and choice probabilities were used to rank the top 10 most preferred follow-up scenarios for respondents. Results: A total of 836 women participated in the study, of whom 722 (86.4%) completed the DCE. In the absence of specialist follow-up, the 10 most valued surveillance scenarios all included a Breast Physician as the provider of follow-up care. The most preferred scenario is a face-to-face local breast cancer follow-up clinic held every 6 months and led by a Breast Physician, where additional clinics focused on the side effects of treatment are also provided. Conclusion: Beyond the first 2 years from diagnosis, in the absence of a specialist led follow-up, women prefer to have their routine breast cancer follow-up by a Breast Physician (or a Breast Cancer Nurse) in a dedicated local breast cancer clinic, rather than with their local General
Cross, H; Newcombe, L
This paper describes, in detail, an intensive 14 day Self Care Training Programme that is conducted at Lalgadh Leprosy Services Centre in Nepal. An evaluation of the programme was undertaken in which hospital admission for infected plantar ulceration was the outcome measure. It was found that those who had undertaken the programme were less likely to have been admitted for hospital treatment in a 3-month follow-up period (chi 2 = 5.1, P = 0.02). An odds ratio of 1:1.8 (95% CI = 0.15-0.01) was also calculated. This paper presents an overview of the issues related to impairment, a description of the Self Care Training Programme, an analysis of the evaluation results and a discussion of the findings.
Moscrop, Andrew; Harrison, Sian; Heppell, Victoria; Heneghan, Carl; Ward, Alison
Objectives To examine the extent of primary care follow-up and mental health outcomes among women referred for ultrasound assessment of pain and/or bleeding in early pregnancy, including those whose pregnancy is found to be viable on ultrasound assessment. Design Questionnaire study with prospective follow-up. Setting Urgent gynaecology clinic in secondary care, England. Participants 57 women participated in the study. Entry criteria: referral to the urgent gynaecology clinic with pain and/or bleeding in early pregnancy; gestation less than 16 weeks (the clinic's own ‘cut-off’); no previous attendance at the clinic during the current pregnancy. Exclusion criteria: inability to understand English or to provide informed consent. Primary and secondary outcome measures Incidence of primary care follow-up among women referred to the urgent gynaecology clinic; incidence of women with measured mental health scores suggesting significant symptoms of distress. Results Fewer than 1 in 10 women referred for ultrasound assessment of pain and/or bleeding in early pregnancy had follow-up arrangements made with their general practitioner (GP). Most women who had GP follow-up found it helpful and a significant minority of women who did not have GP follow-up felt that it would have been helpful. Following ultrasound assessment, more than one-third of women had significant symptoms of distress. Symptoms of distress, particularly anxiety, were present among those women found to have viable pregnancies, as well as among those with non-viable pregnancies. Conclusions GPs are advised to consider offering follow-up to all women referred for ultrasound assessment of pain and/or bleeding in early pregnancy. Researchers in this area are advised to consider the experiences of women with pain and/or bleeding in early pregnancy whose pregnancies are ultimately found to be viable on ultrasound scan. PMID:23585390
Pape, L; de Zwaan, M; Tegtbur, U; Feldhaus, F; Wolff, J K; Schiffer, L; Lerch, C; Hellrung, N; Kliem, V; Lonnemann, G; Nolting, H D; Schiffer, M
Follow-up care after kidney transplantation is performed in transplant centers as well as in local nephrologist's practices in Germany. However, organized integrated care of these different sectors of the German health care system is missing. This organizational deficit as well as non-adherence of kidney recipients and longterm cardiovascular complications are major reasons for an impaired patient and graft survival. The KTx360° study is supported by a grant from the Federal Joint Committee of the Federal Republic of Germany. The study will include 448 (39 children) incident patients of all ages with KTx after study start in May 2017 and 963 (83 children) prevalent patients with KTx between 2010 and 2016. The collaboration between transplant centers and nephrologists in private local practices will be supported by internet-based case-files and scheduled virtual visits (patient consultation via video conferencing). At specified points of the care process patients will receive cardiovascular and adherence assessments and respective interventions. Care will be coordinated by an additional case management. The goals of the study will be evaluated by an independent institute using claims data from the statutory health insurances and data collected from patients and their caregivers during study participation. To model longitudinal changes after transplantation and differences in changes and levels of immunosuppresive therapy after transplantation between study participants and historical data as well as data from control patients who do not participate in KTx360°, adjusted regression analyses, such as mixed models with repeated measures, will be used. Relevant confounders will be controlled in all analyses. The study aims to prolong patient and graft survival, to reduce avoidable hospitalizations, co-morbidities and health care costs, and to enhance quality of life of patients after kidney transplantation. ISRCTN29416382 (retrospectively registered on 05.05.2017).
McFarlane, K; Dixon, L; Wakeman, C J; Robertson, G M; Eglinton, T W; Frizelle, F A
Evidence suggests that follow-up after colorectal cancer improves survival. Colorectal cancer is so common that patient follow-up can overwhelm a service, affecting the ability to see new referrals and reassess patients seen previously who have new symptoms. In order to cope with this demand a nurse-led follow-up service was started in 2004. We aimed to review the results of a nurse-led colorectal cancer follow-up clinic. Between 1 December 2004 and 31 January 2011, patients who underwent resection for colorectal cancer were followed up by a nurse specialist according to a protocol determined by the colorectal surgeons in the unit. All patient details were recorded prospectively in a purpose designed database. Nine hundred and fifty patients were followed up over 7 years. Some 368 patients were discharged from the follow-up programme, 474 patients remain actively involved in the programme and 108 patients died. Of the patients discharged from the follow-up scheme 269 (73%) were discharged to their general practitioner free of disease after 5 years. Of the 108 who patients died, 98 were as a result of colorectal cancer. Twenty patients (2.1%) were identified with local (peri-anastomotic) disease recurrence and 93 patients (9.8%) were found to have developed distant metastatic disease. Of these, 65 patients (6.8%) were referred for palliative care and 28 (2.9%) had surgery for focal metastatic disease of whom 18 were still alive at the time of this analysis. This paper shows that a nurse-led clinic for colorectal cancer follow-up can achieve satisfactory results with detection rates of recurrent or metastatic disease comparable to consultant follow-up. A nurse-led clinic provides the benefits of follow-up without overwhelming the consultant colorectal surgical clinic practice. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.
Odafe, Solomon; Idoko, Ochanya; Badru, Titilope; Aiyenigba, Bolatito; Suzuki, Chiho; Khamofu, Hadiza; Onyekwena, Obinna; Okechukwu, Emeka; Torpey, Kwasi; Chabikuli, Otto N
Introduction Clinical outcome is an important determinant of programme success. This study aims to evaluate patients’ baseline characteristics as well as level of care associated with lost to follow-up (LTFU) and mortality of patients on antiretroviral treatment (ART). Methods Retrospective cohort study using routine service data of adult patients initiated on ART in 2007 in 10 selected hospitals in Nigeria. We captured data using an electronic medical record system and analyzed using Stata. Outcome measures were probability of being alive and retained in care at 12, 24 and 36 months on ART. Potential predictors associated with time to mortality and time to LTFU were assessed using competing risks regression models. Results After 12 months on therapy, 85% of patients were alive and on ART. Survival decreased to 81.2% and 76.1% at 24 and 36 months, respectively. Median CD4 count for patients at ART start, 12, 18 and 24 months were 152 (interquartile range, IQR: 75 to 242), 312 (IQR: 194 to 450), 344 (IQR: 227 to 501) and 372 (IQR: 246 to 517) cells/µl, respectively. Competing risk regression showed that patients’ baseline characteristics significantly associated with LTFU were male (adjusted sub-hazard ratio, sHR=1.24 [95% CI: 1.08 to 1.42]), ambulatory functional status (adjusted sHR=1.25 [95% CI: 1.01 to 1.54]), World Health Organization (WHO) clinical Stage II (adjusted sHR=1.31 [95% CI: 1.08 to 1.59]) and care in a secondary site (adjusted sHR=0.76 [95% CI: 0.66 to 0.87]). Those associated with mortality include CD4 count <50 cells/µl (adjusted sHR=2.84 [95% CI: 1.20 to 6.71]), WHO clinical Stage III (adjusted sHR=2.67 [95% CI: 1.26 to 5.65]) and Stage IV (adjusted sHR=5.04 [95% CI: 1.93 to 13.16]) and care in a secondary site (adjusted sHR=2.21 [95% CI: 1.30 to 3.77]). Conclusions Mortality was associated with advanced HIV disease and care in secondary facilities. Earlier initiation of therapy and strengthening systems in secondary level facilities may
Odafe, Solomon; Idoko, Ochanya; Badru, Titilope; Aiyenigba, Bolatito; Suzuki, Chiho; Khamofu, Hadiza; Onyekwena, Obinna; Okechukwu, Emeka; Torpey, Kwasi; Chabikuli, Otto N
Clinical outcome is an important determinant of programme success. This study aims to evaluate patients' baseline characteristics as well as level of care associated with lost to follow-up (LTFU) and mortality of patients on antiretroviral treatment (ART). Retrospective cohort study using routine service data of adult patients initiated on ART in 2007 in 10 selected hospitals in Nigeria. We captured data using an electronic medical record system and analyzed using Stata. Outcome measures were probability of being alive and retained in care at 12, 24 and 36 months on ART. Potential predictors associated with time to mortality and time to LTFU were assessed using competing risks regression models. After 12 months on therapy, 85% of patients were alive and on ART. Survival decreased to 81.2% and 76.1% at 24 and 36 months, respectively. Median CD4 count for patients at ART start, 12, 18 and 24 months were 152 (interquartile range, IQR: 75 to 242), 312 (IQR: 194 to 450), 344 (IQR: 227 to 501) and 372 (IQR: 246 to 517) cells/µl, respectively. Competing risk regression showed that patients' baseline characteristics significantly associated with LTFU were male (adjusted sub-hazard ratio, sHR = 1.24 [95% CI: 1.08 to 1.42]), ambulatory functional status (adjusted sHR = 1.25 [95% CI: 1.01 to 1.54]), World Health Organization (WHO) clinical Stage II (adjusted sHR = 1.31 [95% CI: 1.08 to 1.59]) and care in a secondary site (adjusted sHR = 0.76 [95% CI: 0.66 to 0.87]). Those associated with mortality include CD4 count < 50 cells/µl (adjusted sHR = 2.84 [95% CI: 1.20 to 6.71]), WHO clinical Stage III (adjusted sHR = 2.67 [95% CI: 1.26 to 5.65]) and Stage IV (adjusted sHR = 5.04 [95% CI: 1.93 to 13.16]) and care in a secondary site (adjusted sHR = 2.21 [95% CI: 1.30 to 3.77]). Mortality was associated with advanced HIV disease and care in secondary facilities. Earlier initiation of therapy and strengthening systems in secondary level facilities may improve retention and
Aliarzadeh, Babak; Meaney, Christopher; Moineddin, Rahim; White, David; Birken, Catherine; Parkin, Patricia; Greiver, Michelle
Background: Uncertainty exists about the need to screen for hypertension in children and adolescents. Information on current screening and follow-up rates in Canadian community practices is not available. There are no Canadian guidelines on the subject. We sought to identify current rates of pediatric hypertension screening and follow-up in Canada. In addition, we examined patient and provider characteristics associated with rates of blood pressure screening. Methods: We used electronic medical record data extracted on Apr. 1, 2013, from 79 family practices in Toronto. We identified children seen at least twice between the ages of 3 and 18 years, with at least 6 months between first and last encounter. We used Multivariate Poisson regression analysis to analyze variation in blood pressure measurement rates and associations with patient and physician factors. Results: We identified 5996 children (62% of 9667 in total) who had at least 1 blood pressure measurement recorded. Of these children, 14% had at least 1 abnormal blood pressure measurement, and of those children, only 5% had a follow-up measurement recorded within 6 months. After adjustment, increases in rates of blood pressure measurements were associated with greater number of encounters (rate ratio [RR] = 1.03, 95% confidence interval [CI] 1.02-1.04, p < 0.001), older age at first encounter (RR = 1.06, 95% CI 1.03-1.10, p = 0.002), and female sex (RR = 1.12, 95% CI 1.03-1.20, p = 0.006). Obesity or a recorded family history of hypertension were not associated with more blood pressure measurements. Female physicians recorded more blood pressure measurements than did male physicians (RR = 1.41, 95% CI 1.04-1.89, p = 0.02). Interpretation: This screening measure was frequently done and appeared to be incompletely followed up. Clear guidance is needed; guideline developers should consider reviewing this topic. PMID:27398368
van Hezewijk, Marjan; Smit, Dennis J F; Bastiaannet, Esther; Scholten, Astrid N; Ranke, Gemma M C; Kroep, Judith R; Marijnen, Corrie A M; van de Velde, Cornelis J H
As the number of breast cancer survivors increases, this study prospectively examined whether tailored follow-up with differentiated number of visits per risk group, based on a prognostic index for local recurrence, is feasible and acceptable for patients and professionals. Between March 2007 and March 2010, 180 breast cancer patients (pT1-2N0-2cM0) were included. Primary endpoint was feasibility of tailored follow-up, based on the number of follow-up visits, patient satisfaction, anxiety and attitude towards follow-up. Secondary endpoints were reasons for visits, incidence, time to detection of local recurrences and the use of alternative care. In the second and third year of follow-up, the results show a 22% reduction in visits per patient in the low-risk group compared to the intermediate-risk group; 2.8 versus 3.6 visits. The majority of interval visits in both groups was initiated by the professional. No significant differences were found in attitude towards follow-up, patient satisfaction, anxiety and depression, alternative health care use or local recurrences between the risk groups. In conclusion, implementation of a tailored follow-up programme with decreased number of visits for low-risk patients is feasible and acceptable to patients. Appointing one coordinating professional, possibly a nurse practitioner, could further reduce the number of follow-up visits.
Follow-up of patients who are clinically disease-free after primary treatment for fallopian tube, primary peritoneal, or epithelial ovarian cancer: a Program in Evidence-Based Care guideline adaptation
Le, T.; Kennedy, E.B.; Dodge, J.; Elit, L.
Background A need for follow-up recommendations for survivors of fallopian tube, primary peritoneal, or epithelial ovarian cancer after completion of primary treatment was identified by Cancer Care Ontario’s Program in Evidence-Based Care. Methods We searched for existing guidelines, conducted a systematic review (medline, embase, and cdsr, January 2010 to March 2015), created draft recommendations, and completed a comprehensive review process. Outcomes included overall survival, quality of life, and patient preferences. Results The Cancer Australia guidance document Follow Up of Women with Epithelial Ovarian Cancer was adapted for the Ontario context. A key randomized controlled trial found that the overall survival rate did not differ between asymptomatic women who received early treatment based on elevated serum cancer antigen 125 (ca125) alone and women who waited for the appearance of clinical symptoms before initiating treatment (hazard ratio: 0.98; 95% confidence interval: 0.80 to 1.20; p = 0.85); in addition, patients in the delayed treatment group reported good global health scores for longer. No randomized studies were found for other types of follow-up. We recommend that survivors be made aware of the potential harms and benefits of surveillance, including a discussion of the limitations of ca125 testing. Women could be offered the option of no formal follow-up or a follow-up schedule that is agreed upon by the woman and her health care provider. Education about the most common symptoms of recurrence should be provided. Alternative models of care such as nurse-led or telephone-based follow-up (or both) could be emerging options. Conclusions The recommendations provided in this guidance document have a limited evidence base. Recommendations should be updated as further information becomes available. PMID:27803599
Cullington, Helen; Kitterick, Padraig; DeBold, Lisa; Weal, Mark; Clarke, Nicholas; Newberry, Eva; Aubert, Lisa
Many resources are required to provide postoperative care to patients who receive a cochlear implant. The implant service commits to lifetime follow-up. The patient commits to regular adjustment and rehabilitation appointments in the first year and annual follow-up appointments thereafter. Offering remote follow-up may result in more stable hearing, reduced patient travel expense, time and disruption, more empowered patients, greater equality in service delivery and more freedom to optimise the allocation of clinic resources. This will be a two-arm feasibility randomised controlled trial (RCT) involving 60 adults using cochlear implants with at least 6 months device experience in a 6-month clinical trial of remote care. This project will design, implement and evaluate a person-centred long-term follow-up pathway for people using cochlear implants offering a triple approach of remote and self-monitoring, self-adjustment of device and a personalised online support tool for home speech recognition testing, information, self-rehabilitation, advice, equipment training and troubleshooting. The main outcome measure is patient activation. Secondary outcomes are stability and quality of hearing, stability of quality of life, clinic resources, patient and clinician experience, and any adverse events associated with remote care. We will examine the acceptability of remote care to service users and clinicians, the willingness of participants to be randomised, and attrition rates. We will estimate numbers required to plan a fully powered RCT. Ethical approval was received from North West-Greater Manchester South Research Ethics Committee (15/NW/0860) and the University of Southampton Research Governance Office (ERGO 15329). Results will be disseminated in the clinical and scientific communities and also to the patient population via peer-reviewed research publications both online and in print, conference and meeting presentations, posters, newsletter articles, website reports
van Vollenhoven, Ronald F; Emery, Paul; Bingham, Clifton O; Keystone, Edward C; Fleischmann, Roy M; Furst, Daniel E; Tyson, Nicola; Collinson, Neil; Lehane, Patricia B
Objectives Evaluation of long-term safety of rituximab in rheumatoid arthritis (RA). Methods Pooled observed case analysis of data from patients with moderate-to-severe, active RA treated with rituximab in a global clinical trial programme. Results As of September 2010, 3194 patients had received up to 17 rituximab courses over 9.5 years (11 962 patient-years). Of these, 627 had >5 years’ follow-up (4418 patient-years). A pooled placebo population (n=818) (placebo+methotrexate (MTX)) was also analysed. Serious adverse event and infection rates generally remained stable over time and multiple courses. The overall serious infection event (SIE) rate was 3.94/100 patient-years (3.26/100 patient-years in patients observed for >5 years) and was comparable with placebo+MTX (3.79/100 patient-years). Serious opportunistic infections were rare. Overall, 22.4% (n=717) of rituximab-treated patients developed low immunoglobulin (Ig)M and 3.5% (n=112) low IgG levels for ≥4 months after ≥1 course. SIE rates were similar before and during/after development of low Ig levels; however, in patients with low IgG, rates were higher than in patients who never developed low IgG. Rates of myocardial infarction and stroke were consistent with rates in the general RA population. No increased risk of malignancy over time was observed. Conclusions This analysis demonstrates that rituximab remains generally well tolerated over time and multiple courses, with a safety profile consistent with published data and clinical trial experience. Overall, the findings indicate that there was no evidence of an increased safety risk or increased reporting rates of any types of adverse events with prolonged exposure to rituximab during the 9.5 years of observation. PMID:23136242
Ball, R A; Moore, E; Kuipers, L
Expressed Emotion was measured in the staff of two similar hostels for the long term mentally ill in an Inner London Borough (Hostel A and Hostel B). Patients in the two hostels showed similar levels of disturbance as measured by the PSE and symptom and behaviour profile scores. Staff from Hostel B displayed higher levels of EE, and were more critical, and these attitudes generalised easily into hostility and rejection. Those from Hostel A showed lower EE with warmth and positive attitudes towards clients. At 9 month follow up, Hostel A and B had similar levels of relapse requiring hospital admission. However Hostel B had a 64% discharge rate compared with 12.5% for Hostel A. These results are discussed with reference to the literature.
Sauve, Reg; Lee, Shoo K
The present report reviews some highlights in the history of neonatal intensive care and neonatal follow-up programs, particularly developments and reports that were based on experiences in Canada. Early outcomes reported from ‘preemie baby units’ were distressing, but attention has consistently been paid to preterm infant outcomes, even from the early days of neonatal intensive care units. Most current follow-up programs have goals related to ‘audit’ functions, education and clinical roles, but existing literature related to these functions is limited. Several reports have provided guidance in terms of neonatal follow-up research issues, and these strengthen the place of follow-up studies in outcomes research. PMID:19030284
Della Volpe, A; De Lucia, A; Pastore, V; Bracci Laudiero, L; Buonissimo, I; Ricci, G
Programmes for early childhood childhood hearing impairment identification allows to quickly start the appropriate hearing aid fitting and rehabilitation process; nevertheless, a large number of patients do not join the treatment program. The goal of this article is to present the results of a strategic review of the strengths, weaknesses, opportunities and threats connected with the audiologic/prosthetic/language follow-up process of children with bilateral permanent hearing impairment. Involving small children, the follow-up includes the involvement of specialised professionals of a multidisciplinary team and a complex and prolonged multi-faced management. Within the framework of the Italian Ministry of Health project CCM 2013 "Preventing Communication Disorders: a Regional Program for Early Identification, Intervention and Care of Hearing Impaired Children", the purpose of this analysis was to propose recommendations that can harmonise criteria for outcome evaluation and provide guidance on the most appropriate assessment methods to be used in the follow-up course of children with permanent hearing impairment. © Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale.
Ahmad, A; Qahar, J; Siddiq, A; Majeed, A; Rasheed, J; Jabar, F; von Knorring, A-L
This paper aims to compare orphans' development in two different care systems. Based on age, sex, psychological trauma scores, competence and psychological problem scores, two comparable samples were found representing orphans in the traditional foster care (n = 94) and the orphanages (n = 48) in a middle-large city in Iraqi Kurdistan. At an index interview, Child Behaviour Checklist (CBCL), Harvard-Uppsala Trauma Questionnaire for Children and Post-traumatic Stress Symptoms for Children (PTSS-C) were administered to the caregivers. After 1 year the CBCL, and after 2 years both the CBCL and the PTSS-C, were-re-administered, consecutively. Although both samples revealed significant decrease in the means of total competence and problem scores over time, the improvement in activity scale, externalizing problem scores and post-traumatic stress disorder-related symptoms proved to be more significant in the foster care than in the orphanages. While the activity scale improved in the foster care, the school competence deteriorated in both samples, particularly among the girls in the orphanages. The improvement of boys' activity scores in the foster care, and deterioration of girls' school competence in the orphanages were the most significant gender differences between samples over time. Even if the two orphan care systems showed more similarities than differences, the foster care revealed better outcomes over time. The results are discussed in relation to gender, age, socio-economic situation, cultural values and the characteristics of each care system.
Suokas, Jaana T; Suvisaari, Jaana M; Gissler, Mika; Löfman, Rasmus; Linna, Milla S; Raevuori, Anu; Haukka, Jari
Elevated mortality risk in anorexia nervosa has been established, but less is known about the outcomes of bulimia nervosa and binge eating disorder. In this follow-up study we determined mortality in adults (N=2450, 95% women) admitted to the eating disorder clinic of the Helsinki University Central Hospital in the period 1995-2010. Most of the patients (80.7%) were outpatients. For each patient four controls were selected and matched for age, sex and place of residence. The matching was taken into account by modelling end-point events using Cox's proportional hazard model. The hazard ratio (HR) for all-cause mortality was 6.51 (95% CI 3.46-12.26) in broad anorexia nervosa (AN), 2.97 (95% CI 1.90-4.65) in broad bulimia nervosa (BN), and 1.77 (95% CI 0.60-5.27) in binge eating disorder (BED). Mortality risk in broad AN was highest during the first years after admission but declined thereafter, while in broad BN the mortality risk started to rise two years after the first admission. The HR for suicide was elevated both in broad AN (HR 5.07; 95% CI 1.37-18.84) and in broad BN (HR 6.07; 95% CI 2.47-14.89). Results show that eating disorders are associated with increased mortality risk even when specialised treatment is available.
Morténius, Helena; Marklund, Bertil; Palm, Lars; Björkelund, Cecilia; Baigi, Amir
To bridge the gap between theory and practice, methods are needed that promote a positive attitude to change among health care professionals and facilitate the incorporation of new research findings. In this context, communication plays a significant role. The aim of this study was to analyse primary care staff members' readiness to adopt new ways of thinking and willingness to change their work practices by means of strategic communication. An evaluative design was used to study a primary care staff cohort for 7 years. The study population comprised all primary care staff in a region of Sweden (n = 1206). The strategic communication encompassed managerial impact, planning and implementation of reflexive communication processes, in addition to activities in three established communication channels (oral, written and digital). A questionnaire was used, and bivariate and multivariate statistical analyses were performed. A total of 846 individuals participated in the evaluation (70%). Strategic communication had a significant effect on staff members' new way of thinking (61%) and willingness to change daily work practices (33%). The communication channels had a significant synergy effect on the adoption of new ideas and willingness to change attitudes. Oral and digital communication had a significant impact on staff members' readiness to change. Strategic communication plays an important role in the process of creating innovative attitudes and behaviour among primary care professionals. The willingness to change attitudes enhances primary care staff's readiness to change everyday practices, thus facilitating the implementation of evidence-based care. © 2011 Blackwell Publishing Ltd.
Background Older patients are at high risk for poor outcomes after acute hospital admission. The mortality rate in these patients is approximately 20%, whereas 30% of the survivors decline in their level of activities of daily living (ADL) functioning three months after hospital discharge. Most diseases and geriatric conditions that contribute to poor outcomes could be subject to pro-active intervention; not only during hospitalization, but also after discharge. This paper presents the design of a randomised controlled clinical trial concerning the effect of a pro-active, multi-component, nurse-led transitional care program following patients for six months after hospital admission. Methods/Design Three hospitals in the Netherlands will participate in the multi-centre, double-blind, randomised clinical trial comparing a pro-active multi-component nurse-led transitional care program to usual care after discharge. All patients acutely admitted to the Department of Internal Medicine who are 65 years and older, hospitalised for at least 48 hours and are at risk for functional decline are invited to participate in the study. All patients will receive integrated geriatric care by a geriatric consultation team during hospital admission. Randomization, which will be stratified by study site and cognitive impairment, will be conducted during admission. The intervention group will receive the transitional care bridge program, consisting of a handover moment with a community care Care Nurse (CN) during hospital admission and five home visits after discharge. The control group will receive 'care as usual' after discharge. The main outcome is the level of ADL functioning six months after discharge compared to premorbid functioning measured with the Katz ADL index. Secondary outcomes include; survival, cognitive functioning, quality of life, and health care utilization, satisfaction of the patient and primary care giver with the transitional care bridge program. All outcomes
Prestes, Mariana; Gayarre, Maria A; Elgart, Jorge F; Gonzalez, Lorena; Rucci, Enzo; Paganini, Jose M; Gagliardino, Juan J
To present results, 1 year postimplementation at primary care level, of an integrated diabetes care programme including systemic changes, education, registry (clinical, metabolic, and therapeutic indicators), and disease management (DIAPREM). We randomly selected and trained 15 physicians and 15 nurses from primary care units of La Matanza County (intervention-IG) and another 15 physicians/nurses to participate as controls (control-CG). Each physician-nurse team controlled and followed up 10 patients with type 2 diabetes for 1 year; both groups used structured medical records. Patients in IG had quarterly clinical appointments, whereas those in CG received traditional care. Statistical data analysis included parametric/nonparametric tests according to data distribution profile and Chi-squared test for proportions. After 12 months, the dropout rate was significantly lower in IG than in CG. Whereas in IG HbA1c, blood pressure and lipid profile levels significantly decreased, no changes were recorded in CG. Drug prescriptions showed no significant changes in IG except a decrease in oral monotherapy. DIAPREM is an expedient and simple multistrategic model to implement at the primary care level in order to decrease patient dropout and improve control and treatment adherence, and quality of care of people with diabetes.
Lehtovuori, Tuomo; Kauppila, Timo; Kallio, Jouko; Raina, Marko; Suominen, Lasse; Heikkinen, Anna Maria
In primary care, financial incentives have usually been directed to physicians because they are thought to make the key decisions in order to change the functions of a medical organization. There are no studies regarding the impact that directing these incentives to all disciplines of the care team (e.g. group bonuses for both nurses and doctors) may have, despite the low frequency with which diagnoses were being recorded for primary care visits to doctors. This study tested the effect of offering group bonuses to the care teams. This was a retrospective quasi-experimental study with before-and-after settings and two control groups. In the intervention group, the mean percentage of visits to a doctor for which a diagnosis was recorded by each individual care team (mean team-based percentage of monthly visits to a doctor with recorded diagnoses) and simultaneously the same data was gathered from two different primary care settings where no team bonuses were applied. To study the sustainability of changes obtained with the group bonuses the respective data were derived from the electronic health record system for 2 years after the cessation of the intervention. The differences in the rate of marking diagnoses was analyzed with ANOVA and RM-ANOVA with appropriate post hoc tests, and the differences in the rate of change in marking diagnoses was analyzed with linear regression followed by t-test. The proportion of doctor visits having recorded diagnoses in the teams was about 55 % before starting to use group bonuses and 90 % after this intervention. There was no such increase in control units. The effect of the intervention weakened slightly after cessation of the group bonuses. Group bonuses may provide a method to alter clinical practices in primary care. However, sustainability of these interventions may diminish after ceasing this type of financial incentive.
Berkhof, Farida F; van den Berg, Jan W K; Uil, Steven M; Kerstjens, Huib A M
Telemedicine, care provided by electronic communication, may serve as an alternative or extension to traditional outpatient visits. This pilot study determined the effects of telemedicine on health-care utilization and health status of chronic obstructive pulmonary disease (COPD) patients. One hundred and one patients were randomized, 52 patients received telemedicine care and 49 had traditional outpatient visits. The primary outcome was COPD-specific health status, measured with the Clinical COPD Questionnaire (CCQ). Secondary outcomes included St. George's Respiratory Questionnaire (SGRQ) and the Short Form-36 (SF-36) and resource use in primary and secondary care. The mean age of the participants was 68 ± 9 years and the mean per cent of predicted forced expiratory volume in 1 s was 40.4 ± 12.5. The CCQ total score deteriorated by 0.14 ± 0.13 in the telemedicine group, and improved by -0.03 ± 0.14 in the control group (difference 0.17 ± 0.19, 95% confidence interval (CI): -0.21-0.55, P = 0.38). The CCQ symptom domain showed a significant and clinically relevant difference in favour of the control group, 0.52 ± 0.24 (95% CI: 0.04-0.10, P = 0.03). Similar results were found for the SGRQ, whereas results for SF-36 were inconsistent. Patients in the control group had significantly fewer visits to the pulmonologist in comparison to patients in the telemedicine group (P = 0.05). The same trend, although not significant, was found for exacerbations after 6 months. This telemedicine model of initiated phone calls by a health-care provider had a negative effect on health status and resource use in primary and secondary care, in comparison with usual care and therefore cannot be recommended in COPD patients in its current form. © 2014 Asian Pacific Society of Respirology.
Daperno, Marco; Bortoli, Aurora; Kohn, Anna; Politi, Patrizia; Marconi, Stefano; Ardizzone, Sandro; Cortelezzi, Claudio Camillo; Grasso, Gianalberto; Ferraris, Luca; Milla, Monica; Spina, Luisa; Guidi, Luisa; Losco, Alessandra; Inserra, Gaetano; Sablich, Renato; Morganti, Daniela; Bodini, Giorgia; Comberlato, Michele
Perception of quality of care is important in the management of patients with chronic diseases, particularly inflammatory bowel disease. This longitudinal study aimed to investigate variations of the Quality of Care through the Patients' Eyes (QUOTE-IBD) questionnaire scores one year after the basal evaluation in the Studio Osservazionale quaLità cUre malatTIe crOniche intestiNali (SOLUTION-1) study. Of the cohort of 992 patients, 936 were evaluable. The QUOTE-IBD score overcame satisfactory levels of more than the 80%, overall and in all subdomains except for the "Continuity of Care" sub-dimension (mean, 8.3; standard deviation, 1.49), scored satisfactory only by 34% of the patients. No significant changes in satisfaction were recorded overall, or considering patients subgroups. Significant differences were found at the end of the follow-up between physicians' and patients' perceptions of quality of care, with the former over-rating their performance in "Continuity of Cares" and under-rating "Costs", "Competence", and "Accessibility" sub-domains of the score (p<0.05 for all). Perceived quality of care in a large cohort of Italian patients with inflammatory bowel disease remains unchanged after one-year follow-up and was not significantly affected by disease activity or therapeutic interventions. Differences between physicians' and patients' perceptions of quality of care should be taken into account. Copyright © 2017 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Vanderwert, Ross E.; Zeanah, Charles H.; Fox, Nathan A.; Nelson, Charles A.
Extreme social and cognitive deprivation as a result of institutional care has profound effects on developmental outcomes across multiple domains for many abandoned or orphaned children. The Bucharest Early Intervention Project (BEIP) examines the outcomes for children originally placed in institutions who were assessed comprehensively and then randomized to foster care (FCG) or care as usual (CAUG) and followed longitudinally. Here we report on the brain electrical activity (electroencephalogram: EEG) of 12-year-old children enrolled in the BEIP. Previous reports suggested improvement in resting EEG activity for the group of children placed in the foster care intervention, particularly those placed before 24 months of age compared to children who were randomized to CAUG or those placed into families after this age. At 12 years, differences between those in the FCG and those in the CAUG persist in the alpha band (8–13Hz), but not in higher frequency bands (i.e. in the beta band; 15–30Hz), except in those children placed into the FCG who remained in high quality care environments over the course of the study. These findings highlight the importance of maintaining a stable high quality caregiving environment, particularly for children exposed to early psychosocial deprivation, for promoting healthy brain development. PMID:26724564
Vanderwert, Ross E; Zeanah, Charles H; Fox, Nathan A; Nelson, Charles A
Extreme social and cognitive deprivation as a result of institutional care has profound effects on developmental outcomes across multiple domains for many abandoned or orphaned children. The Bucharest Early Intervention Project (BEIP) examines the outcomes for children originally placed in institutions who were assessed comprehensively and then randomized to foster care (FCG) or care as usual (CAUG) and followed longitudinally. Here we report on the brain electrical activity (electroencephalogram: EEG) of 12-year-old children enrolled in the BEIP. Previous reports suggested improvement in resting EEG activity for the group of children placed in the foster care intervention, particularly those placed before 24 months of age compared to children who were randomized to CAUG or those placed into families after this age. At 12 years, differences between those in the FCG and those in the CAUG persist in the alpha band (8-13 Hz), but not in higher frequency bands (i.e. in the beta band; 15-30 Hz), except in those children placed into the FCG who remained in high quality care environments over the course of the study. These findings highlight the importance of maintaining a stable high quality caregiving environment, particularly for children exposed to early psychosocial deprivation, for promoting healthy brain development. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.
Iversen, Peter; McLeod, David G; See, William A; Morris, Thomas; Armstrong, Jon; Wirth, Manfred P
To evaluate the efficacy and tolerability of bicalutamide 150 mg once-daily as immediate hormonal therapy in patients with prostate cancer or as adjuvant to radical prostatectomy or radiotherapy. In all, 8113 patients with localized (T1-2, N0/Nx) or locally advanced (T3-4, any N; or any T, N+) prostate cancer (all M0) were enrolled in three complementary, double-blind, placebo-controlled trials. Patients were randomized to receive standard care plus either oral bicalutamide 150 mg once-daily or oral placebo. Primary endpoints were progression-free survival (PFS) and overall survival (OS). Data were collated from individual trials and evaluated in a combined analysis. Overall, at a median follow-up of 9.7 years, bicalutamide significantly improved PFS (hazard ratio 0.85, 95% confidence interval 0.79-0.91; P= 0.001). Compared with placebo there was no difference in OS (hazard ratio 1.01, P= 0.77). Patients who derived benefit from bicalutamide in terms of PFS were those with locally advanced disease, with OS significantly favouring bicalutamide in patients with locally advanced disease undergoing radiotherapy (P= 0.031). Patients with localized disease showed no clinically or statistically significant improvements in PFS; there was a survival trend in favour of placebo in patients with localized disease undergoing watchful waiting (P= 0.054). The overall tolerability of bicalutamide was consistent with previous analyses, with breast pain (73.7%) and gynaecomastia (68.8%) the most frequently reported adverse events in patients randomized to bicalutamide. Bicalutamide 150 mg, either as monotherapy or adjuvant to standard care, improved PFS in patients with locally advanced prostate cancer, but not in patients with localized disease. A pre-planned subset analysis showed a benefit for OS in patients with locally advanced disease undergoing radiotherapy. Bicalutamide 150 mg might represent an alternative for patients with locally advanced prostate cancer considering
Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial.
Sørensen, J; Primdahl, J; Horn, H C; Hørslev-Petersen, K
To compare the cost-effectiveness of three types of follow-up for outpatients with stable low-activity rheumatoid arthritis (RA). In total, 287 patients were randomized to either planned rheumatologist consultations, shared care without planned consultations, or planned nurse consultations. Effectiveness measures included disease activity (Disease Activity Score based on 28 joint counts and C-reactive protein, DAS28-CRP), functional status (Health Assessment Questionnaire, HAQ), and health-related quality of life (EuroQol EQ-5D). Cost measures included activities in outpatient clinics and general practice, prescription and non-prescription medicine, dietary supplements, other health-care resources, and complementary and alternative care. Measures of effectiveness and costs were collected by self-reported questionnaires at inclusion and after 12 and 24 months. Incremental cost-effectiveness rates (ICERs) were estimated in comparison with rheumatologist consultations. Changes in disease activity, functional status, and health-related quality of life were not statistically significantly different for the three groups, although the mean scores were better for the shared care and nurse care groups compared with the rheumatologist group. Shared care and nurse care were non-significantly less costly than rheumatologist care. As both shared care and nurse care were associated with slightly better EQ-5D improvements and lower costs, they dominated rheumatologist care. At EUR 10,000 per quality-adjusted life year (QALY) threshold, shared care and nurse care were cost-effective with more than 90% probability. Nurse care was cost-effective in comparison with shared care with 75% probability. Shared care and nurse care seem to cost less but provide broadly similar health outcomes compared with rheumatologist outpatient care. However, it is still uncertain whether nurse care and shared care are cost-effective in comparison with rheumatologist outpatient care.
It has been recommended that nursing staff who are new to paediatric intensive care should be offered an orientation programme There is no guidance currently available to influence the content or duration of such a programme on a national level A multi-centre research study was carried out to identify the existing provision of orientation programmes and how beneficial these are perceived to be Supernumerary status and effective mentoring are seen as essential to the success of these programmes Many new starters perceive that they receive inadequate preparation on stress management and psychosocial issues National communication between paediatric intensive care educators will help to improve and develop orientation programme provision.
Kok, Lotte; Hillegers, Manon H; Veldhuijzen, Dieuwke S; Cornelisse, Sandra; Nierich, Arno P; van der Maaten, Joost M; Rosseel, Peter M; Hofland, Jan; Sep, Milou S; Dieleman, Jan M; Vinkers, Christiaan H; Peelen, Linda M; Joëls, Marian; van Dijk, Diederik
Cardiac surgery and postoperative admission to the ICU may lead to posttraumatic stress disorder and depression. Perioperatively administered corticosteroids potentially alter the risk of development of these psychiatric conditions, by affecting the hypothalamic-pituitary-adrenal axis. However, findings of previous studies are inconsistent. We aimed to assess the effect of a single dose of dexamethasone compared with placebo on symptoms of posttraumatic stress disorder and depression and health-related quality of life after cardiac surgery and ICU admission. Follow-up study of a randomized clinical trial. Five Dutch heart centers. Cardiac surgery patients (n = 1,244) who participated in the Dexamethasone for Cardiac Surgery trial. A single intraoperative IV dose of dexamethasone or placebo was administered in a randomized, double-blind way. Symptoms of posttraumatic stress disorder, depression, and health-related quality of life were assessed with validated questionnaires 1.5 years after randomization. Data were available for 1,125 patients (90.4%); of which 561 patients received dexamethasone and 564 patients received placebo. Overall, the prevalence of psychopathology was not influenced by dexamethasone. Posttraumatic stress disorder and depression were present in, respectively, 52 patients (9.3%) and 69 patients (12.3%) who received dexamethasone and in 66 patients (11.7%) and 78 patients (13.8%) who received placebo (posttraumatic stress disorder: odds ratio, 0.82; 95% CI, 0.55-1.20; p = 0.30; depression: odds ratio, 0.92; 95% CI, 0.64-1.31; p = 0.63). Subgroup analysis revealed a lower prevalence of posttraumatic stress disorder (odds ratio, 0.23; 95% CI, 0.07-0.72; p < 0.01) and depression (odds ratio, 0.29; 95% CI, 0.11-0.77; p < 0.01) in female patients after dexamethasone administration. Health-related quality of life did not differ between groups and was not associated with psychopathology. Overall, our findings suggest that exogenous administration of
Carlsson, Marianne; Arman, Maria; Backman, Marie; Flatters, Ursula; Hatschek, Thomas; Hamrin, Elisabeth
Complementary and alternative medicine is used by many cancer patients in most parts of the world, and its use is increasing. The aim of the present study was to examine, over 5 years, the perceived quality of life/life satisfaction in two samples of women with breast cancer who were treated with anthroposophic care or conventional medical treatment only. Data from admission, after 1 year and after 5 years are used for the comparisons. On admission to the study the women in anthroposophic care perceived their quality of life to be lower than that of the women in the conventional treatment group, especially for emotional, cognitive and social functioning and overall quality of life. Sixty women who actively chose treatment with anthroposophic medicine and 60 individually matched women treated with conventional medicine participated. Quality of life was measured by the EORTC QLQ-C30 and the Life Satisfaction Questionnaire. Twenty-six women within anthroposophic care and 31 women within conventional medicine survived the 5 years. Effect size (ES) estimation favored the anthroposophic group in seven of the subscales mostly measuring emotional functioning. The ES for four of the subscales favored the conventional treatment group, mostly concerning physical functioning. After 5 years there were improvements in overall quality of life and in emotional and social functioning compared to admission for the women in anthroposophic care. The improvements took place between admission and 1 year, but not further on. Only minor improvements were found in the matching group. PMID:17173117
Addis, Michael E.; Hatgis, Christina; Cardemil, Esteban; Jacob, Karen; Krasnow, Aaron D.; Mansfield, Abigail
Eighty clients meeting criteria for panic disorder and receiving either panic control therapy (PCT; M. G. Craske, E. Meadows, & D. H. Barlow, 1994) or treatment as usual (TAU) in a managed care setting were assessed 1 and 2 years following acute treatment. PCT was provided by therapists with little or no previous exposure to cognitive-behavioral…
Addis, Michael E.; Hatgis, Christina; Cardemil, Esteban; Jacob, Karen; Krasnow, Aaron D.; Mansfield, Abigail
Eighty clients meeting criteria for panic disorder and receiving either panic control therapy (PCT; M. G. Craske, E. Meadows, & D. H. Barlow, 1994) or treatment as usual (TAU) in a managed care setting were assessed 1 and 2 years following acute treatment. PCT was provided by therapists with little or no previous exposure to cognitive-behavioral…
Bahadin, Juliana; Shum, Eugene; Ng, Grace; Tan, Nicolette; Sellayah, Pushpavalli; Tan, Sze Wee
The global healthcare kiosk market is growing, and kiosks are projected to be a larger part of healthcare delivery in the coming decades. We developed an unmanned healthcare kiosk that automates the management of stable patients with chronic conditions to complement face-to-face primary care physician (PCP) visits. The aim of our study was to show that the kiosk could be a feasible means of delivering care for stable patients with chronic conditions and could generate cost savings for the management of patients with stable chronic disease. We conducted a prospective single-arm study of 95 participants with well-controlled chronic cardiovascular diseases who visited our clinic in Singapore every 3 months for review and medication refill. During their subsequent appointments for chronic disease management at 3 and 6 months, participants used the kiosk instead of consulting a physician. All participants who used the kiosk were also evaluated by a nurse clinician (NC). The kiosk assessment of whether the patient was well controlled was then compared to the NC's assessment to determine rates of agreement. Patient satisfaction was evaluated through a questionnaire, and any adverse outcomes were documented. Cohen's κ for agreement between the kiosk and the NC assessment of patients' chronic care control was 0.575 (95% CI, 0.437-0.713). The modest agreement was due to differences in systolic blood pressure measurements between the kiosk and the NC. The 96% of participants who completed two kiosk visits were all satisfied with the kiosk as a care delivery alternative. None of the participants managed through the kiosk suffered any adverse outcomes. Use of the kiosk resulted in a reduction of 128 face-to-face PCP visits. Healthcare kiosks can potentially be used to complement primary care clinician visits for managing patients with stable chronic diseases and can generate cost savings.
Wang, Yao; Xiao, Lily Dongxia; Ullah, Shahid; He, Guo-Ping; De Bellis, Anita
The lack of dementia education programmes for health professionals in primary care is one of the major factors contributing to the unmet demand for dementia care services. To determine the effectiveness of a nurse-led dementia education and knowledge translation programme for health professionals in primary care; participants' satisfaction with the programme; and to understand participants' perceptions of and experiences in the programme. A cluster randomized controlled trial was used as the main methodology to evaluate health professionals' knowledge, attitudes and care approach. Focus groups were used at the end of the project to understand health professionals' perceptions of and experiences in the programme. Fourteen community health service centres in a province in China participated in the study. Seven centres were randomly assigned to the intervention or control group respectively and 85 health professionals in each group completed the programme. A train-the-trainer model was used to implement a dementia education and knowledge translation programme. Outcome variables were measured at baseline, on the completion of the programme and at 3-month follow-up. A mixed effect linear regression model was applied to compare the significant differences of outcome measures over time between the two groups. Focus groups were guided by four semi-structured questions and analysed using content analysis. Findings revealed significant effects of the education and knowledge translation programme on participants' knowledge, attitudes and a person-centred care approach. Focus groups confirmed that the programme had a positive impact on dementia care practice. A dementia education and knowledge translation programme for health professionals in primary care has positive effects on their knowledge, attitudes, care approach and care practice. Copyright © 2016 Elsevier Ltd. All rights reserved.
Ramachandran, Ambili; Snyder, Frederick R; Katz, Mira L; Darnell, Julie S; Dudley, Donald J; Patierno, Steven R; Sanders, Mechelle R; Valverde, Patricia A; Simon, Melissa A; Warren-Mears, Victoria; Battaglia, Tracy A
There is limited understanding of the association between barriers to care and clinical outcomes within patient navigation programs. Secondary analyses of data from the intervention arms of the Patient Navigation Research Program were performed, which included navigated participants with abnormal breast and cervical cancer screening tests from 2007 to 2010. Independent variables were: 1) the number of unique barriers to care (0, 1, 2, or ≥3) documented during patient navigation encounters; and 2) the presence of socio-legal barriers originating from social policy (yes/no). The median time to diagnostic resolution of index screening abnormalities was estimated using Kaplan-Meier cumulative incidence curves. Multivariable Cox proportional hazards regression examined the impact of barriers on time to resolution, controlling for sociodemographics and stratifying by study center. Among 2600 breast screening participants, approximately 75% had barriers to care documented (25% had 1 barrier, 16% had 2 barriers, and 34% had ≥3 barriers). Among 1387 cervical screening participants, greater than one-half had barriers documented (31% had 1 barrier, 11% had 2 barriers, and 13% had ≥3 barriers). Among breast screening participants, the presence of barriers was associated with less timely resolution for any number of barriers compared with no barriers. Among cervical screening participants, only the presence of ≥2 barriers was found to be associated with less timely resolution. Both types of barriers, socio-legal and other barriers, were found to be associated with delay among breast and cervical screening participants. Navigated women with barriers resolved cancer screening abnormalities at a slower rate compared with navigated women with no barriers. Further innovations in navigation care are necessary to maximize the impact of patient navigation programs nationwide. © 2015 American Cancer Society.
Amer, Mohamed; Diab, Nagwa; Soliman, Mohamed; Amer, Amin
Taking care of newborn skin is necessary to avoid skin infections. The normal daily exposure to external factors affects the skin negatively. Skin hygiene and proper skin cleansing as well as protection of the infant skin barrier are essential to maintain barrier function and overall infant health. The aim of this work is to assess the neonatal skin care effectiveness in promotion of normal skin development and protection of the optimal skin function by avoiding the different neonatal skin disorders which cause skin infection. In conclusion, proper care and good hygiene of the normal mature neonatal skin are essential to maintain skin barrier function and overall health. This is achieved by optimizing epidermal barrier integrity that includes: bathing and using emollient; preventing and managing infections and skin injury; minimizing transepidermal water loss (TEWL); minimizing heat loss and percutaneous absorption of toxins. Baby bath products as well as baby wipes are safe to use and do not appear to affect an infant's skin barrier integrity. It is therefore sensible to use cleansers that have been specially designed for baby's skin, which are pH neutral and very mild to avoid irritant dermatitis and allergic dermatitis. © 2017 The International Society of Dermatology.
Berges, Jean Claude; Beltrando, Gerard; Cacault, Philippe
The follow up of intense precipitation system is a key information for climate studies. Whereas some rainfall measurement series cover more than one century they cannot retrieve these phenomena in their spatial and temporal continuity. The geostationary satellite data offer a good trade-off between the length of data series and the retrieval accuracy. However a difficulty arise from ambiguous interpretation of the lone infrared signal in nephanalysis. Hence the tropopause temperature is used as a proxy to characterize extreme precipitation event. That does not mean that the more intense rain-rate will be always collocated with the coldest temperature but that most of these intense events is produced by systems whose a part is colder than tropopause. Computations have been carried out on 38 months of MSG and Meteosat/IODC. System follow up is achieved by a simple 3D connexity algorithm, the time being considered as the third dimension. This algorithm produce three dimension clusters from where the main system parameters can be easily extracted. Thus the systems can be classified trajectory characteristic (duration, speed ans size variation). A drawback of this simple threshold method relies is some over-segmentation. In most of case the bias is minor as unconnected clusters are small and short-lived. However an aggregating algorithm have been developed to retrieve the most complex system trajectories. To assess the efficiency of this method three regional studies are displayed: the North African Maghreb, the West African Sahel and the Indian Ocean. On Maghreb, the location of system initialization shows a dramatic difference between the eastern and western parts. Whereas in Tunisia a significant part of these systems are generated on sea and most have no clear relation with relief, the Morocco is mainly characterized with land initiated system with a strong orographic effect on system triggering. Another difference relies on the low level wind shear impact which
Rödjer, Lars; H Jonsdottir, Ingibjörg; Börjesson, Mats
To study the self-reported level of physical activity (PA) and quality of life (QOL) in patients receiving physical activity on prescription (PAP) for up to 24 months. Observational study conducted in a regular healthcare setting. A primary care population in Sweden receiving physical activity on prescription as part of regular care was studied alongside a reference group. The group comprised 146 patients receiving PAP at two different primary care locations (n = 96 and 50, respectively). The reference group comprised 58 patients recruited from two different primary care centres in the same region. We used two self-report questionnaires - the four-level Saltin-Grimby Physical Activity Level Scale (SGPALS) to assess physical activity, and SF-36 to assess QOL. A significant increase in the PA level was found at six and 12 months following PAP, with an ongoing non-significant trend at 24 months (p = .09). A clear improvement in QOL was seen during the period. At 24 months, significant and clinically relevant improvements in QOL persisted in four out of eight sub-scale scores (Physical Role Limitation, Bodily Pain, General Health,Vitality) and in one out of two summary scores (Physical Component Summary). Patients receiving PAP showed an increased level of self-reported PA at six and 12 months and improved QOL for up to 24 months in several domains. The Swedish PAP method seems to be a feasible method for bringing about changes in physical activity in different patient populations in regular primary healthcare. While increased physical activity (PA) is shown to improve health, the implementation of methods designed to increase activity is still being developed. Key points The present study confirms that the Swedish physical activity on prescription (PAP) method increases the self-reported level of PA in the primary care setting at six and 12 months. Furthermore, this study shows that PAP recipients report a clinically relevant long-term improvement in quality
Rödjer, Lars; H. Jonsdottir, Ingibjörg; Börjesson, Mats
Objective To study the self-reported level of physical activity (PA) and quality of life (QOL) in patients receiving physical activity on prescription (PAP) for up to 24 months. Design Observational study conducted in a regular healthcare setting. Setting A primary care population in Sweden receiving physical activity on prescription as part of regular care was studied alongside a reference group. Subjects The group comprised 146 patients receiving PAP at two different primary care locations (n = 96 and 50, respectively). The reference group comprised 58 patients recruited from two different primary care centres in the same region. Main outcome measurements We used two self-report questionnaires – the four-level Saltin-Grimby Physical Activity Level Scale (SGPALS) to assess physical activity, and SF-36 to assess QOL. Results A significant increase in the PA level was found at six and 12 months following PAP, with an ongoing non-significant trend at 24 months (p = .09). A clear improvement in QOL was seen during the period. At 24 months, significant and clinically relevant improvements in QOL persisted in four out of eight sub-scale scores (Physical Role Limitation, Bodily Pain, General Health,Vitality) and in one out of two summary scores (Physical Component Summary). Conclusion Patients receiving PAP showed an increased level of self-reported PA at six and 12 months and improved QOL for up to 24 months in several domains. The Swedish PAP method seems to be a feasible method for bringing about changes in physical activity in different patient populations in regular primary healthcare. While increased physical activity (PA) is shown to improve health, the implementation of methods designed to increase activity is still being developed. Key points The present study confirms that the Swedish physical activity on prescription (PAP) method increases the self-reported level of PA in the primary care setting at six and 12 months. Furthermore, this study shows
Eggly, Susan; Meert, Kathleen L.; Berger, John; Zimmerman, Jerry; Anand, K.J.S.; Newth, Christopher J.L.; Harrison, Rick; Carcillo, Joseph; Dean, J. Michael; Willson, Douglas F.; Nicholson, Carol
We examined physicians’ conceptualization of closure as a benefit of follow-up meetings with bereaved parents. The frequency of use and the meaning of the word “closure” were analyzed in transcripts of interviews with 67 critical care physicians affiliated with the Collaborative Pediatric Critical Care Research Network. In all, 38 physicians (57 percent) used the word “closure” at least once (median: 2; range: 1 to 7), for a total of 86 times. Physicians indicated that closure is a process or trajectory rather than an achievable goal. They also indicated that parents and physicians can move toward closure by gaining a better understanding of the causes and circumstances of the death and by reconnecting with, or resolving relationships between, parents and health professionals. Physicians suggested that a primary reason to conduct follow-up meetings is that such meetings offer parents and physicians an opportunity to move toward closure. Future research should attempt to determine whether follow-up meetings reduce the negative effects of bereavement for parents and physicians. PMID:23923469
Kaltenborn, H; Schild, H; Höhne, U; Gast, U; Lorenz, J; Schinzel, H
Correlation between chest radiographs and clinical indicators was studied in 212 patients in intensive care. 1. There was good correlation between raised pulmonary artery pressure and radiological signs of left heart insufficiency, but not with the value of central venous pressure. 2. Fever and leukocytosis nearly always precede radiological evidence of pneumonia; their persistence does not necessarily indicate persistent pneumonia. 3. Pneumonias, effusions, atelectases and emboli are more common on the right. 4. More than 70% of central venous catheters were incorrectly placed; most commonly, the catheter was placed too low. Life-threatening complications occurred in 1.3%.
Manski-Nankervis, Jo-Anne; Furler, John; O'Neal, David; Ginnivan, Louise; Thuraisingam, Sharmala; Blackberry, Irene
To examine the two-year impact of Stepping Up, a general practice based model of care intervention for insulin initiation and titration in Australia. 266 participants from 74 general practices participated in the Stepping Up cluster randomised controlled trial between 2012-2014. Control practices received training in the model of care on completion of the 12-month trial. Patients were followed for 24 months. Participant baseline characteristics, insulin and non-insulin medication use were summarised for each study group. Linear mixed-effects models with random intercepts were used to estimate differences in mean outcome (HbA1c and weight) between the study groups using restricted maximum likelihood estimation. At baseline 61% of patients were male, mean (SD) age 62 (10) years, diabetes duration 9 (5, 13) years and mean (95% CI) HbA1c was 8.9 (8.8-9.1)% (74 (73-76)mmol/mol) for both groups. There was a significant between group difference at 6 months which was sustained at 24 months; Mean (95% CI) HbA1c at 24 months in the intervention group was 7.6 (7.5-7.8)% (60 (58-62)mmol/mol) and 8.0 (7.7-8.4)% (64 (61-68)mmol/mol) in the control group. At 24 months 97 (71.3%) of the intervention group and 26 (31.0%) of the control group were prescribed insulin; there was no significant difference in weight. Use of non-insulin anti-hyperglycaemic agents was similar in both groups with the exception of dipeptidyl peptidase-4 inhibitors which were prescribed more frequently in the control group (30(36%) vs 21(16%)). Stepping Up was associated with improved glycaemic control compared to usual care for 24 months, suggesting that the model facilitated more timely treatment intensification. Ongoing RN-CDE support may be needed to facilitate ongoing treatment intensification. Copyright © 2017 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Nielsen-Kudsk, Jens Erik; Johnsen, Søren Paaske; Wester, Per; Damgaard, Dorte; Airaksinen, Juhani; Lund, Juha; De Backer, Ole; Pakarinen, Sami; Odenstedt, Jacob; Vikman, Saila; Settergren, Magnus; Kongstad, Ole; Rosenqvist, Mårten; Krieger, Derk W
The aim of this study was to investigate the prognosis in patients with atrial fibrillation (AF) and intracerebral haemorrhage (ICH) having a left atrial appendage occlusion (LAAO) versus patients receiving standard medical therapy. A total of 151 patients from the Nordic countries with AF and previous ICH who underwent LAAO using the AMPLATZER Cardiac Plug or the AMPLATZER AMULET were compared to a propensity score-matched group of 151 patients receiving standard medical therapy. The two groups were matched so that their risks for stroke and bleeding were similar (CHA2DS2-VASc and HAS-BLED scores). The standard care patients were identified from the Danish Stroke Registry among 787 patients with AF and ICH. The primary endpoint was a composite of all-cause mortality, ischaemic stroke and major bleeding. Patients with AF and a prior ICH treated with LAAO had a lower risk of the composite outcome as compared to patients treated with standard medical care (events/1,000 years [95% confidence interval]: 53.3 [44.3-64.1] vs. 366.7 [298.2-450.9]; hazard ratio 0.16 [0.07-0.37]). LAAO is suggested to be of major clinical benefit in AF patients having sustained an ICH. These results have to be confirmed in a randomised clinical trial.
Bonin, Jean-Pierre; Fournier, Louise; Blais, Régis; Perreault, Michel; White, Noé Djawn
The objective of this cohort study is to describe the service utilization by clients of homeless resources in Quebec and Montreal (Canada) over a 5-year period. Participants (N = 426) were recruited from a survey conducted in 1999 about clients' utilization of resources intended for homeless people in Montreal and Quebec. Data analyzed in this study were also drawn from three administrative databanks managed by the Quebec health care system. Results revealed that: (1) in general, mental health services are less used than physical health services; (2) generally, women, older persons, nonhomeless persons, and persons with mental health problems utilized proportionately more health services; and (3) participants involved in this study tend to continue using services over years in a system where health services are free. These findings are discussed in terms of long-term service utilization by clients of homeless resources.
Rifas-Shiman, Sheryl L; Taveras, Elsie M; Gortmaker, Steven L; Hohman, Katherine H; Horan, Christine M; Kleinman, Ken P; Mitchell, Kathleen; Price, Sarah; Prosser, Lisa A; Gillman, Matthew W
The obesity epidemic has spared no age group, even young infants. Most childhood obesity is incident by the age of 5 years, making prevention in preschool years a priority. To examine 2-year changes in age- and sex-specific BMI z-scores and obesity-related behaviours among 441 of the 475 originally recruited participants in High Five for Kids, a cluster randomized controlled trial in 10 paediatric practices. The intervention included a more intensive 1-year intervention period (four in-person visits and two phone calls) followed by a less intensive 1-year maintenance period (two in-person visits) among children who were overweight or obese and age 2-6 years at enrolment. The five intervention practices restructured care to manage these children including motivational interviewing and educational modules targeting television viewing and intakes of fast food and sugar-sweetened beverages. After 2 years, compared with usual care, intervention participants had similar changes in BMI z-scores (-0.04 units; 95% CI -0.14, 0.06), television viewing (-0.20 h/d; -0.49 to 0.09) and intakes of fast food (-0.09 servings/week; -0.34 to 0.17) and sugar-sweetened beverages (-0.26 servings/day; -0.67 to 0.14). High Five for Kids, a primarily clinical-based intervention, did not affect BMI z-scores or obesity-related behaviours after 2 years. © 2016 World Obesity Federation.
Middleton, Sandy; Coughlan, Kelly; Mnatzaganian, George; Low Choy, Nancy; Dale, Simeon; Jammali-Blasi, Asmara; Levi, Chris; Grimshaw, Jeremy M; Ward, Jeanette; Cadilhac, Dominique A; McElduff, Patrick; Hiller, Janet E; D'Este, Catherine
Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005-2010). We now examine long-term all-cause mortality. Mortality was ascertained using Australia's National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber-White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates. One thousand and seventy-six participants (intervention n=600; control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival (>20%), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.58-1.07; P=0.13; adjusted HR, 0.77; 95% CI, 0.59-0.99; P=0.045). Older age (75-84 years; HR, 4.9; 95% CI, 2.8-8.7; P<0.001) and increasing stroke severity (HR, 1.5; 95% CI, 1.3-1.9; P<0.001) were associated with increased mortality, while being married (HR, 0.70; 95% CI, 0.49-0.99; P=0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths. Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care. URL: http://www.anzctr.org.au. Unique
Vaswani, A.N.; Howard, J.E.
This is the 17th and final report of the Marshall Islands Medical Program as carried out by the Brookhaven National Laboratory (BNL). The purpose of these publications has been to provide information on the medical status of 253 Marshallese exposed to radiation fallout in 1954. The medical program fulfills a commitment to disclose unique medical information relevant to public health. Details of the Bravo thermonuclear accident that caused the exposure have been published. A 1955 article in the Journal of the American Medical Association, which described the acute medical effects on the population that required special medical care, remains a definitive and relevant description of events. Marshallese participation in this Congressionally mandated program is voluntary. Throughout the 44 years of the program, each participating individual`s relevant medical findings, laboratory data, disease morbidity, and mortality have been published in the BNL reports in a manner preserving patient confidentiality. In each report, there has been an attempt to interpret these findings and to infer the role of radiation exposure in their development. An equally important aspect of the reports has been the presentation of data that allows for analyses of the medical consequences of the Marshallese exposure.
Sukhavasi, Sowmya; Jothimuthu, Pretha; Papautsky, Ian; Beyette, Fred R
In the Unites States Pediatric septic shock is a major health problem with about 42,000 cases per y ear and a mortality rate of about 10% . Studies have indicated that children with pediatric septic shock have demonstrated critically low levels of serum z inc (Zn) and supplementation of Zn is being suggested as a therapeutic strategy. However, to protect patient safety, it is vital that Z n levels be monitored during supplementation to insure the Zn concentration levels remain at or near physiologic normal levels. Currently Atomic Absorption Spectroscopy (AAS) is used to quantify Zn levels in serum samples. Unfortunately, AAS frequently involves sending serum samples to external laboratory facilities which yields measurement turnaround time that range from hours to days. Thus, timely monitoring of Zn levels is critical to preventing over supplementation that could result in critical conditions such as heavy metal (Zn) toxicity. This paper reports on the development of a Point-of-Care device for rap id electrochemical measurement of Zn. The prototype device is able to accurately quantify Zn in serum with a turn-around time of about 30 minutes. The devices is based on a three electrode sensor which uses Anodic stripping voltammetry (ASV) for sensing Zn levels. The ASV electrode sensor is read using a reader that has be en developed using commercially available embedded system components and custom analog circuitry.
Kasteleyn, Marise J; Gorter, Kees J; van Puffelen, Anne L; Heijmans, Monique; Vos, Rimke C; Jansen, Hanneke; Rutten, Guy E H M
Despite diabetes patients' efforts to control their disease, many of them are confronted with an acute coronary event. This may evoke depressive feelings and self-management may be complicated. According to the American Diabetes Association, the transition from hospital to home after an acute coronary event (ACE) is a high-risk time for diabetes patients; it should be improved. Before developing an intervention for diabetes patients with an ACE in the period after discharge from hospital, we want to gain a detailed understanding of patients' views, perceptions and feelings in this respect. Qualitative design. Two semi-structured focus groups were conducted with 14 T2DM patients (71% male, aged 61-77 years) with a recent ACE. One focus group with partners (67% male, aged 64-75 years) was held. All interviews were transcribed verbatim and analyzed by two independent researchers. Patients believed that coping with an ACE differs between patients with and without T2DM. They had problems with physical exercise, sexuality and pharmacotherapy. Patients and partners were neither satisfied with the amount of information, especially on the combination of T2DM and ACE, nor with the support offered by healthcare professionals after discharge. Participants would appreciate tailored self-management support after discharge from hospital. Patients with T2DM and their partners lack tailored support after a first ACE. Our findings underpin the ADA recommendations to improve the transition from hospital to home. The results of our study will help to determine the exact content of a self-management support program delivered at home to help this specific group of patients to cope with both conditions. Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Huter, Beate Marina
The study was set out to investigate whether the Marcovich model of a "soft treatment" of premature infants encourages the parent-infant-relationship to such an extent that, at school age, the Marcovich-children would be found to differ significantly from children treated with standard care with regard to the quality of their attachment and the prevalence of emotional and behavioural disorders. The Marcovich-children of the present sample had been discharged from hospital much earlier than the standard group, they were less frequently treated with artificial respiration, infant-parent body contact was encouraged significantly earlier, and, although they were less frequently breast-fed, those who were breast-fed were allowed to do so at a much earlier stage. The Marcovich-children were found to display higher social competence, more emotional openness, more emotional coherence, less dismissal of attachment and less preoccupied anger. The two samples did not differ with regard to their total attachment quality as well as their emotional and behavioural problems. The fact that no significant differences could be established with regard to the quality of the attachment suggests that the complex life-saving attachment system is not irreversibly affected by the early separation and distress and that the months and years after the hospital stay have the power to make up with any experienced trauma. It seems, however, that special aspects of the attachment system, such as the communication and interaction, are positively encouraged and enhanced by the soft treatment of the premature infant, which leads to greater emotional openness and social competence, as well as less preoccupied anger against the attachment figures.
Shear, Katherine; Newth, Christopher J.L.; Harrison, Rick; Berger, John; Zimmerman, Jerry; Anand, K.J.S.; Carcillo, Joseph; Donaldson, Amy E.; Dean, J. Michael; Willson, Douglas F.; Nicholson, Carol
Abstract Objective We previously demonstrated that parents whose children die in a pediatric intensive care unit (PICU) have a high level of complicated grief symptoms 6 months after the death. In this study, we investigate the change in the extent of complicated grief symptoms among these parents between 6 and 18 months postdeath and identify factors predicting improvement. Methods One hundred thirty-eight parents of 106 children completed surveys at 6 and 18 months. Surveys included the Inventory of Complicated Grief (ICG), measures of grief avoidance, attachment, caregiving and social support, and demographics. Multivariable analysis was performed using generalized estimating equations to identify characteristics independently associated with improvement in ICG score. Results ICG scores were 33.4 ± 13.6 at 6 months and 28.0 ± 13.5 at 18 months, representing an improvement in ICG score of 5.4 + 8.0 (95% confidence interval [CI] 4.1–6.8, p < 0.001). Variables independently associated with greater improvement in ICG score included traumatic death and greater grief avoidance. Variables independently associated with less improvement included being the biological parent and having more responsive caregiving. Parents with one or two surviving children had more improvement in ICG score than those with no surviving children whereas parents with three or more surviving children had less improvement. Conclusion Complicated grief symptoms decrease among parents between 6 and 18 months after their child's death in the PICU; however, high symptom levels persists for some. Better understanding of the trajectory of complicated grief will allow parents at risk for persistent distress to receive professional support. PMID:21281122
Cardiac rehabilitation after acute coronary syndrome comparing adherence and risk factor modification in a community-based shared care model versus hospital-based care in a randomised controlled trial with 12 months of follow-up.
Bertelsen, Jannik B; Refsgaard, Jens; Kanstrup, Helle; Johnsen, Søren P; Qvist, Ina; Christensen, Bo; Christensen, Kent L
To investigate whether phase II cardiac rehabilitation (CR) conducted by a community model of shared care CR (SC-CR) including health care centres and general practice was feasible and provided acceptable results and to compare SC-CR to hospital-based CR (H-CR) in a randomised controlled trial. Patients were randomised to H-CR or SC-CR after admission for acute coronary syndrome. In SC-CR, the general practitioner took over the responsibility of the remaining rehabilitation, pharmacological treatment and risk factor management after the initial visit to the hospital outpatient clinic. The Municipal Health Care Centres provided courses on smoking cessation, nutrition, and exercise training and contributed to disease education and psychosocial support. The main endpoint was adherence to the CR programme and compliance with lifestyle modifications. In total, 1364 patients were screened, 327 (24%) were eligible, and 212 (65%) accepted participation. Phase II CR was completed by 192 (91%) of the participants. Full adherence to the CR programme was seen in 53% in SC-CR versus 54% in H-CR (relative risk (RR): 0.98, 95% confidence interval: 0.73-1.32). In H-CR, patients had higher rates of adherence to dietary advice and health education. In SC-CR, 12% of patients did not attend the risk factor evaluation and clinical assessment with their general practitioner. No difference in risk factor improvement was found. Exercise training was declined by 25% in both groups. Adherence to phase II CR was high in both groups. SC-CR did not improve adherence and efficacy, but had comparable effects on medication and risk factors. Thus, SC-CR was safe and effective.
Evensen, Stig; Ueland, Torill; Lystad, June Ullevoldsæter; Bull, Helen; Klungsøyr, Ole; Martinsen, Egil W; Falkum, Erik
Employment is an important part of recovery for individuals with schizophrenia. The employment rate for this group is as low as 10% in Norway, and major system related barriers to employment are evident. This study reports the competitive employment outcome at 2-year follow-up of a vocational rehabilitation study augmented with cognitive remediation (CR) or elements from cognitive behaviour therapy (CBT) for individuals with schizophrenia spectrum disorders. It also investigates if global functioning, self-esteem, and depression at baseline predicts employment outcome, and if change in these variables during the intervention period is associated with employment outcome. One hundred and forty-eight participants with schizophrenia spectrum disorders in six Norwegian counties received 10 months vocational rehabilitation augmented with either CBT (n = 84) or CR (n = 64). Both competitive and sheltered workplaces were used. Participants were assessed at baseline, at the end of the intervention period, and at 2-year follow-up. At 2-year follow-up, 21.2% had obtained competitive employment. A further 25.3% had work placements in competitive workplaces. Significant improvements were found in global functioning, self-esteem, and depression during the intervention period, but no significant differences between the two intervention groups. High baseline global functioning and self-esteem, as well as positive change in these variables during the intervention period, were significantly associated with higher competitive employment outcome at 2-year follow-up. The results add to existing evidence that competitive employment is attainable for individuals with schizophrenia. High global functioning and self-esteem were strongly associated with competitive employment outcome.
Longo, Christopher J; Heyland, Daren K; Fisher, Harold N; Fowler, Robert A; Martin, Claudio M; Day, Andrew G
Introduction Recombinant human activated protein C (APC) therapy has been shown to reduce short-term mortality in patients with severe sepsis. However, survivors of sepsis may have long-term complications affecting health-related quality of life (HRQoL) and resource utilization. The objective of this study was to evaluate prospectively the effect of APC on long-term HRQoL and resource utilization compared with a nonrandomized control group that received standard care. Methods This was an observational cohort study at nine Canadian intensive care units. Patients with severe sepsis who survived to 28 days were recruited. Patients who received APC formed the treatment group and those that did not formed the standard care group. Patients who did not receive APC because of central nervous system bleeding risk were excluded from the standard care group. HRQoL (determined using the 36-item Short Form) and resource use were recorded at 28 days, and 3, 5 and 7 months. Results One hundred patients were enrolled (64 in the standard care group and 36 in the APC group), with 70 patients completing all follow-up visits. Over the 6 months of follow up, APC-treated patients exhibited statistically significantly better scores for the physical component score (P = 0.04) and trends toward improvements in physical functioning (P = 0.12), role physical (P = 0.10) and bodily pain (P = 0.14) as compared with standard care patients. Shorter hospital length of stay was observed for the APC group (36 days versus 48 days; P = 0.05). Conclusion These findings challenge earlier assumptions suggesting equivalent HRQoL and resource use in APC-treated and standard care patients who survive severe sepsis. PMID:18072978
Shrestha, Sharmila; Adachi, Kumiko; Petrini, Marcia A; Shrestha, Sarita; Rana Khagi, Bina
the health and survival of newborns depend on high levels of attention and care from caregivers. The growth and development of some infants are unhealthy because of their mother's or caregiver's lack of knowledge or the use of inappropriate or traditional child-rearing practices that may be harmful. to develop a newborn care educational programme and evaluate its impact on infant and maternal health in Nepal. a randomised controlled trial. one hundred and forty-three mothers were randomly assigned to the intervention (n=69) and control (n=74) groups. Eligible participants were primiparous mothers who had given birth to a single, full-term, healthy infant, and were without a history of obstetric, medical, or psychological problems. prior to being discharged from the postnatal unit, the intervention group received our structured newborn care education programme, which consisted of one-on-one educational sessions lasting 10-15minutes each and one postpartum follow-up telephone support within two weeks after discharge, in addition to the hospital's routine general newborn care education. The control group received only the regular general newborn care education. Outcomes were measured by using Newborn care Knowledge Questionnaires, Karitane Parenting Confidence Scale, State-Trait Anxiety Inventory for Adults and infant health and care status. the number of mothers attending the health centre due to the sickness of their babies was significantly decreased in the intervention group compared to the control group. Moreover, the intervention group had significant increases in newborn care knowledge and confidence, and decreases in anxiety, compared with the control group. the structured newborn care education programme enhanced the infant and mother health. Moreover, it increased maternal knowledge of newborn care and maternal confidence; and reduced anxiety in primiparous mothers. Thus, this educational programme could be integrated into routine educational programs to
Kozicka, Izabela; Kostka, Tomasz
Purpose To assess the relative role of handgrip strength (HGS), quadriceps muscle power (Pmax), and optimal shortening velocity (υopt) in maintaining functional abilities (FAs) in older adults living in a long-term care home over a 1-year follow-up. Subjects and methods Forty-one inactive older institutionalized adults aged 69.8±9.0 years participated in this study. HGS, Pmax, υopt, cognitive function using the Mini-Mental State Examination, depressive symptoms using the Geriatric Depression Scale, nutritional status using the Mini Nutritional Assessment (MNA), and physical activity (PA) using the Seven-Day Physical Activity Recall Questionnaire were assessed at baseline and at 1-year follow-up. FAs were assessed with activities of daily living (ADL), instrumental ADL, and Timed Up & Go test. Results Both at baseline and at follow-up, FAs were related to age, HGS, Pmax/kg, υopt, MNA, and PA. These associations were generally similar in both sexes. As revealed in multiple regression analysis, υopt was the strongest predictor of FA, followed by Pmax/kg, PA, and MNA. FA deteriorated after 1 year as measured by ADL and Timed Up & Go test. Pmax and υopt, but not HGS, also decreased significantly after 1 year. Nevertheless, 1-year changes in FAs were not related to changes in HGS, Pmax, υopt, or PA. Conclusion The 1-year period of physical inactivity among older institutionalized adults was found to have a negative effect on their FAs, Pmax, and υopt. The present study demonstrates that Pmax and, especially, υopt correlated with FAs of older adults more than HGS, both at baseline and at follow-up. Despite this, 1-year natural fluctuations of PA, Pmax, and υopt are not significant enough to influence FAs in inactive institutionalized older adults. PMID:27307720
... problems they are experiencing, such as anxiety or depression Any changes in their family medical history , including any new cancers It is ... is completed? It is common to experience stress, depression, and ... with family and friends, health professionals, other patients, members of ...
Cutler, Liz; King, Bronwen; McCarthy, Nicky; Hamilton, Greg; Cook, Lynley
Appetite for Life is a six-week primary care-based programme for women who are overweight, and aims to achieve long-term health gain through establishing healthy eating and physical activity patterns and a healthier weight. To evaluate the outcomes of Appetite for Life, a primary care-based healthy lifestyle programme for women who are overweight. Two hundred and sixty-one women enrolled and consented to take part in the six-week Appetite for Life programme via general practice and were followed for 12 months. Eating behaviours and physical activity levels were measured at baseline, six weeks, six months and 12 months. Anthropometric and biomedical data was collected at visits to the participants' general practitioners at baseline and 12 months. Positive lifestyle changes were reported that were sustained for the duration of the 12-month follow-up period. Participants reported an increase in intake of fruit and vegetables, dairy products, healthy fats and an increased level of physical activity. There was also an increase in reported enjoyment and participation in exercise. Mean weight was maintained over this time period. There was a reduction in mean LDL and total plasma cholesterol. A healthy lifestyle programme offered through primary care that is based on a non-dieting approach may help overweight women develop and sustain positive lifestyle changes.
Mejhert, Märit; Kahan, Thomas
The diagnosis of new onset congestive heart failure (CHF) is often difficult as symptoms and signs are non-specific. Proper diagnostic investigations and treatments are underused in primary care. To describe a management programme for patients with suspected CHF in primary care in cooperation with specialists in cardiology. Prospective study of 102 consecutive primary care patients with suspected new onset CHF referred to an easily accessible hospital-based cardiology outpatient clinic management programme. Following clinical examination, ECG, echocardiography, blood chemistry including NT-proBNP, and assessment of NYHA class and quality of life (EQ5D), patients with a confirmed diagnosis of CHF were prescribed medication with advice on titration and target doses. Trained CHF nurses gave Information on CHF and provided follow up. Half (47%) of the referred patients had the diagnosis of CHF confirmed. Low NT-proBNP values (< 300 ng/l) provided a negative predictive value of 73%. Respiratory tract diseases were common differential diagnoses. At one year of follow-up, medication in the CHF group was 86% ACE-inhibitors/angiotensin receptor blockers, 61% ß-blocking agents, and 81% diuretics (P < 0.001 for the increase in ACE-inhibitors/angiotensin receptor blockers from baseline). NYHA class improved from baseline (median 2, range: 1-3) to one year (P < 0.05), whereas NT-proBNP (1491-1261 ng/l), and quality of life (EQ5D; 67-67) were unchanged. A management programme to optimize quality of care for patients with suspected new onset CHF in primary care, with referral to a hospital-based specialist team, can be applied successfully.
Long-term follow-up of moderately hypercholesterolemic hypertensive patients following randomization to pravastatin vs usual care: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT).
Margolis, Karen L; Davis, Barry R; Baimbridge, Charles; Ciocon, Jerry O; Cuyjet, Aloysius B; Dart, Richard A; Einhorn, Paula T; Ford, Charles E; Gordon, David; Hartney, Thomas J; Julian Haywood, L; Holtzman, Jordan; Mathis, David E; Oparil, Suzanne; Probstfield, Jeffrey L; Simpson, Lara M; Stokes, John D; Wiegmann, Thomas B; Williamson, Jeff D
The authors conducted a randomized, controlled, multicenter trial, in which they assigned well-controlled hypertensive participants aged 55 years and older with moderate hypercholesterolemia to receive pravastatin (n=5170) or usual care (n=5185) for 4 to 8 years, when trial therapy was discontinued. Passive surveillance using national databases to ascertain deaths and hospitalizations continued for a total follow-up of 8 to 13 years to assess whether mortality and morbidity differences persisted or new differences developed. During the post-trial period, fatal and nonfatal outcomes were available for 98% and 64% of participants, respectively. The primary outcome was all-cause mortality and the secondary outcomes included cardiovascular mortality, coronary heart disease (CHD), stroke, heart failure, cardiovascular disease, and end-stage renal disease. No significant differences appeared in mortality for pravastatin vs usual care (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.89-1.03) or other secondary outcomes. Similar to the previously reported in-trial result, there was a significant treatment effect for CHD in black patients (HR, 0.79; 95% CI, 0.64-0.98). However, the in-trial result showing a significant treatment by race effect did not remain significant during the entire follow-up (P=.08). These findings are consistent with evidence from other large trials that show statins prevent CHD and add evidence that they are effective for CHD prevention in black patients. © 2013 Wiley Periodicals, Inc.
Hassan, Amin S; Fielding, Katherine L; Thuo, Nahashon M; Nabwera, Helen M; Sanders, Eduard J; Berkley, James A
To determine the rate and predictors of early loss to follow-up (LTFU) for recently diagnosed HIV-infected, antiretroviral therapy (ART)-ineligible adults in rural Kenya. Prospective cohort study. Clients registering for HIV care between July 2008 and August 2009 were followed up for 6 months. Baseline data were used to assess predictors of pre-ART LTFU (not returning for care within 2 months of a scheduled appointment), LTFU before the second visit and LTFU after the second visit. Logistic regression was used to determine factors associated with LTFU before the second visit, while Cox regression was used to assess predictors of time to LTFU and LTFU after the second visit. Of 530 eligible clients, 178 (33.6%) were LTFU from pre-ART care (11.1/100 person-months). Of these, 96 (53.9%) were LTFU before the second visit. Distance (>5 km vs. <1 km: adjusted hazard ratio 2.6 [1.9-3.7], P < 0.01) and marital status (married vs. single: 0.5 [0.3-0.6], P < 0.01) independently predicted pre-ART LTFU. Distance and marital status were independently associated with LTFU before the second visit, while distance, education status and seasonality showed weak evidence of predicting LTFU after the second visit. HIV disease severity did not predict pre-ART LTFU. A third of recently diagnosed HIV-infected, ART-ineligible clients were LTFU within 6 months of registration. Predictors of LTFU among ART-ineligible clients are different from those among clients on ART. These findings warrant consideration of an enhanced pre-ART care package aimed at improving retention and timely ART initiation. © 2011 Blackwell Publishing Ltd.
Stempliuk, Valeska; Ramon-Pardo, Pilar; Holder, Reynaldo
Core components Health care-associated infections (HAIs) are a major cause of morbidity and mortality. In addition to pain and suffering, HAIs increase the cost of health care and generates indirect costs from loss of productivity for patients and society as a whole. Since 2005, the Pan American Health Organization has provided support to countries for the assessment of their capacities in infection prevention and control (IPC). More than 130 hospitals in 18 countries were found to have poor IPC programmes. However, in the midst of many competing health priorities, IPC programmes are not high on the agenda of ministries of health, and the sustainability of national programmes is not viewed as a key point in making health care systems more consistent and trustworthy. Comprehensive IPC programmes will enable countries to reduce the mobility, mortality and cost of HAIs and improve quality of care. This paper addresses the relevance of national infection prevention and control (NIPC) programmes in promoting, supporting and reinforcing IPC interventions at the level of hospitals. A strong commitment from national health authorities in support of national IPC programmes is crucial to obtaining a steady decrease of HAIs, lowering health costs due to HAIs and ensuring safer care.
Kelly, J. Daniel; Schlough, Gabriel Warren; Conteh, Sulaiman; Barrie, M. Bailor; Kargbo, Brima; Giordano, Thomas P.
Background The heterogeneity of the pre-antiretroviral (pre-ART) population calls for more granular depictions of the cascade of HIV care. Methods We studied a prospective cohort of persons newly diagnosed with HIV infection from a single center in Freetown, Sierra Leone, over a 12-month period and then traced those persons who were lost to follow-up (LTFU) during pre-ART care (before ART initiation). ART eligibility was based on a CD4 cell count result of ≤ 350 mm/cells and/or WHO clinical stage 3 or 4. Persons who attended an appointment in the final three months were considered to be retained in care. Adherence to ART was measured using pharmacy refill dates. “Effective HIV care” was defined as completion of the cascade of care at 12-months regardless of whether patients are on ART. Tracing outcomes were obtained for those who were LTFU during pre-ART care. Results 408 persons newly diagnosed with HIV infection were screened, 338 were enrolled, and 255 persons were staged for ART. ART-ineligible persons had higher retention rates than ART-eligible persons (59.6% vs 41.8%, p = 0.03). 77 (22.8%) of 338 persons received effective HIV care. Most attrition (61.9%) occurred with persons during pre-ART care. 123 of 138 persons (89.1%) who were LTFU prior to ART initiation were found, and 91 of those 123 (74.0%) were alive. Of the 74 persons who were alive and described their engagement in care, 40 (54.1%) stopped care. Nearly half (42.5%) of those 40 stopped after assessment of ART-eligibility but before ART initiation. The main limitation of this study was the lack of tracing outcomes for those lost during ART care. Conclusions The majority of the pre-ART LTFU population stopped their care, particularly after ART-eligibility but before ART initiation. Interventions to hasten ART initiation and retain this at-risk group may have significant downstream impact on effective HIV care. PMID:26901765
Keenan, E; Dorman, A; O'Connor, J
Forty five pregnant addicts had attended the National Drug Treatment Centre between 1984-1986. At that time they received intensive counselling, low dose Methadone maintenance and both ante natal and post natal care. Our aim was to follow these women six years later focusing on their drug use and outcome of their children. The women were followed up by chart review, individual interviews and liaison with the social and probation services. Results indicate that a high proportion of the women abused chaotically (50%). There is a worrying high incidence of HIV positive patients (53.4%) and a mortality figure of 15.5% (7). However only 13 women (28.6%) have had further children and 22 women (49%) are currentl