A patient-focused framework integrating self-management and informatics.

PubMed

Knight, Elizabeth P; Shea, Kimberly

2014-03-01

This article introduces a framework to (a) guide chronic illness self-management interventions through the integration of self-management and nursing informatics, (b) focus self-management research, and (c) promote ethical, patient-empowering technology use by practicing nurses. Existing theory and research focusing on chronic illness, self-management, health-enabling technology, and nursing informatics were reviewed and examined and key concepts were identified. A care paradigm focusing on concordance, rather than compliance, served as the overall guiding principle. This framework identifies key relationships among self-management (patient behaviors), health force (patient characteristics), and patient-defined goals. The role of health-enabling technology supporting these relationships is explored in the context of nursing informatics. The Empowerment Informatics framework can guide intervention design and evaluation and support practicing nurses' ethical use of technology as part of self-management support. Nurses worldwide provide support to patients who are living with chronic illnesses. As pressures related to cost and access to care increase, technology-enabled self-management interventions will become increasingly common. This patient-focused framework can guide nursing practice using technology that prioritizes patient needs. © 2013 Sigma Theta Tau International.

Using Intervention Mapping for child development and wellbeing programs in early childhood education and care settings.

PubMed

O'Connor, Amanda; Blewitt, Claire; Nolan, Andrea; Skouteris, Helen

2018-06-01

Supporting children's social and emotional learning benefits all elements of children's development and has been associated with positive mental health and wellbeing, development of values and life skills. However, literature relating to the creation of interventions designed for use within the early childhood education and care settings to support children's social and emotional skills and learning is lacking. Intervention Mapping (IM) is a systematic intervention development framework, utilising principles centred on participatory co-design methods, multiple theoretical approaches and existing literature to enable effective decision-making during the development process. Early childhood pedagogical programs are also shaped by these principles; however, educators tend to draw on implicit knowledge when working with families. IM offers this sector the opportunity to formally incorporate theoretical, evidence-based research into the development of early childhood education and care social and emotional interventions. Emerging literature indicates IM is useful for designing health and wellbeing interventions for children within early childhood education and care settings. Considering the similar underlying principles of IM, existing applications within early childhood education and care and development of interventions beyond health behaviour change, it is recommended IM be utilised to design early childhood education and care interventions focusing on supporting children's social and emotional development. Copyright © 2018 Elsevier Ltd. All rights reserved.

Using mixed methods to develop and evaluate complex interventions in palliative care research.

PubMed

Farquhar, Morag C; Ewing, Gail; Booth, Sara

2011-12-01

there is increasing interest in combining qualitative and quantitative research methods to provide comprehensiveness and greater knowledge yield. Mixed methods are valuable in the development and evaluation of complex interventions. They are therefore particularly valuable in palliative care research where the majority of interventions are complex, and the identification of outcomes particularly challenging. this paper aims to introduce the role of mixed methods in the development and evaluation of complex interventions in palliative care, and how they may be used in palliative care research. the paper defines mixed methods and outlines why and how mixed methods are used to develop and evaluate complex interventions, with a pragmatic focus on design and data collection issues and data analysis. Useful texts are signposted and illustrative examples provided of mixed method studies in palliative care, including a detailed worked example of the development and evaluation of a complex intervention in palliative care for breathlessness. Key challenges to conducting mixed methods in palliative care research are identified in relation to data collection, data integration in analysis, costs and dissemination and how these might be addressed. the development and evaluation of complex interventions in palliative care benefit from the application of mixed methods. Mixed methods enable better understanding of whether and how an intervention works (or does not work) and inform the design of subsequent studies. However, they can be challenging: mixed method studies in palliative care will benefit from working with agreed protocols, multidisciplinary teams and engaging staff with appropriate skill sets.

PROTECTED-UK - Clinical pharmacist interventions in the UK critical care unit: exploration of relationship between intervention, service characteristics and experience level.

PubMed

Rudall, Nicola; McKenzie, Catherine; Landa, June; Bourne, Richard S; Bates, Ian; Shulman, Rob

2017-08-01

Clinical pharmacist (CP) interventions from the PROTECTED-UK cohort, a multi-site critical care interventions study, were further analysed to assess effects of: time on critical care, number of interventions, CP expertise and days of week, on impact of intervention and ultimately contribution to patient care. Intervention data were collected from 21 adult critical care units over 14 days. Interventions could be error, optimisation or consults, and were blind-coded to ensure consistency, prior to bivariate analysis. Pharmacy service demographics were further collated by investigator survey. Of the 20 758 prescriptions reviewed, 3375 interventions were made (intervention rate 16.1%). CPs spent 3.5 h per day (mean, ±SD 1.7) on direct patient care, reviewed 10.3 patients per day (±SD 4.2) and required 22.5 min (±SD 9.5) per review. Intervention rate had a moderate inverse correlation with the time the pharmacist spent on critical care (P = 0.05; r = 0.4). Optimisation rate had a strong inverse association with total number of prescriptions reviewed per day (P = 0.001; r = 0.7). A consultant CP had a moderate inverse correlation with number of errors identified (P = 0.008; r = 0.6). No correlation existed between the presence of electronic prescribing in critical care and any intervention rate. Few centres provided weekend services, although the intervention rate was significantly higher on weekends than weekdays. A CP is essential for safe and optimised patient medication therapy; an extended and developed pharmacy service is expected to reduce errors. CP services should be adequately staffed to enable adequate time for prescription review and maximal therapy optimisation. © 2016 Royal Pharmaceutical Society.

Assessing the performance of maternity care in Europe: a critical exploration of tools and indicators.

PubMed

Escuriet, Ramón; White, Joanna; Beeckman, Katrien; Frith, Lucy; Leon-Larios, Fatima; Loytved, Christine; Luyben, Ans; Sinclair, Marlene; van Teijlingen, Edwin

2015-11-02

This paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or "normal birth". The work formed part of COST Actions IS0907: "Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care" (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care. A structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions. A total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or "good" or positive outcomes more generally. The tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures.

Barriers and enablers to the delivery of psychological care in the management of patients with type 2 diabetes mellitus in China: a qualitative study using the theoretical domains framework.

PubMed

Chapman, Anna; Yang, Hui; Thomas, Shane A; Searle, Kendall; Browning, Colette

2016-03-29

China has the largest number of type 2 diabetes mellitus (T2DM) cases globally and individuals with T2DM have an increased risk of developing mental health disorders and functional problems. Despite guidelines recommending that psychological care be delivered in conjunction with standard T2DM care; psychological care is not routinely delivered in China. Community Health Centre (CHC) doctors play a key role in the management of patients with T2DM in China. Understanding the behavioural determinants of CHC doctors in the implementation of psychological care recommendations allows for the design of targeted and culturally appropriate interventions. As such, this study aimed to examine barriers and enablers to the delivery of psychological care to patients with T2DM from the perspective of CHC doctors in China. Two focus groups were conducted with 23 CHC doctors from Shenzhen, China. The discussion guide applied the Theoretical Domains Framework (TDF) that examines current practice and identifies key barriers and enablers perceived to influence practice. Focus groups were conducted with an interpreter, and were digitally recorded and transcribed. Two researchers independently coded transcripts into pre-defined themes using deductive thematic analysis. Barriers and enablers perceived by doctors as being relevant to the delivery of psychological care for patients with T2DM were primarily categorised within eight TDF domains. Key barriers included: CHC doctors' knowledge and skills; time constraints; and absence of financial incentives. Other barriers included: societal perception that treating psychological aspects of health is less important than physical health; lack of opinion leaders; doctors' intentional disregard of psychological care; and doubts regarding the efficacy of psychological care. In contrast, perceived enablers included: training of CHC doctors in psychological skills; identification of afternoon/evening clinic times when recommendations could be implemented; introduction of financial incentives; and the creation of a professional role (e.g. diabetes educator), that could implement psychological care recommendations to patients with T2DM. The utilisation of the TDF allowed for the comprehensive understanding of barriers and enablers to the implementation of psychological care recommendations for patients with T2DM, and consequently, has given direction to future interventions strategies aimed at improving the implementation of such recommendations.

Self-management support interventions that are clinically linked and technology enabled: can they successfully prevent and treat diabetes?

PubMed

Kaufman, Neal D; Woodley, Paula D Patnoe

2011-05-01

Patients with diabetes need a complex set of services and supports. The challenge of integrating these services into the diabetes regimen can be successfully overcome through self-management support interventions that are clinically linked and technology enabled: self-management support because patients need help mastering the knowledge, attitudes, skills, and behaviors so necessary for good outcomes; interventions because comprehensive theory-based, evidence-proven, long-term, longitudinal interventions work better than direct-to-consumer or nonplanned health promotion approaches; clinically linked because patients are more likely to adopt new behaviors when the approach is in the context of a trusted therapeutic relationship and within an effective medical care system; and technology enabled because capitalizing on the amazing power of information technology leads to the delivery of cost-effective, scalable, engaging solutions that prevent and manage diabetes. © 2011 Diabetes Technology Society.

Margaret Newman's Theory of Health as Expanding Consciousness and a Nursing Intervention from a Unitary Perspective

PubMed Central

Endo, Emiko

2017-01-01

This mini-review aims to introduce Margaret Newman's theory of health as expanding consciousness and caring partnership as a nursing intervention. Emanating from a unitary and transformative perspective of nursing, caring partnership enables nurses to identify with cancer patients as well as to help the patients find meaning in their situation and their lives. In genuine patient–nurse interactions, both patients and nurses experience higher levels of consciousness. PMID:28217730

Embedding fundamental care in the pre-registration nursing curriculum: Results from a pilot study.

PubMed

Feo, Rebecca; Donnelly, Frank; Frensham, Lauren; Conroy, Tiffany; Kitson, Alison

2018-05-01

International evidence suggests nursing is not providing fundamental care consistently or adequately, resulting in poor outcomes for patients and healthcare systems. One possible reason for this inadequate care delivery is nursing education, with fundamental care often implicit or invisible in nursing curricula. To understand how best to teach fundamental care to pre-registration (pre-licensure) students, we developed and piloted a six-week intervention that incorporated into the first-year curriculum a more explicit focus on fundamental care. A conceptual fundamental care framework was used to guide students' learning, and clinical skills sessions were structured to reinforce the framework's conceptual understanding and enable students to practice delivering fundamental care in an integrated manner. The intervention's impact was explored via a pre-post survey and focus groups. The survey demonstrated that the intervention did not affect students' ability to identify patients' fundamental care needs; however, focus groups showed the intervention assisted students in understanding the complexity of fundamental care and its importance to patients' experiences. The pilot provides preliminary evidence on the importance of embedding fundamental care into nursing curricula early and explicitly, and emphasising the integrated nature of such care, particularly through structured debriefs, consistent terminology, and opportunities for students to experience care as a patient. Copyright © 2018 Elsevier Ltd. All rights reserved.

Cost-effectiveness of a vocational enablement protocol for employees with hearing impairment; design of a randomized controlled trial

PubMed Central

2012-01-01

Background Hearing impairment at the workplace, and the resulting psychosocial problems are a major health problem with substantial costs for employees, companies, and society. Therefore, it is important to develop interventions to support hearing impaired employees. The objective of this article is to describe the design of a randomized controlled trial evaluating the (cost-) effectiveness of a Vocational Enablement Protocol (VEP) compared with usual care. Methods/Design Participants will be selected with the 'Hearing and Distress Screener'. The study population will consist of 160 hearing impaired employees. The VEP intervention group will be compared with usual care. The VEP integrated care programme consists of a multidisciplinary assessment of auditory function, work demands, and personal characteristics. The goal of the intervention is to facilitate participation in work. The primary outcome measure of the study is 'need for recovery after work'. Secondary outcome measures are coping with hearing impairment, distress, self-efficacy, psychosocial workload, job control, general health status, sick leave, work productivity, and health care use. Outcome measures will be assessed by questionnaires at baseline, and 3, 6, 9, and 12 months after baseline. The economic evaluation will be performed from both a societal and a company perspective. A process evaluation will also be performed. Discussion Interventions addressing occupational difficulties of hearing impaired employees are rare but highly needed. If the VEP integrated care programme proves to be (cost-) effective, the intervention can have an impact on the well-being of hearing impaired employees, and thereby, on the costs for the company as well for the society. Trial registration Netherlands Trial Register (NTR): NTR2782 PMID:22380920

Evaluating a dignity care intervention for palliative care in the community setting: community nurses' perspectives.

PubMed

McIlfatrick, Sonja; Connolly, Michael; Collins, Rita; Murphy, Tara; Johnston, Bridget; Larkin, Philip

2017-12-01

To evaluate a dignity care intervention provided by community nurses seeking to address dignity concerns for people with advanced and life-limiting conditions. Evidence would suggest that dying people fear a loss of dignity and a central focus of palliative care is to assist people to die with dignity. Whilst community nurses have a key role to play in the delivery of palliative care, specific interventions for dignity are lacking. A mixed methods study using online survey and focus group interviews and thematic analysis to examine data. Twenty four community nurses implemented the dignity care intervention for people with advanced and life-limiting conditions were recruited from four pilot sites across Ireland. Four focus group interviews and on line survey were conducted between March-June 2015. The community nurses found the dignity care intervention useful. It helped the nurses to provide holistic end-of-life care and assisted in the overall assessment of palliative care patients, identifying areas that might not otherwise have been noted. Whilst it was a useful tool for communication, they noted that it stimulated some emotionally sensitive conversations for which they felt unprepared. Implementing the dignity care intervention in practice was challenging. However, the dignity care intervention facilitated holistic assessment and identified patient dignity-related concerns that may not have been otherwise identified. Further support is required to overcome barriers and enable dignity-conserving care. Ensuring dignity is a key aspect of palliative and end-of-life care; however, community nurses may not feel equipped to address this aspect of care. Implementing a dignity care intervention can assist in identifying patient dignity-related concerns and provision of holistic care. Community nurses need more training to assist in difficult conversations relating to dignity and end-of-life care. © 2017 John Wiley & Sons Ltd.

Improving outcomes of hospitalized patients: the Physician Relationships, Improvising, and Sensemaking intervention protocol.

PubMed

Leykum, Luci K; Lanham, Holly J; Provost, Shannon M; McDaniel, Reuben R; Pugh, Jacqueline

2014-11-26

Our goal is to improve the safety and effectiveness of inpatient care. Rather than focus on improving process of care, we focus on the social structure within physician teams. We have developed the Physician Relationships, Improvising, and Sensemaking (PRISm) intervention to improve the way physician teams round, enabling them to better relate, make sense of their patients' conditions, and improvise in uncertain clinical situations. We are currently studying the impact of PRISm on adverse events and complications in hospitalized patients. This manuscript describes the PRISm intervention. PRISm is a structured communication tool consisting of three components: daily briefings before rounds; use of the Situation, Task, Intent, Concern, and Calibrate (STICC) framework during rounds as part of the discussion of individual patients; and debriefings after rounds. We are implementing the PRISm intervention on eight inpatient medical and surgical physician teams in the South Texas Veterans Health Care System. We are assessing PRISm impact on the way team members relate to each other, round, and discuss patients through pre- and post-implementation observations and surveys. We are also assessing PRISm impact on complications and adverse events. Finally, we are interviewing physicians regarding their experience using the intervention. Our results will allow us to begin to understand the potential impact of interventions designed to improve how providers relate to each other, improvise, and make sense of what is happening as a strategy for improving inpatient care. Our in-depth data collection will enable us to assess how relationships, improvising, and sensemaking influence patient outcomes, potentially through creating shared mental models or enhancing distributed cognition during clinical reasoning. Finally, our results will lay the groundwork for larger implementation studies to improve clinical outcomes through improving how providers, and providers, patients, and caregivers, relate.

Effectiveness of interventions to provide culturally appropriate maternity care in increasing uptake of skilled maternity care: a systematic review

PubMed Central

Coast, Ernestina; Jones, Eleri; Lattof, Samantha R; Portela, Anayda

2016-01-01

Addressing cultural factors that affect uptake of skilled maternity care is recognized as an important step in improving maternal and newborn health. This article describes a systematic review to examine the evidence available on the effects of interventions to provide culturally appropriate maternity care on the use of skilled maternity care during pregnancy, for birth or in the postpartum period. Items published in English, French and/or Spanish between 1 January 1990 and 31 March 2014 were considered. Fifteen studies describing a range of interventions met the inclusion criteria. Data were extracted on population and intervention characteristics; study design; definitions and data for relevant outcomes; and the contexts and conditions in which interventions occurred. Because most of the included studies focus on antenatal care outcomes, evidence of impact is particularly limited for care seeking for birth and after birth. Evidence in this review is clustered within a small number of countries, and evidence from low- and middle-income countries is notably lacking. Interventions largely had positive effects on uptake of skilled maternity care. Cultural factors are often not the sole factor affecting populations’ use of maternity care services. Broader social, economic, geographical and political factors interacted with cultural factors to affect targeted populations’ access to services in included studies. Programmes and policies should seek to establish an enabling environment and support respectful dialogue with communities to improve use of skilled maternity care. Whilst issues of culture are being recognized by programmes and researchers as being important, interventions that explicitly incorporate issues of culture are rarely evaluated. PMID:27190222

Primary Care Practice Transformation Is Hard Work

PubMed Central

Crabtree, Benjamin F.; Nutting, Paul A.; Miller, William L.; McDaniel, Reuben R.; Stange, Kurt C.; Jaén, Carlos Roberto; Stewart, Elizabeth

2010-01-01

Background Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches. Methods Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change. Results A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with “agents” who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice. Conclusions It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change. PMID:20856145

Intervention for Diabetes with Education, Advancement and Support (IDEAS) study: protocol for a cluster randomised controlled trial.

PubMed

Lee, Jun Yang; Chan, Carina Ka Yee; Chua, Siew Siang; Ng, Chirk Jenn; Paraidathathu, Thomas; Lee, Kenneth Kwing-Chin; Lee, Shaun Wen Huey

2016-09-29

The high market penetration of mobile phones has triggered an opportunity to combine mobile technology with health care to overcome challenges in today's health care setting. Although Malaysia has a high Internet and mobile penetration rate, evaluations of the efficacy of incorporating this technology in diabetes care is not common. We report the development of a telemonitoring coaching system, using the United Kingdom (UK) Medical Research Council (MRC) framework, for patients with type 2 diabetes mellitus. The Intervention for Diabetes with Education, Technological Advancement and Support (IDEAS) study is a telemonitoring programme based on an empowerment philosophy to enable participants to be responsible for their own health decision and behaviour. An iterative cycle of development, piloting, and collating qualitative and quantitative data will be used to inform and refine the intervention. To increase compliance, the intervention will be designed to encourage self-management using simple, non-technical knowledge. The primary outcomes will be HbA1c, blood pressure, total cholesterol, and quality of life and diabetes self-efficacy. In addition, an economic analysis on health service utilisation will be collected. The mixed-method approach in this study will allow for a holistic overview of using telemonitoring in diabetes care. This design enables researchers to understand the effectiveness of telemonitoring as well as provide insights towards the receptiveness of incorporating information technology amongst type 2 diabetes patients in a community setting. ClinicalTrials.gov NCT02466880 Registered 2 June 2015.

Implementing national guidelines for person-centered care of people with dementia in residential aged care: effects on perceived person-centeredness, staff strain, and stress of conscience.

PubMed

Edvardsson, David; Sandman, P O; Borell, Lena

2014-07-01

Person-centeredness has had substantial uptake in the academic literature on care of older people and people with dementia. However, challenges exist in interpreting and synthesizing the evidence on effects of providing person-centered care, as the person-centered components of some intervention studies are unclear - targeting very different and highly specific aspects of person-centeredness, as well as not providing empirical data to indicate the extent to which care practice was actually perceived to become more person-centered post-intervention. The study employed a quasi-experimental, one-group pre-test-post-test design with a 12-month follow-up to explore intervention effects on person-centeredness of care and the environment (primary endpoints), and on staff strain and stress of conscience (secondary endpoints). The intervention resulted in significantly higher scores on person-centeredness of care at follow-up, and the facility was rated as being significantly more hospitable at follow-up. A significant reduction of staff stress of conscience was also found at follow-up, which suggests that, to a larger extent, staff could provide the care and activities they wanted to provide after the intervention. The results indicated that an interactive and step-wise action-research intervention consisting of knowledge translation, generation, and dissemination, based on national guidelines for care of people with dementia, increased the staff self-reported person-centeredness of care practice, perceived hospitality of the setting, and reduced staff stress of conscience by enabling staff to provide the care and activities they want to provide.

Barriers and enablers of health system adoption of kangaroo mother care: a systematic review of caregiver perspectives.

PubMed

Smith, Emily R; Bergelson, Ilana; Constantian, Stacie; Valsangkar, Bina; Chan, Grace J

2017-01-25

Despite improvements in child survival in the past four decades, an estimated 6.3 million children under the age of five die each year, and more than 40% of these deaths occur in the neonatal period. Interventions to reduce neonatal mortality are needed. Kangaroo mother care (KMC) is one such life-saving intervention; however it has not yet been fully integrated into health systems around the world. Utilizing a conceptual framework for integration of targeted health interventions into health systems, we hypothesize that caregivers play a critical role in the adoption, diffusion, and assimilation of KMC. The objective of this research was to identify barriers and enablers of implementation and scale up of KMC from caregivers' perspective. We searched Pubmed, Embase, Web of Science, Scopus, and WHO regional databases using search terms 'kangaroo mother care' or 'kangaroo care' or 'skin to skin care'. Studies published between January 1, 1960 and August 19, 2015 were included. To be eligible, published work had to be based on primary data collection regarding barriers or enablers of KMC implementation from the family perspective. Abstracted data were linked to the conceptual framework using a deductive approach, and themes were identified within each of the five framework areas using Nvivo software. We identified a total of 2875 abstracts. After removing duplicates and ineligible studies, 98 were included in the analysis. The majority of publications were published within the past 5 years, had a sample size less than 50, and recruited participants from health facilities. Approximately one-third of the studies were conducted in the Americas, and 26.5% were conducted in Africa. We identified four themes surrounding the interaction between families and the KMC intervention: buy in and bonding (i.e. benefits of KMC to mothers and infants and perceptions of bonding between mother and infant), social support (i.e. assistance from other people to perform KMC), sufficient time to perform KMC, and medical concerns about mother or newborn health. Furthermore, we identified barriers and enablers of KMC adoption by caregivers within the context of the health system regarding financing and service delivery. Embedded within the broad social context, barriers to KMC adoption by caregivers included adherence to traditional newborn practices, stigma surrounding having a preterm infant, and gender roles regarding childcare. Efforts to scale up and integrate KMC into health systems must reduce barriers in order to promote the uptake of the intervention by caregivers.

Correlates of health care utilization under targeted interventions: The case of female sex workers in Andhra Pradesh, India.

PubMed

Sharma, Varun; Suryawanshi, Dipak; Saggurti, Niranjan; Bharat, Shalini

2017-11-01

Accessibility and frequency of use of health care services among female sex workers (FSWs) are constrained by various factors. In this analysis, we examined the correlates of frequency of using health care services under targeted interventions among FSWs. A sample of FSWs (N = 1,973) was obtained from a second round (2012) of Behavioral Tracking Survey, conducted in five districts of Andhra Pradesh, a high-HIV-prevalence state in southern India. We used negative binomial regression models to analyze frequency of utilization of health care services among FSWs. Based on our analysis, we suggest that various predisposing and enabling factors were found to be significantly associated with the visit to NGO clinics for treatment of any health problem, any sexually transmitted infection symptom, and the number of condoms received from the peer worker or condom depot. We suggest the need for further research with respect to various correlates of frequency of using health care among FSWs to develop effective intervention strategies in countries that have high HIV prevalence among FSWs and targeted interventions need more diligent implementation to reach the unreached.

Effectiveness of interventions to provide culturally appropriate maternity care in increasing uptake of skilled maternity care: a systematic review.

PubMed

Coast, Ernestina; Jones, Eleri; Lattof, Samantha R; Portela, Anayda

2016-12-01

Addressing cultural factors that affect uptake of skilled maternity care is recognized as an important step in improving maternal and newborn health. This article describes a systematic review to examine the evidence available on the effects of interventions to provide culturally appropriate maternity care on the use of skilled maternity care during pregnancy, for birth or in the postpartum period. Items published in English, French and/or Spanish between 1 January 1990 and 31 March 2014 were considered. Fifteen studies describing a range of interventions met the inclusion criteria. Data were extracted on population and intervention characteristics; study design; definitions and data for relevant outcomes; and the contexts and conditions in which interventions occurred. Because most of the included studies focus on antenatal care outcomes, evidence of impact is particularly limited for care seeking for birth and after birth. Evidence in this review is clustered within a small number of countries, and evidence from low- and middle-income countries is notably lacking. Interventions largely had positive effects on uptake of skilled maternity care. Cultural factors are often not the sole factor affecting populations' use of maternity care services. Broader social, economic, geographical and political factors interacted with cultural factors to affect targeted populations' access to services in included studies. Programmes and policies should seek to establish an enabling environment and support respectful dialogue with communities to improve use of skilled maternity care. Whilst issues of culture are being recognized by programmes and researchers as being important, interventions that explicitly incorporate issues of culture are rarely evaluated. © The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.

Applying Behavior Change Theories and Qualitative Methods in Substance Misuse Implementation Research: Conceptualizing the Adoption of Breaking Free Online in Real-World Clinical Practice.

PubMed

Dugdale, Stephanie; Elison, Sarah; Davies, Glyn; Ward, Jonathan

2017-06-01

There is insufficient research examining the implementation of complex novel interventions within health care. This may be due to a lack of qualitative research providing subjective insights into these implementation processes. The authors investigate the advantages of applying behavior change theories to conceptualize qualitative data describing the processes of implementation of complex interventions. Breaking Free Online (BFO), a digital treatment intervention for substance misuse, is described as an example of a complex intervention. The authors review previous qualitative research which explored initial diffusion, or spread, of the BFO program, and its subsequent normalization as part of standard treatment for substance misuse within the health and social care charity, "Change, Grow, Live" (CGL). The use of behavior change models to structure qualitative interview findings enabled identification of facilitators and barriers to the use of BFO within CGL. These findings have implications for the development of implementation research in novel health care interventions.

'Care for Stroke', a web-based, smartphone-enabled educational intervention for management of physical disabilities following stroke: feasibility in the Indian context.

PubMed

Sureshkumar, K; Murthy, G V S; Munuswamy, Suresh; Goenka, Shifalika; Kuper, Hannah

2015-07-01

Stroke rehabilitation is a process targeted towards restoration or maintenance of the physical, mental, intellectual and social abilities of an individual affected by stroke. Unlike high-income countries, the resources for stroke rehabilitation are very limited in many low-income and middle-income countries (LMICs). Provision of cost-effective, post-stroke multidisciplinary rehabilitation services for the stroke survivors therefore becomes crucial to address the unmet needs and growing magnitude of disability experienced by the stroke survivors in LMICs. In order to meet the growing need for post-stroke rehabilitation services in India, we developed a web-based Smartphone-enabled educational intervention for management of physical disabilities following a stroke. On the basis of the findings from the rehabilitation needs assessment study, guidance from the expert group and available evidence from systematic reviews, the framework of the intervention content was designed. Web-based application designing and development by Professional application developers were subsequently undertaken. The application is called 'Care for Stroke'. It is a web-based educational intervention for management of physical disabilities following a stroke. This intervention is developed for use by the Stroke survivors who have any kind of rehabilitation needs to independently participate in his/her family and social roles. 'Care for stroke' is an innovative intervention which could be tested not just for its feasibility and acceptability but also for its clinical and cost-effectiveness through rigorously designed, randomised clinical trials. It is very important to test this intervention in LMICs where the rehabilitation and information needs of the stroke survivors seem to be substantial and largely unmet.

Who needs collaborative care treatment? A qualitative study exploring attitudes towards and experiences with mental healthcare among general practitioners and care managers.

PubMed

Møller, Marlene Christina Rosengaard; Mygind, Anna; Bro, Flemming

2018-05-30

Collaborative care treatment is widely recognized as an effective approach to improve the quality of mental healthcare through enhanced and structured collaboration between general practice and specialized psychiatry. However, studies indicate that the complexity of collaborative care treatment interventions challenge the implementation in real-life general practice settings. Four Danish Collaborative Care Models were launched in 2014 for patients with mild/moderate anxiety and depression. These involved collaboration between general practitioners, care managers and consultant psychiatrists. Taking a multi-practice bottom-up approach, this paper aims to explore the perceived barriers and enablers related to collaborative care for patients with mental health problems and to investigate the actual experiences with a Danish collaborative care model in a single-case study in order to identify enablers and barriers for successful implementation. Combining interviews and observations of usual treatment practices, we conducted a multi-practice study among general practitioners who were not involved in the Danish collaborative care models to explore their perspectives on existing mental health treatment and to investigate (from a bottom-up approach) their perceptions of and need for collaborative care in mental health treatment. Additionally, by combining observations and qualitative interviews, we followed the implementation of a Danish collaborative care model in a single-case study to convey identified barriers and enablers of the collaborative care model. Experienced and perceived enablers of the Danish collaborative care model mainly consisted of a need for new treatment options to deal with mild/moderate anxiety and depression. The model was considered to meet the need for a free fast track to high-quality treatment. Experienced barriers included: poor adaptation of the model to the working conditions and needs in daily general practice, time consumption, unsustainable logistical set-up and unclear care manager role. General practitioners in the multi-practice study considered access to treatment and not collaboration with specialised psychiatry to be essential for this group of patients. The study calls for increased attention to implementation processes and better adaptation of collaborative care models to the clinical reality of general practice. Future interventions should address the treatment needs of specific patient populations and should involve relevant stakeholders in the design and implementation processes.

Innovation in sexually transmitted disease and HIV prevention: internet and mobile phone delivery vehicles for global diffusion.

PubMed

Swendeman, Dallas; Rotheram-Borus, Mary Jane

2010-03-01

Efficacious behavioral interventions and practices have not been universally accepted, adopted, or diffused by policy makers, administrators, providers, advocates, or consumers. Biomedical innovations for sexually transmitted disease (STD) and HIV prevention have been embraced but their effectiveness is hindered by behavioral factors. Behavioral interventions are required to support providers and consumers for adoption and diffusion of biomedical innovations, protocol adherence, and sustained prevention for other STDs. Information and communication technology such as the Internet and mobile phones can deliver behavioral components for STD/HIV prevention and care to more people at less cost. Recent innovations in STD/HIV prevention with information and communication technology-mediated behavioral supports include STD/HIV testing and partner interventions, behavioral interventions, self-management, and provider care. Computer-based and Internet-based behavioral STD/HIV interventions have demonstrated efficacy comparable to face-to-face interventions. Mobile phone STD/HIV interventions using text-messaging are being broadly utilized but more work is needed to demonstrate efficacy. Electronic health records and care management systems can improve care, but interventions are needed to support adoption. Information and communication technology is rapidly diffusing globally. Over the next 5-10 years smart-phones will be broadly disseminated, connecting billions of people to the Internet and enabling lower cost, highly engaging, and ubiquitous STD/HIV prevention and treatment support interventions.

Describing methods and interventions: a protocol for the systematic analysis of the perioperative quality improvement literature.

PubMed

Jones, Emma; Lees, Nicholas; Martin, Graham; Dixon-Woods, Mary

2014-09-05

Quality improvement (QI) methods are widely used in surgery in an effort to improve care, often using techniques such as Plan-Do-Study-Act cycles to implement specific interventions. Explicit definition of both the QI method and quality intervention is necessary to enable the accurate replication of effective interventions in practice, facilitate cumulative learning, reduce research waste and optimise benefits to patients. This systematic review aims to assess quality of reporting of QI methods and quality interventions in perioperative care. Studies reporting on quality interventions implemented in perioperative care settings will be identified. Searches will be conducted in the Ovid SP version of Medline, Scopus, the Cochrane Central Register of Controlled Trials, the Cochrane Effective Practice and Organisation of Care database and the related articles function of PubMed. The journal BMJ Quality will be searched separately. Search strategy terms will relate to (i) surgery, (ii) QI and (iii) evaluation methods. Explicit exclusion and inclusion criteria will be applied. Data from studies will be extracted using a data extraction form. The Template for Intervention Description and Replication (TIDieR) checklist will be used to evaluate quality of reporting, together with additional items aimed at assessing QI methods specifically. PROSPERO http://CRD42014012845.

Balancing health care education and patient care in the UK workplace: a realist synthesis.

PubMed

Sholl, Sarah; Ajjawi, Rola; Allbutt, Helen; Butler, Jane; Jindal-Snape, Divya; Morrison, Jill; Rees, Charlotte

2017-08-01

Patient care activity has recently increased without a proportionate rise in workforce numbers, impacting negatively on health care workplace learning. Health care professionals are prepared in part by spending time in clinical practice, and for medical staff this constitutes a contribution to service. Although stakeholders have identified the balance between health care professional education and patient care as a key priority for medical education research, there have been very few reviews to date on this important topic. We conducted a realist synthesis of the UK literature from 1998 to answer two research questions. (1) What are the key workplace interventions designed to help achieve a balance between health care professional education and patient care delivery? (2) In what ways do interventions enable or inhibit this balance within the health care workplace, for whom and in what contexts? We followed Pawson's five stages of realist review: clarifying scope, searching for evidence, assessment of quality, data extraction and data synthesis. The most common interventions identified for balancing health care professional education and patient care delivery were ward round teaching, protected learning time and continuous professional development. The most common positive outcomes were simultaneous improvements in learning and patient care or improved learning or improved patient care. The most common contexts in which interventions were effective were primary care, postgraduate trainee, nurse and allied health professional contexts. By far the most common mechanisms through which interventions worked were organisational funding, workload management and support. Our novel findings extend existing literature in this emerging area of health care education research. We provide recommendations for the development of educational policy and practice at the individual, interpersonal and organisational levels and call for more research using realist approaches to evaluate the increasing range of complex interventions to help balance health care professional education and patient care delivery. © 2017 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.

Using the collaborative intervention planning framework to adapt a health-care manager intervention to a new population and provider group to improve the health of people with serious mental illness.

PubMed

Cabassa, Leopoldo J; Gomes, Arminda P; Meyreles, Quisqueya; Capitelli, Lucia; Younge, Richard; Dragatsi, Dianna; Alvarez, Juana; Manrique, Yamira; Lewis-Fernández, Roberto

2014-11-30

Health-care manager interventions improve the physical health of people with serious mental illness (SMI) and could be widely implemented in public mental health clinics. Local adaptations and customization may be needed to increase the reach of these interventions in the public mental health system and across different racial and ethnic communities. In this study, we describe how we used the collaborative intervention planning framework to customize an existing health-care manager intervention to a new patient population (Hispanics with SMI) and provider group (social workers) to increase its fit with our local community. The study was conducted in partnership with a public mental health clinic that serves predominantly Hispanic clients. A community advisory board (CAB) composed of researchers and potential implementers (e.g., social workers, primary care physicians) used the collaborative intervention planning framework, an approach that combines community-based participatory research principles and intervention mapping (IM) procedures, to inform intervention adaptations. The adaptation process included four steps: fostering collaborations between CAB members; understanding the needs of the local population through a mixed-methods needs assessment, literature reviews, and group discussions; reviewing intervention objectives to identify targets for adaptation; and developing the adapted intervention. The application of this approach enabled the CAB to identify a series of cultural and provider level-adaptations without compromising the core elements of the original health-care manager intervention. Reducing health disparities in people with SMI requires community engagement, particularly when preparing existing interventions to be used with new communities, provider groups, and practice settings. Our study illustrates one approach that can be used to involve community stakeholders in the intervention adaptation process from the very beginning to enhance the transportability of a health-care manager intervention in order to improve the health of people with SMI.

Application of the Intervention Mapping protocol to develop Keys, a family child care home intervention to prevent early childhood obesity.

PubMed

Mann, Courtney M; Ward, Dianne S; Vaughn, Amber; Benjamin Neelon, Sara E; Long Vidal, Lenita J; Omar, Sakinah; Namenek Brouwer, Rebecca J; Østbye, Truls

2015-12-10

Many families rely on child care outside the home, making these settings important influences on child development. Nearly 1.5 million children in the U.S. spend time in family child care homes (FCCHs), where providers care for children in their own residences. There is some evidence that children in FCCHs are heavier than those cared for in centers. However, few interventions have targeted FCCHs for obesity prevention. This paper will describe the application of the Intervention Mapping (IM) framework to the development of a childhood obesity prevention intervention for FCCHs Following the IM protocol, six steps were completed in the planning and development of an intervention targeting FCCHs: needs assessment, formulation of change objectives matrices, selection of theory-based methods and strategies, creation of intervention components and materials, adoption and implementation planning, and evaluation planning Application of the IM process resulted in the creation of the Keys to Healthy Family Child Care Homes program (Keys), which includes three modules: Healthy You, Healthy Home, and Healthy Business. Delivery of each module includes a workshop, educational binder and tool-kit resources, and four coaching contacts. Social Cognitive Theory and Self-Determination Theory helped guide development of change objective matrices, selection of behavior change strategies, and identification of outcome measures. The Keys program is currently being evaluated through a cluster-randomized controlled trial The IM process, while time-consuming, enabled rigorous and systematic development of intervention components that are directly tied to behavior change theory and may increase the potential for behavior change within the FCCHs.

Construction and validation of forms: systematization of the care of people under hemodialysis.

PubMed

Arreguy-Sena, Cristina; Marques, Tais de Oliveira; Souza, Luciene Carnevale de; Alvarenga-Martins, Nathália; Krempser, Paula; Braga, Luciene Muniz; Parreira, Pedro Miguel Dos Santos Dinis

2018-01-01

create and validate forms to subsidize the systematization of nursing care with people on hemodialysis. institutional case study to support the systematization of assistance from the construction of forms for data collection, diagnoses, interventions and nursing results, using cross-mapping, Risner's reasoning, Neuman's theory, taxonomies of diagnoses, interventions and nursing results with application in clinical practice and validation by focal group with specialist nurses. 18 people on hemodialysis and 7 nurses participated. Consensus content of form matter with specialist nurses in the area (Crombach 0.86). The papers captured 43 diagnoses, 26 interventions and 78 nursing results depicting human responses in their singularities. the validated forms fill a gap by enabling the capture of human responses from people on hemodialysis and by subsidizing the planning of nursing care on a scientific basis.

Information and communication technology-enabled person-centered care for the "big five" chronic conditions: scoping review.

PubMed

Wildevuur, Sabine E; Simonse, Lianne W L

2015-03-27

Person-centered information and communication technology (ICT) could encourage patients to take an active part in their health care and decision-making process, and make it possible for patients to interact directly with health care providers and services about their personal health concerns. Yet, little is known about which ICT interventions dedicated to person-centered care (PCC) and connected-care interactions have been studied, especially for shared care management of chronic diseases. The aim of this research is to investigate the extent, range, and nature of these research activities and identify research gaps in the evidence base of health studies regarding the "big 5" chronic diseases: diabetes mellitus, cardiovascular disease, chronic respiratory disease, cancer, and stroke. The objective of this paper was to review the literature and to scope the field with respect to 2 questions: (1) which ICT interventions have been used to support patients and health care professionals in PCC management of the big 5 chronic diseases? and (2) what is the impact of these interventions, such as on health-related quality of life and cost efficiency? This research adopted a scoping review method. Three electronic medical databases were accessed: PubMed, EMBASE, and Cochrane Library. The research reviewed studies published between January 1989 and December 2013. In 5 stages of systematic scanning and reviewing, relevant studies were identified, selected, and charted. Then we collated, summarized, and reported the results. From the initial 9380 search results, we identified 350 studies that qualified for inclusion: diabetes mellitus (n=103), cardiovascular disease (n=89), chronic respiratory disease (n=73), cancer (n=67), and stroke (n=18). Persons with one of these chronic conditions used ICT primarily for self-measurement of the body, when interacting with health care providers, with the highest rates of use seen in chronic respiratory (63%, 46/73) and cardiovascular (53%, 47/89) diseases. We found 60 relevant studies (17.1%, 60/350) on person-centered shared management ICT, primarily using telemedicine systems as personalized ICT. The highest impact measured related to the increase in empowerment (15.4%, 54/350). Health-related quality of life accounted for 8%. The highest impact connected to health professionals was an increase in clinical outcome (11.7%, 41/350). The impacts on organization outcomes were decrease in hospitalization (12.3%, 43/350) and increase of cost efficiency (10.9%, 38/350). This scoping review outlined ICT-enabled PCC in chronic disease management. Persons with a chronic disease could benefit from an ICT-enabled PCC approach, but ICT-PCC also yields organizational paybacks. It could lead to an increase in health care usage, as reported in some studies. Few interventions could be regarded as "fully" addressing PCC. This review will be especially helpful to those deciding on areas where further development of research or implementation of ICT-enabled PCC may be warranted.

Information and Communication Technology–Enabled Person-Centered Care for the “Big Five” Chronic Conditions: Scoping Review

PubMed Central

Simonse, Lianne WL

2015-01-01

Background Person-centered information and communication technology (ICT) could encourage patients to take an active part in their health care and decision-making process, and make it possible for patients to interact directly with health care providers and services about their personal health concerns. Yet, little is known about which ICT interventions dedicated to person-centered care (PCC) and connected-care interactions have been studied, especially for shared care management of chronic diseases. The aim of this research is to investigate the extent, range, and nature of these research activities and identify research gaps in the evidence base of health studies regarding the “big 5” chronic diseases: diabetes mellitus, cardiovascular disease, chronic respiratory disease, cancer, and stroke. Objective The objective of this paper was to review the literature and to scope the field with respect to 2 questions: (1) which ICT interventions have been used to support patients and health care professionals in PCC management of the big 5 chronic diseases? and (2) what is the impact of these interventions, such as on health-related quality of life and cost efficiency? Methods This research adopted a scoping review method. Three electronic medical databases were accessed: PubMed, EMBASE, and Cochrane Library. The research reviewed studies published between January 1989 and December 2013. In 5 stages of systematic scanning and reviewing, relevant studies were identified, selected, and charted. Then we collated, summarized, and reported the results. Results From the initial 9380 search results, we identified 350 studies that qualified for inclusion: diabetes mellitus (n=103), cardiovascular disease (n=89), chronic respiratory disease (n=73), cancer (n=67), and stroke (n=18). Persons with one of these chronic conditions used ICT primarily for self-measurement of the body, when interacting with health care providers, with the highest rates of use seen in chronic respiratory (63%, 46/73) and cardiovascular (53%, 47/89) diseases. We found 60 relevant studies (17.1%, 60/350) on person-centered shared management ICT, primarily using telemedicine systems as personalized ICT. The highest impact measured related to the increase in empowerment (15.4%, 54/350). Health-related quality of life accounted for 8%. The highest impact connected to health professionals was an increase in clinical outcome (11.7%, 41/350). The impacts on organization outcomes were decrease in hospitalization (12.3%, 43/350) and increase of cost efficiency (10.9%, 38/350). Conclusions This scoping review outlined ICT-enabled PCC in chronic disease management. Persons with a chronic disease could benefit from an ICT-enabled PCC approach, but ICT-PCC also yields organizational paybacks. It could lead to an increase in health care usage, as reported in some studies. Few interventions could be regarded as “fully” addressing PCC. This review will be especially helpful to those deciding on areas where further development of research or implementation of ICT-enabled PCC may be warranted. PMID:25831199

Proactive and integrated primary care for frail older people: design and methodological challenges of the Utrecht primary care PROactive frailty intervention trial (U-PROFIT).

PubMed

Bleijenberg, Nienke; Drubbel, Irene; Ten Dam, Valerie H; Numans, Mattijs E; Schuurmans, Marieke J; de Wit, Niek J

2012-04-25

Currently, primary care for frail older people is reactive, time consuming and does not meet patients' needs. A transition is needed towards proactive and integrated care, so that daily functioning and a good quality of life can be preserved. To work towards these goals, two interventions were developed to enhance the care of frail older patients in general practice: a screening and monitoring intervention using routine healthcare data (U-PRIM) and a nurse-led multidisciplinary intervention program (U-CARE). The U-PROFIT trial was designed to evaluate the effectiveness of these interventions. The aim of this paper is to describe the U-PROFIT trial design and to discuss methodological issues and challenges. The effectiveness of U-PRIM and U-CARE is being tested in a three-armed, cluster randomized trial in 58 general practices in the Netherlands, with approximately 5000 elderly individuals expected to participate. The primary outcome is the effect on activities of daily living as measured with the Katz ADL index. Secondary outcomes are quality of life, mortality, nursing home admission, emergency department and out-of-hours General Practice (GP), surgery visits, and caregiver burden. In a large, pragmatic trial conducted in daily clinical practice with frail older patients, several challenges and methodological issues will occur. Recruitment and retention of patients and feasibility of the interventions are important issues. To enable broad generalizability of results, careful choices of the design and outcome measures are required. Taking this into account, the U-PROFIT trial aims to provide robust evidence for a structured and integrated approach to provide care for frail older people in primary care. NTR2288.

Evaluation of Knowledge Among Interns in a Medical College Regarding Palliative Care in People Living with HIV/AIDS and the Impact of a Structured Intervention

PubMed Central

Valsangkar, Sameer; Bodhare, Trupti N; Pande, Shripad B; Bele, Samir D; Rao, B Sitarama

2011-01-01

Background: The evolving nature of palliative care and its renewed role in people living with HIV/AIDS (PLWHA) in the post-HAART (highly active anti-retroviral therapy) era warrants an evaluation of the present curriculum in medical under graduates. Objectives: The objectives are(1) to measure the existing knowledge regarding palliative care and its application to PLWHA among medical interns and (2) to measure the impact of a structured intervention on knowledge dimensions. Design and Setting: Interventional repeated measures study. Materials and Methods: A convenience sample of 106 interns in the medical college completed a pre-test assessment and a post-test assessment following a structured intervention for evaluation and comparison of knowledge over three dimensions which were (1) knowledge of palliative care and its application in PLWHA, (2) medical symptoms in PLWHA requiring palliative care and (3) psychosocial needs in PLWHA requiring palliative care. Results: The mean scores on knowledge showed a consistent increase after the structured intervention and Student’s t-test was significant across three dimensions of knowledge of palliative care and its application (t=9.12, P value <0.001), medical symptoms in PLWHA requiring palliative care (t=12.72, P value <0.001) and psychosocial needs in PLWHA (t=11.14, P value <0.001). Conclusion: In spite of the unique challenges presented by the varying course of illness in PLWHA and the variety of needs on the medical, psychosocial and family dimensions, a structured approach and an integrated course curriculum involving principles of both primary and palliative care principles will improve the efficiency of the undergraduate medical education program and enable delivery of effective palliative care interventions and improve quality of life in PLWHA. PMID:21633615

Evaluation of Knowledge Among Interns in a Medical College Regarding Palliative Care in People Living with HIV/AIDS and the Impact of a Structured Intervention.

PubMed

Valsangkar, Sameer; Bodhare, Trupti N; Pande, Shripad B; Bele, Samir D; Rao, B Sitarama

2011-01-01

The evolving nature of palliative care and its renewed role in people living with HIV/AIDS (PLWHA) in the post-HAART (highly active anti-retroviral therapy) era warrants an evaluation of the present curriculum in medical under graduates. The objectives are(1) to measure the existing knowledge regarding palliative care and its application to PLWHA among medical interns and (2) to measure the impact of a structured intervention on knowledge dimensions. Interventional repeated measures study. A convenience sample of 106 interns in the medical college completed a pre-test assessment and a post-test assessment following a structured intervention for evaluation and comparison of knowledge over three dimensions which were (1) knowledge of palliative care and its application in PLWHA, (2) medical symptoms in PLWHA requiring palliative care and (3) psychosocial needs in PLWHA requiring palliative care. The mean scores on knowledge showed a consistent increase after the structured intervention and Student's t-test was significant across three dimensions of knowledge of palliative care and its application (t=9.12, P value <0.001), medical symptoms in PLWHA requiring palliative care (t=12.72, P value <0.001) and psychosocial needs in PLWHA (t=11.14, P value <0.001). In spite of the unique challenges presented by the varying course of illness in PLWHA and the variety of needs on the medical, psychosocial and family dimensions, a structured approach and an integrated course curriculum involving principles of both primary and palliative care principles will improve the efficiency of the undergraduate medical education program and enable delivery of effective palliative care interventions and improve quality of life in PLWHA.

Educational Intervention on Delirium Assessment Using Confusion Assessment Method-ICU (CAM-ICU) in a General Intensive Care Unit.

PubMed

Ramoo, Vimala; Abu, Harlinna; Rai, Vineya; Surat Singh, Surindar Kaur; Baharudin, Ayuni Asma'; Danaee, Mahmoud; Thinagaran, Raveena Rajalachimi R

2018-05-18

The primary objective was to assess intensive care unit nurses' knowledge of intensive care unit delirium and delirium assessment before and after an educational intervention. In addition, nurses' perception on the usefulness of a delirium assessment tool and barriers against delirium assessment were assessed as secondary objectives. Early identification of delirium in intensive care units is crucial for patient care. Hence, nurses require adequate knowledge to enable appropriate evaluation of delirium using standardised practice and assessment tools. This study, performed in Malaysia, used a single group pretest-posttest study design to assess the effect of educational interventions and hands-on practices on nurses' knowledge of intensive care unit delirium and delirium assessment. Sixty-one nurses participated in educational intervention sessions, including classroom learning, demonstrations, and hands-on practices on the Confusion Assessment Method-Intensive Care Unit. Data were collected using self-administered questionnaires for the pre- and post-intervention assessments. Analysis to determine the effect of the educational intervention consisted of the repeated-measures analysis of covariance. There were significant differences in the knowledge scores pre- and post-intervention, after controlling for demographic characteristics. The two most common perceived barriers to the adoption of the intensive care unit delirium assessment tool were "physicians did not use nurses' delirium assessment in decision making" and "difficult to interpret delirium in intubated patients". Educational intervention and hands-on practices increased nurses' knowledge of delirium assessment. Teaching and inter-professional involvements are essential for a successful implementation of intensive care unit delirium assessment practice. This study supports existing evidences, indicating that education and training could increase nurses' knowledge of delirium and delirium assessment. Improving nurses' knowledge could potentially lead to better delirium management practice and improve ICU patient care. Thus, continuous efforts to improve and sustain nurses' knowledge become relevant in ICU settings. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Fostering Child Development by Improving Care Quality: A Systematic Review of the Effectiveness of Structural Interventions and Caregiver Trainings in Institutional Care.

PubMed

Hermenau, Katharin; Goessmann, Katharina; Rygaard, Niels Peter; Landolt, Markus A; Hecker, Tobias

2017-12-01

Quality of child care has been shown to have a crucial impact on children's development and psychological adjustment, particularly for orphans with a history of maltreatment and trauma. However, adequate care for orphans is often impacted by unfavorable caregiver-child ratios and poorly trained, overburdened personnel, especially in institutional care in countries with limited resources and large numbers of orphans. This systematic review investigated the effects of structural interventions and caregiver trainings on child development in institutional environments. The 24 intervention studies included in this systematic review reported beneficial effects on the children's emotional, social, and cognitive development. Yet, few studies focused on effects of interventions on the child-caregiver relationship or the general institutional environment. Moreover, our review revealed that interventions aimed at improving institutional care settings have largely neglected violence and abuse prevention. Unfortunately, our findings are partially limited by constraints of study design and methodology. In sum, this systematic review sheds light on obstacles and possibilities for the improvement in institutional care. There must be greater efforts at preventing violence, abuse, and neglect of children living in institutional care. Therefore, we advocate for combining attachment theory-based models with maltreatment prevention approaches and then testing them using rigorous scientific standards. By using approaches grounded in the evidence, it could be possible to enable more children to grow up in supportive and nonviolent environments.

An organizing framework for informal caregiver interventions: detailing caregiving activities and caregiver and care recipient outcomes to optimize evaluation efforts

PubMed Central

2011-01-01

Background Caregiver interventions may help improve the quality of informal care. Yet the lack of a systematic framework specifying the targets and outcomes of caregiver interventions hampers our ability to understand what has been studied, to evaluate existing programs, and to inform the design of future programs. Our goal was to develop an organizing framework detailing the components of the caregiving activities and the caregiver and care recipient outcomes that should be affected by an intervention. In so doing, we characterize what has been measured in the published literature to date and what should be measured in future studies to enable comparisons across interventions and across time. Methods Our data set comprises 121 reports of caregiver interventions conducted in the United States and published between 2000 and 2009. We extracted information on variables that have been examined as primary and secondary outcomes. These variables were grouped into categories, which then informed the organizing framework. We calculated the frequency with which the interventions examined each framework component to identify areas about which we have the most knowledge and under-studied areas that deserve attention in future research. Results The framework stipulates that caregiver interventions seek to change caregiving activities, which in turn affect caregiver and care recipient outcomes. The most frequently assessed variables have been caregiver psychological outcomes (especially depression and burden) and care recipient physical and health care use outcomes. Conclusions Based on the organizing framework, we make three key recommendations to guide interventions and inform research and policy. First, all intervention studies should assess quality and/or quantity of caregiving activities to help understand to what extent and how well the intervention worked. Second, intervention studies should assess a broad range of caregiver and care recipient outcomes, including considering whether expanding to economic status and health care use of the caregiver can be accommodated, to ease subsequent economic evaluations of caregiving. Third, intervention studies should measure a common set of outcomes to facilitate cross-time and cross-study comparisons of effectiveness. PMID:22107600

Protocol of a Pilot Study of Technology-Enabled Coproduction in Pediatric Chronic Illness Care

PubMed Central

Thakkar, Sunny Narendra; Burns, Lisa; Chini, Barbara; Dykes, Dana MH; McPhail, Gary L; Moore, Erin; Saeed, Shehzad Ahmed; Eslick, Ian; Margolis, Peter A

2017-01-01

Background Pediatric chronic illness care models are traditionally organized around acute episodes of care and may not meet the needs of patients and their families. Interventions that extend the patient-clinician interaction beyond the health care visit, allow for asynchronous and bidirectional feedback loops that span visits and daily life, and facilitate seamless sharing of information are needed to support a care delivery system that is more collaborative, continuous, and data-driven. Orchestra is a mobile health technology platform and intervention designed to transform the management of chronic diseases by optimizing patient-clinician coproduction of care. Objective The aim of this study is to assess the feasibility, acceptability, and preliminary impact of the Orchestra technology and intervention in the context of pediatric chronic illness care. Methods This study will be conducted in the cystic fibrosis and inflammatory bowel disease clinics at Cincinnati Children’s Hospital Medical Center. We will enroll interested patients and their caregivers to work with clinicians to use the Orchestra technology platform and care model over a 6-month period. In parallel, we will use quality improvement methods to improve processes for integrating Orchestra into clinic workflows and patient/family lifestyles. We will use surveys, interviews, technology use data, and measures of clinical outcomes to assess the feasibility, acceptability, and preliminary impact of Orchestra. Outcome measures will include assessments of: (1) enrollment and dropout rates; (2) duration of engagement/sustained use; (3) symptom and patient-reported outcome tracker completion rates; (4) perceived impact on treatment plan, communication with the clinical team, visit preparation, and overall care; (5) changes in disease self-efficacy and engagement in care; and (6) clinical outcomes and health care utilization. Results Participant recruitment began in mid-2015, with results expected in 2017. Conclusions Chronic disease management needs a dramatic transformation to support more collaborative, effective, and patient-centered care. This study is unique in that it is testing not only the impact of technology, but also the necessary processes that facilitate patient and clinician collaboration. This pilot study is designed to examine how technology-enabled coproduction can be implemented in real-life clinical contexts. Once the Orchestra technology and intervention are optimized to ensure feasibility and acceptability, future studies can test the effectiveness of this approach to improve patient outcomes and health care value. PMID:28455274

Surgical data science: The new knowledge domain

PubMed Central

Vedula, S. Swaroop; Hager, Gregory D.

2017-01-01

Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care with the goal of maximizing quality and value of care. While innovations in diagnostic and therapeutic technologies have driven past improvements in quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytic techniques, and translation or integration of research findings into patient care. We foresee the emergence of Surgical/Interventional Data Science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model and quantify the pathways or processes within the context of patient health states or outcomes, and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data is pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care including prevention, diagnosis, intervention, or post-operative recovery. Existing literature already provides preliminary results suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from pre-, intra-, and post-operative contexts, how it could support intra-operative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future. PMID:28936475

Surgical data science: The new knowledge domain.

PubMed

Vedula, S Swaroop; Hager, Gregory D

2017-04-01

Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care with the goal of maximizing quality and value of care. While innovations in diagnostic and therapeutic technologies have driven past improvements in quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytic techniques, and translation or integration of research findings into patient care. We foresee the emergence of Surgical/Interventional Data Science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model and quantify the pathways or processes within the context of patient health states or outcomes, and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data is pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care including prevention, diagnosis, intervention, or post-operative recovery. Existing literature already provides preliminary results suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from pre-, intra-, and post-operative contexts, how it could support intra-operative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future.

Cost-benefit analysis of telehealth in pre-hospital care.

PubMed

Langabeer, James R; Champagne-Langabeer, Tiffany; Alqusairi, Diaa; Kim, Junghyun; Jackson, Adria; Persse, David; Gonzalez, Michael

2017-09-01

Objective There has been very little use of telehealth in pre-hospital emergency medical services (EMS), yet the potential exists for this technology to transform the current delivery model. In this study, we explore the costs and benefits of one large telehealth EMS initiative. Methods Using a case-control study design and both micro- and gross-costing data from the Houston Fire Department EMS electronic patient care record system, we conducted a cost-benefit analysis (CBA) comparing costs with potential savings associated with patients treated through a telehealth-enabled intervention. The intervention consisted of telehealth-based consultation between the 911 patient and an EMS physician, to evaluate and triage the necessity for patient transport to a hospital emergency department (ED). Patients with non-urgent, primary care-related conditions were then scheduled and transported by alternative means to an affiliated primary care clinic. We measured CBA as both total cost savings and cost per ED visit averted, in US Dollars ($USD). Results In total, 5570 patients were treated over the first full 12 months with a telehealth-enabled care model. We found a 6.7% absolute reduction in potentially medically unnecessary ED visits, and a 44-minute reduction in total ambulance back-in-service times. The average cost for a telehealth patient was $167, which was a statistically significantly $103 less than the control group ( p < .0001). The programme produced a $928,000 annual cost savings from the societal perspective, or $2468 cost savings per ED visit averted (benefit). Conclusion Patient care enabled by telehealth in a pre-hospital environment, is a more cost effective alternative compared to the traditional EMS 'treat and transport to ED' model.

[The organizational projects management led by head nurses: qualitative study from an educational device.

PubMed

Dujardin, Pierre-Philippe; Reverdy, Thomas; Valette, Annick; François, Patrice

2017-09-01

The work of operational coordination led by head nurses (HN) is more known than their abilities to change work organization, as well as, care practices. In this article, we explore organizational projects led by HN. Depending on the situations, they may concern their health care team or involve institutional hierarchy or other teams. We rely on an intervention study, which enabled us to follow 17 organizational projects led by HN for one year. The results of this study highlight as the main condition for success, the HN' efforts to enable mutual understanding with other interested actors. Managers, who engage their health care team in the development of solutions, bring sustainable results. When problems involve the hierarchy, the managers focus on the development of personal relationships. When problems involve other departments, which they depend on, then they engage themselves into integrative negotiations. These results invite to open discussion about work organization and to formalize organizational projects. This intervention study also points out that work - training at operational audit is relevant for HN. Activé par Editorial Manager® et ProduXion.

Supportive care in older adults with cancer - An update of research in 2015.

PubMed

Steer, Christopher B

2016-09-01

The motto of the Multinational Association for Supportive Care in Cancer (MASCC) is "supportive care makes excellent cancer care possible". This is especially important in the care of older adults with cancer. The use of geriatric assessment in this patient population enables targeted supportive care interventions to work alongside appropriate anticancer therapy. It is the opinion of this author that geriatric oncology is mostly about the provision of streamlined, appropriate supportive care. There are many facets of supportive care of patients with cancer that are important regardless of age. These include issues such as the use of appropriate antiemetics, infection management, oral health, nutritional intervention, psychosocial care, and palliative care. This article provides an update on novel yet important supportive care research specifically in older adults with cancer published in peer-reviewed journals in 2015. This year saw important publications in geriatric assessment, psychosocial care, in the information and supportive care needs of older adults and the role of pharmacists and rehabilitation specialists in the geriatric oncology clinic. Copyright © 2016 Elsevier Inc. All rights reserved.

Self-management of hypertension using technology enabled interventions in primary care settings.

PubMed

Chandak, Aastha; Joshi, Ashish

2015-01-01

Self-management of hypertension by controlling Blood Pressure (BP) through technology-based interventions can effectively reduce the burden of high BP, which affects one out of every three adults in the United States. The primary aim of this study is to explore the role of technology enabled interventions to improve or enhance self-management among individuals with hypertension. We conducted a systematic review of the literature published between July 2008 and June 2013 on the MEDLINE database (via PubMed interface) during July 2013. The search words were "hypertension" and "primary care" in combination with each of the terms of "technology", "internet", "computer" and "cell phone". Our inclusion criteria consisted of: (a) Randomized Controlled Trials (RCTs) (b) conducted on human subjects; (c) technology-based interventions (d) to improve self-management (e) of hypertension and if the (f) final results of the study were published in the study. Our exclusion criteria included (a) management of other conditions and (b) literature reviews. The initial search resulted in 108 results. After applying the inclusion and exclusion criteria, a total of 12 studies were analyzed. Various technologies implemented in the studies included internet-based telemonitoring and education, telephone-based telemonitoring and education, internet-based education, telemedicine via videoconferencing, telehealth kiosks and automated modem device. Some studies also involved a physician intervention, in addition to patient intervention. The outcomes of proportion of subjects with BP control and change in mean SBP and DBP were better for the group of subjects who received combined physician and patient interventions. Interventions to improve BP control for self-management of hypertension should be aimed at both physicians as well as the patients. More interventions should utilize the JNC-7 guidelines and cost-effectiveness of the intervention should also be assessed.

Toward Improving Quality of End-of-Life Care: Encoding Clinical Guidelines and Standing Orders Using the Omaha System.

PubMed

Slipka, Allison F; Monsen, Karen A

2018-02-01

End-of-life care (EOLC) relieves the suffering of millions of people around the globe each year. A growing body of hospice care research has led to the creation of several evidence-based clinical guidelines for EOLC. As evidence for the effectiveness of timely EOLC swells, so does the increased need for efficient information exchange between disciplines and across the care continuum. The purpose of this study was to investigate the feasibility of using the Omaha System as a framework for encoding interoperable evidence-based EOL interventions with specified temporality for use across disciplines and settings. Four evidence-based clinical guidelines and one current set of hospice standing orders were encoded using the Omaha System Problem Classification Scheme and Intervention Scheme, as well as Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT). The resulting encoded guideline was entered on a Microsoft Excel spreadsheet and made available for public use on the Omaha System Guidelines website. The resulting EOLC guideline consisted of 153 interventions that may enable patients and their surrogates, clinicians, and ancillary providers to communicate interventions in a universally comprehensible way. Evidence-based interventions from diverse disciplines involved in EOLC are described within this guideline using the Omaha System. Because the Omaha System and clinical guidelines are maintained in the public domain, encoding interventions is achievable by anyone with access to the Internet and basic Excel skills. Using the guideline as a documentation template customized for unique patient needs, clinicians can quantify and track patient care across the care continuum to ensure timely evidence-based interventions. Clinical guidelines coded in the Omaha System can support the use of multidisciplinary evidence-based interventions to improve quality of EOLC across settings and professions. © 2017 Sigma Theta Tau International.

Process evaluation of a cluster-randomised trial testing a pressure ulcer prevention care bundle: a mixed-methods study.

PubMed

Roberts, Shelley; McInnes, Elizabeth; Bucknall, Tracey; Wallis, Marianne; Banks, Merrilyn; Chaboyer, Wendy

2017-02-13

As pressure ulcers contribute to significant patient burden and increased health care costs, their prevention is a clinical priority. Our team developed and tested a complex intervention, a pressure ulcer prevention care bundle promoting patient participation in care, in a cluster-randomised trial. The UK Medical Research Council recommends process evaluation of complex interventions to provide insight into why they work or fail and how they might be improved. This study aimed to evaluate processes underpinning implementation of the intervention and explore end-users' perceptions of it, in order to give a deeper understanding of its effects. A pre-specified, mixed-methods process evaluation was conducted as an adjunct to the main trial, guided by a framework for process evaluation of cluster-randomised trials. Data was collected across eight Australian hospitals but mainly focused on the four intervention hospitals. Quantitative and qualitative data were collected across the evaluation domains: recruitment, reach, intervention delivery and response to intervention, at both cluster and individual patient level. Quantitative data were analysed using descriptive and inferential statistics. Qualitative data were analysed using thematic analysis. In the context of the main trial, which found a 42% reduction in risk of pressure ulcer with the intervention that was not significant after adjusting for clustering and covariates, this process evaluation provides important insights. Recruitment and reach among clusters and individuals was high, indicating that patients, nurses and hospitals are willing to engage with a pressure ulcer prevention care bundle. Of 799 intervention patients in the trial, 96.7% received the intervention, which took under 10 min to deliver. Patients and nurses accepted the care bundle, recognising benefits to it and describing how it enabled participation in pressure ulcer prevention (PUP) care. This process evaluation found no major failures relating to implementation of the intervention. The care bundle was found to be easy to understand and deliver, and it reached a large proportion of the target population and was found to be acceptable to patients and nurses; therefore, it may be an effective way of engaging patients in their pressure ulcer prevention care and promoting evidence-based practise.

The role of conversation in health care interventions: enabling sensemaking and learning.

PubMed

Jordan, Michelle E; Lanham, Holly J; Crabtree, Benjamin F; Nutting, Paul A; Miller, William L; Stange, Kurt C; McDaniel, Reuben R

2009-03-13

Those attempting to implement changes in health care settings often find that intervention efforts do not progress as expected. Unexpected outcomes are often attributed to variation and/or error in implementation processes. We argue that some unanticipated variation in intervention outcomes arises because unexpected conversations emerge during intervention attempts. The purpose of this paper is to discuss the role of conversation in shaping interventions and to explain why conversation is important in intervention efforts in health care organizations. We draw on literature from sociolinguistics and complex adaptive systems theory to create an interpretive framework and develop our theory. We use insights from a fourteen-year program of research, including both descriptive and intervention studies undertaken to understand and assist primary care practices in making sustainable changes. We enfold these literatures and these insights to articulate a common failure of overlooking the role of conversation in intervention success, and to develop a theoretical argument for the importance of paying attention to the role of conversation in health care interventions. Conversation between organizational members plays an important role in the success of interventions aimed at improving health care delivery. Conversation can facilitate intervention success because interventions often rely on new sensemaking and learning, and these are accomplished through conversation. Conversely, conversation can block the success of an intervention by inhibiting sensemaking and learning. Furthermore, the existing relationship contexts of an organization can influence these conversational possibilities. We argue that the likelihood of intervention success will increase if the role of conversation is considered in the intervention process. The generation of productive conversation should be considered as one of the foundations of intervention efforts. We suggest that intervention facilitators consider the following actions as strategies for reducing the barriers that conversation can present and for using conversation to leverage improvement change: evaluate existing conversation and relationship systems, look for and leverage unexpected conversation, create time and space where conversation can unfold, use conversation to help people manage uncertainty, use conversation to help reorganize relationships, and build social interaction competence.

The role of conversation in health care interventions: enabling sensemaking and learning

PubMed Central

Jordan, Michelle E; Lanham, Holly J; Crabtree, Benjamin F; Nutting, Paul A; Miller, William L; Stange, Kurt C; McDaniel, Reuben R

2009-01-01

Background Those attempting to implement changes in health care settings often find that intervention efforts do not progress as expected. Unexpected outcomes are often attributed to variation and/or error in implementation processes. We argue that some unanticipated variation in intervention outcomes arises because unexpected conversations emerge during intervention attempts. The purpose of this paper is to discuss the role of conversation in shaping interventions and to explain why conversation is important in intervention efforts in health care organizations. We draw on literature from sociolinguistics and complex adaptive systems theory to create an interpretive framework and develop our theory. We use insights from a fourteen-year program of research, including both descriptive and intervention studies undertaken to understand and assist primary care practices in making sustainable changes. We enfold these literatures and these insights to articulate a common failure of overlooking the role of conversation in intervention success, and to develop a theoretical argument for the importance of paying attention to the role of conversation in health care interventions. Discussion Conversation between organizational members plays an important role in the success of interventions aimed at improving health care delivery. Conversation can facilitate intervention success because interventions often rely on new sensemaking and learning, and these are accomplished through conversation. Conversely, conversation can block the success of an intervention by inhibiting sensemaking and learning. Furthermore, the existing relationship contexts of an organization can influence these conversational possibilities. We argue that the likelihood of intervention success will increase if the role of conversation is considered in the intervention process. Summary The generation of productive conversation should be considered as one of the foundations of intervention efforts. We suggest that intervention facilitators consider the following actions as strategies for reducing the barriers that conversation can present and for using conversation to leverage improvement change: evaluate existing conversation and relationship systems, look for and leverage unexpected conversation, create time and space where conversation can unfold, use conversation to help people manage uncertainty, use conversation to help reorganize relationships, and build social interaction competence. PMID:19284660

Health information technology adoption: Understanding research protocols and outcome measurements for IT interventions in health care.

PubMed

Colicchio, Tiago K; Facelli, Julio C; Del Fiol, Guilherme; Scammon, Debra L; Bowes, Watson A; Narus, Scott P

2016-10-01

To classify and characterize the variables commonly used to measure the impact of Information Technology (IT) adoption in health care, as well as settings and IT interventions tested, and to guide future research. We conducted a descriptive study screening a sample of 236 studies from a previous systematic review to identify outcome measures used and the availability of data to calculate these measures. We also developed a taxonomy of commonly used measures and explored setting characteristics and IT interventions. Clinical decision support is the most common intervention tested, primarily in non-hospital-based clinics and large academic hospitals. We identified 15 taxa representing the 79 most commonly used measures. Quality of care was the most common category of these measurements with 62 instances, followed by productivity (11 instances) and patient safety (6 instances). Measures used varied according to type of setting, IT intervention and targeted population. This study provides an inventory and a taxonomy of commonly used measures that will help researchers select measures in future studies as well as identify gaps in their measurement approaches. The classification of the other protocol components such as settings and interventions will also help researchers identify underexplored areas of research on the impact of IT interventions in health care. A more robust and standardized measurement system and more detailed descriptions of interventions and settings are necessary to enable comparison between studies and a better understanding of the impact of IT adoption in health care settings. Copyright © 2016 Elsevier Inc. All rights reserved.

Barriers and enablers to implementing clinical treatment protocols for fever, hyperglycaemia, and swallowing dysfunction in the Quality in Acute Stroke Care (QASC) Project--a mixed methods study.

PubMed

Dale, Simeon; Levi, Christopher; Ward, Jeanette; Grimshaw, Jeremy M; Jammali-Blasi, Asmara; D'Este, Catherine; Griffiths, Rhonda; Quinn, Clare; Evans, Malcolm; Cadilhac, Dominique; Cheung, N Wah; Middleton, Sandy

2015-02-01

The Quality in Acute Stroke Care (QASC) trial evaluated systematic implementation of clinical treatment protocols to manage fever, sugar, and swallow (FeSS protocols) in acute stroke care. This cluster-randomised controlled trial was conducted in 19 stroke units in Australia. To describe perceived barriers and enablers preimplementation to the introduction of the FeSS protocols and, postimplementation, to determine which of these barriers eventuated as actual barriers. Preimplementation: Workshops were held at the intervention stroke units (n = 10). The first workshop involved senior clinicians who identified perceived barriers and enablers to implementation of the protocols, the second workshop involved bedside clinicians. Postimplementation, an online survey with stroke champions from intervention sites was conducted. A total of 111 clinicians attended the preimplementation workshops, identifying 22 barriers covering four main themes: (a) need for new policies, (b) limited workforce (capacity), (c) lack of equipment, and (d) education and logistics of training staff. Preimplementation enablers identified were: support by clinical champions, medical staff, nursing management and allied health staff; easy adaptation of current protocols, care-plans, and local policies; and presence of specialist stroke unit staff. Postimplementation, only five of the 22 barriers identified preimplementation were reported as actual barriers to adoption of the FeSS protocols, namely, no previous use of insulin infusions; hyperglycaemic protocols could not be commenced without written orders; medical staff reluctance to use the ASSIST swallowing screening tool; poor level of engagement of medical staff; and doctors' unawareness of the trial. The process of identifying barriers and enablers preimplementation allowed staff to take ownership and to address barriers and plan for change. As only five of the 22 barriers identified preimplementation were reported to be actual barriers at completion of the trial, this suggests that barriers are often overcome whilst some are only ever perceived rather than actual barriers. © 2015 Sigma Theta Tau International.

Optimising self-care support for people with heart failure and their caregivers: development of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention using intervention mapping.

PubMed

Greaves, Colin J; Wingham, Jennifer; Deighan, Carolyn; Doherty, Patrick; Elliott, Jennifer; Armitage, Wendy; Clark, Michelle; Austin, Jackie; Abraham, Charles; Frost, Julia; Singh, Sally; Jolly, Kate; Paul, Kevin; Taylor, Louise; Buckingham, Sarah; Davis, Russell; Dalal, Hasnain; Taylor, Rod S

2016-01-01

We aimed to establish the support needs of people with heart failure and their caregivers and develop an intervention to improve their health-related quality of life. We used intervention mapping to guide the development of our intervention. We identified "targets for change" by synthesising research evidence and international guidelines and consulting with patients, caregivers and health service providers. We then used behaviour change theory, expert opinion and a taxonomy of behaviour change techniques, to identify barriers to and facilitators of change and to match intervention strategies to each target. A patient and public involvement group helped to identify patient and caregiver needs, refine the intervention objectives and strategies and deliver training to the intervention facilitators. A feasibility study (ISRCTN25032672) involving 23 patients, 12 caregivers and seven trained facilitators at four sites assessed the feasibility and acceptability of the intervention and quality of delivery and generated ideas to help refine the intervention. The Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention is a comprehensive self-care support programme comprising the "Heart Failure Manual", a choice of two exercise programmes for patients, a "Family and Friends Resource" for caregivers, a "Progress Tracker" tool and a facilitator training course. The main targets for change are engaging in exercise training, monitoring for symptom deterioration, managing stress and anxiety, managing medications and understanding heart failure. Secondary targets include managing low mood and smoking cessation. The intervention is facilitated by trained healthcare professionals with specialist cardiac experience over 12 weeks, via home and telephone contacts. The feasibility study found high levels of satisfaction and engagement with the intervention from facilitators, patients and caregivers. Intervention fidelity analysis and stakeholder feedback suggested that there was room for improvement in several areas, especially in terms of addressing caregivers' needs. The REACH-HF materials were revised accordingly. We have developed a comprehensive, evidence-informed, theoretically driven self-care and rehabilitation intervention that is grounded in the needs of patients and caregivers. A randomised controlled trial is underway to assess the effectiveness and cost-effectiveness of the REACH-HF intervention in people with heart failure and their caregivers.

Welfare-to-Work Programs in America, 1980 to 2005: Meta-Analytic Evidence of the Importance of Job and Child Care Availability

PubMed Central

GOREY, KEVIN M.

2016-01-01

This meta-analysis extended a Campbell Collaboration review of welfare-to-work programs. Its synthesis of 65 randomized trials in America over the past generation replicated a small overall intervention effect. Moreover, it found (1) there was no long-term employment effect of interventions in areas where jobs were relatively unavailable, and (2) programs that provided child care were more effective than those that did not in the short and long term, even in areas of high labor market withdrawal. The availability of jobs as well as such supports as child care that enable their access seem to be key elements of welfare-to-work programs that work. PMID:27932938

Implementing a Trauma-Informed Model of Care in a Community Acute Mental Health Team.

PubMed

Moloney, Bill; Cameron, Ian; Baker, Ashley; Feeney, Johanna; Korner, Anthony; Kornhaber, Rachel; Cleary, Michelle; McLean, Loyola

2018-04-12

In this paper, we demonstrate the value of implementing a Trauma-Informed Model of Care in a Community Acute Mental Health Team by providing brief intensive treatment (comprising risk interventions, brief counselling, collaborative formulation and pharmacological treatment). The team utilised the Conversational Model (CM), a psychotherapeutic approach for complex trauma. Key features of the CM are described in this paper using a clinical case study. The addition of the Conversational Model approach to practice has enabled better understandings of consumers' capacities and ways to then engage, converse, and intervene. The implementation of this intervention has led to a greater sense of self-efficacy amongst clinicians, who can now articulate a clear counselling model of care.

Key enablers to facilitate healthy behavior change: workshop summary.

PubMed

Teyhen, Deydre S; Aldag, Matt; Centola, Damon; Edinborough, Elton; Ghannadian, Jason D; Haught, Andrea; Jackson, Theresa; Kinn, Julie; Kunkler, Kevin J; Levine, Betty; Martindale, Valerie E; Neal, David; Snyder, Leslie B; Styn, Mindi A; Thorndike, Frances; Trabosh, Valerie; Parramore, David J

2014-05-01

The increases in preventable chronic diseases and the rising costs of health care are unsustainable. The US Army Surgeon General's vision to transition from a health care system to a system of health requires the identification of key health enablers to facilitate the adoption of healthy behaviors. In support of this vision, the US Army Telemedicine and Advanced Technology Research Center hosted a workshop in April 2013 titled "Incentives to Create and Sustain Change for Health." Members of government and academia participated to identify key health enablers that could ultimately be leveraged by technology. The key health enablers discussed included (1) public health messaging, (2) changing health habits and the environmental influence on health, (3) goal setting and tracking, (4) the role of incentives in behavior-change intervention, and (5) the role of peer and social networks on change. This report summarizes leading evidence and the group consensus on evidence-based practices with respect to the key enablers in creating healthy behavior change.

Advance Care Planning: is quality end of life care really that simple?

PubMed

Johnson, Stephanie; Kerridge, Ian; Butow, Phyllis N; Tattersall, Martin H N

2017-04-01

The routine implementation of Advance Care Planning (ACP) is now a prominent feature of policy directed at improving end of life care in Australia. However, while complex ACP interventions may modestly reduce medical care at the end of life and enable more people to die at home or outside of acute hospital settings, existing legal, organisational, cultural and conceptual barriers limit the implementation and utility of ACP. We suggest that meaningful improvements in end of life care will not result from the institutionalisation of ACP but from more significant changes to the design and delivery of care. © 2017 Royal Australasian College of Physicians.

Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT): protocol for a general practice-based cluster randomised trial.

PubMed

Spanou, Clio; Simpson, Sharon A; Hood, Kerry; Edwards, Adrian; Cohen, David; Rollnick, Stephen; Carter, Ben; McCambridge, Jim; Moore, Laurence; Randell, Elizabeth; Pickles, Timothy; Smith, Christine; Lane, Claire; Wood, Fiona; Thornton, Hazel; Butler, Chris C

2010-09-21

Smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are the key modifiable factors contributing to premature morbidity and mortality in the developed world. Brief interventions in health care consultations can be effective in changing single health behaviours. General Practice holds considerable potential for primary prevention through modifying patients' multiple risk behaviours, but feasible, acceptable and effective interventions are poorly developed, and uptake by practitioners is low. Through a process of theoretical development, modeling and exploratory trials, we have developed an intervention called Behaviour Change Counselling (BCC) derived from Motivational Interviewing (MI). This paper describes the protocol for an evaluation of a training intervention (the Talking Lifestyles Programme) which will enable practitioners to routinely use BCC during consultations for the above four risk behaviours. This cluster randomised controlled efficacy trial (RCT) will evaluate the outcomes and costs of this training intervention for General Practitioners (GPs) and nurses. Training methods will include: a practice-based seminar, online self-directed learning, and reflecting on video recorded and simulated consultations. The intervention will be evaluated in 29 practices in Wales, UK; two clinicians will take part (one GP and one nurse) from each practice. In intervention practices both clinicians will receive training. The aim is to recruit 2000 patients into the study with an expected 30% drop out. The primary outcome will be the proportion of patients making changes in one or more of the four behaviours at three months. Results will be compared for patients seeing clinicians trained in BCC with patients seeing non-BCC trained clinicians. Economic and process evaluations will also be conducted. Opportunistic engagement by health professionals potentially represents a cost effective medical intervention. This study integrates an existing, innovative intervention method with an innovative training model to enable clinicians to routinely use BCC, providing them with new tools to encourage and support people to make healthier choices. This trial will evaluate effectiveness in primary care and determine costs of the intervention.

Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT): protocol for a general practice-based cluster randomised trial

PubMed Central

2010-01-01

Background Smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are the key modifiable factors contributing to premature morbidity and mortality in the developed world. Brief interventions in health care consultations can be effective in changing single health behaviours. General Practice holds considerable potential for primary prevention through modifying patients' multiple risk behaviours, but feasible, acceptable and effective interventions are poorly developed, and uptake by practitioners is low. Through a process of theoretical development, modeling and exploratory trials, we have developed an intervention called Behaviour Change Counselling (BCC) derived from Motivational Interviewing (MI). This paper describes the protocol for an evaluation of a training intervention (the Talking Lifestyles Programme) which will enable practitioners to routinely use BCC during consultations for the above four risk behaviours. Methods/Design This cluster randomised controlled efficacy trial (RCT) will evaluate the outcomes and costs of this training intervention for General Practitioners (GPs) and nurses. Training methods will include: a practice-based seminar, online self-directed learning, and reflecting on video recorded and simulated consultations. The intervention will be evaluated in 29 practices in Wales, UK; two clinicians will take part (one GP and one nurse) from each practice. In intervention practices both clinicians will receive training. The aim is to recruit 2000 patients into the study with an expected 30% drop out. The primary outcome will be the proportion of patients making changes in one or more of the four behaviours at three months. Results will be compared for patients seeing clinicians trained in BCC with patients seeing non-BCC trained clinicians. Economic and process evaluations will also be conducted. Discussion Opportunistic engagement by health professionals potentially represents a cost effective medical intervention. This study integrates an existing, innovative intervention method with an innovative training model to enable clinicians to routinely use BCC, providing them with new tools to encourage and support people to make healthier choices. This trial will evaluate effectiveness in primary care and determine costs of the intervention. Trial Registration ISRCTN22495456 PMID:20858273

A Pilot Randomized Controlled Trial of a Holistic Needs Assessment Questionnaire in a Supportive and Palliative Care Service.

PubMed

Ahmed, Nisar; Hughes, Philippa; Winslow, Michelle; Bath, Peter A; Collins, Karen; Noble, Bill

2015-11-01

At present, there is no widely used systematic evidence-based holistic approach to assessment of patients' supportive and palliative care needs. To determine whether the use of a holistic needs assessment questionnaire, Sheffield Profile for Assessment and Referral for Care (SPARC), will lead to improved health care outcomes for patients referred to a palliative care service. This was an open, pragmatic, randomized controlled trial. Patients (n = 182) referred to the palliative care service were randomized to receive SPARC at baseline (n = 87) or after a period of two weeks (waiting-list control n = 95). Primary outcome measure is the difference in score between Measure Yourself Concerns and Wellbeing (MYCAW) patient-nominated Concern 1 on the patient self-scoring visual analogue scale at baseline and the two-week follow-up. Secondary outcomes include difference in scores in the MYCAW, EuroQoL (EQ-5D), and Patient Enablement Instrument (PEI) scores at Weeks 2, 4, and 6. There was a significant association between change in MYCAW score and whether the patients were in the intervention or control group (χ(2)trend = 5.51; degrees of freedom = 1; P = 0.019). A higher proportion of patients in the control group had an improvement in MYCAW score from baseline to Week 2: control (34 of 70 [48.6%]) vs. intervention (19 of 66 [28.8%]). There were no significant differences (no detectable effect) between the control and intervention groups in the scores for EQ-5D and Patient Enablement Instrument at 2-, 4-, or 6-week follow-up. This trial result identifies a potential negative effect of SPARC in specialist palliative care services, raising questions that standardized holistic needs assessment questionnaires may be counterproductive if not integrated with a clinical assessment that informs the care plan. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

Rehabilitation Enablement in Chronic Heart Failure-a facilitated self-care rehabilitation intervention in patients with heart failure with preserved ejection fraction (REACH-HFpEF) and their caregivers: rationale and protocol for a single-centre pilot randomised controlled trial.

PubMed

Eyre, V; Lang, C C; Smith, K; Jolly, K; Davis, R; Hayward, C; Wingham, J; Abraham, C; Green, C; Warren, F C; Britten, N; Greaves, C J; Doherty, P; Austin, J; Van Lingen, R; Singh, S; Buckingham, S; Paul, K; Taylor, R S; Dalal, H M

2016-10-25

The Rehabilitation EnAblement in CHronic Heart Failure in patients with Heart Failure (HF) with preserved ejection fraction (REACH-HFpEF) pilot trial is part of a research programme designed to develop and evaluate a facilitated, home-based, self-help rehabilitation intervention to improve self-care and quality of life (QoL) in heart failure patients and their caregivers. We will assess the feasibility of a definitive trial of the REACH-HF intervention in patients with HFpEF and their caregivers. The impact of the REACH-HF intervention on echocardiographic outcomes and bloodborne biomarkers will also be assessed. A single-centre parallel two-group randomised controlled trial (RCT) with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention) or usual care alone (control) in 50 HFpEF patients and their caregivers. The REACH-HF intervention comprises a REACH-HF manual with supplementary tools, delivered by trained facilitators over 12 weeks. A mixed methods approach will be used to assess estimation of recruitment and retention rates; fidelity of REACH-HF manual delivery; identification of barriers to participation and adherence to the intervention and study protocol; feasibility of data collection and outcome burden. We will assess the variance in study outcomes to inform a definitive study sample size and assess methods for the collection of resource use and intervention delivery cost data to develop the cost-effectiveness analyses framework for any future trial. Patient outcomes collected at baseline, 4 and 6 months include QoL, psychological well-being, exercise capacity, physical activity and HF-related hospitalisation. Caregiver outcomes will also be assessed, and a substudy will evaluate impact of the REACH-HF manual on resting global cardiovascular function and bloodborne biomarkers in HFpEF patients. The study is approved by the East of Scotland Research Ethics Service (Ref: 15/ES/0036). Findings will be disseminated via journals and presentations to clinicians, commissioners and service users. ISRCTN78539530; Pre-results . Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

A Systematic Review of Reviews Evaluating Technology-Enabled Diabetes Self-Management Education and Support.

PubMed

Greenwood, Deborah A; Gee, Perry M; Fatkin, Kathy J; Peeples, Malinda

2017-09-01

Since the introduction of mobile phones, technology has been increasingly used to enable diabetes self-management education and support. This timely systematic review summarizes how currently available technology impacts outcomes for people living with diabetes. A systematic review of high quality review articles and meta analyses focused on utilizing technology in diabetes self-management education and support services was conducted. Articles were included if published between January 2013 and January 2017. Twenty-five studies were included for analysis. The majority evaluated the use of mobile phones and secure messaging. Most studies described healthy eating, being active and metabolic monitoring as the predominant self-care behaviors evaluated. Eighteen of 25 reviews reported significant reduction in A1c as an outcome measure. Four key elements emerged as essential for improved A1c: (1) communication, (2) patient-generated health data, (3) education, and (4) feedback. Technology-enabled diabetes self-management solutions significantly improve A1c. The most effective interventions incorporated all the components of a technology-enabled self-management feedback loop that connected people with diabetes and their health care team using 2-way communication, analyzed patient-generated health data, tailored education, and individualized feedback. The evidence from this systematic review indicates that organizations, policy makers and payers should consider integrating these solutions in the design of diabetes self-management education and support services for population health and value-based care models. With the widespread adoption of mobile phones, digital health solutions that incorporate evidence-based, behaviorally designed interventions can improve the reach and access to diabetes self-management education and ongoing support.

Development of theory-based knowledge translation interventions to facilitate the implementation of evidence-based guidelines on the early management of adults with traumatic spinal cord injury.

PubMed

Bérubé, Mélanie; Albert, Martin; Chauny, Jean-Marc; Contandriopoulos, Damien; DuSablon, Anne; Lacroix, Sébastien; Gagné, Annick; Laflamme, Élise; Boutin, Nathalie; Delisle, Stéphane; Pauzé, Anne-Marie; MacThiong, Jean-Marc

2015-12-01

Optimal, early management following a spinal cord injury (SCI) can limit individuals' disabilities and costs related to their care. Several knowledge syntheses were recently published to guide health care professionals with regard to early interventions in SCI patients. However, no knowledge translation (KT) intervention, selected according to a behaviour change theory, has been proposed to facilitate the use of SCI guidelines in an acute care setting. To develop theory-informed KT interventions to promote the application of evidence-based recommendations on the acute care management of SCI patients. The first four phases of the knowledge-to-action model were used to establish the study design. Knowledge selection was based on the Grading of Recommendations Assessment, Development and Evaluation system. Knowledge adaptation to the local context was sourced from the ADAPTE process. The theoretical domains framework oriented the selection and development of the interventions based on an assessment of barriers and enablers to knowledge application. Twenty-nine recommendations were chosen and operationalized in measurable clinical indicators. Barriers related to knowledge, skills, perceived capacities, beliefs about consequences, social influences, and the environmental context and resources theoretical domains were identified. The mapping of behaviour change techniques associated with those barriers led to the development of an online educational curriculum, interdisciplinary clinical pathways as well as policies and procedures. This research project allowed us developing KT interventions according to a thorough behavioural change methodology. Exposure to the generated interventions will support health care professionals in providing the best care to SCI patients. © 2015 John Wiley & Sons, Ltd.

Telemedicine in diabetes foot care delivery: health care professionals' experience.

PubMed

Kolltveit, Beate-Christin Hope; Gjengedal, Eva; Graue, Marit; Iversen, Marjolein M; Thorne, Sally; Kirkevold, Marit

2016-04-18

Introducing new technology in health care is inevitably a challenge. More knowledge is needed to better plan future telemedicine interventions. Our aim was therefore to explore health care professionals' experience in the initial phase of introducing telemedicine technology in caring for people with diabetic foot ulcers. Our methodological strategy was Interpretive Description. Data were collected between 2014 and 2015 using focus groups (n = 10). Participants from home-based care, primary care and outpatient hospital clinics were recruited from the intervention arm of an ongoing cluster randomized controlled trial (RCT) (Clinicaltrials.gov: NCT01710774). Most were nurses (n = 29), but the sample also included one nurse assistant, podiatrists (n = 2) and physicians (n = 2). The participants reported experiencing meaningful changes to their practice arising from telemedicine, especially associated with increased wound assessment knowledge and skills and improved documentation quality. They also experienced more streamlined communication between primary health care and specialist health care. Despite obstacles associated with finding the documentation process time consuming, the participants' attitudes to telemedicine were overwhelmingly positive and their general enthusiasm for the innovation was high. Our findings indicate that using a telemedicine intervention enabled the participating health care professionals to approach their patients with diabetic foot ulcer with more knowledge, better wound assessment skills and heightened confidence. Furthermore, it streamlined the communication between health care levels and helped seeing the patients in a more holistic way.

Supporting home care for the dying: an evaluation of healthcare professionals' perspectives of an individually tailored hospice at home service.

PubMed

Jack, Barbara A; Baldry, Catherine R; Groves, Karen E; Whelan, Alison; Sephton, Janice; Gaunt, Kathryn

2013-10-01

To explore health care professionals' perspective of hospice at home service that has different components, individually tailored to meet the needs of patients. Over 50% of adults diagnosed with a terminal illness and the majority of people who have cancer, prefer to be cared for and to die in their own home. Despite this, most deaths occur in hospital. Increasing the options available for patients, including their place of care and death is central to current UK policy initiatives. Hospice at home services aim to support patients to remain at home, yet there are wide variations in the design of services and delivery. A hospice at home service was developed to provide various components (accompanied transfer home, crisis intervention and hospice aides) that could be tailored to meet the individual needs of patients. An evaluation study. Data were collected from 75 health care professionals. District nurses participated in one focus group (13) and 31 completed an electronic survey. Palliative care specialist nurses participated in a focus group (9). One hospital discharge co-ordinator and two general practitioners participated in semi-structured interviews and a further 19 general practitioners completed the electronic survey. Health care professionals reported the impact and value of each of the components of the service, as helping to support patients to remain at home, by individually tailoring care. They also positively reported that support for family carers appeared to enable them to continue coping, rapid access to the service was suggested to contribute to faster hospital discharges and the crisis intervention service was identified as helping patients remain in their own home, where they wanted to be. Health care professionals perceived that the additional individualised support provided by this service contributed to enabling patients to continue be cared for and to die at home in their place of choice. This service offers various components of a hospice at home service, enabling a tailor made package to meet individual and local area needs. Developing an individually tailored package of care appears to be able to meet specific needs. © 2013 Blackwell Publishing Ltd.

Coaching Family Caregivers to Become Better Problem Solvers When Caring for Persons with Advanced Cancer.

PubMed

Dionne-Odom, J Nicholas; Lyons, Kathleen D; Akyar, Imatullah; Bakitas, Marie A

2016-01-01

Family caregivers of persons with advanced cancer often take on responsibilities that present daunting and complex problems. Serious problems that go unresolved may be burdensome and result in negative outcomes for caregivers' psychological and physical health and affect the quality of care delivered to the care recipients with cancer, especially at the end of life. Formal problem-solving training approaches have been developed over the past several decades to assist individuals with managing problems faced in daily life. Several of these problem-solving principles and techniques were incorporated into ENABLE (Educate, Nurture, Advise, Before Life End), an "early" palliative care telehealth intervention for individuals diagnosed with advanced cancer and their family caregivers. A hypothetical case resembling the situations of actual caregiver participants in ENABLE that exemplifies the complex problems that caregivers face is presented, followed by presentation of an overview of ENABLE's problem-solving key principles, techniques, and steps in problem-solving support. Though more research is needed to formally test the use of problem-solving support in social work practice, social workers can easily incorporate these techniques into everyday practice.

Effect of Village Health Team Home Visits and Mobile Phone Consultations on Maternal and Newborn Care Practices in Masindi and Kiryandongo, Uganda: A Community-Intervention Trial

PubMed Central

Mangwi Ayiasi, Richard; Kolsteren, Patrick; Batwala, Vincent; Criel, Bart; Orach, Christopher Garimoi

2016-01-01

Introduction The World Health Organisation recommends home visits conducted by Community Health Workers (in Uganda known as Village Health Teams—VHTs) in order to improve maternal and newborn health. This study measured the effect of home visits combined with mobile phone consultations on maternal and newborn care practices. Method In a community intervention trial design 16 health centres in Masindi and Kiryandongo districts, Uganda were randomly and equally allocated to one of two arms: control and intervention arms. Eight control health centres received the usual maternal and newborn educational messages offered by professional health workers and eight intervention health centres that received an intervention package for maternal care and essential newborn care practices. In the intervention arm VHTs made two prenatal and one postnatal home visit to households. VHTs were provided with mobile phones to enable them make regular telephone consultations with health workers at the health centre serving the catchment area. The primary outcome was health facility delivery. Other outcomes included antenatal attendances, birth preparedness, cord and thermal care and breastfeeding practices. Analysis was by intention-to-treat. Results A total of 1385 pregnant women were analysed: 758 and 627 in the control and intervention arms respectively. Significant post-intervention differences were: delivery place [adjusted Odds Ratio aOR: 17.94(95%CI: 6.26–51.37); p<0.001], cord care [aOR: 3.05(95%CI: 1.81–5.12); p<0.001] thermal care [aOR: 7.58(95%CI: 2.52–22.82); p<0.001], and timely care-seeking for newborn illness [aOR: 4.93(95%CI: 1.59–15.31); p = 0.006]. Conclusion VHTs can have an effect in promoting proper cord and thermal care for the newborn and improve timely care-seeking for health facility delivery and newborn illness, because they could answer questions and refer patients correctly. However, VHTs should be supported by professional health workers through the use of mobile phones. Trial Registration ClinicalTrials.gov NCT02084680 PMID:27101379

[Cost analysis of telemedical treatment of stroke].

PubMed

Schenkel, J; Reitmeir, P; Von Reden, S; Holle, R; Boy, S; Haberl, R; Audebert, H

2013-07-01

Telemedicine-enabled stroke networks increase the probability of a good clinical outcome. There is a shortage of evidence about the effects of this new approach on costs for inpatient care and nursing care. We analysed health insurance and nursing care fund data of a statutory health insurance company (AOK Bayern). Data from stroke patients initially treated in a TeleStroke network (TEMPiS - telemedical project for integrative stroke care) between community hospitals and academic stroke centres were compared to data of matched hospitals without specialised stroke care and telemedical support. Costs for nursing care were obtained over a 30-month period after the initial stroke. To rule out pre-existing differences between network and control hospitals, costs of stroke care were also analysed during a time period before network implementation. 1 277 patients (767 in intervention, 510 in control hospitals) were analysed in the post-implementation period. An increased proportion of patients treated in intervention hospitals had a favourable outcome concerning the level of required nursing care. Patients in intervention hospitals had higher costs for acute inpatient care (5 309 € vs. 4 901 €, p=0.04), but lower nursing care fund costs (3 946 € vs. 5 132 €; p=0.04). There was no difference in relation to absolute total costs obtained in the post-implementation period. However, nursing care costs per survived year were significantly lower in intervention hospitals (1 953 € vs. 2 635 €; p=0.005). No significant differences were found in the pre-implementation period. Considering both health insurance and nursing care fund costs, the incremental costs for TeleStroke network care in hospitals are compensated by savings in outpatient care. © Georg Thieme Verlag KG Stuttgart · New York.

Applying evidence from economic evaluations to translate cancer survivorship research into care.

PubMed

de Moor, Janet S; Alfano, Catherine M; Breen, Nancy; Kent, Erin E; Rowland, Julia

2015-09-01

This paper summarizes recommendations stemming from the meeting, Applying Evidence from Economic Evaluations to Translate Cancer Survivorship Research into Care, hosted by the National Cancer Institute. The meeting convened funded investigators, experts in cancer control, survivorship, health economics, and team science to identify the economic and health services data needed to facilitate the dissemination of cancer survivorship interventions into care and how survivorship and health economic investigators can successfully collaborate together and with other stakeholders. Recommendations from the meeting are as follows. First, investigators must engage key stakeholders early in the planning process to understand the outcomes and cost domains on which they base decisions. Second, evaluations of intervention efficacy and value should be conducted using standardized and comparable measures and analytic approaches to enable comparisons across studies. Finally, a health economist should be included during the planning phase of the study so that the economic evaluation is pursued in concert with the survivorship intervention. Economic analyses, from the perspective of key stakeholders, must be incorporated into survivorship intervention research. The results from these analyses should be disseminated in a manner that is transparent, accessible, and comparable across studies. To optimize cancer survivors' health and quality of life, it is essential deliver high-quality and high-value care. Incorporating economic analyses into survivorship intervention research can inform the translation of effective interventions into practice.

Building a new life: a chaplain's theory based case study of chronic illness.

PubMed

Risk, James L

2013-01-01

This article presents the case study of spiritual care for a patient suffering from Parkinson's disease who was referred to the chaplain in an out-patient depression research program. The chaplain's interventions were informed by an application of narrative theory, and the article demonstrates how this theory enabled the chaplain to help a patient develop new coping strategies for dealing with chronic disease. Using narrative theory, the chaplain assisted the patient to develop a new sense of identity as a spiritual, contingent self as the disease eroded his physical self and former life. The article includes a description of a patient's spiritual needs, chaplain interventions, and an outcomes measure of those interventions. The author argues that narrative theory provides chaplains with a language to identify and craft the unique intervention that spiritual care has in the life trajectory of this Parkinson's patient and other patients dealing with chronic illnesses.

Receiving care for intimate partner violence in primary care: Barriers and enablers for women participating in the weave randomised controlled trial.

PubMed

O'Doherty, Lorna; Taket, Ann; Valpied, Jodie; Hegarty, Kelsey

2016-07-01

Interventions in health settings for intimate partner violence (IPV) are being increasingly recognised as part of a response to addressing this global public health problem. However, interventions targeting this sensitive social phenomenon are complex and highly susceptible to context. This study aimed to elucidate factors involved in women's uptake of a counselling intervention delivered by family doctors in the weave primary care trial (Victoria, Australia). We analysed associations between women's and doctors' baseline characteristics and uptake of the intervention. We interviewed a random selection of 20 women from an intervention group women to explore cognitions relating to intervention uptake. Interviews were audio-recorded, transcribed, coded in NVivo 10 and analysed using the theory of planned behaviour (TPB). Abuse severity and socio-demographic characteristics (apart from current relationship status) were unrelated to uptake of counselling (67/137 attended sessions). Favourable doctor communication was strongly associated with attendance. Eight themes emerged, including four sets of beliefs that influenced attitudes to uptake: (i) awareness of the abuse and readiness for help; (ii) weave as an avenue to help; (iii) doctor's communication; and (iv) role in providing care for IPV; and four sets of beliefs regarding women's control over uptake: (v) emotional health, (vi) doctors' time, (vii) managing the disclosure process and (viii) viewing primary care as a safe option. This study has identified factors that can promote the implementation and evaluation of primary care-based IPV interventions, which are relevant across health research settings, for example, ensuring fit between implementation strategies and characteristics of the target group (such as range in readiness for intervention). On practice implications, providers' communication remains a key issue for engaging women. A key message arising from this work concerns the critical role of primary care and health services more broadly in reaching victims of domestic violence, and providing immediate and ongoing support (depending on the healthcare context). Copyright © 2016 Elsevier Ltd. All rights reserved.

[Nursing care systematization for outpatient treatment care of patients with multiple sclerosis].

PubMed

Corso, Nair Assunta Antônia; Gondim, Ana Paula Soares; Dalmeida, Patrícia Chagas Rocha; Albuquerque, Maria Girlene de Freitas

2013-06-01

An experience report of nurses in the implementation of care systematization in ambulatory care in an interdisciplinary care center for patients with multiple sclerosis of a public hospital in Fortaleza, Ceará, Brazil. This implementation is based on the NANDA International, Inc., Nursing Interventions Classification, and Nursing Outcomes Classifications. One of the results concerns systemized nursing care, which has enabled the identification and understanding of the responses of MS patients to potential and current health problems. Systematization entails expanding knowledge through a practice based on approach and encourage further research scientific evidence, in addition to promoting the role of the nurse in acomprehensive approachand encourage further research.

Evaluation of nurses’ changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care: a qualitative study

PubMed Central

Roets-Merken, Lieve M; Vernooij-Dassen, Myrra J F J; Zuidema, Sytse U; Dees, Marianne K; Hermsen, Pieter G J M; Kempen, Gertrudis I J M; Graff, Maud J L

2016-01-01

Objectives To gain insights into the process of nurses’ changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care, and into the factors that contributed to these changes in their perceptions. Design Qualitative study alongside a cluster randomised controlled trial. Setting 17 long-term care homes spread across the Netherlands. Participants 34 licensed practical nurses supporting 54 dual sensory impaired older adults. Intervention A 5-month training programme designed to enable nurses to support the self-management of dual sensory impaired older adults in long-term care. Primary outcomes Nurses’ perceptions on relevance and feasibility of the self-management programme collected from nurses’ semistructured coaching diaries over the 5-month training and intervention period, as well as from trainers’ reports. Results Nurses’ initial negative perceptions on relevance and feasibility of the intervention changed to positive as nurses better understood the concept of autonomy. Through interactions with older adults and by self-evaluations of the effect of their behaviour, nurses discovered that their usual care conflicted with client autonomy. From that moment, nurses felt encouraged to adapt their behaviour to the older adults’ autonomy needs. However, nurses’ initial unfamiliarity with conversation techniques required a longer exploration period than planned. Once client autonomy was understood, nurses recommended expanding the intervention as a generic approach to all their clients, whether dual sensory impaired or not. Conclusions Longitudinal data collection enabled exploration of nurses’ changes in perceptions when moving towards self-management support. The training programme stimulated nurses to go beyond ‘protocol thinking’, discovering client autonomy and exploring the need for their own behavioural adaptations. Educational programmes for practical nurses should offer more longitudinal coaching of autonomy supportive conversational skills. Intervention programming should acknowledge that change is a process rather than an event, and should include self-evaluations of professional behaviours over a period of time. Trial registration number NCT01217502, Post-results. PMID:27856482

Enhancing system-wide implementation of opioid prescribing guidelines in primary care: protocol for a stepped-wedge quality improvement project.

PubMed

Zgierska, Aleksandra E; Vidaver, Regina M; Smith, Paul; Ales, Mary W; Nisbet, Kate; Boss, Deanne; Tuan, Wen-Jan; Hahn, David L

2018-06-05

Systematic implementation of guidelines for opioid therapy management in chronic non-cancer pain can reduce opioid-related harms. However, implementation of guideline-recommended practices in routine care is subpar. The goal of this quality improvement (QI) project is to assess whether a clinic-tailored QI intervention improves the implementation of a health system-wide, guideline-driven policy on opioid prescribing in primary care. This manuscript describes the protocol for this QI project. A health system with 28 primary care clinics caring for approximately 294,000 primary care patients developed and implemented a guideline-driven policy on long-term opioid therapy in adults with opioid-treated chronic non-cancer pain (estimated N = 3980). The policy provided multiple recommendations, including the universal use of treatment agreements, urine drug testing, depression and opioid misuse risk screening, and standardized documentation of the chronic pain diagnosis and treatment plan. The project team drew upon existing guidelines, feedback from end-users, experts and health system leadership to develop a robust QI intervention, targeting clinic-level implementation of policy-directed practices. The resulting multi-pronged QI intervention included clinic-wide and individual clinician-level educational interventions. The QI intervention will augment the health system's "routine rollout" method, consisting of a single educational presentation to clinicians in group settings and a separate presentation for staff. A stepped-wedge design will enable 9 primary care clinics to receive the intervention and assessment of within-clinic and between-clinic changes in adherence to the policy items measured by clinic-level electronic health record-based measures and process measures of the experience with the intervention. Developing methods for a health system-tailored QI intervention required a multi-step process to incorporate end-user feedback and account for the needs of targeted clinic team members. Delivery of such tailored QI interventions has the potential to enhance uptake of opioid therapy management policies in primary care. Results from this study are anticipated to elucidate the relative value of such QI activities.

[Towards culturally sensitive care for elderly immigrants! Design and development of a community based intervention programme in the Netherlands].

PubMed

Steunenberg, B; Verhagen, I; Ros, W J; de Wit, N J

2014-04-01

In Western countries, health and social welfare facilities are not easily accessible for elderly immigrants and their needs are sub optimally addressed. A transition is needed towards culturally sensitive services to make cure and care accessible for elderly immigrants. We developed an intervention programme in which ethnic community health workers (CHWs) act as liaisons between immigrant elderly and local health care and social welfare services. In a quasi experimental design, the effectiveness of introduction of CHWs, will be evaluated in three (semi) urban residential areas in the Netherlands within three different migrant groups and compared with a control group. The primary outcome is use of health care and social welfare facilities by the elderly. Secondary outcomes are quality of life and functional impairments. Implementation of the intervention programme will be examined with focus groups and data registration of CHW activities. In this paper design and methodological issues are discussed. This study can contribute to the improvement of care for elderly immigrants by developing culturally sensitive care whereby the elderly immigrants themselves actively participate. To enable a successful transition, proper identification and recruitment of CHWs is required. Once proven effective, the CHW function can be further integrated into the existing local health care and welfare system.

Mixed Methods Research in the Development and Evaluation of Complex Interventions in Palliative and End-of-Life Care: Report on the MORECare Consensus Exercise

PubMed Central

Preston, Nancy; Evans, Catherine J.; Grande, Gunn; Short, Vicky; Benalia, Hamid; Higginson, Irene J.; Todd, on behalf of MORECare, Chris

2013-01-01

Abstract Background: Complex interventions are common in palliative and end-of-life care. Mixed methods approaches sit well within the multiphase model of complex intervention development and evaluation. Generic mixed methods guidance is useful but additional challenges in the research design and operationalization within palliative and end-of-life care may have an impact on the use of mixed methods. Objective: The objective of the study was to develop guidance on the best methods for combining quantitative and qualitative methods for health and social care intervention development and evaluation in palliative and end-of-life care. Methods: A one-day workshop was held where experts participated in facilitated groups using Transparent Expert Consultation to generate items for potential recommendations. Agreement and consensus were then sought on nine draft recommendations (DRs) in a follow-up exercise. Results: There was at least moderate agreement with most of the DRs, although consensus was low. Strongest agreement was with DR1 (usefulness of mixed methods to palliative and end-of-life care) and DR5 (importance of attention to respondent burden), and least agreement was with DR2 (use of theoretical perspectives) and DR6 (therapeutic effects of research interviews). Narrative comments enabled recommendation refinement. Two fully endorsed, five partially endorsed, and two refined DRs emerged. The relationship of these nine to six key challenges of palliative and end-of-life care research was analyzed. Conclusions: There is a need for further discussion of these recommendations and their contribution to methodology. The recommendations should be considered when designing and operationalizing mixed methods studies of complex interventions in palliative care, and because they may have wider relevance, should be considered for other applications. PMID:24195755

Mixed methods research in the development and evaluation of complex interventions in palliative and end-of-life care: report on the MORECare consensus exercise.

PubMed

Farquhar, Morag; Preston, Nancy; Evans, Catherine J; Grande, Gunn; Short, Vicky; Benalia, Hamid; Higginson, Irene J; Todd, Chris

2013-12-01

Complex interventions are common in palliative and end-of-life care. Mixed methods approaches sit well within the multiphase model of complex intervention development and evaluation. Generic mixed methods guidance is useful but additional challenges in the research design and operationalization within palliative and end-of-life care may have an impact on the use of mixed methods. The objective of the study was to develop guidance on the best methods for combining quantitative and qualitative methods for health and social care intervention development and evaluation in palliative and end-of-life care. A one-day workshop was held where experts participated in facilitated groups using Transparent Expert Consultation to generate items for potential recommendations. Agreement and consensus were then sought on nine draft recommendations (DRs) in a follow-up exercise. There was at least moderate agreement with most of the DRs, although consensus was low. Strongest agreement was with DR1 (usefulness of mixed methods to palliative and end-of-life care) and DR5 (importance of attention to respondent burden), and least agreement was with DR2 (use of theoretical perspectives) and DR6 (therapeutic effects of research interviews). Narrative comments enabled recommendation refinement. Two fully endorsed, five partially endorsed, and two refined DRs emerged. The relationship of these nine to six key challenges of palliative and end-of-life care research was analyzed. There is a need for further discussion of these recommendations and their contribution to methodology. The recommendations should be considered when designing and operationalizing mixed methods studies of complex interventions in palliative care, and because they may have wider relevance, should be considered for other applications.

Outcomes for family carers of a nurse-delivered hospital discharge intervention for older people (the Further Enabling Care at Home Program): Single blind randomised controlled trial.

PubMed

Toye, Christine; Parsons, Richard; Slatyer, Susan; Aoun, Samar M; Moorin, Rachael; Osseiran-Moisson, Rebecca; Hill, Keith D

2016-12-01

Hospital discharge of older people receiving care at home offers a salient opportunity to identify and address their family caregivers' self-identified support needs. This study tested the hypothesis that the extent to which family caregivers of older people discharged home from hospital felt prepared to provide care at home would be positively influenced by their inclusion in the new Further Enabling Care at Home program. This single-blind randomised controlled trial compared outcomes from usual care alone with those from usual care plus the new program. The program, delivered by a specially trained nurse over the telephone, included: support to facilitate understanding of the patient's discharge letter; caregiver support needs assessment; caregiver prioritisation of urgent needs; and collaborative guidance, from the nurse, regarding accessing supports. Dyads were recruited from the medical assessment unit of a Western Australian metropolitan public hospital. Each dyad comprised a patient aged 70 years or older plus an English speaking family caregiver. The primary outcome was the caregiver's self-reported preparedness to provide care for the patient. Data collection time points were designated as: Time 1, within four days of discharge; Time 2, 15-21days after discharge; Time 3, six weeks after discharge. Other measures included caregivers' ratings of: their health, patients' symptoms and independence, caregiver strain, family well-being, caregiver stress, and positive appraisals of caregiving. Data were collected by telephone. Complete data sets were obtained from 62 intervention group caregivers and 79 controls. Groups were equivalent at baseline. Needs prioritised most often by caregivers were: to know whom to contact and what to expect in the future and to access practical help at home. Support guidance included how to: access help, information, and resources; develop crisis plans; obtain referrals and services; and organise legal requirements. Compared to controls, preparedness to care improved in the intervention group from Time 1 to Time 2 (effect size=0.52; p=0.006) and from Time 1 to Time 3 (effect size=0.43; p=0.019). These improvements corresponded to a change of approximately 2 points on the Preparedness for Caregiving instrument. Small but significant positive impacts were also observed in other outcomes, including caregiver strain. These unequivocal findings provide a basis for considering the Furthering Enabling Care at Home program's implementation in this and other similar settings. Further testing is required to determine the generalisability of results. Copyright © 2016 Elsevier Ltd. All rights reserved.

The use of data for process and quality improvement in long term care and home care: a systematic review of the literature.

PubMed

Sales, Anne E; Bostrom, Anne-Marie; Bucknall, Tracey; Draper, Kellie; Fraser, Kimberly; Schalm, Corinne; Warren, Sharon

2012-02-01

Standardized resident or client assessments, including the Resident Assessment Instrument (RAI), have been available in long term care and home care settings (continuing care sector) in many jurisdictions for a number of years. Although using these data can make quality improvement activities more efficient and less costly, there has not been a review of the literature reporting quality improvement interventions using standardized data. To address 2 questions: (1) How have RAI and other standardized data been used in process or quality improvement activities in the continuing care sector? and (2) Has the use of RAI and similar data resulted in improvements to resident or other outcomes? Searches using a combination of keyword and controlled vocabulary term searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, the Cochrane Library, and PsychINFO. ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: English language publications from database inception to October 2008 were included. Eligibility criteria included the following: (1) set in continuing care (long-term care facility or home care), (2) involved some form of intervention designed to improve quality or process of care, and (3) used standardized data in the quality or process improvement intervention. After reviewing the articles, we grouped the studies according to the type of intervention used to initiate process improvement. Four different intervention types were identified. We organized the results and discussion by these 4 intervention types. Key word searches identified 713 articles, of which we excluded 639 on abstract review because they did not meet inclusion criteria. A further 50 articles were excluded on full-text review, leaving a total of 24 articles. Of the 24 studies, 10 used a defined process improvement model, 8 used a combination of interventions (multimodal), 5 implemented new guidelines or protocols, and 1 used an education intervention. The most frequently cited issues contributing to unsuccessful quality improvement interventions were lack of staff, high staff turnover, and limited time available to train staff in ways that would improve client care. Innovative strategies and supporting research are required to determine how to intervene successfully to improve quality in these settings characterized by low staffing levels and predominantly nonprofessional staff. Research on how to effectively enable practitioners to use data to improve quality of care, and ultimately quality of life, needs to be a priority. Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Sample size calculations for cluster randomised crossover trials in Australian and New Zealand intensive care research.

PubMed

Arnup, Sarah J; McKenzie, Joanne E; Pilcher, David; Bellomo, Rinaldo; Forbes, Andrew B

2018-06-01

The cluster randomised crossover (CRXO) design provides an opportunity to conduct randomised controlled trials to evaluate low risk interventions in the intensive care setting. Our aim is to provide a tutorial on how to perform a sample size calculation for a CRXO trial, focusing on the meaning of the elements required for the calculations, with application to intensive care trials. We use all-cause in-hospital mortality from the Australian and New Zealand Intensive Care Society Adult Patient Database clinical registry to illustrate the sample size calculations. We show sample size calculations for a two-intervention, two 12-month period, cross-sectional CRXO trial. We provide the formulae, and examples of their use, to determine the number of intensive care units required to detect a risk ratio (RR) with a designated level of power between two interventions for trials in which the elements required for sample size calculations remain constant across all ICUs (unstratified design); and in which there are distinct groups (strata) of ICUs that differ importantly in the elements required for sample size calculations (stratified design). The CRXO design markedly reduces the sample size requirement compared with the parallel-group, cluster randomised design for the example cases. The stratified design further reduces the sample size requirement compared with the unstratified design. The CRXO design enables the evaluation of routinely used interventions that can bring about small, but important, improvements in patient care in the intensive care setting.

Individualized population care: linking personal care to population care in general practice.

PubMed

Buetow, Stephen; Getz, Linn; Adams, Peter

2008-10-01

General practice is increasingly expected to deliver population care to individual patients. The feasibility and ethics of this policy shift have been challenged. Our aim is to suggest how to deliver population care while protecting personal care. We outline and discuss concepts of these types of care, their relation to the prevailing discourse regarding intervention benefits, and arguments for individualized population care. Individualized population care can enable general practice to meet the health targets of individual patients in the light of population-based goals. It unifies the concepts of personal care and whole population care. Personal care focuses on the individual good in particular consultations. Whole population care focuses on the overall health good of a population without reference to the individuality of each population member. These types of care constitute elements of a continuum that varies in purpose and objects of focus. The limitations of a crude dichotomy of personal care and population care are made explicit in a series of five arguments that lend support to the concept of individualized population care. We advocate a constructive but critical attitude towards the idea of population-based interventions in everyday general practice. Traditional personal care and whole population care can theoretically be integrated into individualized population care. However, this presupposes clinical-epidemiological expertise and moral awareness in practising clinicians.

Family-centred interventions by primary healthcare services for Indigenous early childhood wellbeing in Australia, Canada, New Zealand and the United States: a systematic scoping review.

PubMed

McCalman, Janya; Heyeres, Marion; Campbell, Sandra; Bainbridge, Roxanne; Chamberlain, Catherine; Strobel, Natalie; Ruben, Alan

2017-02-21

Primary healthcare services in Australia, Canada, New Zealand and the United States have embraced the concept of family-centred care as a promising approach to supporting and caring for the health of young Indigenous children and their families. This scoping review assesses the quality of the evidence base and identifies the published literature on family- centred interventions for Indigenous early childhood wellbeing. Fourteen electronic databases, grey literature sources and the reference lists of Indigenous maternal and child health reviews were searched to identify relevant publications from 2000 to 2015. Studies were included if the intervention was: 1) focussed on Indigenous children aged from conception to 5 years from the abovementioned countries; 2) led by a primary healthcare service; 3) described or evaluated; and 4) scored greater than 50% against a validated scale for family-centredness. The study characteristics were extracted and quality rated. Reported aims, strategies, enablers and outcomes of family-centredcare were identified using grounded theory methods. Eighteen studies (reported in 25 publications) were included. Three were randomised controlled studies; most were qualitative and exploratory in design. More than half of the publications were published from 2012 to 2015. The overarching aim of interventions was to promote healthy families. Six key strategies were to: support family behaviours and self- care, increase maternal knowledge, strengthen links with the clinic, build the Indigenous workforce, promote cultural/ community connectedness and advocate for social determinants of health. Four enablers were: competent and compassionate program deliverers, flexibility of access, continuity and integration of healthcare, and culturally supportive care. Health outcomes were reported for Indigenous children (nutritional status; emotional/behavioural; and prevention of injury and illness); parents/caregivers (depression and substance abuse; and parenting knowledge, confidence and skills); health services (satisfaction; access, utilization and cost) and community/cultural revitalisation. The evidence for family-centred interventions is in the early stages of development, but suggests promise for generating diverse healthcare outcomes for Indigenous children and their parents/caregivers, as well as satisfaction with and utilisation of healthcare, and community/cultural revitalisation. Further research pertaining to the role of fathers in family-centred care, and the effects and costs of interventions is needed.

Evaluation of a large scale implementation of disease management programmes in various Dutch regions: a study protocol

PubMed Central

2011-01-01

Background Disease management programmes (DMPs) have been developed to improve effectiveness and economic efficiency within chronic care delivery by combining patient-related, professional-directed, and organisational interventions. The benefits of DMPs within different settings, patient groups, and versions remain unclear. In this article we propose a protocol to evaluate a range of current DMPs by capturing them in a single conceptual framework, employing comparable structure, process, and outcome measures, and combining qualitative and quantitative research methods. Methods To assess DMP effectiveness a practical clinical trial will be conducted. Twenty-two disease management experiments will be studied in various Dutch regions consisting of a variety of collaborations between organisations and/or professionals. Patient cohorts include those with cardiovascular diseases, chronic obstructive pulmonary disease, diabetes, stroke, depression, psychotic diseases, and eating disorders. Our methodological approach combines qualitative and quantitative research methods to enable a comprehensive evaluation of complex programmes. Process indicators will be collected from health care providers' data registries and measured via physician and staff questionnaires. Patient questionnaires include health care experiences, health care utilisation, and quality of life. Qualitative data will be gathered by means of interviews and document analysis for an in depth description of project interventions and the contexts in which DMPs are embedded, and an ethnographic process evaluation in five DMPs. Such a design will provide insight into ongoing DMPs and demonstrate which elements of the intervention are potentially (cost)-effective for which patient populations. It will also enable sound comparison of the results of the different programmes. Discussion The study will lead to a better understanding of (1) the mechanisms of disease management, (2) the feasibility, and cost-effectiveness of a disease management approach to improving health care, and (3) the factors that determine success and failure of DMPs. Our study results will be relevant to decision makers and managers who confront the challenge of implementing and integrating DMPs into the health care system. Moreover, it will contribute to the search for methods to evaluate complex healthcare interventions. PMID:21219620

Evaluation of a large scale implementation of disease management programmes in various Dutch regions: a study protocol.

PubMed

Lemmens, Karin M M; Rutten-Van Mölken, Maureen P M H; Cramm, Jane M; Huijsman, Robbert; Bal, Roland A; Nieboer, Anna P

2011-01-10

Disease management programmes (DMPs) have been developed to improve effectiveness and economic efficiency within chronic care delivery by combining patient-related, professional-directed, and organisational interventions. The benefits of DMPs within different settings, patient groups, and versions remain unclear. In this article we propose a protocol to evaluate a range of current DMPs by capturing them in a single conceptual framework, employing comparable structure, process, and outcome measures, and combining qualitative and quantitative research methods. To assess DMP effectiveness a practical clinical trial will be conducted. Twenty-two disease management experiments will be studied in various Dutch regions consisting of a variety of collaborations between organisations and/or professionals. Patient cohorts include those with cardiovascular diseases, chronic obstructive pulmonary disease, diabetes, stroke, depression, psychotic diseases, and eating disorders. Our methodological approach combines qualitative and quantitative research methods to enable a comprehensive evaluation of complex programmes. Process indicators will be collected from health care providers' data registries and measured via physician and staff questionnaires. Patient questionnaires include health care experiences, health care utilisation, and quality of life. Qualitative data will be gathered by means of interviews and document analysis for an in depth description of project interventions and the contexts in which DMPs are embedded, and an ethnographic process evaluation in five DMPs. Such a design will provide insight into ongoing DMPs and demonstrate which elements of the intervention are potentially (cost)-effective for which patient populations. It will also enable sound comparison of the results of the different programmes. The study will lead to a better understanding of (1) the mechanisms of disease management, (2) the feasibility, and cost-effectiveness of a disease management approach to improving health care, and (3) the factors that determine success and failure of DMPs. Our study results will be relevant to decision makers and managers who confront the challenge of implementing and integrating DMPs into the health care system. Moreover, it will contribute to the search for methods to evaluate complex healthcare interventions.

Barriers to and enablers of evidence-based practice in perinatal care in the SEA-ORCHID project.

PubMed

Turner, Tari; Short, Jacki

2013-08-01

The South-East Asia Optimising Reproductive and Child Health in Developing Countries (SEA-ORCHID) project aimed to improve health outcomes for mothers and babies in nine hospitals in South-East Asia by supporting evidence-based perinatal health care. In this research, we aimed to identify and explore the factors that may have acted as barriers to or enablers of evidence-based practice change at each of the hospitals. During the final 6 months of the intervention phase of the project, semi-structured, face-to-face interviews were undertaken with 179 nurses, midwives and doctors from the maternal and neonatal departments at each of the nine participating South-East Asian hospitals. The interviews identified several factors that participants believed had a substantial impact on the effectiveness of the SEA-ORCHID intervention. These included knowledge, skills, hierarchy, multidisciplinarity and leadership, beliefs about consequences, resources, and the nature of the behaviours. The success of the SEA-ORCHID intervention in improving practice may reflect the extent to which tailored strategies were effective in overcoming these barriers. Effective interventions to align practice with evidence rely on identifying and addressing barriers to practice change. The barriers identified in this study may be useful for those designing similar clinical practice improvement projects, as well as for continued efforts to improve practice in the SEA-ORCHID hospitals. © 2011 John Wiley & Sons Ltd.

Internet-enabled interactive multimedia asthma education program: a randomized trial.

PubMed

Krishna, Santosh; Francisco, Benjamin D; Balas, E Andrew; König, Peter; Graff, Gavin R; Madsen, Richard W

2003-03-01

To determine whether health outcomes of children who have asthma can be improved through the use of an Internet-enabled interactive multimedia asthma education program. Two hundred twenty-eight children with asthma visiting a pediatric pulmonary clinic were randomly assigned to control and intervention groups. Children and caregivers in both groups received traditional patient education based on the National Asthma Education and Prevention Program. Intervention group participants received additional self-management education through the Interactive Multimedia Program for Asthma Control and Tracking. Pediatric Asthma Care Knowledge Survey, Pediatric Asthma Caregiver's Quality of Life Questionnaire, asthma symptom history, spirometry, and health services utilization data were collected at the initial visit and at 3 and 12 months. Interactive Multimedia Program for Asthma Control and Tracking significantly increased asthma knowledge of children and caregivers, decreased asthma symptom days (81 vs 51 per year), and decreased number of emergency department visits (1.93 vs 0.62 per year) among the intervention group participants. The intervention group children were also using a significantly lower average daily dose of inhaled corticosteroids (434 vs 754 micro g [beclomethasone equivalents]) at visit 3. Asthma knowledge of all 7- to 17-year-old children correlated with fewer urgent physician visits (r = 0.37) and less frequent use of quick-relief medicines (r = 0.30). Supplementing conventional asthma care with interactive multimedia education can significantly improve asthma knowledge and reduce the burden of childhood asthma.

Default options in advance directives: study protocol for a randomised clinical trial

PubMed Central

Gabler, Nicole B; Cooney, Elizabeth; Small, Dylan S; Troxel, Andrea B; Arnold, Robert M; White, Douglas B; Angus, Derek C; Loewenstein, George; Volpp, Kevin G; Bryce, Cindy L; Halpern, Scott D

2016-01-01

Introduction Although most seriously ill Americans wish to avoid burdensome and aggressive care at the end of life, such care is often provided unless patients or family members specifically request otherwise. Advance directives (ADs) were created to provide opportunities to set limits on aggressive care near life's end. This study tests the hypothesis that redesigning ADs such that comfort-oriented care is provided as the default, rather than requiring patients to actively choose it, will promote better patient-centred outcomes. Methods and analysis This multicentre trial randomises seriously ill adults to receive 1 of 3 different ADs: (1) a traditional AD that requires patients to actively choose their goals of care or preferences for specific interventions (eg, feeding tube insertion) or otherwise have their care guided by their surrogates and the prevailing societal default toward aggressive care; (2) an AD that defaults to life-extending care and receipt of life-sustaining interventions, enabling patients to opt out from such care; or (3) an AD that defaults to comfort care, enabling patients to opt into life-extending care. We seek to enrol 270 patients who return complete, legally valid ADs so as to generate sufficient power to detect differences in the primary outcome of hospital-free days (days alive and not in an acute care facility). Secondary outcomes include hospital and intensive care unit admissions, costs of care, hospice usage, decision conflict and satisfaction, quality of life, concordance of preferences with care received and bereavement outcomes for surrogates of patients who die. Ethics and dissemination This study has been approved by the Institutional Review Boards at all trial centres, and is guided by a data safety and monitoring board and an ethics advisory board. Study results will be disseminated using methods that describe the results in ways that key stakeholders can best understand and implement. Trial registration number NCT02017548; Pre-results. PMID:27266769

LEVERAGING TECHNOLOGY TO ENHANCE ADDICTION TREATMENT AND RECOVERY

PubMed Central

Marsch, Lisa A.

2012-01-01

Technology such as the Internet and mobile phones offers considerable promise for affecting the assessment, prevention, and treatment of and recovery from substance use disorders. Technology may enable entirely new models of behavioral health care within and outside of formal systems of care. This article reviews the promise of technology-based therapeutic tools for affecting the quality and reach of addiction treatment and recovery support systems, as well as the empirical support to date for this approach. Potential models for implementing technology-based interventions targeting substance use disorders are described. Opportunities to optimize the effectiveness and impact of technology-based interventions targeting addiction and recovery, along with outstanding research needs, are discussed. PMID:22873192

Leveraging technology to enhance addiction treatment and recovery.

PubMed

Marsch, Lisa A

2012-01-01

Technology such as the Internet and mobile phones offers considerable promise for affecting the assessment, prevention, and treatment of and recovery from substance use disorders. Technology may enable entirely new models of behavioral health care within and outside of formal systems of care. This article reviews the promise of technology-based therapeutic tools for affecting the quality and reach of addiction treatment and recovery support systems, as well as the empirical support to date for this approach. Potential models for implementing technology-based interventions targeting substance use disorders are described. Opportunities to optimize the effectiveness and impact of technology-based interventions targeting addiction and recovery, along with outstanding research needs, are discussed.

The Arab American experience with diabetes: Perceptions, myths and implications for culturally-specific interventions.

PubMed

Bertran, Elizabeth A; Pinelli, Nicole R; Sills, Stephen J; Jaber, Linda A

2017-02-01

Culturally-specific lifestyle diabetes prevention programs require an assessment of population disease perceptions and cultural influences on health beliefs and behaviors. The primary objectives were to assess Arab Americans' knowledge and perceptions of diabetes and their preferences for a lifestyle intervention. Sixty-nine self-identified Arab or Arab Americans ≥30 years of age and without diabetes participated in 8 focus groups. Emerging themes from the data included myths about diabetes etiology, folk remedies, and social stigma. The main barrier to healthcare was lack of health insurance and/or cost of care. Intervention preferences included gender-specific exercise, group-delivered education featuring religious ideology, inclusion of the family, and utilization of community facilities. Lifestyle interventions for Arab Americans need to address cultural preferences, diabetes myths, and folk remedies. Interventions should incorporate Arabic cultural content and gender-specific group education and exercise. Utilization of family support and religious centers will enable culturally-acceptable and cost-effective interventions. Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Turning risk assessment and adaptation policy priorities into meaningful interventions and governance processes.

PubMed

Brown, Kathryn; DiMauro, Manuela; Johns, Daniel; Holmes, Gemma; Thompson, David; Russell, Andrew; Style, David

2018-06-13

The UK is one of the first countries in the world to have set up a statutory system of national climate risk assessments followed by a national adaptation programme. Having this legal framework has been essential for enabling adaptation at the government level in a challenging political environment. However, using this framework to create an improvement in resilience to climate change across the country requires more than publishing a set of documents; it requires careful thought about what interventions work, how they can be enabled and what level of risk acceptability individuals, organizations and the country should be aiming for.This article is part of the theme issue 'Advances in risk assessment for climate change adaptation policy'. © 2018 The Author(s).

Turning risk assessment and adaptation policy priorities into meaningful interventions and governance processes

NASA Astrophysics Data System (ADS)

Brown, Kathryn; DiMauro, Manuela; Johns, Daniel; Holmes, Gemma; Thompson, David; Russell, Andrew; Style, David

2018-06-01

The UK is one of the first countries in the world to have set up a statutory system of national climate risk assessments followed by a national adaptation programme. Having this legal framework has been essential for enabling adaptation at the government level in a challenging political environment. However, using this framework to create an improvement in resilience to climate change across the country requires more than publishing a set of documents; it requires careful thought about what interventions work, how they can be enabled and what level of risk acceptability individuals, organizations and the country should be aiming for. This article is part of the theme issue `Advances in risk assessment for climate change adaptation policy'.

Barriers and enablers of kangaroo mother care implementation from a health systems perspective: a systematic review.

PubMed

Chan, Grace; Bergelson, Ilana; Smith, Emily R; Skotnes, Tobi; Wall, Stephen

2017-12-01

Kangaroo Mother Care (KMC) is an evidence-based intervention that reduces neonatal morbidity and mortality. However, adoption among health systems has varied. Understanding the interaction between health system functions-leadership, financing, healthcare workers (HCWs), technologies, information and research, and service delivery-and KMC is essential to understanding KMC adoption. We present a systematic review of the barriers and enablers of KMC implementation from the perspective of health systems, with a focus on HCWs and health facilities. Using the search terms 'kangaroo mother care', 'skin to skin (STS) care' and 'kangaroo care', we searched Embase, Scopus, Web of Science, Pubmed, and World Health Organization Regional Databases. Reports and hand searched references from publications were also included. Screening and data abstraction were conducted by two independent reviewers using standardized forms. A conceptual model to assess KMC adoption themes was developed using NVivo software. Our search strategy yielded 2875 studies. We included 86 studies with qualitative data on KMC implementation from the perspective of HCWs and/or facilities. Six themes emerged on barriers and enablers to KMC adoption: buy-in and bonding; social support; time; medical concerns; training; and cultural norms. Analysis of interactions between HCWs and facilities yielded further barriers and enablers in the areas of training, communication, and support. HCWs and health facilities serve as two important adopters of Kangaroo Mother Care within a health system. The complex components of KMC lead to multifaceted barriers and enablers to integration, which inform facility, regional, and country-level recommendations for increasing adoption. Further research of methods to promote context-specific adoption of KMC at the health systems level is needed. © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.

Defibrillation and external pacing in flight: incidence and implications.

PubMed

Daly, Stuart; Milne, Helen J; Holmes, Dan P; Corfield, Alasdair R

2014-01-01

Emergency electrical intervention for patients in the form of defibrillation, cardioversion and external cardiac pacing can be life saving. Advances in medical technology have enabled electrical intervention to be delivered from small, portable devices. With the rising use of air transport for patients, electrical intervention during aeromedical transfer has an increasing incidence. Our aim was to describe the incidence of electrical intervention in a cohort of critically ill patients undergoing aeromedical transfer and review the risks associated with electrical intervention. All secondary retrievals undertaken by a national aeromedical critical care retrieval service were reviewed over a 48-month period. In a mixed medical and trauma critical care population, 11 of 967 (1.1%) secondary retrievals required electrical intervention during aeromedical critical care retrieval. The median age of these patients was 77 years (range 32-86) and the median transport time was 70 min (range 40-100 min). All of these patients had an underlying primary cardiac condition and had been identified as high risk for developing an arrhythmia. Electrical intervention in a transport environment brings unique challenges, particularly during aeromedical transport. Our study in a European model shows that there is a small but significant incidence of electrical intervention required during aeromedical flight for critically ill patients. There are potential safety issues with electrical intervention in aeromedical flight; therefore, any service involved in the transport of critically ill patients needs to have a robust procedure in place to deliver this safely.

Systematic development of a theory-informed multifaceted behavioural intervention to increase physical activity of adults with type 2 diabetes in routine primary care: Movement as Medicine for Type 2 Diabetes.

PubMed

Avery, Leah; Charman, Sarah J; Taylor, Louise; Flynn, Darren; Mosely, Kylie; Speight, Jane; Lievesley, Matthew; Taylor, Roy; Sniehotta, Falko F; Trenell, Michael I

2016-07-19

Despite substantial evidence for physical activity (PA) as a management option for type 2 diabetes, there remains a lack of PA behavioural interventions suitable for delivery in primary care. This paper describes the systematic development of an evidence-informed PA behavioural intervention for use during routine primary care consultations. In accordance with the Medical Research Council Framework for the Development and Evaluation of Complex Interventions, a four-stage systematic development process was undertaken: (1) exploratory work involving interviews and workshop discussions identified training needs of healthcare professionals and support needs of adults with type 2 diabetes; (2) a systematic review with meta- and moderator analyses identified behaviour change techniques and optimal intervention intensity and duration; (3) usability testing identified strategies to increase implementation of the intervention in primary care and (4) an open pilot study in two primary care practices facilitated intervention optimisation. Healthcare professional training needs included knowledge about type, intensity and duration of PA sufficient to improve glycaemic control and acquisition of skills to promote PA behaviour change. Patients lacked knowledge about type 2 diabetes and skills to enable them to make sustainable changes to their level of PA. An accredited online training programme for healthcare professionals and a professional-delivered behavioural intervention for adults with type 2 diabetes were subsequently developed. This multifaceted intervention was informed by the theory of planned behaviour and social cognitive theory and consisted of 15 behaviour change techniques. Intervention intensity and duration were informed by a systematic review. Usability testing resolved technical problems with the online training intervention that facilitated use on practice IT systems. An open pilot study of the intervention with fidelity of delivery assessment informed optimisation and identified mechanisms to enhance implementation of the intervention during routine diabetes consultations. Movement as Medicine for Type 2 diabetes represents an evidence-informed multifaceted behavioural intervention targeting PA for management of type 2 diabetes developed for delivery in primary care. The structured development process undertaken enhances transparency of intervention content, replicability and scalability. Movement as Medicine for Type 2 diabetes is currently undergoing evaluation in a pilot RCT. ISRCTN67997502.

Building and strengthening infrastructure for data exchange: lessons from the beacon communities.

PubMed

Torres, Gretchen W; Swietek, Karen; Ubri, Petry S; Singer, Rachel F; Lowell, Kristina H; Miller, Wilhelmine

2014-01-01

The Beacon Community Cooperative Agreement Program supports interventions, including care-delivery innovations, provider performance measurement and feedback initiatives, and tools for providers and consumers to enhance care. Using a learning health system framework, we examine the Beacon Communities' processes in building and strengthening health IT (HIT) infrastructures, specifically successes and challenges in sharing patient information to improve clinical care. In 2010, the Office of the National Coordinator for Health Information Technology (ONC) launched the three-year program, which provided $250 million to 17 Beacon Communities to invest in HIT and health information exchange (HIE) infrastructure. Beacon Communities used this funding to develop and disseminate HIT-enabled quality improvement practices found effective in particular community and practice environments. NORC conducted 7 site visits, November 2012-March 2013, selecting Communities to represent diverse program features. From August-October 2013, NORC held discussions with the remaining 10 Communities. Following each visit or discussion, NORC summarized the information gathered, including transcripts, team observations, and other documents the Community provided, to facilitate a within-Community analysis of context and stakeholders, intervention strategies, enabling factors, and challenges. Although each Community designed and implemented data-sharing strategies in a unique environment, similar challenges and enabling factors emerged across the Beacons. From a learning health system perspective, their strategies to build and strengthen data-sharing infrastructures address the following crosscutting priorities: promoting technical advances and innovations by helping providers adapt EHRs for data exchange and performance measurement with customizable IT and offering technical support to smaller, independent providers; engaging key stakeholders; and fostering transparent governance and stewardship of the infrastructure with neutral conveners. While all the Communities developed or strengthened data-exchange infrastructure, each did this in a unique environment of existing health care market and legal factors. The Communities, however, encountered similar challenges and enabling factors. Organizations undertaking collaborative data sharing, performance measurement and clinical transformation can learn from the Beacon Communities' experience.

Building and Strengthening Infrastructure for Data Exchange: Lessons from the Beacon Communities

PubMed Central

Torres, Gretchen W.; Swietek, Karen; Ubri, Petry S.; Singer, Rachel F.; Lowell, Kristina H.; Miller, Wilhelmine

2014-01-01

Introduction: The Beacon Community Cooperative Agreement Program supports interventions, including care-delivery innovations, provider performance measurement and feedback initiatives, and tools for providers and consumers to enhance care. Using a learning health system framework, we examine the Beacon Communities’ processes in building and strengthening health IT (HIT) infrastructures, specifically successes and challenges in sharing patient information to improve clinical care. Background: In 2010, the Office of the National Coordinator for Health Information Technology (ONC) launched the three-year program, which provided $250 million to 17 Beacon Communities to invest in HIT and health information exchange (HIE) infrastructure. Beacon Communities used this funding to develop and disseminate HIT-enabled quality improvement practices found effective in particular community and practice environments. Methods: NORC conducted 7 site visits, November 2012–March 2013, selecting Communities to represent diverse program features. From August–October 2013, NORC held discussions with the remaining 10 Communities. Following each visit or discussion, NORC summarized the information gathered, including transcripts, team observations, and other documents the Community provided, to facilitate a within-Community analysis of context and stakeholders, intervention strategies, enabling factors, and challenges. Results: Although each Community designed and implemented data-sharing strategies in a unique environment, similar challenges and enabling factors emerged across the Beacons. From a learning health system perspective, their strategies to build and strengthen data-sharing infrastructures address the following crosscutting priorities: promoting technical advances and innovations by helping providers adapt EHRs for data exchange and performance measurement with customizable IT and offering technical support to smaller, independent providers; engaging key stakeholders; and fostering transparent governance and stewardship of the infrastructure with neutral conveners. Conclusion: While all the Communities developed or strengthened data-exchange infrastructure, each did this in a unique environment of existing health care market and legal factors. The Communities, however, encountered similar challenges and enabling factors. Organizations undertaking collaborative data sharing, performance measurement and clinical transformation can learn from the Beacon Communities’ experience. PMID:25848619

Enhancing person-centred communication in NICU: a comparative thematic analysis.

PubMed

Weis, Janne; Zoffmann, Vibeke; Egerod, Ingrid

2015-11-01

Aims of this article were (a) to explore how parents of premature infants experience guided family-centred care (GFCC), and (b) to compare how parents receiving GFCC versus standard care (SC) describe nurse-parent communication in the neonatal intensive care unit. Family-centred care (FCC) is acknowledged as fundamental to supporting parents of premature infants, and communication is central to this practice. Accordingly, nurses need good communication skills. GFCC is an intervention developed to improve nurse-parent communication in the neonatal intensive care unit. This intervention helps nurses to realize person-centred communication as an approach to optimize contemporary practice. Our qualitative study had a descriptive and comparative design using semi-structured interviews to explore the parent's experience of GFCC. We conducted 10 dyad interviews with parents (n = 20) and two individual interviews with mothers of premature infants (n = 2). Parents in the intervention group versus SC group were 13 versus 9. Thematic analysis was applied. GFCC was generally experienced as supportive. Three interrelated themes were identified that illustrated how the intervention helped parents cope as persons, parents and couples: (a) discovering and expressing emotions, (b) reaching a deeper level of communication, and (c) obtaining mutual understanding. In contrast, SC communication was more superficial and less structured. Factors such as inaccessibility of nurses, inability to ask for assistance and parent popularity impaired successful communication. Our study suggested that compared to SC, GFCC provided structured delivery of supportive communication between nurses and parents of premature infants. The intervention promoted the discovery of the parents' individual preferences and concerns, which enabled more focused communication, and set the stage for better nurse-parent and parent-parent understanding. We recommend GFCC as a method to improve communication in the neonatal intensive care unit. © 2013 British Association of Critical Care Nurses.

Evidence-based practices to increase hand hygiene compliance in health care facilities: An integrated review.

PubMed

Neo, Jun Rong Jeffrey; Sagha-Zadeh, Rana; Vielemeyer, Ole; Franklin, Ella

2016-06-01

Hand hygiene (HH) in health care facilities is a key component to reduce pathogen transmission and nosocomial infections. However, most HH interventions (HHI) have not been sustainable. This review aims to provide a comprehensive summary of recently published evidence-based HHI designed to improve HH compliance (HHC) that will enable health care providers to make informed choices when allocating limited resources to improve HHC and patient safety. The Medline electronic database (using PubMed) was used to identify relevant studies. English language articles that included hand hygiene interventions and related terms combined with health care environments or related terms were included. Seventy-three studies that met the inclusion criteria were summarized. Interventions were categorized as improving awareness with education, facility design, and planning, unit-level protocols and procedures, hospital-wide programs, and multimodal interventions. Past successful HHIs may not be as effective when applied to other health care environments. HH education should be interactive and engaging. Electronic monitoring and reminders should be implemented in phases to ensure cost-effectiveness. To create hospitalwide programs that engage end users, policy makers should draw expertise from interdisciplinary fields. Before implementing the various components of multimodal interventions, health care practitioners should identify and examine HH difficulties unique to their organizations. Future research should seek to achieve the following: replicate successful HHI in other health care environments, develop reliable HHC monitoring tools, understand caregiver-patient-family interactions, examine ways (eg, hospital leadership, financial support, and strategies from public health and infection prevention initiatives) to sustain HHC, and use simulated lab environments to refine study designs. Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

The use of non-pharmacological interventions for dementia behaviours in care homes: findings from four in-depth, ethnographic case studies.

PubMed

Backhouse, Tamara; Killett, Anne; Penhale, Bridget; Gray, Richard

2016-11-01

antipsychotic medications have been used to manage behavioural and psychological symptoms of dementia (BPSD). Due to the potential risks associated with these medications for people with dementia, non-pharmacological interventions (NPIs) have been recommended as safer alternatives. However, it is unknown if, or how, these interventions are used in care homes to help people experiencing BPSD. to explore the use of NPIs in care homes to manage BPSD. In-depth, ethnographic case studies were conducted in four care homes; in total, they included interviews with 40 care-home staff and 384 hours of participant observations. NPIs, some of which are the focus of efficacy research, were used in care homes but predominantly as activities to improve the quality of life of all residents and not identified by staff as meeting individual needs in order to prevent or manage specific behaviours. Socially relevant activities such as offering a cup of tea were used to address behaviours in the moment. Residents with high levels of need experienced barriers to inclusion in the activities. there is a gap between rhetoric and practice with most NPIs in care homes used as social activities rather than as targeted interventions. If NPIs are to become viable alternatives to antipsychotic medications in care homes, further work is needed to embed them into usual care practices and routines. Training for care-home staff could also enable residents with high needs to gain better access to suitable activities. © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Nurses' perceptions of a pressure ulcer prevention care bundle: a qualitative descriptive study.

PubMed

Roberts, Shelley; McInnes, Elizabeth; Wallis, Marianne; Bucknall, Tracey; Banks, Merrilyn; Chaboyer, Wendy

2016-01-01

Pressure ulcer prevention is a critical patient safety indicator for acute care hospitals. An innovative pressure ulcer prevention care bundle targeting patient participation in their care was recently tested in a cluster randomised trial in eight Australian hospitals. Understanding nurses' perspectives of such an intervention is imperative when interpreting results and translating evidence into practice. As part of a process evaluation for the main trial, this study assessed nurses' perceptions of the usefulness and impact of a pressure ulcer prevention care bundle intervention on clinical practice. This qualitative descriptive study involved semi-structured interviews with nursing staff at four Australian hospitals that were intervention sites for a cluster randomised trial testing a pressure ulcer prevention care bundle. Four to five participants were purposively sampled at each site. A trained interviewer used a semi-structured interview guide to question participants about their perceptions of the care bundle. Interviews were digitally recorded, transcribed and analysed using thematic analysis. Eighteen nurses from four hospitals participated in the study. Nurses' perceptions of the intervention are described in five themes: 1) Awareness of the pressure ulcer prevention care bundle and its similarity to current practice; 2) Improving awareness, communication and participation with the pressure ulcer prevention care bundle; 3) Appreciating the positive aspects of patient participation in care; 4) Perceived barriers to engaging patients in the pressure ulcer prevention care bundle; and 5) Partnering with nursing staff to facilitate pressure ulcer prevention care bundle implementation. Overall, nurses found the care bundle feasible and acceptable. They identified a number of benefits from the bundle, including improved communication, awareness and participation in pressure ulcer prevention care among patients and staff. However, nurses thought the care bundle was not appropriate or effective for all patients, such as those who were cognitively impaired. Perceived enablers to implementation of the bundle included facilitation through effective communication and dissemination of evidence about the care bundle; strong leadership and ability to influence staff behaviour; and simplicity of the care bundle.

The efficacy of computer-enabled discharge communication interventions: a systematic review.

PubMed

Motamedi, Soror Mona; Posadas-Calleja, Juan; Straus, Sharon; Bates, David W; Lorenzetti, Diane L; Baylis, Barry; Gilmour, Janet; Kimpton, Shandra; Ghali, William A

2011-05-01

Traditional manual/dictated discharge summaries are inaccurate, inconsistent and untimely. Computer-enabled discharge communications may improve information transfer by providing a standardised document that immediately links acute and community healthcare providers. To conduct a systematic review evaluating the efficacy of computer-enabled discharge communication compared with traditional communication for patients discharged from acute care hospitals. MEDLINE, EMBASE, Cochrane CENTRAL Register of Controlled Trials and MEDLINE In-Process. Keywords from three themes were combined: discharge communication, electronic/online/web-based and controlled interventional studies. Study types included: clinical trials, quasiexperimental studies with concurrent controls and controlled before--after studies. Interventions included: (1) automatic population of a discharge document by computer database(s); (2) transmission of discharge information via computer technology; or (3) computer technology providing a 'platform' for dynamic discharge communication. Controls included: no intervention or traditional manual/dictated discharge summaries. Primary outcomes included: mortality, readmission and adverse events/near misses. Secondary outcomes included: timeliness, accuracy, quality/completeness and physician/patient satisfaction. Description of interventions and study outcomes were extracted by two independent reviewers. 12 unique studies were identified: eight randomised controlled trials and four quasi-experimental studies. Pooling/meta-analysis was not possible, given the heterogeneity of measures and outcomes reported. The primary outcomes of mortality and readmission were inconsistently reported. There was no significant difference in mortality, and one study reported reduced long-term readmission. Intervention groups experienced reductions in perceived medical errors/adverse events, and improvements in timeliness and physician/patient satisfaction. Computer-enabled discharge communications appear beneficial with respect to a number of important secondary outcomes. Primary outcomes of mortality and readmission are less commonly reported in this literature and require further study.

Increasing the provision of preventive care by community healthcare services: a stepped wedge implementation trial.

PubMed

Wiggers, John; McElwaine, Kathleen; Freund, Megan; Campbell, Libby; Bowman, Jenny; Wye, Paula; Wolfenden, Luke; Tremain, Danika; Barker, Daniel; Slattery, Carolyn; Gillham, Karen; Bartlem, Kate

2017-08-22

Although clinical guidelines recommend the provision of care to reduce client chronic disease risk behaviours, such care is provided sub-optimally by primary healthcare providers. A study was undertaken to determine the effectiveness of an intervention in increasing community-based clinician implementation of multiple elements of recommended preventive care for four risk behaviours. A three-group stepped-wedge trial was undertaken with all 56 community-based primary healthcare facilities in one health district in New South Wales, Australia. A 12-month implementation intervention was delivered sequentially in each of three geographically and administratively defined groups of facilities. The intervention consisted of six key strategies: leadership and consensus processes, enabling systems, educational meetings and training, audit and feedback, practice change support, and practice change information and resources. Client-reported receipt of three elements of preventive care: assessment; brief advice; referral for four behavioural risks: smoking, inadequate fruit and/or vegetable consumption, alcohol overconsumption, and physical inactivity, individually, and for all such risks combined were collected for 56 months (October 2009-May 2014). Segmented logistic regression models were developed to assess intervention effectiveness. A total of 5369 clients participated in data collection. Significant increases were found for receipt of four of five assessment outcomes (smoking OR 1.53; fruit and/or vegetable intake OR 2.18; alcohol consumption OR 1.69; all risks combined OR 1.78) and two of five brief advice outcomes (fruit and/or vegetable intake OR 2.05 and alcohol consumption OR 2.64). No significant increases in care delivery were observed for referral for any risk behaviour, or for physical inactivity. The implementation intervention was effective in enhancing assessment of client risk status but less so for elements of care that could reduce client risk: provision of brief advice and referral. The intervention was ineffective in increasing care addressing physical inactivity. Further research is required to identify barriers to the provision of preventive care and the effectiveness of practice change interventions in increasing its provision. Australian Clinical Trials Registry ACTRN12611001284954 . Registered 15 December 2011. Retrospectively registered.

Family Caregiver Depressive Symptom and Grief Outcomes from the ENABLE III Randomized Controlled Trial

PubMed Central

Dionne-Odom, J. Nicholas; Azuero, Andres; Lyons, Kathleen D.; Hull, Jay G.; Prescott, Anna T.; Tosteson, Tor; Frost, Jennifer; Dragnev, Konstantin H.; Bakitas, Marie A

2016-01-01

Context Little is known about whether early palliative care (EPC) support for family caregivers (CGs) impacts depressive symptoms and grief after care recipients die. Objectives To assess after-death CG depressive symptom and grief scores for early compared to delayed group CGs. Methods We conducted a randomized controlled trial (RCT) (10/2010-9/2013) of an EPC telehealth intervention for CGs (n=123) initiated at the time of care recipients' advanced cancer diagnosis (early group) or 12 weeks later (delayed group) in a rural comprehensive cancer center, affiliated clinics, and a Veterans Administration medical center. The ENABLE [Educate, Nurture, Advise, Before Life Ends] CG intervention consisted of three weekly sessions, monthly follow-up, and a bereavement call. CGs completed the Center for Epidemiological Study-Depression scale (CESD) and the Prigerson Inventory of Complicated Grief-Short Form (PG13) 8-12 weeks after care recipients' deaths. Crude and covariate-adjusted between-group differences were estimated and tested using general linear models. Results For care recipients who died (n=70), 44 CGs (early: n=19; delayed: n=25) completed after-death questionnaires. Mean depressive symptom scores (CESD) for the early group was 14.6 (standard deviation [SD]=10.7) and for the delayed group was 17.6 (SD=11.8). Mean complicated grief scores (PG13) for the early group was 22.7 (SD=4.9) and for the delayed group was 24.9 (SD=6.9). Adjusted between-group differences were not statistically significant (CESD: d=0.07, P=0.88; PG13: d=-0.21, P=0.51). Conclusion CGs' depressive symptom and complicated grief scores 8-12 weeks after care recipients' deaths were not statistically different based on the timing of EPC support. The impact of timing of CG EPC interventions on CGs bereavement outcomes requires further investigation. PMID:27265814

Implementation of a pharmaceutical care programme for patients receiving new molecular-targeted agents in a clinical trial unit.

PubMed

Riu, G; Gaba, L; Victoria, I; Molas, G; do Pazo, F; Gómez, B; Creus, N; Vidal, L

2018-01-01

A pharmaceutical care programme was implemented at our hospital in early 2013. The main objectives were to analyse and describe the pharmaceutical interventions made, to calculate adherence, interventions and to evaluate patient satisfaction with the care programme. We performed a single-centre descriptive and prospective intervention in cancer patients who received oral chemotherapy as part of a clinical trial in 2013. Eighty-three patients were included. Median age was 58 years (range, 31-80) and 42 patients (50.6%) were men. We recorded 23 interventions, 13 of which were associated with drug interactions. The mean percentage of adherence was 98.9%. The interview with the pharmacist was considered to be very important by 84.6% of the respondents. A total of 92.3% said that they would like to speak to the pharmacist at subsequent visits. The doubts detected during the visits enable us to conclude that the information patients receive with respect to their study medication is usually incomplete. An integrated pharmaceutical care programme for cancer patients participating in clinical trials with oral cytostatic drugs was successful in terms of adherence and patient satisfaction and makes it possible to guarantee the safety and effectiveness of treatment on an individual basis. © 2016 John Wiley & Sons Ltd.

Costing interventions in primary care.

PubMed

Kernick, D

2000-02-01

Against a background of increasing demands on limited resources, studies that relate benefits of health interventions to the resources they consume will be an important part of any decision-making process in primary care, and an accurate assessment of costs will be an important part of any economic evaluation. Although there is no such thing as a gold standard cost estimate, there are a number of basic costing concepts that underlie any costing study. How costs are derived and combined will depend on the assumptions that have been made in their derivation. It is important to be clear what assumptions have been made and why in order to maintain consistency across comparative studies and prevent inappropriate conclusions being drawn. This paper outlines some costing concepts and principles to enable primary care practitioners and researchers to have a basic understanding of costing exercises and their pitfalls.

Image fusion and navigation platforms for percutaneous image-guided interventions.

PubMed

Rajagopal, Manoj; Venkatesan, Aradhana M

2016-04-01

Image-guided interventional procedures, particularly image guided biopsy and ablation, serve an important role in the care of the oncology patient. The need for tumor genomic and proteomic profiling, early tumor response assessment and confirmation of early recurrence are common scenarios that may necessitate successful biopsies of targets, including those that are small, anatomically unfavorable or inconspicuous. As image-guided ablation is increasingly incorporated into interventional oncology practice, similar obstacles are posed for the ablation of technically challenging tumor targets. Navigation tools, including image fusion and device tracking, can enable abdominal interventionalists to more accurately target challenging biopsy and ablation targets. Image fusion technologies enable multimodality fusion and real-time co-displays of US, CT, MRI, and PET/CT data, with navigational technologies including electromagnetic tracking, robotic, cone beam CT, optical, and laser guidance of interventional devices. Image fusion and navigational platform technology is reviewed in this article, including the results of studies implementing their use for interventional procedures. Pre-clinical and clinical experiences to date suggest these technologies have the potential to reduce procedure risk, time, and radiation dose to both the patient and the operator, with a valuable role to play for complex image-guided interventions.

Thai health education program for improving TB migrant's compliance.

PubMed

Khortwong, Pornsak; Kaewkungwal, Jaranit

2013-03-01

Investigate the effectiveness of health education programs by using the PRECEDE-PROCEED Model to improve non-Thai migrant TB patient's compliance during treatment. This quasi-intervention study was conducted in three targeted hospitals, between August 2009 and December 2010. The study sample consisted of 100 cases, 50 cases who registered in Samutsakorn Province served as the intervention group and 50 cases who registered in Samutprakarn Province served as the control group. At the end of the health education intervention, the intervention group showedsignificantly improved health-behavior scores in nine domains-health promotion, health education, predisposing, reinforcing, enabling factors, behavior and lifestyle, environment, and health status, which were also significantly higher than the control group (p < 0.001). The percentage of patients achieving successful treatment outcomes was 76% in the intervention group and 62% in the control group. The tuberculosis treatment and care program, and the associated health education interventions enabled migrants to complete the treatment regimen and achieve treatment success. It could also help TB staff develop an appropriate program and clear understanding of TB control among migrants. It is recommended that this type of information and health education program be used in other hospitals and healthcare settings providing TB services for migrants throughout the nation.

Correctional nursing: a study protocol to develop an educational intervention to optimize nursing practice in a unique context.

PubMed

Almost, Joan; Gifford, Wendy A; Doran, Diane; Ogilvie, Linda; Miller, Crystal; Rose, Don N; Squires, Mae

2013-06-21

Nurses are the primary healthcare providers in correctional facilities. A solid knowledge and expertise that includes the use of research evidence in clinical decision making is needed to optimize nursing practice and promote positive health outcomes within these settings. The institutional emphasis on custodial care within a heavily secured, regulated, and punitive environment presents unique contextual challenges for nursing practice. Subsequently, correctional nurses are not always able to obtain training or ongoing education that is required for broad scopes of practice. The purpose of the proposed study is to develop an educational intervention for correctional nurses to support the provision of evidence-informed care. A two-phase mixed methods research design will be used. The setting will be three provincial correctional facilities. Phase one will focus on identifying nurses' scope of practice and practice needs, describing work environment characteristics that support evidence-informed practice and developing the intervention. Semi-structured interviews will be completed with nurses and nurse managers. To facilitate priorities for the intervention, a Delphi process will be used to rank the learning needs identified by participants. Based on findings, an online intervention will be developed. Phase two will involve evaluating the acceptability and feasibility of the intervention to inform a future experimental design. The context of provincial correctional facilities presents unique challenges for nurses' provision of care. This study will generate information to address practice and learning needs specific to correctional nurses. Interventions tailored to barriers and supports within specific contexts are important to enable nurses to provide evidence-informed care.

Paths to improving care of Australian Aboriginal and Torres Strait Islander women following gestational diabetes.

PubMed

Campbell, Sandra; Roux, Nicolette; Preece, Cilla; Rafter, Eileen; Davis, Bronwyn; Mein, Jackie; Boyle, Jacqueline; Fredericks, Bronwyn; Chamberlain, Catherine

2017-11-01

Aim To understand enablers and barriers influencing postpartum screening for type 2 diabetes following gestational diabetes in Australian Indigenous women and how screening might be improved. Australian Indigenous women with gestational diabetes mellitus (GDM) are less likely than other Australian women to receive postpartum diabetes screening. This is despite a fourfold higher risk of developing type 2 diabetes within eight years postpartum. We conducted interviews with seven Indigenous women with previous GDM, focus groups with 20 Indigenous health workers and workshops with 24 other health professionals. Data collection included brainstorming, visualisation, sorting and prioritising activities. Data were analysed thematically using the Theoretical Domains Framework. Barriers are presented under the headings of 'capability', 'motivation' and 'opportunity'. Enabling strategies are presented under 'intervention' and 'policy' headings. Findings Participants generated 28 enabling environmental, educational and incentive interventions, and service provision, communication, guideline, persuasive and fiscal policies to address barriers to screening and improve postpartum support for women. The highest priorities included providing holistic social support, culturally appropriate resources, improving Indigenous workforce involvement and establishing structured follow-up systems. Understanding Indigenous women's perspectives, developing strategies with health workers and action planning with other health professionals can generate context-relevant feasible strategies to improve postpartum care after GDM. Importantly, we need evidence which can demonstrate whether the strategies are effective.

A feasibility study of the Mini-AFTER telephone intervention for the management of fear of recurrence in breast cancer survivors: a mixed-methods study protocol.

PubMed

Cruickshank, Susanne; Steel, Emma; Fenlon, Deborah; Armes, Jo; Scanlon, Karen; Banks, Elspeth; Humphris, Gerald

2018-01-01

Fear of recurrence (FoR) is a major concern for patients following treatment for primary breast cancer, affecting 60-99% of breast cancer survivors. Mini-AFTER is a brief intervention developed to address this fear, that breast care nurses are ideally placed to deliver. However, their interest in delivering such an intervention is unknown and crucial to its introduction. This study aims to assess the perceived feasibility of the Mini-AFTER telephone intervention for implementation by breast care nurses to manage moderate levels of fear of recurrence among breast cancer survivors. A sequential explanatory mixed-methods design will be used, informed by normalisation process theory (NPT). The design will be guided by the stages of NPT. Specifically, understanding and evaluating the process (implementation) that would enable an intervention, such as the Mini-AFTER, not only to be operationalised and normalised into everyday work (embedded) but also sustained in practice (integration). Phase 1: all members on the UK Breast Cancer Care Nursing Network database ( n  = 905) will be emailed a link to a web-based survey, designed to investigate how breast cancer survivors' FoR is identified and managed within current services and their willingness to deliver the Mini-AFTER. Phase 2: a purposive sample of respondents ( n  = 20) will be interviewed to build upon the responses in phase 1 and explore breast care nurses' individual views on the importance of addressing fear of recurrence in their clinical consultations, interest in the Mini-AFTER intervention, the content, skills required and challenges to deliver the intervention. This study will provide information about the willingness of breast care nurses (BCNs) to provide a structured intervention to manage fear of recurrence. It will identify barriers and facilitators for effective delivery and inform the future design of a larger trial of the Mini-AFTER intervention.

Engaging patients and families to create a feasible clinical trial integrating palliative and heart failure care: results of the ENABLE CHF-PC pilot clinical trial.

PubMed

Bakitas, Marie; Dionne-Odom, J Nicholas; Pamboukian, Salpy V; Tallaj, Jose; Kvale, Elizabeth; Swetz, Keith M; Frost, Jennifer; Wells, Rachel; Azuero, Andres; Keebler, Konda; Akyar, Imatullah; Ejem, Deborah; Steinhauser, Karen; Smith, Tasha; Durant, Raegan; Kono, Alan T

2017-08-31

Early palliative care (EPC) is recommended but rarely integrated with advanced heart failure (HF) care. We engaged patients and family caregivers to study the feasibility and site differences in a two-site EPC trial, ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers). We conducted an EPC feasibility study (4/1/14-8/31/15) for patients with NYHA Class III/IV HF and their caregivers in academic medical centers in the northeast and southeast U.S. The EPC intervention comprised: 1) an in-person outpatient palliative care consultation; and 2) telephonic nurse coach sessions and monthly calls. We collected patient- and caregiver-reported outcomes of quality of life (QOL), symptom, health, anxiety, and depression at baseline, 12- and 24-weeks. We used linear mixed-models to assess baseline to week 24 longitudinal changes. We enrolled 61 patients and 48 caregivers; between-site demographic differences included age, race, religion, marital, and work status. Most patients (69%) and caregivers (79%) completed all intervention sessions; however, we noted large between-site differences in measurement completion (38% southeast vs. 72% northeast). Patients experienced moderate effect size improvements in QOL, symptoms, physical, and mental health; caregivers experienced moderate effect size improvements in QOL, depression, mental health, and burden. Small-to-moderate effect size improvements were noted in patients' hospital and ICU days and emergency visits. Between-site demographic, attrition, and participant-reported outcomes highlight the importance of intervention pilot-testing in culturally diverse populations. Observations from this pilot feasibility trial allowed us to refine the methodology of an in-progress, full-scale randomized clinical efficacy trial. Clinicaltrials.gov NCT03177447 (retrospectively registered, June 2017).

Effects of a Problem-Solving Intervention (COPE) on Quality of Life for Patients with Advanced Cancer on Clinical Trials and their Caregivers: Simultaneous Care Educational Intervention (SCEI): Linking Palliation and Clinical Trials

PubMed Central

Carducci, Michael; Loscalzo, Matthew J.; Linder, John; Greasby, Tamara; Beckett, Laurel A.

2011-01-01

Abstract Context Patients on investigational clinical trials and their caregivers experience poor quality of life (QOL), which declines as the disease progresses. Objective To examine the effect of a standardized cognitive–behavioral problem-solving educational intervention on the QOL of patients enrolled on investigational clinical trials and their caregivers. Design Prospective, multi-institution, randomized trial. QOL was measured repeatedly over 6 months. Participants Patients were simultaneously enrolled onto phase 1, 2, or 3 Institutional Review Board (IRB)-approved cancer clinical trials. Intervention Intervention arm dyads participated in three conjoint educational sessions during the first month, learning the COPE problem solving model. Nonintervention arm dyads received usual care. Outcome Measures Global QOL was measured by the City of Hope Quality of Life Instruments for Patients or Caregivers; problem solving skills were measured by the Social Problem Solving Inventory-Revised. Results The results are reported using the CONSORT statement. The analytic data set included 476 dyads including 1596 patient data points and 1576 care giver data points. Patient QOL showed no significant difference in the rate of change between the intervention and usual care arms (p = 0.70). Caregiver QOL scores in the intervention arm declined, but at less than half the rate in the control arm (p = 0.02). Conclusions The COPE intervention enabled the average caregiver to come much closer to stable QOL over the 6-month follow-up. Future studies should enroll subjects much earlier in the cancer illness trajectory, a common patient/caregiver theme. The maximum effect was seen in caregivers who completed the 6-month follow-up, suggesting that the impact may increase over time. PMID:21413846

"It's not just about walking.....it's the practice nurse that makes it work": a qualitative exploration of the views of practice nurses delivering complex physical activity interventions in primary care.

PubMed

Beighton, Carole; Victor, Christina; Normansell, Rebecca; Cook, Derek; Kerry, Sally; Iliffe, Steve; Ussher, Michael; Whincup, Peter; Fox-Rushby, Julia; Woodcock, Alison; Harris, Tess

2015-12-12

Physical activity (PA) is important for physical and mental health in adults and older adults. Interventions incorporating theory-based behaviour change techniques (BCTs) can be useful in helping people to increase their PA levels and can be delivered by practice nurses in primary care. We undertook two primary care based complex walking interventions among adults and older adults. Both interventions were underpinned by BCTs and delivered by practice nurses and we sought their views and experiences of delivering over 1400 complex PA consultations. Semi structured interviews with two practice nurse groups (n = 4 and n = 5) and two individual interviews (total n = 11) were conducted by independent facilitators; audio-recorded, transcribed verbatim and analysed using thematic analysis. Five key themes emerged as enablers and/or barriers to delivering the intervention: preparation and training; initial and ongoing support; adherence to the protocol; the use of materials and equipment; and engagement of participants. The themes were organised into a framework of 'pre-trial' and 'delivery of the intervention'. Two additional 'post-trial' themes were identified; changed practice and the future feasibility of the intervention. Nurses believed that taking part in the trial, especially the BCT training, enhanced the quality and delivery of advice and support they provided within routine consultations, although the lack of time available routinely makes this challenging. Delivering an effective behaviour change intervention in primary care requires adequate training and support for practice nurses both initially and throughout the trial as well as adequate consultation time. Enhanced skills from participating in such trials can lead to long-term changes, including more patient-centred consulting. PACE-Lift ISRCTN 42122561 , PACE-UP ISRCTN 98538934 .

A population management system for improving colorectal cancer screening in a primary care setting.

PubMed

Wu, Charlotte A; Mulder, Amara L; Zai, Adrian H; Hu, Yuanshan; Costa, Manuela; Tishler, Lori Wiviott; Saltzman, John R; Ellner, Andrew L; Bitton, Asaf

2016-06-01

Provision of colorectal cancer (CRC) screening in primary care is suboptimal; failure to observe screening guidelines poses unnecessary risks to patients and doctors. Implement a population management system for CRC screening; evaluate impact on compliance with evidence-based guidelines. A quasi-experimental, prospective quality improvement study design using pre-post-analyses with concurrent controls. Six suites within an academic primary care practice. 5320 adults eligible for CRC screening treated by 70 doctors. In three intervention suites, doctors reviewed real-time rosters of patients due for CRC screening and chose practice delegate outreach or default reminder letter. Delegates tracked overdue patients, made outreach calls, facilitated test ordering, obtained records and documented patient deferral, exclusion or decline. In three control suites, doctors followed usual preventive care practices. CRC screening compliance (including documented decline, deferral or exclusion) and CRC screening completion rates over 5 months. At baseline, there was no significant difference in CRC screening compliance (I: 80.4% and C: 79.6%, P = 0.439) and CRC screening completion rates (I: 78.3% and C: 77.3%, P = 0.398) between intervention and control groups. Post-intervention, compliance rates (I: 88.1% and C: 80.5%, P < 0.01) and completion rates (I: 81.0% and C: 78.1%, P < 0.05) were significantly higher in the intervention group. A population management system using closed-loop communication may improve CRC screening compliance and completion rates within academic primary care practices. Team-based care using well-designed IT systems can enable sharing of patient care responsibilities and improve patient outcomes. © 2015 John Wiley & Sons, Ltd.

Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework.

PubMed

French, Simon D; Green, Sally E; O'Connor, Denise A; McKenzie, Joanne E; Francis, Jill J; Michie, Susan; Buchbinder, Rachelle; Schattner, Peter; Spike, Neil; Grimshaw, Jeremy M

2012-04-24

There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research. The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood? A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change. We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process.

Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework

PubMed Central

2012-01-01

Background There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research. Methods The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood? Results A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change. Conclusions We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process. PMID:22531013

'Imagine if I gave up smoking ...': a qualitative exploration of Aboriginal participants' perspectives of a self-management pilot training intervention.

PubMed

Chapple, Kimberley; Kowanko, Inge; Harvey, Peter; Chong, Alwin; Battersby, Malcolm

2016-01-01

This paper reports on a pilot qualitative study investigating Aboriginal participants' perspectives of the Flinders Living Well Smoke Free (LWSF) 'training intervention'. Health workers nationally have been trained in this program, which offers a self-management approach to reducing smoking among Aboriginal clients. A component of the training involves Aboriginal clients volunteering their time in a mock care-planning session providing the health workers with an opportunity to practise their newly acquired skills. During this simulation, the volunteer clients receive one condensed session of the LWSF intervention imitating how the training will be implemented when the health workers have completed the training. For the purpose of this study, 10 Aboriginal clients who had been volunteers in the mock care-planning process, underwent a semi-structured interview at seven sites in Australia, including mainstream health services, Aboriginal community controlled health services and remote Aboriginal communities. The study aimed to gauge their perspectives of the training intervention they experienced. Early indications suggest that Aboriginal volunteer clients responded positively to the process, with many reporting substantial health behaviour change or plans to make changes since taking part in this mock care-planning exercise. Enablers of the intervention are discussed along with factors to be considered in the training program.

The Patient Remote Intervention and Symptom Management System (PRISMS) - a Telehealth- mediated intervention enabling real-time monitoring of chemotherapy side-effects in patients with haematological malignancies: study protocol for a randomised controlled trial.

PubMed

Breen, Sibilah; Ritchie, David; Schofield, Penelope; Hsueh, Ya-Seng; Gough, Karla; Santamaria, Nick; Kamateros, Rose; Maguire, Roma; Kearney, Nora; Aranda, Sanchia

2015-10-19

Outpatient chemotherapy is a core treatment for haematological malignancies; however, its toxicities frequently lead to distressing/potentially life-threatening side-effects (neutropenia/infection, nausea/vomiting, mucositis, constipation/diarrhoea, fatigue). Early detection/management of side-effects is vital to improve patient outcomes, decrease morbidity and limit lengthy/costly hospital admissions. The ability to capture patient-reported health data in real-time, is regarded as the 'gold-standard' to allow rapid clinical decision-making/intervention. This paper presents the protocol for a Phase 3 multi-site randomised controlled trial evaluating a novel nurse-led Telehealth intervention for remote monitoring/management of chemotherapy side-effects in Australian haematological cancer patients. Two hundred and twenty-two patients will be recruited from two hospitals. Eligibility criteria include: diagnosis of chronic lymphocytic leukaemia/Hodgkin's/non-Hodgkin's lymphoma; aged ≥ 18 years; receiving ≥ 2 cycles chemotherapy. Patients will be randomised 1:1 to either the control or intervention arm with stratification by diagnosis, chemotherapy toxicity (high versus low), receipt of previous chemotherapy and hospital. Patients allocated to the control arm will receive 'Usual Care' whilst those allocated to the intervention will receive the intervention in addition to 'Usual Care'. Intervention patients will be provided with a computer tablet and software prompting twice-daily completion of physical/emotional scales for up to four chemotherapy cycles. Should patient data exceed pre-determined limits an Email alert is delivered to the treatment team, prompting nurses to view patient data, and contact the patient to provide clinical intervention. In addition, six scheduled nursing interventions will be completed to educate/support patients in use of the software. Patient outcomes will be measured cyclically (midpoint and end of cycles) via pen-and-paper self-report alongside review of the patient medical record. The primary outcome is burden due to nausea, mucositis, constipation and fatigue. Secondary outcomes include: burden due to vomiting and diarrhoea; psychological distress; ability to self-manage health; level of cancer information/support needs and; utilisation of health services. Analyses will be intention-to-treat. A cost-effectiveness analysis is planned. This trial is the first in the world to test a remote monitoring/management intervention for adult haematological cancer patients receiving chemotherapy. Future use of such interventions have the potential to improve patient outcomes/safety and decrease health care costs by enabling early detection/clinical intervention. ACTRN12614000516684 . Date registered: 12 March 2014 (registered retrospectively).

Principles of Point of Care Culture, the Spatial Care Path™, and Enabling Community and Global Resilience: Enabling Community and Global Resilience.

PubMed

Gerald, J Kost; William, J Ferguson; Laurie, E Kost

2014-09-01

This article a) defines point of care (POC) culture; b) presents seven underlying fundamental principles; c) describes the importance of needs assessment; d) introduces a new innovation, the spatial care path™; and e) illustrates how POC testing that properly fulfills needs and spatial care paths™ enable community and global resilience. Often, POC testing supplants the conventional clinical laboratory, which may be too distant, prohibitively expensive, or simply not available in limited-resource settings. New POC technologies "fit" future medical problem solving. Screening and testing directly in the home or primary care facilitate rapid diagnosis, monitoring, and treatment. In contrast to the past where attention has been placed on emergency departments, hospitals, and referral centers, the spatial care path™ starts with the patient and guides him or her through an efficient strategy of care in small-world networks (SWNs) defined by local geography and topology, long-standing customs, public health jurisdictions, and geographic information systems (GIS). POC testing needs in limited-resource settings are striking. Fulfillment is best guided by thorough understanding of POC culture. Quick feedback and fast decision-making by patients and physicians alike yield significant value that motivates changes in patient lifestyles and physician interactions. Culturally sensitive technology assimilation addresses leadership challenges in nations adapting to increasing populations of young and old, despite scarcity of resources. The spatial care path™ facilitates an essential balance of prevention and intervention in public health and shifts future focus to the patient, empowerment, and primary care within the context of POC culture.

Why Aren't Our Digital Solutions Working for Everyone?

PubMed

Winkle, Brian Van; Carpenter, Neil; Moscucci, Mauro

2017-11-01

The article explores a digital injustice that is occurring across the country: that digital solutions intended to increase health care access and quality often neglect those that need them most. It further shows that when it comes to digital innovation, health care professionals and technology companies rarely have any incentives to focus on underserved populations. Nevertheless, we argue that the technologies that are leaving these communities behind are the same ones that can best support them. The key is in leveraging these technologies with: (a) design features that accommodate various levels of technological proficiency (e-literacy), (b) tech-enabled community health workers and navigators who can function as liaisons between patients and clinicians, and (c) analytics and customer relationship management tools that enable health care professionals and support networks to provide the right interventions to the right patients. Finally, we argue that community health care workers will need to be incentivized to play a larger role in building and adopting innovations targeting the underserved. © 2017 American Medical Association. All Rights Reserved.

"Knowing I can be helpful makes me feel good inside, it makes me feel essential": community health care workers' experiences of conducting a home-based rehabilitation intervention for people living with HIV in KwaZulu-Natal, South Africa.

PubMed

Cobbing, Saul; Chetty, Verusia; Hanass-Hancock, Jill; Myezwa, Hellen

2017-10-01

People living with HIV (PLHIV) are living longer lives on antiretroviral therapy and are prone to a wide range of disabilities. Innovative strategies are required to meet the rehabilitation needs of PLHIV, particularly in resource-poor communities where HIV is endemic and access to institution-based rehabilitation is limited. Home-based rehabilitation (HBR) is one such approach, but there is a paucity of research related to HBR programmes for PLHIV or the experiences of community care workers (CCWs) involved in these programmes. Following a four month randomised controlled trial of a HBR intervention designed specifically for PLHIV in KwaZulu-Natal, South Africa; four CCWs were interviewed. This study employed a qualitative research design, using semi-structured interviews to explore these workers' experiences of being involved in carrying out this intervention. Participants reported how their personal development, improvement in their own health and increased feelings of self-worth enabled them to successfully implement the intervention. Participants also described a number of inhibitors, including stigma and environmental challenges related to the distances between patients' homes, the steep terrain and the hot climate. Despite this, the participants felt empowered by acquiring knowledge and skills that enabled them to shift roles beyond rehabilitation provision. The findings of this study should be considered when employing a task shifting approach in the development and implementation of HBR interventions for PLHIV. By employing a less specialised cadre of community workers to conduct basic HBR interventions, both the relative lack of qualified rehabilitation professionals and the high levels of disability in HIV-epidemic communities can be simultaneously addressed.

Health-social partnership intervention programme for community-dwelling older adults: a research protocol for a randomized controlled trial.

PubMed

Wong, Kwan Ching; Wong, Frances Kam Yuet; Chang, Katherine Ka Pik

2015-11-01

This paper aims to describe the research protocol that will be used to determine the effectiveness of a health-social partnership intervention programme among community-dwelling older adults. Ageing in place is a preferred option for overcoming challenges of the increasing prevalence of chronic diseases and the risk for hospitalization associated with the ageing population. Nevertheless, our knowledge of how to implement this concept is limited. The integrated efforts of health and social services may help to enable older adults to live with a sense of control over their daily life and to be independent to the fullest extent possible in the community. This is a randomized, controlled trial. Participants are community-dwelling older adults referred from a community centre. Sample size calculation was based on power analysis. The intervention group will receive the programme with the standard protocols guided by a comprehensive assessment-intervention-evaluation framework. Home visits and telephones follow-up will be employed as means of conducting the interventions and monitoring their progress. The customary care group will receive placebo social calls. The duration of the interventions will be 3 months. The study was funded by the School of Nursing in Hong Kong. Research Ethics Committee approval was obtained in September 2014. The results of this research are expected to enable older adults to stay in the community with optimal health and well-being. Health and social sciences are integrated into the practice in this research protocol. The scarce literature on this topic means that this study can also provide an opportunity to bridge the caring gap among older adults. © 2015 John Wiley & Sons Ltd.

Improving primary health care for people with learning disabilities.

PubMed

Bollard, M

'Signposts for Success' (Department of Health (DoH), 1998a) states that specialist learning disability services (SpLDS) must promote liaisons with, and offer specialist advice to, primary healthcare teams (PHCTs). With the advent primary care groups (DoH, 1998b), genuine collaboration and partnership-forging is necessary and timely to prevent people with learning disabilities being excluded from healthcare services. The project described in the article had three broad aims: first, to establish a practice register of people with learning disabilities in all practices involved in the project; second, to enable practice nurses (PNs), with support, to carry out a systematic health check within the practice of people with learning disabilities; and third, to enable the project nurse to act as a crucial link between SpLDS and the PHCT. The health checks highlighted unmet health and social needs, which were then met through appropriate referral and intervention, mainly to specialist services. Follow ups were conducted to measure any health gain as a result of the applied Interventions. Evidence of health gain was revealed, pointing to the clinical effectiveness of performing such checks within the PHCTs.

Implementing collaborative care for depression treatment in primary care: A cluster randomized evaluation of a quality improvement practice redesign

PubMed Central

2011-01-01

Background Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness. Methods The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM. For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months. Results Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003). Conclusions Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed. Trial Registration ClinicalTrials.gov: NCT00105820 PMID:22032247

Is home-based palliative care cost-effective? An economic evaluation of the Palliative Care Extended Packages at Home (PEACH) pilot.

PubMed

McCaffrey, Nikki; Agar, Meera; Harlum, Janeane; Karnon, Jonathon; Currow, David; Eckermann, Simon

2013-12-01

The aim of this study was to evaluate the cost-effectiveness of a home-based palliative care model relative to usual care in expediting discharge or enabling patients to remain at home. Economic evaluation of a pilot randomised controlled trial with 28 days follow-up. Mean costs and effectiveness were calculated for the Palliative Care Extended Packages at Home (PEACH) and usual care arms including: days at home; place of death; PEACH intervention costs; specialist palliative care service use; acute hospital and palliative care unit inpatient stays; and outpatient visits. PEACH mean intervention costs per patient ($3489) were largely offset by lower mean inpatient care costs ($2450) and in this arm, participants were at home for one additional day on average. Consequently, PEACH is cost-effective relative to usual care when the threshold value for one extra day at home exceeds $1068, or $2547 if only within-study days of hospital admission are costed. All estimates are high uncertainty. The results of this small pilot study point to the potential of PEACH as a cost-effective end-of-life care model relative to usual care. Findings support the feasibility of conducting a definitive, fully powered study with longer follow-up and comprehensive economic evaluation.

Mobilization of ventilated patients in the intensive care unit: An elicitation study using the theory of planned behavior.

PubMed

Holdsworth, Clare; Haines, Kimberley J; Francis, Jill J; Marshall, Andrea; O'Connor, Denise; Skinner, Elizabeth H

2015-12-01

Early mobilization in intensive care unit (ICU) is safe, feasible, and beneficial. However, mobilization frequently does not occur in practice. The study objective was to elicit attitudinal, normative, and control beliefs (barriers and enablers) toward the mobilization of ventilated patients, to inform development of targeted implementation interventions. A 9-item elicitation questionnaire was administered electronically to a convenience sample of multidisciplinary staff in a tertiary ICU. A snowball recruitment approach was used to target a sample size of 20 to 25. Two investigators performed word count and thematic analyses independently. Themes were cross-checked by a third investigator. Twenty-two questionnaires were completed. Respondents wrote the most text about disadvantages. Positive attitudinal beliefs included better respiratory function, reduced functional decline, and reduced muscle wasting/weakness. The main negative attitudinal beliefs were that mobilization is perceived as time consuming and poses a risk of line dislodgement/disconnection. Positive control beliefs (enablers) included increased staff availability, positive staff attitudes, engagement, and teamwork. Negative control beliefs (barriers) included unstable patient physiology and negative workplace culture. Intensive care unit staff expressed positive and negative attitudinal, normative, and control beliefs across the spectrum, and disadvantages were most frequently reported. Identified beliefs can be used to inform development of future interventions. Copyright © 2015 Elsevier Inc. All rights reserved.

Linkage to care among adults being investigated for tuberculosis in South Africa: pilot study of a case manager intervention.

PubMed

Maraba, Noriah; Chihota, Violet; McCarthy, Kerrigan; Churchyard, Gavin J; Grant, Alison D

2018-05-24

We piloted an intervention to determine if support from a case manager would assist adults being investigated for tuberculosis (TB) to link into TB and HIV care. Pilot interventional cohort study. Patients identified by primary healthcare clinic staff in South Africa as needing TB investigations were enrolled. Participants were supported for 3 months by case managers who facilitated the care pathway by promoting HIV testing, getting laboratory results, calling patients to return for results and facilitating treatment initiation. Linkage to TB care was defined as starting TB treatment within 28 days in those with a positive test result; linkage to HIV care, for HIV-positive people, was defined as having blood taken for CD4 count and, for those eligible, starting antiretroviral therapy within 3 months. Intervention implementation was measured by number of attempts to contact participants. Among 562 participants (307 (54.6%) female, median age: 36 years (IQR 29-44)), most 477 (84.8%) had previously tested for HIV; of these, 328/475 (69.1%) self-reported being HIV-positive. Overall, 189/562 (33.6%) participants needed linkage to care (132 HIV care linkage only; 35 TB treatment linkage only; 22 both). Of 555 attempts to contact these 189 participants, 407 were to facilitate HIV care linkage, 78 for TB treatment linkage and 70 for both. At the end of 3-month follow-up, 40 participants had not linked to care (29 of the 132 (22.0%) participants needing linkage to HIV care only, 4 of the 35 (11.4%) needing to start on TB treatment only and 7 of the 22 (31.8%) needing both). Many people testing for TB need linkage to care. Despite case manager support, non-linkage into HIV care remained higher than desirable, suggesting a need to modify this intervention before implementation. Innovative strategies to enable linkage to care are needed. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Examining the Heterogeneity and Cost Effectiveness of a Complex Intervention by Segmentation of Patients with Chronic Obstructive Pulmonary Disease.

PubMed

Sørensen, Sabrina Storgaard; Jensen, Morten Berg; Pedersen, Kjeld Møller; Ehlers, Lars

2018-02-01

To examine the heterogeneity in cost-effectiveness analyses of patient-tailored complex interventions. Latent class analysis (LCA) was performed on data from a randomized controlled trial evaluating a patient-tailored case management strategy for patients suffering from chronic obstructive pulmonary disease (COPD). LCA was conducted on detailed process variables representing service variation in the intervention group. Features of the identified latent classes were compared for consistency with baseline demographic, clinical, and economic characteristics for each class. Classes for the control group, corresponding to the identified latent classes for the intervention group, were identified using multinomial logistic regression. Cost-utility analyses were then conducted at the class level, and uncertainty surrounding the point estimates was assessed by probabilistic sensitivity analysis. The LCA identified three distinct classes: the psychologically care class, the extensive COPD care class, and the limited COPD care class. Patient baseline characteristics were in line with the features identified in the LCA. Evaluation of cost-effectiveness revealed highly disparate results, and case management for only the extensive COPD care class appeared cost-effective with an incremental cost-effectiveness ratio of £26,986 per quality-adjusted life-year gained using the threshold value set by the National Institute of Health and Care Excellence. Findings indicate that researchers evaluating patient-tailored complex interventions need to address both supply-side variation and demand-side heterogeneity to link findings with outcome. The article specifically proposes the use of LCA because it is believed to have the potential to enable more appropriate targeting of complex care strategies. Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Evaluation of nurses' changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care: a qualitative study.

PubMed

Roets-Merken, Lieve M; Vernooij-Dassen, Myrra J F J; Zuidema, Sytse U; Dees, Marianne K; Hermsen, Pieter G J M; Kempen, Gertrudis I J M; Graff, Maud J L

2016-11-17

To gain insights into the process of nurses' changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care, and into the factors that contributed to these changes in their perceptions. Qualitative study alongside a cluster randomised controlled trial. 17 long-term care homes spread across the Netherlands. 34 licensed practical nurses supporting 54 dual sensory impaired older adults. A 5-month training programme designed to enable nurses to support the self-management of dual sensory impaired older adults in long-term care. Nurses' perceptions on relevance and feasibility of the self-management programme collected from nurses' semistructured coaching diaries over the 5-month training and intervention period, as well as from trainers' reports. Nurses' initial negative perceptions on relevance and feasibility of the intervention changed to positive as nurses better understood the concept of autonomy. Through interactions with older adults and by self-evaluations of the effect of their behaviour, nurses discovered that their usual care conflicted with client autonomy. From that moment, nurses felt encouraged to adapt their behaviour to the older adults' autonomy needs. However, nurses' initial unfamiliarity with conversation techniques required a longer exploration period than planned. Once client autonomy was understood, nurses recommended expanding the intervention as a generic approach to all their clients, whether dual sensory impaired or not. Longitudinal data collection enabled exploration of nurses' changes in perceptions when moving towards self-management support. The training programme stimulated nurses to go beyond 'protocol thinking', discovering client autonomy and exploring the need for their own behavioural adaptations. Educational programmes for practical nurses should offer more longitudinal coaching of autonomy supportive conversational skills. Intervention programming should acknowledge that change is a process rather than an event, and should include self-evaluations of professional behaviours over a period of time. NCT01217502, Post-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Detection and management of familial hypercholesterolaemia in primary care in Australia: protocol for a pragmatic cluster intervention study with pre-post intervention comparisons.

PubMed

Arnold-Reed, Diane E; Brett, Tom; Troeung, Lakkhina; Vickery, Alistair; Garton-Smith, Jacquie; Bell, Damon; Pang, Jing; Grace, Tegan; Bulsara, Caroline; Li, Ian; Bulsara, Max; Watts, Gerald F

2017-10-22

Familial hypercholesterolaemia (FH), an autosomal dominant disorder of lipid metabolism, results in accelerated onset of atherosclerosis if left untreated. Lifelong treatment with diet, lifestyle modifications and statins enable a normal lifespan for most patients. Early diagnosis is critical. This protocol trials a primary care-based model of care (MoC) to improve detection and management of FH. Pragmatic cluster intervention study with pre-post intervention comparisons in Australian general practices. At study baseline, current FH detection practice is assessed. Medical records over 2 years are electronically scanned using a data extraction tool (TARB-Ex) to identify patients at increased risk. High-risk patients are clinically reviewed to provide definitive, phenotypic diagnosis using Dutch Lipid Clinic Network Criteria. Once an index family member with FH is identified, the primary care team undertake cascade testing of first-degree relatives to identify other patients with FH. Management guidance based on disease complexity is provided to the primary care team. Study follow-up to 12 months with TARB-Ex rerun to identify total number of new FH cases diagnosed over study period (via TARB-Ex, cascade testing and new cases presenting). At study conclusion, patient and clinical staff perceptions of enablers/barriers and suggested improvements to the approach will be examined. Resources at each stage will be traced to determine the economic implications of implementing the MoC and costed from health system perspective. Primary outcomes: increase in number of index cases clinically identified; reduction in low-density lipoprotein cholesterol of treated cases. increase in the number of family cases detected/contacted; cost implications of the MoC. Study approval by The University of Notre Dame Australia Human Research Ethics Committee Protocol ID: 0 16 067F. Registration: Australian New Zealand Clinical Trials Registry ID: 12616000630415. Information will be disseminated via research seminars, conference presentations, journal articles, media releases and community forums. Australian New Zealand Clinical Trials Registry ID 12616000630415; Pre-results. © 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.

The Empirical Foundations of Telemedicine Interventions in Primary Care.

PubMed

Bashshur, Rashid L; Howell, Joel D; Krupinski, Elizabeth A; Harms, Kathryn M; Bashshur, Noura; Doarn, Charles R

2016-05-01

This article presents the scientific evidence for the merits of telemedicine interventions in primary care. Although there is no uniform and consistent definition of primary care, most agree that it occupies a central role in the healthcare system as first contact for patients seeking care, as well as gatekeeper and coordinator of care. It enables and supports patient-centered care, the medical home, managed care, accountable care, and population health. Increasing concerns about sustainability and the anticipated shortages of primary care physicians have sparked interest in exploring the potential of telemedicine in addressing many of the challenges facing primary care in the United States and the world. The findings are based on a systematic review of scientific studies published from 2005 through 2015. The initial search yielded 2,308 articles, with 86 meeting the inclusion criteria. Evidence is organized and evaluated according to feasibility/acceptance, intermediate outcomes, health outcomes, and cost. The majority of studies support the feasibility/acceptance of telemedicine for use in primary care, although it varies significantly by demographic variables, such as gender, age, and socioeconomic status, and telemedicine has often been found more acceptable by patients than healthcare providers. Outcomes data are limited but overall suggest that telemedicine interventions are generally at least as effective as traditional care. Cost analyses vary, but telemedicine in primary care is increasingly demonstrated to be cost-effective. Telemedicine has significant potential to address many of the challenges facing primary care in today's healthcare environment. Challenges still remain in validating its impact on clinical outcomes with scientific rigor, as well as in standardizing methods to assess cost, but patient and provider acceptance is increasingly making telemedicine a viable and integral component of primary care around the world.

The Empirical Foundations of Telemedicine Interventions in Primary Care

PubMed Central

Howell, Joel D.; Krupinski, Elizabeth A.; Harms, Kathryn M.; Bashshur, Noura; Doarn, Charles R.

2016-01-01

Abstract Introduction: This article presents the scientific evidence for the merits of telemedicine interventions in primary care. Although there is no uniform and consistent definition of primary care, most agree that it occupies a central role in the healthcare system as first contact for patients seeking care, as well as gatekeeper and coordinator of care. It enables and supports patient-centered care, the medical home, managed care, accountable care, and population health. Increasing concerns about sustainability and the anticipated shortages of primary care physicians have sparked interest in exploring the potential of telemedicine in addressing many of the challenges facing primary care in the United States and the world. Materials and Methods: The findings are based on a systematic review of scientific studies published from 2005 through 2015. The initial search yielded 2,308 articles, with 86 meeting the inclusion criteria. Evidence is organized and evaluated according to feasibility/acceptance, intermediate outcomes, health outcomes, and cost. Results: The majority of studies support the feasibility/acceptance of telemedicine for use in primary care, although it varies significantly by demographic variables, such as gender, age, and socioeconomic status, and telemedicine has often been found more acceptable by patients than healthcare providers. Outcomes data are limited but overall suggest that telemedicine interventions are generally at least as effective as traditional care. Cost analyses vary, but telemedicine in primary care is increasingly demonstrated to be cost-effective. Conclusions: Telemedicine has significant potential to address many of the challenges facing primary care in today's healthcare environment. Challenges still remain in validating its impact on clinical outcomes with scientific rigor, as well as in standardizing methods to assess cost, but patient and provider acceptance is increasingly making telemedicine a viable and integral component of primary care around the world. PMID:27128779

Knowledge enabled plan of care and documentation prototype.

PubMed

DaDamio, Rebecca; Gugerty, Brian; Kennedy, Rosemary

2006-01-01

There exist significant challenges in integrating the plan of care into documentation and point of care operational processes. A plan of care is often a static artifact that meets regulatory standards with limited influence on supporting goal-directed care delivery processes. Although this prototype is applicable to many clinical disciplines, we will highlight nursing processes in demonstrating a knowledge-driven computerized solution that fully integrates the plan of care within documentation. The knowledge-driven solution reflects evidenced-based practice; is an effective tool for managing problems, orders/interventions, and the patient's progress towards expected outcomes; meets regulatory standards; and drives quality and process improvement. The knowledge infrastructure consists of fully represented terminology, structured clinical expressions utilizing the controlled terminology and clinical knowledge representing evidence-based practice.

Quasi-experiments to establish causal effects of HIV care and treatment and to improve the cascade of care

PubMed Central

Bor, Jacob; Geldsetzer, Pascal; Venkataramani, Atheendar; Bärnighausen, Till

2015-01-01

Purpose of review Randomized, population-representative trials of clinical interventions are rare. Quasi-experiments have been used successfully to generate causal evidence on the cascade of HIV care in a broad range of real-world settings. Recent findings Quasi-experiments exploit exogenous, or quasi-random, variation occurring naturally in the world or because of an administrative rule or policy change to estimate causal effects. Well designed quasi-experiments have greater internal validity than typical observational research designs. At the same time, quasi-experiments may also have potential for greater external validity than experiments and can be implemented when randomized clinical trials are infeasible or unethical. Quasi-experimental studies have established the causal effects of HIV testing and initiation of antiretroviral therapy on health, economic outcomes and sexual behaviors, as well as indirect effects on other community members. Recent quasi-experiments have evaluated specific interventions to improve patient performance in the cascade of care, providing causal evidence to optimize clinical management of HIV. Summary Quasi-experiments have generated important data on the real-world impacts of HIV testing and treatment and on interventions to improve the cascade of care. With the growth in large-scale clinical and administrative data, quasi-experiments enable rigorous evaluation of policies implemented in real-world settings. PMID:26371463

Quasi-experiments to establish causal effects of HIV care and treatment and to improve the cascade of care.

PubMed

Bor, Jacob; Geldsetzer, Pascal; Venkataramani, Atheendar; Bärnighausen, Till

2015-11-01

Randomized, population-representative trials of clinical interventions are rare. Quasi-experiments have been used successfully to generate causal evidence on the cascade of HIV care in a broad range of real-world settings. Quasi-experiments exploit exogenous, or quasi-random, variation occurring naturally in the world or because of an administrative rule or policy change to estimate causal effects. Well designed quasi-experiments have greater internal validity than typical observational research designs. At the same time, quasi-experiments may also have potential for greater external validity than experiments and can be implemented when randomized clinical trials are infeasible or unethical. Quasi-experimental studies have established the causal effects of HIV testing and initiation of antiretroviral therapy on health, economic outcomes and sexual behaviors, as well as indirect effects on other community members. Recent quasi-experiments have evaluated specific interventions to improve patient performance in the cascade of care, providing causal evidence to optimize clinical management of HIV. Quasi-experiments have generated important data on the real-world impacts of HIV testing and treatment and on interventions to improve the cascade of care. With the growth in large-scale clinical and administrative data, quasi-experiments enable rigorous evaluation of policies implemented in real-world settings.

Depression in Cardiovascular Patients in Middle Eastern Populations: A Literature Review.

PubMed

Donnelly, Tam Truong; Al Suwaidi, Jassim Mohd; Al-Qahtani, Awad; Asaad, Nidal; Qader, Najlaa Abdul; Singh, Rajvir; Fung, Tak Shing; Mueed, Irem; Sharara, Shima; El Banna, Noha; Omar, Sarah

2015-08-01

Cardiovascular disease (CVD) is increasing in Middle Eastern countries. Depression is associated with increased morbidity and mortality rates among cardiovascular (CV) patients. Early detection of and intervention for depression among CV patients can reduce morbidity and mortality and save health care costs. Public information on mental health care needs of Arab CV patients living in Middle East regions is scattered and limited. This literature review surveyed and summarized research studies to learn what is known about the relationship between depression and CVD in Middle Eastern populations. The information will raise awareness among health care professionals and policy makers regarding the clinical significance of depression in Arab CV patients. It might contribute to development of culturally appropriate and effective mental health care services. Multiple databases were searched and 60 articles were assessed, including studies that investigated depression in Arab CV patient populations, physiological mechanisms of depression-CVD comorbidity, and intervention strategies that affect CV risk in depressed Arab patients. We discuss the extent to which this issue has been explored in Arab populations living in Middle East regions and Arab populations living abroad. We recommend that more comprehensive and in-depth research studies be conducted with Arab cardiac patients to enable implementation of culturally appropriate and effective mental health care interventions.

Intravenous vitamin C in the supportive care of cancer patients: a review and rational approach

PubMed Central

Klimant, E.; Wright, H.; Rubin, D.; Seely, D.; Markman, M.

2018-01-01

This article reviews intravenous vitamin C (IV C) in cancer care and offers a rational approach to enable medical oncologists and integrative practitioners to safely provide IV C combined with oral vitamin C to patients. The use of IV C is a safe supportive intervention to decrease inflammation in the patient and to improve symptoms related to antioxidant deficiency, disease processes, and side effects of standard cancer treatments. A proposed rationale, together with relevant clinical safety considerations for the application of IV C in oncologic supportive care, is provided. PMID:29719430

The effects of health sector market factors and vulnerable group membership on access to alcohol, drug, and mental health care.

PubMed

Stockdale, Susan E; Tang, Lingqi; Zhang, Lily; Belin, Thomas R; Wells, Kenneth B

2007-06-01

This study adapts Andersen's Behavioral Model to determine if health sector market conditions affect vulnerable subgroups' use of alcohol, drug, and mental health services (ADM) differently than the general population, focusing specifically on community-level predisposing and enabling characteristics. Wave 2 data (2000-2001) from the Health Care for Communities study, supplemented with cases from wave 1 (1997-1998), were merged with area characteristics taken from Census, Area Resource File (ARF), and other data sources. The study used four-level hierarchical logistic regression to examine access to ADM care from any provider and specialty ADM access. Interactions between community-level predisposing and enabling vulnerability characteristics with individual race/ethnicity, age, income category, and insurance type were explored. Nonwhites, the poor, uninsured, and elderly had lower likelihoods of service use, but interactions between race/ethnicity, income, age and insurance status with community-level vulnerability factors were not statistically significant for any service use. For ADM specialty care, those with Medicare, Medicaid, private fully managed, and private partially managed insurance, the likelihood of utilization was higher in areas with higher HMO penetration. However, for those with other insurance or no insurance plan, the likelihood of utilization was lower in areas with higher HMO penetration. Community-level enabling factors explain part of the effect of disadvantaged status but, with the exception of the effect of HMO penetration on the relationship between insurance and specialty care use, do not modify any of the residual individual-level effects of disadvantage. Interventions targeting both structural and individual levels may be necessary to address the problem of health disparities. More research with longitudinal data is necessary to sort out the causal direction of social context and ADM access outcomes, and whether policy interventions to change health sector market conditions can shift ADM treatment utilization.

Precision nutrition - review of methods for point-of-care assessment of nutritional status.

PubMed

Srinivasan, Balaji; Lee, Seoho; Erickson, David; Mehta, Saurabh

2017-04-01

Precision nutrition encompasses prevention and treatment strategies for optimizing health that consider individual variability in diet, lifestyle, environment and genes by accurately determining an individual's nutritional status. This is particularly important as malnutrition now affects a third of the global population, with most of those affected or their care providers having limited means of determining their nutritional status. Similarly, program implementers often have no way of determining the impact or success of their interventions, thus hindering their scale-up. Exciting new developments in the area of point-of-care diagnostics promise to provide improved access to nutritional status assessment, as a first step towards enabling precision nutrition and tailored interventions at both the individual and community levels. In this review, we focus on the current advances in developing portable diagnostics for assessment of nutritional status at point-of-care, along with the numerous design challenges in this process and potential solutions. Copyright © 2016 Elsevier Ltd. All rights reserved.

Moving beyond caregiver burden: identifying helpful interventions for family caregivers.

PubMed

Sorrell, Jeanne M

2014-03-01

Family members serving as informal caregivers for loved ones often experience physical, psychological, emotional, social, and financial consequences that can be conceptualized as caregiver burden. As the number of older adults in our society continues to increase, there will be even more demand for family caregivers. It is important to move beyond a focus on the statistics and characteristics of caregiver burden and identify helpful interventions to reduce this burden. Interventions that decrease caregiver burden can enable family caregivers to delay placement of the individual in an institutional setting and improve quality of life for both the caregiver and care recipient. Copyright 2014, SLACK Incorporated.

Suicide Prevention Strategies for Improving Population Health.

PubMed

Wilcox, Holly C; Wyman, Peter A

2016-04-01

Suicide is a public health problem that accounts for more than 1 million deaths annually worldwide. This article addresses evidence-based and promising youth suicide prevention approaches at the primary, secondary, and tertiary levels. Coordinated, developmentally timed, evidence-based suicide prevention approaches at all intervention levels are likely to reduce youth suicide. For most youth who die by suicide, there are opportunities for intervention before imminent risk develops. Current research in suicide prevention points to the value of investing in "upstream" universal interventions that build skills and resilience as well as policies that enable access to care and protection from lethal means. Copyright © 2016 Elsevier Inc. All rights reserved.

Conducting experimental research in marginalised populations: clinical and methodological implications from a mixed-methods randomised controlled trial in Kenya.

PubMed

Lowther, Keira; Harding, Richard; Ahmed, Aabid; Gikaara, Nancy; Ali, Zippy; Kariuki, Hellen; Sherr, Lorraine; Simms, Victoria; Selman, Lucy

2016-01-01

Experimental studies to test interventions for people living with HIV in low- and middle-income countries are essential to ensure appropriate and effective clinical care. The implications of study participation on outcome data in such populations have been discussed theoretically, but rarely empirically examined. We aimed to explore the effects of participating in a randomised controlled trial conducted in an HIV clinic in Mombasa, Kenya. We report qualitative data from the Treatment Outcomes in Palliative Care trial, which evaluated the impact of a nurse-led palliative care intervention for HIV positive adults on antiretroviral therapy compared to standard care. Participants in both arms attended five monthly quantitative data collection appointments. Post-trial exit, 10 control and 20 intervention patients participated in semi-structured qualitative interviews, analysed using thematic analysis. We found benefit attributed to the compassion of the research team, social support, communication, completion of patient reported outcome measures (PROMs) and material support (transport reimbursement). Being treated with compassion and receiving social support enabled participants to build positive relationships with the research team, which improved mental health and well-being. Open and non-judgmental communication made participants feel accepted. Participants described how repeated completion of the PROMs was a prompt for reflection, through which they began to help themselves and self-care. Participant reimbursements relieved financial hardship and enabled them to fulfil their social responsibilities, enhancing self-worth. These findings emphasise the importance of compassion, support and effective communication in the clinical encounter, particularly in stigmatised and isolated populations, and the potential of the integration of simple PROMs to improve patient outcomes. Participation in research has unexpected positive benefits for participants, which should be taken into account when designing research in similar populations. Researchers should be aware of the effects of financial reimbursement and contact with researchers in isolated and impoverished communities.

Investigating the health profile of patients with end-stage renal failure receiving peritoneal dialysis: a cluster analysis.

PubMed

Chan, M F; Wong, Frances K Y; Chow, Susan K Y

2010-03-01

To determine whether the patients with end stage renal failure can be differentiated into several subtypes based on five main variables. There is a lack of interventional research linking to clinical outcomes among the patients with end stage renal failure in Hong Kong and with no clear evidence of differences in terms of their clinical/health outcomes and characteristics. A cross-sectional survey. Data were collected using a structured questionnaire. One hundred and fifty-three patients with end stage renal failure were recruited during 2007 at three renal centres in Hong Kong. Five main variables were employed: predisposing characteristic, enabling resources, quality of life, symptom control and self-care adherence. A cluster analysis yielded two clusters. Each cluster represented a different profile of patients with end stage renal failure. Cluster A consisted of 49.7% (n = 76) and Cluster B consisted of 50.3% (n = 77) of the patients. Cluster A patients, more of whom were women, were older, less educated, had higher quality of life scores, a better adherence rate and more had received nursing care supports than patients in Cluster B. We have identified two groupings of patients with end stage renal failure who were experiencing unique health profile. Nursing support services may have an effect on patient health outcomes but only on a group of patients whose profile is similar to the patients in Cluster A and not for patients in Cluster B. A clear profile may help health care professional make appropriate strategies to target a specific group of patients to improve patient outcomes. The identification of risk for future health-care use could enable better targeting of interventional strategies in these groups. The results of this study might provide health care professionals with a model to design specified interventions to improve life quality for each profile group.

Using embedded music therapy interventions to support outdoor play of young children with autism in an inclusive community-based child care program.

PubMed

Kern, Petra; Aldridge, David

2006-01-01

For young children with autism enrolled in community-based inclusive child care programs, outdoor play can be a major challenge. The aim of this music therapy intervention was to improve peer interactions and meaningful play on the playground for four boys with autism by adding an outdoor music center and using original songs composed for each participant. A collaborative approach was used to support the implementation of the intervention by the children's teachers, engaging classroom peers as formal and informal helpers. The effects of the interventions were examined using a multiple baseline design with four conditions replicated across the four children. The results indicate that the musical adaptation of the playground itself did not improve social interactions of children with autism significantly, but it facilitated their play and involvement with peers by attraction to the sound and opportunity to use the instruments. The song interventions produced desirable peer interaction outcomes, and the collaborative consultative approach enabled teachers to implement interventions successfully in ongoing playground routines. In addition, peer-mediated strategies increased peer interactions and meaningful play on the playground.

Developing family-centred care in a neonatal intensive care unit: An action research study.

PubMed

Skene, Caryl; Gerrish, Kate; Price, Fiona; Pilling, Elizabeth; Bayliss, Pauline; Gillespie, Siobhan

2018-06-21

To develop, implement and evaluate family-centred interventions to promote parental involvement in caregiving in a Neonatal Intensive Care Unit. A participatory action research approach was used to implement two changes in practice a) improved skin-to-skin contact b) unlimited parental presence at the cot-side. The changes were underpinned by a family-centred philosophy of care and education. Data were collected from staff using a questionnaire, focus groups and interviews, and from parents using focus groups and interviews. Qualitative data were analysed using Framework and quantitative data analysed using descriptive and t-test statistics. A Neonatal Intensive Care Unit in England. Changes in practice were successfully implemented. Nurses reported positively on improvements in Family Centred Care; most notably information-sharing with parents, providing family support, enabling parental participation in care and improved competence supporting parents in care-giving. These changes were reflected in parental feedback. Understanding the context of the neonatal unit can support cultural change when change is actively facilitated and owned by the staff concerned. Acknowledging parents as the main caregiver can be challenging for nurses and they require support and education to enable them to manage the changes necessary to provide Family-Centred Care. Copyright © 2018 Elsevier Ltd. All rights reserved.

Providing activity for people with dementia in care homes: a cluster randomised controlled trial.

PubMed

Wenborn, Jennifer; Challis, David; Head, Jenny; Miranda-Castillo, Claudia; Popham, Carolyn; Thakur, Ruchi; Illes, Jacqueline; Orrell, Martin

2013-12-01

Activity levels remain low in care homes, but activity engagement can enhance residents' quality of life. This study aimed to assess an occupational therapy programme designed to enable care home staff to increase activity provision. A cluster randomised controlled trial with blinded assessment of outcome was conducted. A total of 210 residents with dementia in 16 care homes were recruited. Intervention homes received the programme, and control homes were provided usual care. Primary outcome is quality of life; secondary measures are dependency, challenging behaviour, depression, anxiety, severity of dementia and number and type of medication. Quality of life decreased overall with statistically significant change in staff ratings (p < 0.001). At follow-up, staff-rated quality of life was slightly lower in the intervention group (mean difference in staff ratings = -1.91, 95% CI -3.39 to -0.43, p = 0.01). There were no significant differences between the two groups for self-rated quality of life or secondary outcomes. The results may be related to the following: wide variability in how the intervention was implemented, such as low staff attendance at the education and coaching sessions, and patchy provision of additional activities to residents; or the residents' severity of dementia or the choice of outcome measures. Future studies need to pay more attention to process measures such as implementation and fidelity strategies, and outcome measures that better capture the focus of the intervention such as level of engagement and activity. Copyright © 2013 John Wiley & Sons, Ltd.

Clinical trials in palliative care: a systematic review of their methodological characteristics and of the quality of their reporting.

PubMed

Bouça-Machado, Raquel; Rosário, Madalena; Alarcão, Joana; Correia-Guedes, Leonor; Abreu, Daisy; Ferreira, Joaquim J

2017-01-25

Over the past decades there has been a significant increase in the number of published clinical trials in palliative care. However, empirical evidence suggests that there are methodological problems in the design and conduct of studies, which raises questions about the validity and generalisability of the results and of the strength of the available evidence. We sought to evaluate the methodological characteristics and assess the quality of reporting of clinical trials in palliative care. We performed a systematic review of published clinical trials assessing therapeutic interventions in palliative care. Trials were identified using MEDLINE (from its inception to February 2015). We assessed methodological characteristics and describe the quality of reporting using the Cochrane Risk of Bias tool. We retrieved 107 studies. The most common medical field studied was oncology, and 43.9% of trials evaluated pharmacological interventions. Symptom control and physical dimensions (e.g. intervention on pain, breathlessness, nausea) were the palliative care-specific issues most studied. We found under-reporting of key information in particular on random sequence generation, allocation concealment, and blinding. While the number of clinical trials in palliative care has increased over time, methodological quality remains suboptimal. This compromises the quality of studies. Therefore, a greater effort is needed to enable the appropriate performance of future studies and increase the robustness of evidence-based medicine in this important field.

Kangaroo mother care: a systematic review of barriers and enablers.

PubMed

Chan, Grace J; Labar, Amy S; Wall, Stephen; Atun, Rifat

2016-02-01

To investigate factors influencing the adoption of kangaroo mother care in different contexts. We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization's regional databases, for studies on "kangaroo mother care" or "kangaroo care" or "skin-to-skin care" from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems. We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption. Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake.

Two-year Follow-up of a Pragmatic Randomised Controlled Trial Examining the Effect of Adding a Carer's Skill Training Intervention in Inpatients with Anorexia Nervosa.

PubMed

Magill, Nicholas; Rhind, Charlotte; Hibbs, Rebecca; Goddard, Elizabeth; Macdonald, Pamela; Arcelus, Jon; Morgan, John; Beecham, Jennifer; Schmidt, Ulrike; Landau, Sabine; Treasure, Janet

2016-03-01

Active family engagement improves outcomes from adolescent inpatient care, but the impact on adult anorexia nervosa is uncertain. The aim of this study was to describe the 2-year outcome following a pragmatic randomised controlled trial in which a skill training intervention (Experienced Caregivers Helping Others) for carers was added to inpatient care. Patient, caregiver and service outcomes were measured for 2 years following discharge from the index inpatient admission. There were small-sized/moderate-sized effects and consistent improvements in all outcomes from both patients and carers in the Experienced Caregivers Helping Others group over 2 years. The marked change in body mass index and carers' time caregiving following inpatient care was sustained. Approximately 20% of cases had further periods of inpatient care. In this predominately adult anorexia nervosa sample, enabling carers to provide active support and management skills may improve the benefits in all symptom domains that gradually follow from a period of inpatient care. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.

Workplace deviance: strategies for modifying employee behavior.

PubMed

Pulich, Marcia; Tourigny, Louise

2004-01-01

More than ever, today's health care employees must perform their jobs as efficiently and effectively as possible. Job performance must integrate both technical and necessary soft skills. Workplace deviant behaviors are counterproductive to good job performance. Various deviant behaviors are examined. Areas and strategies of managerial intervention are reviewed which will enable the prevention or modification of undesired employee behaviors.

Default options in advance directives: study protocol for a randomised clinical trial.

PubMed

Gabler, Nicole B; Cooney, Elizabeth; Small, Dylan S; Troxel, Andrea B; Arnold, Robert M; White, Douglas B; Angus, Derek C; Loewenstein, George; Volpp, Kevin G; Bryce, Cindy L; Halpern, Scott D

2016-06-06

Although most seriously ill Americans wish to avoid burdensome and aggressive care at the end of life, such care is often provided unless patients or family members specifically request otherwise. Advance directives (ADs) were created to provide opportunities to set limits on aggressive care near life's end. This study tests the hypothesis that redesigning ADs such that comfort-oriented care is provided as the default, rather than requiring patients to actively choose it, will promote better patient-centred outcomes. This multicentre trial randomises seriously ill adults to receive 1 of 3 different ADs: (1) a traditional AD that requires patients to actively choose their goals of care or preferences for specific interventions (eg, feeding tube insertion) or otherwise have their care guided by their surrogates and the prevailing societal default toward aggressive care; (2) an AD that defaults to life-extending care and receipt of life-sustaining interventions, enabling patients to opt out from such care; or (3) an AD that defaults to comfort care, enabling patients to opt into life-extending care. We seek to enrol 270 patients who return complete, legally valid ADs so as to generate sufficient power to detect differences in the primary outcome of hospital-free days (days alive and not in an acute care facility). Secondary outcomes include hospital and intensive care unit admissions, costs of care, hospice usage, decision conflict and satisfaction, quality of life, concordance of preferences with care received and bereavement outcomes for surrogates of patients who die. This study has been approved by the Institutional Review Boards at all trial centres, and is guided by a data safety and monitoring board and an ethics advisory board. Study results will be disseminated using methods that describe the results in ways that key stakeholders can best understand and implement. NCT02017548; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Clinical- and cost-effectiveness of the STAR care pathway compared to usual care for patients with chronic pain after total knee replacement: study protocol for a UK randomised controlled trial.

PubMed

Wylde, Vikki; Bertram, Wendy; Beswick, Andrew D; Blom, Ashley W; Bruce, Julie; Burston, Amanda; Dennis, Jane; Garfield, Kirsty; Howells, Nicholas; Lane, Athene; McCabe, Candy; Moore, Andrew J; Noble, Sian; Peters, Tim J; Price, Andrew; Sanderson, Emily; Toms, Andrew D; Walsh, David A; White, Simon; Gooberman-Hill, Rachael

2018-02-21

Approximately 20% of patients experience chronic pain after total knee replacement. There is little evidence for effective interventions for the management of this pain, and current healthcare provision is patchy and inconsistent. Given the complexity of this condition, multimodal and individualised interventions matched to pain characteristics are needed. We have undertaken a comprehensive programme of work to develop a care pathway for patients with chronic pain after total knee replacement. This protocol describes the design of a randomised controlled trial to evaluate the clinical- and cost-effectiveness of a complex intervention care pathway compared with usual care. This is a pragmatic two-armed, open, multi-centred randomised controlled trial conducted within secondary care in the UK. Patients will be screened at 2 months after total knee replacement and 381 patients with chronic pain at 3 months postoperatively will be recruited. Recruitment processes will be optimised through qualitative research during a 6-month internal pilot phase. Patients are randomised using a 2:1 intervention:control allocation ratio. All participants receive usual care as provided by their hospital. The intervention comprises an assessment clinic appointment at 3 months postoperatively with an Extended Scope Practitioner and up to six telephone follow-up calls over 12 months. In the assessment clinic, a standardised protocol is followed to identify potential underlying causes for the chronic pain and enable appropriate onward referrals to existing services for targeted and individualised treatment. Outcomes are assessed by questionnaires at 6 and 12 months after randomisation. The co-primary outcomes are pain severity and pain interference assessed using the Brief Pain Inventory at 12 months after randomisation. Secondary outcomes relate to resource use, function, neuropathic pain, mental well-being, use of pain medications, satisfaction with pain relief, pain frequency, capability, health-related quality of life and bodily pain. After trial completion, up to 30 patients in the intervention group will be interviewed about their experiences of the care pathway. If shown to be clinically and cost-effective, this care pathway intervention could improve the management of chronic pain after total knee replacement. ISRCTN registry ( ISRCTN92545361 ), prospectively registered on 30 August 2016.

Need, Enabling, Predisposing, and Behavioral Determinants of Access to Preventative Care in Argentina: Analysis of the National Survey of Risk Factors

PubMed Central

Jahangir, Eiman; Irazola, Vilma; Rubinstein, Adolfo

2012-01-01

Introduction Health care utilization is an important step to disease management, providing opportunities for prevention and treatment. Anderson’s Health Behavior Model has defined utilization by need, predisposing, and enabling determinants. We hypothesize that need, predisposing, and enabling, highlighting behavioral factors are associated with utilization in Argentina. Methods We performed a logistic regression analysis of the 2005 and 2009 Argentinean Survey of Risk Factors, a cohort of 41,392 and 34,732 individuals, to explore the association between need, enabling, predisposing, and behavioral factors to blood pressure measurement in the last year. Results In the 2005 cohort, blood pressure measurement was associated with perception of health, insurance coverage, basic needs met, and income. Additionally, female sex, civil state, household type, older age groups, education, and alcohol use were associated with utilization. The 2009 cohort showed similar associations with only minor differences between the models. Conclusions We explored the association between utilization of clinical preventive services with need, enabling, predisposing, and behavioral factors. While predisposing and need determinants are associated with utilization, enabling factors such as insurance coverage provides an area for public intervention. These are important findings where policies should be focused to improve utilization of preventive services in Argentina. PMID:22984608

Psychosocial interventions in bipolar disorder: a review.

PubMed

Lolich, María; Vázquez, Gustavo H; Alvarez, Lina M; Tamayo, Jorge M

2012-01-01

Multiple psychosocial interventions for bipolar disorder have been proposed in recent years. Therefore, we consider that a critical review of empirically validated models would be useful. A review of the literature was conducted in Medline/PubMed for articles published during 2000-2010 that respond to the combination of "bipolar disorder" with the following key words: "psychosocial intervention", "psychoeducational intervention" and "psychotherapy". Cognitive-behavioral, psychoeducational, systematic care models, interpersonal and family therapy interventions were found to be empirically validated. All of them reported significant improvements in therapeutic adherence and in the patients' functionality. Although there are currently several validated psychosocial interventions for treating bipolar disorder, their efficacy needs to be specified in relation to more precise variables such as clinical type, comorbid disorders, stages or duration of the disease. Taking into account these clinical features would enable a proper selection of the most adequate intervention according to the patient's specific characteristics.

Patient participation in postoperative care activities in patients undergoing total knee replacement surgery: Multimedia Intervention for Managing patient Experience (MIME). Study protocol for a cluster randomised crossover trial.

PubMed

McDonall, Jo; de Steiger, Richard; Reynolds, John; Redley, Bernice; Livingston, Patricia; Botti, Mari

2016-07-18

Patient participation is an important indicator of quality care. Currently, there is little evidence to support the belief that participation in care is possible for patients during the acute postoperative period. Previous work indicates that there is very little opportunity for patients to participate in care in the acute context. Patients require both capability, in terms of having the required knowledge and understanding of how they can be involved in their care, and the opportunity, facilitated by clinicians, to engage in their acute postoperative care. This cluster randomised crossover trial aims to test whether a multimedia intervention improves patient participation in the acute postoperative context, as determined by pain intensity and recovery outcomes. A total of 240 patients admitted for primary total knee replacement surgery will be invited to participate in a cluster randomised, crossover trial and concurrent process evaluation in at least two wards at a major non-profit private hospital in Melbourne, Australia. Patients admitted to the intervention ward will receive the multimedia intervention daily from Day 1 to Day 5 (or day of discharge, if prior). The intervention will be delivered by nurses via an iPad™, comprising information on the goals of care for each day following surgery. Patients admitted to the control ward will receive usual care as determined by care pathways currently in use across the organization. The primary endpoint is the "worst pain experienced in the past 24 h" on Day 3 following TKR surgery. Pain intensity will be measured using the numerical rating scale. Secondary outcomes are interference of pain on activities of daily living, length of stay in hospital, function and pain following TKR surgery, overall satisfaction with hospitalisation, postoperative complications and hospital readmission. The results of this study will contribute to our understanding of the effectiveness of interventions that provide knowledge and opportunity for patient participation during postoperative in-hospital care in actually increasing participation, and the impact of participation on patient outcomes. The results of this study will also provide data about the barriers and enablers to participation in the acute care context. Australian New Zealand Clinical Trials Registry ACTRN12614000340639 Trial Registration date 31/03/2014.

Web-Based Architecture to Enable Compute-Intensive CAD Tools and Multi-user Synchronization in Teleradiology

NASA Astrophysics Data System (ADS)

Mehta, Neville; Kompalli, Suryaprakash; Chaudhary, Vipin

Teleradiology is the electronic transmission of radiological patient images, such as x-rays, CT, or MR across multiple locations. The goal could be interpretation, consultation, or medical records keeping. Information technology solutions have enabled electronic records and their associated benefits are evident in health care today. However, salient aspects of collaborative interfaces, and computer assisted diagnostic (CAD) tools are yet to be integrated into workflow designs. The Computer Assisted Diagnostics and Interventions (CADI) group at the University at Buffalo has developed an architecture that facilitates web-enabled use of CAD tools, along with the novel concept of synchronized collaboration. The architecture can support multiple teleradiology applications and case studies are presented here.

Using goal-directed design to create a novel system for improving chronic illness care.

PubMed

Fore, David; Goldenhar, Linda M; Margolis, Peter A; Seid, Michael

2013-10-29

A learning health system enables patients, clinicians, and researchers to work together to choose care based on the best evidence, drive discovery as a natural outgrowth of patient care, and ensure innovation, quality, safety, and value in health care; all in a more real-time fashion. Our paper describes how goal-directed design (GDD) methods were employed to understand the context and goals of potential participants in such a system as part of a design process to translate the concept of a learning health system into a prototype collaborative chronic care network (C3N), specifically for pediatric inflammatory bowel disease. Thirty-six one-on-one in-depth interviews and observations were conducted with patients (10/36, 28%), caregivers (10/36, 28%), physicians/researchers (10/36, 28%), and nurses (6/36, 17%) from a pediatric gastroenterology center participating in the ImproveCareNow network. GDD methods were used to determine the context and goals of participants. These same methods were used in conjunction with idealized design process techniques to help determine characteristics of a learning health system for this pediatric health care ecology. Research was conducted in a clinic and, in the case of some patients and caregivers, at home. Thematic analysis revealed 3 parent-child dyad personas (ie, representations of interviewees' behavior patterns, goals, skills, attitudes, and contextual information) that represented adaptation to a chronic illness over time. These were used as part of a design process to generate scenarios (potential interactions between personas and the learning health system under design) from which system requirements were derived. These scenarios in turn helped guide generation, prioritization, design, measurement, and implementation of approximately 100 prototype interventions consistent with the aim of C3N becoming a learning health network. GDD methods help ensure human goals and contexts inform the design of a network of health care interventions which reflect the shape and purpose of a C3N in pediatric chronic illness care. Developing online and in-person interventions according to well-documented context and motivations of participants increases the likelihood that a C3N will enable all participants to act in ways that achieve their goals with grace and dignity. GDD methods complemented quality-improvement methods to generate prototypes consistent with clinical and research aims, as well as the goals of patient disease management.

Developing an Unguided Internet-Delivered Intervention for Emotional Distress in Primary Care Patients: Applying Common Factor and Person-Based Approaches

PubMed Central

Muñoz, Ricardo F; Yardley, Lucy; Mc Sharry, Jennifer; Little, Paul; Moore, Michael

2016-01-01

Background Developing effective, unguided Internet interventions for mental health represents a challenge. Without structured human guidance, engagement with these interventions is often limited and the effectiveness reduced. If their effectiveness can be increased, they have great potential for broad, low-cost dissemination. Improving unguided Internet interventions for mental health requires a renewed focus on the proposed underlying mechanisms of symptom improvement and the involvement of target users from the outset. Objective The aim of our study was to develop an unguided e-mental health intervention for distress in primary care patients, drawing on meta-theory of psychotherapeutic change and utilizing the person-based approach (PBA) to guide iterative qualitative piloting with patients. Methods Common factors meta-theory informed the selection and structure of therapeutic content, enabling flexibility whilst retaining the proposed necessary ingredients for effectiveness. A logic model was designed outlining intervention components and proposed mechanisms underlying improvement. The PBA provided a framework for systematically incorporating target-user perspective into the intervention development. Primary care patients (N=20) who had consulted with emotional distress in the last 12 months took part in exploratory qualitative interviews, and a subsample (n=13) undertook think-aloud interviews with a prototype of the intervention. Results A flexible intervention was developed, to be used as and when patients need, diverting from a more traditional, linear approach. Based on the in-depth qualitative findings, disorder terms such as “depression” were avoided, and discussions of psychological symptoms were placed in the context of stressful life events. Think-aloud interviews showed that patients were positive about the design and structure of the intervention. On the basis of patient feedback, modifications were made to increase immediate access to all therapeutic techniques. Conclusions Detailing theoretical assumptions underlying Internet interventions for mental health, and integrating this approach with systematic in-depth qualitative research with target patients is important. These strategies may provide novel ways for addressing the challenges of unguided delivery. The resulting intervention, Healthy Paths, will be evaluated in primary care-based randomized controlled trials, and deployed as a massive open online intervention (MOOI). PMID:27998878

Interrupted time-series analysis: studying trends in neurosurgery.

PubMed

Wong, Ricky H; Smieliauskas, Fabrice; Pan, I-Wen; Lam, Sandi K

2015-12-01

OBJECT Neurosurgery studies traditionally have evaluated the effects of interventions on health care outcomes by studying overall changes in measured outcomes over time. Yet, this type of linear analysis is limited due to lack of consideration of the trend's effects both pre- and postintervention and the potential for confounding influences. The aim of this study was to illustrate interrupted time-series analysis (ITSA) as applied to an example in the neurosurgical literature and highlight ITSA's potential for future applications. METHODS The methods used in previous neurosurgical studies were analyzed and then compared with the methodology of ITSA. RESULTS The ITSA method was identified in the neurosurgical literature as an important technique for isolating the effect of an intervention (such as a policy change or a quality and safety initiative) on a health outcome independent of other factors driving trends in the outcome. The authors determined that ITSA allows for analysis of the intervention's immediate impact on outcome level and on subsequent trends and enables a more careful measure of the causal effects of interventions on health care outcomes. CONCLUSIONS ITSA represents a significant improvement over traditional observational study designs in quantifying the impact of an intervention. ITSA is a useful statistical procedure to understand, consider, and implement as the field of neurosurgery evolves in sophistication in big-data analytics, economics, and health services research.

Health coaching interventions for persons with chronic conditions: a systematic review and meta-analysis protocol.

PubMed

Boehmer, Kasey R; Barakat, Suzette; Ahn, Sangwoo; Prokop, Larry J; Erwin, Patricia J; Murad, M Hassan

2016-09-01

Chronic conditions are increasingly more common and negatively impact quality of life, disability, morbidity, and mortality. Health coaching has emerged as a possible intervention to help individuals with chronic conditions adopt health supportive behaviors that improve both quality of life and health outcomes. We planned a systematic review and meta-analysis of the contemporary health coaching literature published in the last decade to evaluate the effect of health coaching on clinically important, disease-specific, functional, and behavioral outcomes. We will include randomized controlled trials or quasi-experimental studies that compared health coaching to alternative interventions or usual care. To enable adoption of effective interventions, we aim to explore how the effect of intervention is modified by the intervention components, delivering personnel (i.e., health professionals vs trained lay or peer persons), dose, frequency, and setting. Analysis of intervention outcomes will be reported and classified using an existing theoretical framework, the Theory of Patient Capacity, to identify the areas of patients' capacity to access and use healthcare and enact self-care where coaching may be an effective intervention. This systematic review and meta-analysis will identify and synthesize evidence to inform the practice of health coaching by providing evidence on components and characteristics of the intervention essential for success in individuals with chronic health conditions. PROSPERO CRD42016039730.

Perception, satisfaction and utilization of the VALUE home telehealth service.

PubMed

Finkelstein, Stanley M; Speedie, Stuart M; Zhou, Xinyu; Potthoff, Sandra; Ratner, Edward R

2011-01-01

We conducted a randomized controlled trial to evaluate the perception, satisfaction and utilization of a home telehealth service for frail elderly people living independently in their home communities. Control group subjects continued with their usual care and intervention group subjects were able to supplement their usual care with the use of a web portal. The web portal allowed videoconferencing and electronic messaging between home care nurses and clients, ordering health-related and home care services, access to health-related information and general access to the Internet. A total of 99 eligible people (59 female, 40 male) from one urban and one rural study site agreed to participate in the study. Eighty-four subjects were active participants for nine months. There were no significant differences in perception of technology between the two groups at baseline. At 60-day follow-up, the intervention group was significantly more positive towards technology compared to their own baseline (P < 0.001) and compared to the 60-day scores for the controls (P < 0.001). The intervention group indicated that overall the telehealth service met their expectations (mean score 9 out of 10) and they would recommend it to others (mean score 9.5 out of 10). All subjects were able to use the portal without difficulty after brief instructions from the nurses. A total of 1054 videoconferences were conducted with the intervention subjects. Fifty-six of these (5%) had to be discontinued after successful connection because of technical problems. Intervention subjects made fewer emergency department visits than control subjects, more visits to the eye doctor, fewer visits in all categories of home care utilization, and lower use of transportation services. Frail elderly people are able to adopt home telehealth technologies which may enable them to maintain independent living arrangements.

Interdisciplinary collaboration and the electronic medical record.

PubMed

Green, Shayla D; Thomas, Joan D

2008-01-01

To examine interdisciplinary collaboration via electronic medical records (EMRs) with a focus on physicians' perception of nursing documentation. Quality improvement project using a survey instrument. Tertiary care pediatric hospital. Thirty-seven physicians. Physicians perceptions of nursing documentation after EMR implementation Physicians desire nursing documentation with greater clarity and additional information. Physicians indicate checklists alone for patient assessment and intervention data are insufficient for effective nurse/physician collaboration. Narrative nursing summaries are invaluable references that guide medical treatment decisions. Physicians see detailed assessments and well-described interventions of nurses' as critical to their ability to effectively practice medicine. Health care technology is called to develop EMRs that enable nurses to document detailed patient data in a swift and straightforward manner. Joint collaboration between nurses, physicians, and technology specialists is recommended to develop effective EMR systems.

MENOS4 trial: a multicentre randomised controlled trial (RCT) of a breast care nurse delivered cognitive behavioural therapy (CBT) intervention to reduce the impact of hot flushes in women with breast cancer: Study Protocol.

PubMed

Fenlon, Deborah; Nuttall, Jacqueline; May, Carl; Raftery, James; Fields, Jo; Kirkpatrick, Emma; Abab, Julia; Ellis, Mary; Rose, Taylor; Khambhaita, Priya; Galanopoulou, Angeliki; Maishman, Tom; Haviland, Jo; Griffiths, Gareth; Turner, Lesley; Hunter, Myra

2018-05-08

Women who have been treated for breast cancer may identify vasomotor symptoms, such as hot flushes and night sweats (HFNS), as a serious problem. HFNS are unpleasant to experience and can have a significant impact on daily life, potentially leading to reduced adherence to life saving adjuvant hormonal therapy. It is known that Cognitive Behavioural Therapy (CBT) is effective for the alleviation of hot flushes in both well women and women who have had breast cancer. Most women with breast cancer will see a breast care nurse and there is evidence that nurses can be trained to deliver psychological treatments to a satisfactory level, whilst also maintaining treatment fidelity. The research team will assess whether breast care nurses can effectively deliver a CBT intervention to alleviate hot flushes in women with breast cancer. This study is a multi-centre phase III individually randomised controlled trial of group CBT versus usual care to reduce the impact of hot flushes in women with breast cancer. 120-160 women with primary breast cancer experiencing seven or more problematic HFNS a week will be randomised to receive either treatment as usual (TAU) or participation in the group CBT intervention plus TAU (CBT Group). A process evaluation using May's Normalisation Process Theory will be conducted, as well as practical and organisational issues relating to the implementation of the intervention. Fidelity of implementation of the intervention will be conducted by expert assessment. The cost effectiveness of the intervention will also be assessed. There is a need for studies that enable effective interventions to be implemented in practice. There is good evidence that CBT is helpful for women with breast cancer who experience HFNS, yet it is not widely available. It is not yet known whether the intervention can be effectively delivered by breast care nurses or implemented in practice. This study will provide information on both whether the intervention can effectively help women with hot flushes and whether and how it can be translated into routine clinical practice. ISRCTN 12824632 . Registered 25-01-2017.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) protocol: testing the effectiveness of a facilitation intervention in a pragmatic, cluster-randomised trial with an embedded process evaluation and cost analysis.

PubMed

Bucknall, Tracey K; Harvey, Gill; Considine, Julie; Mitchell, Imogen; Rycroft-Malone, Jo; Graham, Ian D; Mohebbi, Mohammadreza; Watts, Jennifer; Hutchinson, Alison M

2017-07-11

Vital signs are the primary indicator of physiological status and for determining the need for urgent clinical treatment. Yet, if physiological signs of deterioration are missed, misinterpreted or mismanaged, then critical illness, unplanned intensive care admissions, cardiac arrest and death may ensue. Although evidence demonstrates the benefit of early recognition and management of deteriorating patients, failure to escalate care and manage deteriorating patients remains a relatively frequent occurrence in hospitals. A pragmatic cluster-randomised controlled trial design will be used to measure clinical effectiveness and cost of a facilitation intervention to improve nurses' vital sign measurement, interpretation, treatment and escalation of care for patients with abnormal vital signs. A cost consequence analysis will evaluate the intervention cost and effectiveness, and a process evaluation will determine how the implementation of the intervention contributes to outcomes. We will compare clinical outcomes and costs from standard implementation of clinical practice guidelines (CPGs) to facilitated implementation of CPGs. The primary outcome will be adherence to the CPGs by nurses, as measured by escalation of care as per organisational policy. The study will be conducted in four Australian major metropolitan teaching hospitals. In each hospital, eight to ten wards will be randomly allocated to intervention and control groups. Control wards will receive standard implementation of CPGs, while intervention wards will receive standard CPG implementation plus facilitation, using facilitation methods and processes tailored to the ward context. The intervention will be administered to all nursing staff at the ward level for 6 months. At each hospital, two types of facilitators will be provided: a hospital-level facilitator as the lead; and two ward-level facilitators for each ward. This study uses an innovative, networked approach to facilitation to enable uptake of CPGs. Findings will inform the intervention utility and knowledge translation measurement approaches. If successful, the study methodology and intervention has potential for translation to other health care standards. Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12616000544471p.

Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol.

PubMed

McGillion, Michael; Yost, Jennifer; Turner, Andrew; Bender, Duane; Scott, Ted; Carroll, Sandra; Ritvo, Paul; Peter, Elizabeth; Lamy, Andre; Furze, Gill; Krull, Kirsten; Dunlop, Valerie; Good, Amber; Dvirnik, Nazari; Bedini, Debbie; Naus, Frank; Pettit, Shirley; Henry, Shaunattonie; Probst, Christine; Mills, Joseph; Gossage, Elaine; Travale, Irene; Duquette, Janine; Taberner, Christy; Bhavnani, Sanjeev; Khan, James S; Cowan, David; Romeril, Eric; Lee, John; Colella, Tracey; Choinière, Manon; Busse, Jason; Katz, Joel; Victor, J Charles; Hoch, Jeffrey; Isaranuwatchai, Wanrudee; Kaasalainen, Sharon; Ladak, Salima; O'Keefe-McCarthy, Sheila; Parry, Monica; Sessler, Daniel I; Stacey, Michael; Stevens, Bonnie; Stremler, Robyn; Thabane, Lehana; Watt-Watson, Judy; Whitlock, Richard; MacDermid, Joy C; Leegaard, Marit; McKelvie, Robert; Hillmer, Michael; Cooper, Lynn; Arthur, Gavin; Sider, Krista; Oliver, Susan; Boyajian, Karen; Farrow, Mark; Lawton, Chris; Gamble, Darryl; Walsh, Jake; Field, Mark; LeFort, Sandra; Clyne, Wendy; Ricupero, Maria; Poole, Laurie; Russell-Wood, Karsten; Weber, Michael; McNeil, Jolene; Alpert, Robyn; Sharpe, Sarah; Bhella, Sue; Mohajer, David; Ponnambalam, Sem; Lakhani, Naeem; Khan, Rabia; Liu, Peter; Devereaux, P J

2016-08-01

Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom. Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT). CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups. Study start-up is underway and usability testing is scheduled to begin in the fall of 2016. Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.

Technology-Enabled Remote Monitoring and Self-Management — Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol

PubMed Central

Yost, Jennifer; Turner, Andrew; Bender, Duane; Scott, Ted; Carroll, Sandra; Ritvo, Paul; Peter, Elizabeth; Lamy, Andre; Furze, Gill; Krull, Kirsten; Dunlop, Valerie; Good, Amber; Dvirnik, Nazari; Bedini, Debbie; Naus, Frank; Pettit, Shirley; Henry, Shaunattonie; Probst, Christine; Mills, Joseph; Gossage, Elaine; Travale, Irene; Duquette, Janine; Taberner, Christy; Bhavnani, Sanjeev; Khan, James S; Cowan, David; Romeril, Eric; Lee, John; Colella, Tracey; Choinière, Manon; Busse, Jason; Katz, Joel; Victor, J Charles; Hoch, Jeffrey; Isaranuwatchai, Wanrudee; Kaasalainen, Sharon; Ladak, Salima; O'Keefe-McCarthy, Sheila; Parry, Monica; Sessler, Daniel I; Stacey, Michael; Stevens, Bonnie; Stremler, Robyn; Thabane, Lehana; Watt-Watson, Judy; Whitlock, Richard; MacDermid, Joy C; Leegaard, Marit; McKelvie, Robert; Hillmer, Michael; Cooper, Lynn; Arthur, Gavin; Sider, Krista; Oliver, Susan; Boyajian, Karen; Farrow, Mark; Lawton, Chris; Gamble, Darryl; Walsh, Jake; Field, Mark; LeFort, Sandra; Clyne, Wendy; Ricupero, Maria; Poole, Laurie; Russell-Wood, Karsten; Weber, Michael; McNeil, Jolene; Alpert, Robyn; Sharpe, Sarah; Bhella, Sue; Mohajer, David; Ponnambalam, Sem; Lakhani, Naeem; Khan, Rabia; Liu, Peter

2016-01-01

Background Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT—VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom. Objective Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT). Methods CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise—death, myocardial infarction, and nonfatal stroke— all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups. Results Study start-up is underway and usability testing is scheduled to begin in the fall of 2016. Conclusions Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS. PMID:27480247

Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review

PubMed Central

Kent, Angelle; Kobagi, Nadia; Huynh, Kha Tu; Clarke, Alix; Yoon, Minn N.

2017-01-01

Background Poor oral health has been a persistent problem in nursing home residents for decades, with severe consequences for residents and the health care system. Two major barriers to providing appropriate oral care are residents’ responsive behaviors to oral care and residents’ lack of ability or motivation to perform oral care on their own. Objectives To evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents’ responsive behaviors to oral care, or enable/motivate residents to perform their own oral care. Materials and methods We searched the databases Medline, EMBASE, Evidence Based Reviews–Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science for intervention studies assessing the effectiveness of eligible strategies. Two reviewers independently (a) screened titles, abstracts and retrieved full-texts; (b) searched key journal contents, key author publications, and reference lists of all included studies; and (c) assessed methodological quality of included studies. Discrepancies at any stage were resolved by consensus. We conducted a narrative synthesis of study results. Results We included three one-group pre-test, post-test studies, and one cross-sectional study. Methodological quality was low (n = 3) and low moderate (n = 1). Two studies assessed strategies to enable/motivate nursing home residents to perform their own oral care, and to studies assessed strategies to prevent or overcome responsive behaviors to oral care. All studies reported improvements of at least some of the outcomes measured, but interpretation is limited due to methodological problems. Conclusions Potentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents’ responsive behaviors to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies. PMID:28609476

Family Caregiver Depressive Symptom and Grief Outcomes From the ENABLE III Randomized Controlled Trial.

PubMed

Dionne-Odom, J Nicholas; Azuero, Andres; Lyons, Kathleen D; Hull, Jay G; Prescott, Anna T; Tosteson, Tor; Frost, Jennifer; Dragnev, Konstantin H; Bakitas, Marie A

2016-09-01

Little is known about whether early palliative care (EPC) support for family caregivers (CGs) impacts depressive symptoms and grief after care recipients die. To assess after-death CG depressive symptom and grief scores for early compared to delayed group CGs. We conducted a randomized controlled trial (10/2010-9/2013) of an EPC telehealth intervention for CGs (n = 123) initiated at the time of care recipients' advanced cancer diagnosis (early group) or 12 weeks later (delayed group) in a rural comprehensive cancer center, affiliated clinics, and a Veterans Administration medical center. The ENABLE [Educate, Nurture, Advise, Before Life Ends] CG intervention consisted of three weekly sessions, monthly follow-up, and a bereavement call. CGs completed the Center for Epidemiological Study-Depression (CES-D) scale and the Prigerson Inventory of Complicated Grief-Short Form (PG13) 8-12 weeks after care recipients' deaths. Crude and covariate-adjusted between-group differences were estimated and tested using general linear models. For care recipients who died (n = 70), 44 CGs (early: n = 19; delayed: n = 25) completed after-death questionnaires. Mean depressive symptom scores (CES-D) for the early group was 14.6 (SD = 10.7) and for the delayed group was 17.6 (SD = 11.8). Mean complicated grief scores (PG13) for the early group was 22.7 (SD = 4.9) and for the delayed group was 24.9 (SD = 6.9). Adjusted between-group differences were not statistically significant (CES-D: d = 0.07, P = 0.88; PG13: d = -0.21, P = 0.51). CGs' depressive symptom and complicated grief scores 8-12 weeks after care recipients' deaths were not statistically different based on the timing of EPC support. The impact of timing of CG EPC interventions on CGs bereavement outcomes requires further investigation. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Enablement in health care context: a concept analysis.

PubMed

Hudon, Catherine; St-Cyr Tribble, Denise; Bravo, Gina; Poitras, Marie-Eve

2011-02-01

The enablement process is defined as a professional intervention aiming to recognize, support and emphasize the patient's capacity to have control over her or his health and life. The purpose of this article was to study the enablement concept through a concept analysis in the health care context to identify: (1) its attributes and (2) its antecedents and consequents. A concept analysis was performed according to the method of Rodgers. The literature was reviewed from 1980 to June 2008, using search strategies adapted to the databases Cinahl, Medline, Embase, PsycInfo and Social Works Abstract, and hand searching. All articles contributing to a deeper understanding of the concept were included. The analysis was carried out according to a thematic analysis procedure, as described by Miles & Huberman. The search identified 1305 citations. After in-depth assessment of 148 potentially eligible citations, 61 articles were included in the review. Five articles were added with hand searching. Sixty-seven per cent of these articles were related to nursing. The attributes of the enablement concept included: contribution to the therapeutic relationship; consideration of the person as a whole; facilitation of learning; valorization of the person's strengths; implication and support to decision making; and broadening of the possibilities. These attributes could be used as a basis for other studies on enablement. Conceptual and empirical work is still needed to better position this concept among others such as patient-centred care, shared decision making and patient's participation. © 2010 Blackwell Publishing Ltd.

Perioperative Care Coordination Measurement: A Tool to Support Care Integration of Pediatric Surgical Patients.

PubMed

Ferrari, Lynne R; Ziniel, Sonja I; Antonelli, Richard C

2016-03-01

The relationship of care coordination activities and outcomes to resource utilization and personnel costs has been evaluated for a number of pediatric medical home practices. One of the first tools designed to evaluate the activities and outcomes for pediatric care coordination is the Care Coordination Measurement Tool (CCMT). It has become widely used as an instrument for health care providers in both primary and subspecialty care settings. This tool enables the user to stratify patients based on acuity and complexity while documenting the activities and outcomes of care coordination. We tested the feasibility of adapting the CCMT to a pediatric surgical population at Boston Children's Hospital. The tool was used to assess the preoperative care coordination activities. Care coordination activities were tracked during the interval from the date the patient was scheduled for a surgical or interventional procedure through the day of the procedure. A care coordination encounter was defined as any task, whether face to face or not, supporting the development or implementation of a plan of care. Data were collected to enable analysis of 5675 care coordination encounters supporting the care provided to 3406 individual surgical cases (patients). The outcomes of care coordination, as documented by the preoperative nursing staff, included the elaboration of the care plan through patient-focused communication among specialist, facilities, perioperative team, and primary care physicians in 80.5% of cases. The average time spent on care coordination activities increased incrementally by 30 minutes with each additional care coordination encounter for a surgical case. Surgical cases with 1 care coordination encounter took an average of 35.7 minutes of preoperative care coordination, whereas those with ≥4 care coordination encounters reported an average of 121.6 minutes. We successfully adapted and implemented the CCMT for a pediatric surgical population and measured nonface-to-face, nonbillable encounters performed by perioperative nursing staff. The care coordination activities integrated into the preoperative process include elaboration of care plans and identification and remediation of discrepancies. Capturing the activities and outcomes of care coordination for preoperative care provides a framework for quality improvement and enables documentation of the value of nonface-to-face perioperative nursing encounters that comprise care coordination.

Analysis System for Self-Efficacy Training (ASSET). Assessing treatment fidelity of self-management interventions.

PubMed

Zinken, Katarzyna M; Cradock, Sue; Skinner, T Chas

2008-08-01

The paper presents the development of a coding tool for self-efficacy orientated interventions in diabetes self-management programmes (Analysis System for Self-Efficacy Training, ASSET) and explores its construct validity and clinical utility. Based on four sources of self-efficacy (i.e., mastery experience, role modelling, verbal persuasion and physiological and affective states), published self-efficacy based interventions for diabetes care were analysed in order to identify specific verbal behavioural techniques. Video-recorded facilitating behaviours were evaluated using ASSET. The reliability between four coders was high (K=0.71). ASSET enabled assessment of both self-efficacy based techniques and participants' response to those techniques. Individual patterns of delivery and shifts over time across facilitators were found. In the presented intervention we observed that self-efficacy utterances were followed by longer patient verbal responses than non-self-efficacy utterances. These detailed analyses with ASSET provide rich data and give the researcher an insight into the underlying mechanism of the intervention process. By providing a detailed description of self-efficacy strategies ASSET can be used by health care professionals to guide reflective practice and support training programmes.

Assessing return on investment of defined-population disease management interventions.

PubMed

Wilson, Thomas W; Gruen, Jeff; William, Thar; Fetterolf, Donald; Minalkumar, Patel; Popiel, Richard G; Lewis, Al; Nash, David B

2004-11-01

Strategies to reduce health expenditures through the improvement of health and quality of care are in high demand. A group of experts formed a nonpartisan, independent work group, under the sponsorship of the National Managed Health Care Congress. Its goal was to establish a list of easy-to-understand, actionable, and usable recommendations to enable disease management program advocates to conduct basic-level evaluations. The work group made recommendations concerning identification of reference and intervention population, population definitions, quantitative methods and data quality, confounding and bias, and stakeholder agreements/contracting. A case study was created to quantitatively illustrate some of the major issues raised by the work group. Five typical errors were simulated by applying different rules to the intervention population than to the reference population: differential inclusion (high versus low risk), differential exclusion (high versus low risk) and differential claims run-out. Compared with the true impact, four of the five errors resulted in a bias toward "intervention effect," while one (differential inclusion of high-risk patients) was biased against the "intervention effect." The direction and magnitude of the bias in natural settings will not necessarily follow this pattern.

mHealth Technologies to Influence Physical Activity and Sedentary Behaviors: Behavior Change Techniques, Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PubMed

Direito, Artur; Carraça, Eliana; Rawstorn, Jonathan; Whittaker, Robyn; Maddison, Ralph

2017-04-01

mHealth programs offer potential for practical and cost-effective delivery of interventions capable of reaching many individuals. To (1) compare the effectiveness of mHealth interventions to promote physical activity (PA) and reduce sedentary behavior (SB) in free-living young people and adults with a comparator exposed to usual care/minimal intervention; (2) determine whether, and to what extent, such interventions affect PA and SB levels and (3) use the taxonomy of behavior change techniques (BCTs) to describe intervention characteristics. A systematic review and meta-analysis following PRISMA guidelines was undertaken to identify randomized controlled trials (RCTs) comparing mHealth interventions with usual or minimal care among individuals free from conditions that could limit PA. Total PA, moderate-to-vigorous intensity physical activity (MVPA), walking and SB outcomes were extracted. Intervention content was independently coded following the 93-item taxonomy of BCTs. Twenty-one RCTs (1701 participants-700 with objectively measured PA) met eligibility criteria. SB decreased more following mHealth interventions than after usual care (standardised mean difference (SMD) -0.26, 95 % confidence interval (CI) -0.53 to -0.00). Summary effects across studies were small to moderate and non-significant for total PA (SMD 0.14, 95 % CI -0.12 to 0.41); MVPA (SMD 0.37, 95 % CI -0.03 to 0.77); and walking (SMD 0.14, 95 % CI -0.01 to 0.29). BCTs were employed more frequently in intervention (mean = 6.9, range 2 to 12) than in comparator conditions (mean = 3.1, range 0 to 10). Of all BCTs, only 31 were employed in intervention conditions. Current mHealth interventions have small effects on PA/SB. Technological advancements will enable more comprehensive, interactive and responsive intervention delivery. Future mHealth PA studies should ensure that all the active ingredients of the intervention are reported in sufficient detail.

Characterising an implementation intervention in terms of behaviour change techniques and theory: the 'Sepsis Six' clinical care bundle.

PubMed

Steinmo, Siri; Fuller, Christopher; Stone, Sheldon P; Michie, Susan

2015-08-08

Sepsis is a major cause of death from infection, with a mortality rate of 36 %. This can be halved by implementing the 'Sepsis Six' evidence-based care bundle within 1 h of presentation. A UK audit has shown that median implementation rates are 27-47 % and interventions to improve this have demonstrated minimal effects. In order to develop more effective implementation interventions, it is helpful to obtain detailed characterisations of current interventions and to draw on behavioural theory to identify mechanisms of change. The aim of this study was to illustrate this process by using the Behaviour Change Wheel; Behaviour Change Technique (BCT) Taxonomy; Capability, Opportunity, Motivation model of behaviour; and Theoretical Domains Framework to characterise the content and theoretical mechanisms of action of an existing intervention to implement Sepsis Six. Data came from documentary, interview and observational analyses of intervention delivery in several wards of a UK hospital. A broad description of the intervention was created using the Template for Intervention Description and Replication framework. Content was specified in terms of (i) component BCTs using the BCT Taxonomy and (ii) intervention functions using the Behaviour Change Wheel. Mechanisms of action were specified using the Capability, Opportunity, Motivation model and the Theoretical Domains Framework. The intervention consisted of 19 BCTs, with eight identified using all three data sources. The BCTs were delivered via seven functions of the Behaviour Change Wheel, with four ('education', 'enablement', 'training' and 'environmental restructuring') supported by the three data sources. The most frequent mechanisms of action were reflective motivation (especially 'beliefs about consequences' and 'beliefs about capabilities') and psychological capability (especially 'knowledge'). The intervention consisted of a wide range of BCTs targeting a wide range of mechanisms of action. This study demonstrates the utility of the Behaviour Change Wheel, the BCT Taxonomy and the Theoretical Domains Framework, tools recognised for providing guidance for intervention design, for characterising an existing intervention to implement evidence-based care.

A social-ecological framework: A model for addressing ethical practice in nursing.

PubMed

Davidson, Patricia; Rushton, Cynda Hylton; Kurtz, Melissa; Wise, Brian; Jackson, Debra; Beaman, Adam; Broome, Marion

2018-03-01

To develop a framework to enable discussion, debate and the formulation of interventions to address ethical issues in nursing practice. Social, cultural, political and economic drivers are rapidly changing the landscape of health care in our local environments but also in a global context. Increasingly, nurses are faced with a range of ethical dilemmas in their work. This requires investigation into the culture of healthcare systems and organisations to identify the root causes and address the barriers and enablers of ethical practice. The increased medicalisation of health care; pressures for systemisation; efficiency and cost reduction; and an ageing population contribute to this complexity. Often, ethical issues in nursing are considered within the abstract and philosophical realm until a dilemma is encountered. Such an approach limits the capacity to tangibly embrace ethical values and frameworks as pathways to equitable, accessible, safe and quality health care and as a foundation for strengthening a supportive and enabling workplace for nurses and other healthcare workers. Conceptual framework development. A comprehensive literature review was undertaken using the social-ecological framework as an organising construct. This framework views ethical practice as the outcome of interaction among a range of factors at eight levels: individual factors (patients and families); individual factors (nurses); relationships between healthcare professionals; relationships between patients and nurses; organisational healthcare context; professional and education regulation and standards; community; and social, political and economic. Considering these elements as discrete, yet interactive and intertwined forces can be useful in developing interventions to promote ethical practice. We consider this framework to have utility in policy, practice, education and research. Nurses face ethical challenges on a daily basis, considering these within a social-ecological framework can assist in developing strategies and resolutions. © 2017 John Wiley & Sons Ltd.

Improving the quality of care for mild to moderate dementia: an evaluation of the Croydon Memory Service Model.

PubMed

Banerjee, Sube; Willis, Rosalind; Matthews, David; Contell, Faith; Chan, Jeni; Murray, Joanna

2007-08-01

The large majority of people with dementia receive nothing in the way of specialist assessment and care at any stage of their illness. There is a particular lack of services focussed on early identification and intervention in dementia where there is the possibility of long-term harm reduction for people with dementia and their family carers. We have developed a model of care that is complementary to local systems of health and social care (The Croydon Memory Service Model [CMSM]). This is a low-cost, high-throughput, generic service to enable early identification and intervention in dementia. It is a multi-agency approach with joint ownership by health services, social services and the voluntary sector with embedded specifically-tailored approaches to primary care and minority ethnic communities. We completed a service evaluation of the introduction of the CMSM in a single borough in South London. Six predefined service goals were set: high acceptability; high appropriate referral rate; successful engagement with people from minority ethnic groups; successful engagement with people with young onset dementia; focus on engagement with mild cases to enable early intervention; and an increase in the overall number of new cases of dementia seen. Mixed qualitative and quantitative methodologies were used including a description and 6-month follow-up of a cohort of 290 consecutive referrals. All key predefined service goals were met: 95% acceptability; 94% appropriate referrals; successful engagement with minority ethnic groups (two-fold greater number compared with that expected from general population demographic data); 17% of referrals under 65 years of age; 68% referrals with mild or minimal dementia severity; and an estimated 63% increase in the number of new cases of dementia seen in Croydon. At 6-month follow up, those referred to the service had decreased behavioural disturbance and increased quality of life compared with baseline. Specific services for early dementia, which deliver diagnosis and care, can be established. These services can increase the numbers of people with early dementia identified and provided with care. Those receiving such services appear to improve in terms of quality of life and behavioural and psychological symptoms of dementia. Next steps should include the establishment of such services in other representative areas and evaluation of their effectiveness in comparison with other models of care.

Development of a Smartphone-Enabled Hypertension and Diabetes Mellitus Management Package to Facilitate Evidence-Based Care Delivery in Primary Healthcare Facilities in India: The mPower Heart Project.

PubMed

Ajay, Vamadevan S; Jindal, Devraj; Roy, Ambuj; Venugopal, Vidya; Sharma, Rakshit; Pawar, Abha; Kinra, Sanjay; Tandon, Nikhil; Prabhakaran, Dorairaj

2016-12-21

The high burden of undetected and undertreated hypertension and diabetes mellitus is a major health challenge worldwide. The mPower Heart Project aimed to develop and test a feasible and scalable intervention for hypertension and diabetes mellitus by task-sharing with the use of a mobile phone-based clinical decision support system at Community Health Centers in Himachal Pradesh, India. The development of the intervention and mobile phone-based clinical decision support system was carried out using mixed methods in five Community Health Centers. The intervention was subsequently evaluated using pre-post evaluation design. During intervention, a nurse care coordinator screened, examined, and entered patient parameters into mobile phone-based clinical decision support system to generate a prescription, which was vetted by a physician. The change in systolic blood pressure, diastolic blood pressure, and fasting plasma glucose (FPG) over 18 months of intervention was quantified using generalized estimating equations models. During intervention, 6797 participants were enrolled. Six thousand sixteen participants had hypertension (mean systolic blood pressure: 146.1 mm Hg, 95% CI: 145.7, 146.5; diastolic blood pressure: 89.52 mm Hg, 95% CI: 89.33, 89.72), of which 3152 (52%) subjects were newly detected. Similarly, 1516 participants had diabetes mellitus (mean FPG: 177.9 mg/dL, 95% CI: 175.8, 180.0), of which 450 (30%) subjects were newly detected. The changes in systolic blood pressure, diastolic blood pressure, and FPG observed at 18 months of follow-up were -14.6 mm Hg (95% CI: -15.3, -13.8), -7.6 mm Hg (CI: -8.0, -7.2), and -50.0 mg/dL (95% CI: -54.6, -45.5), respectively, and were statistically significant even after adjusting for age, sex, and Community Health Center. A nurse-facilitated, mobile phone-based clinical decision support system-enabled intervention in primary care was associated with improvements in blood pressure and blood glucose control and has the potential to scale-up in resource poor settings. URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01794052. Clinical Trial Registry-India: CTRI/2013/02/003412. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial.

PubMed

Bardach, Naomi S; Wang, Jason J; De Leon, Samantha F; Shih, Sarah C; Boscardin, W John; Goldman, L Elizabeth; Dudley, R Adams

2013-09-11

Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied. To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative. A cluster-randomized trial of small (<10 clinicians) primary care clinics in New York City from April 2009 through March 2010. A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance. Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments: $200/patient; $100,000/clinic). Quality reports were given quarterly to both the intervention and control groups. Comparison of differences in performance improvement, from the beginning to the end of the study, between control and intervention clinics for aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation interventions. Mixed-effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention. Participating clinics (n = 42 for each group) had similar baseline characteristics, with a mean of 4592 (median, 2500) patients at the intervention group clinics and 3042 (median, 2000) at the control group clinics. Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs 6.1%, difference: 6.0% [95% CI, 2.2% to 9.7%], P = .001 for interaction term), blood pressure control (no comorbidities: 9.7% vs 4.3%, difference: 5.5% [95% CI, 1.6% to 9.3%], P = .01 for interaction term; with diabetes mellitus: 9.0% vs 1.2%, difference: 7.8% [95% CI, 3.2% to 12.4%], P = .007 for interaction term; with diabetes mellitus or ischemic vascular disease: 9.5% vs 1.7%, difference: 7.8% [95% CI, 3.0% to 12.6%], P = .01 for interaction term), and in smoking cessation interventions (12.4% vs 7.7%, difference: 4.7% [95% CI, -0.3% to 9.6%], P = .02 for interaction term). Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant. Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time. clinicaltrials.gov Identifier: NCT00884013.

Using realist review to inform intervention development: methodological illustration and conceptual platform for collaborative care in offender mental health.

PubMed

Pearson, M; Brand, S L; Quinn, C; Shaw, J; Maguire, M; Michie, S; Briscoe, S; Lennox, C; Stirzaker, A; Kirkpatrick, T; Byng, R

2015-09-28

This paper reports how we used a realist review, as part of a wider project to improve collaborative mental health care for prisoners with common mental health problems, to develop a conceptual platform. The importance of offenders gaining support for their mental health, and the need for practitioners across the health service, the criminal justice system, and the third sector to work together to achieve this is recognised internationally. However, the literature does not provide coherent analyses of how these ambitions can be achieved. This paper demonstrates how a realist review can be applied to inform complex intervention development that spans different locations, organisations, professions, and care sectors. We applied and developed a realist review for the purposes of intervention development, using a three-stage process. (1) An iterative database search strategy (extending beyond criminal justice and offender health) and groups of academics, practitioners, and people with lived experience were used to identify explanatory accounts (n = 347). (2) From these accounts, we developed consolidated explanatory accounts (n = 75). (3) The identified interactions between practitioners and offenders (within their organisational, social, and cultural contexts) were specified in a conceptual platform. We also specify, step by step, how these explanatory accounts were documented, consolidated, and built into a conceptual platform. This addresses an important methodological gap for social scientists and intervention developers about how to develop and articulate programme and implementation theory underpinning complex interventions. An integrated person-centred system is proposed to improve collaborative mental health care for offenders with common mental health problems (near to and after release) by achieving consistency between the goals of different sectors and practitioners, enabling practitioners to apply scientific and experiential knowledge in working judiciously and reflectively, and building systems and aligning resources that are centred on offenders' health and social care needs. As part of a broader programme of work, a realist review can make an important contribution to the specification of theoretically informed interventions that have the potential to improve health outcomes. Our conceptual platform has potential application in related systems of health and social care where integrated, and person-centred care is a goal.

Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records—REDUCE Trial study original protocol

PubMed Central

Juszczyk, Dorota; Charlton, Judith; McDermott, Lisa; Soames, Jamie; Sultana, Kirin; Ashworth, Mark; Fox, Robin; Hay, Alastair D; Little, Paul; Moore, Michael V; Yardley, Lucy; Prevost, A Toby; Gulliford, Martin C

2016-01-01

Introduction Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. Methods and analysis 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. Ethics and dissemination Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. Trial registration number ISRCTN95232781; Pre-results. PMID:27491663

Balancing student/trainee learning with the delivery of patient care in the healthcare workplace: a protocol for realist synthesis

PubMed Central

Sholl, Sarah; Ajjawi, Rola; Allbutt, Helen; Butler, Jane; Jindal-Snape, Divya; Morrison, Jill; Rees, Charlotte

2016-01-01

Introduction A national survey was recently conducted to explore medical education research priorities in Scotland. The identified themes and underlying priority areas can be linked to current medical education drivers in the UK. The top priority area rated by stakeholders was: ‘Understanding how to balance service and training conflicts’. Despite its perceived importance, a preliminary scoping exercise revealed the least activity with respect to published literature reviews. This protocol has therefore been developed so as to understand how patient care, other service demands and student/trainee learning can be simultaneously facilitated within the healthcare workplace. The review will identify key interventions designed to balance patient care and student/trainee learning, to understand how and why such interventions produce their effects. Our research questions seek to address how identified interventions enable balanced patient care-trainee learning within the healthcare workplace, for whom, why and under what circumstances. Methods and analysis Pawson's five stages for undertaking a realist review underpin this protocol. These stages may progress in a non-linear fashion due to the iterative nature of the review process. We will: (1) clarify the scope of the review, identifying relevant interventions and existing programme theories, understanding how interventions act to produce their intended outcomes; (2) search journal articles and grey literature for empirical evidence from 1998 (introduction of the European Working Time Directive) on the UK multidisciplinary team working concerning these interventions, theories and outcomes, using databases such as ERIC, Scopus and CINAHL; (3) assess study quality; (4) extract data; and (5) synthesise data, drawing conclusions. Ethics and dissemination A formal ethical review is not required. These findings should provide an important understanding of how workplace-based interventions influence the balance of trainee learning and service provision. They should benefit various stakeholders involved in workplace-based learning interventions, and inform the medical education research agenda in the UK. PMID:27118289

Enhancing Supportive-Educative Nursing Systems to Reduce Risk of Post-Breast Cancer Lymphedema.

PubMed

Armer, Jane M; Shook, Robin P; Schneider, Melanie K; Brooks, Constance W; Peterson, Julie; Stewart, Bob R

2009-10-01

This study describes the use of data regarding self-care agency to enhance a supportive-educative nursing system for breast cancer survivors to reduce the risk of developing lymphedema post surgery. Impetus for this study came from the analysis of participant feedback from a parent study (Lance Armstrong Foundation pilot study) that sought to plan an educational program for nurses that will improve their supportive-educative nursing system when working with breast cancer survivors. The goal is to enable these women to reduce the risk of lymphedema post surgery. The parent study examined a bundled behavioral-educative intervention, which included standard lymphedema education coupled with Modified Manual Lymph Drainage (MMLD) to reduce the risk of developing lymphedema in newly-diagnosed breast cancer survivors. Based upon the feedback received from the parent study, the research team recognized that many of the participants were not fully following the recommendations of the intervention protocol. In order for nurses to help patients develop self-care agency (SCA) (Orem, 2001) to engage in actions that addressed the self-care requisites associated with post-breast cancer surgery, these nurses needed to refine their intervention skills. Prior to the development of a program for the nurses, the research team conducted a study to explore the state of power related to SCA of the study participants. The information obtained from this was then used in the development of an educational program for bundled intervention. Both motivational interviewing (Miller & Rollnick, 2002) and solution-focused therapy (Berg & DeJong, 1996) were incorporated into the educational program for the research nurse team to strengthen and improve supportive-educative nursing systems. Supportive-educative systems of care that integrate self-care deficit nursing theory, motivational interviewing, and solution-focused therapy can assist patients to develop and sustain self-care agency.

Navigating the poverty of heroin addiction treatment and recovery opportunity in Kenya: access work, self-care and rationed expectations.

PubMed

Rhodes, Tim; Ndimbii, James; Guise, Andy; Cullen, Lucy; Ayon, Sylvia

2015-01-01

Drawing on the analyses of qualitative interview accounts of people who inject heroin in Kenya, we describe the narration of addiction treatment access and recovery desire in conditions characterised by a 'poverty of drug treatment opportunity'. We observe the performance of addiction recovery narrative in the face of heavy social constraints limiting access to care. Fee-based residential rehabilitation ('rehab') is the only treatment locally available and inaccessible to most. Its recovery potential is doubted, given normative expectations of relapse. Treating drug use is a product of tightly bounded agency. Individuals enact strategies to maximise their slim chances of treatment access ('access work'), develop self-care alternatives when these fail to materialise and ration their care expectations. The use of rehab as a primary means of respite and harm reduction rather than recovery and the individuation of care in the absence of an enabling recovery environment are key characteristics of drug treatment experience. The recent incorporation of 'harm reduction' into policy discourses may trouble the primacy of recovery narrative in addiction treatment and in how treatment desires are voiced. The diversification of drug treatments in combination with social interventions enabling their access are fundamental.

Contextual barriers to implementation in primary care: an ethnographic study of a programme to improve chronic kidney disease care

PubMed Central

Armstrong, Natalie; Herbert, Georgia; Brewster, Liz

2016-01-01

Background. Context is important in implementation—we know that what works in one setting may not work in the same way elsewhere. Primary care has been described as a unique context both in relation to the care delivered and efforts to carry out research and implementation of new evidence. Objective. To explore some of the distinctive features of the primary care environment that may influence implementation. Methods. We conducted an ethnographic study involving observations, interviews and documentary analysis of the ENABLE-CKD project, which involved general practices implementing a chronic kidney disease care bundle and offering self-management support tools to patients. Analysis was based on the constant comparative method. Results. Four elements of the primary care environment emerged as important influences on the extent to which implementation was successful. First, the nature of delivering care in this setting meant that prioritizing one condition over others was problematic. Second, the lack of alignment with financial and other incentives affected engagement. Third, the project team lacked mechanisms through which engagement could be mandated. Fourth, working relationships within practices impacted on engagement. Conclusions. Those seeking to implement interventions in primary care need to consider the particular context if they are to secure successful implementation. We suggest that there are particular kinds of interventions, which may be best suited to the primary care context. PMID:27297465

Contextual barriers to implementation in primary care: an ethnographic study of a programme to improve chronic kidney disease care.

PubMed

Armstrong, Natalie; Herbert, Georgia; Brewster, Liz

2016-08-01

Context is important in implementation-we know that what works in one setting may not work in the same way elsewhere. Primary care has been described as a unique context both in relation to the care delivered and efforts to carry out research and implementation of new evidence. To explore some of the distinctive features of the primary care environment that may influence implementation. We conducted an ethnographic study involving observations, interviews and documentary analysis of the ENABLE-CKD project, which involved general practices implementing a chronic kidney disease care bundle and offering self-management support tools to patients. Analysis was based on the constant comparative method. Four elements of the primary care environment emerged as important influences on the extent to which implementation was successful. First, the nature of delivering care in this setting meant that prioritizing one condition over others was problematic. Second, the lack of alignment with financial and other incentives affected engagement. Third, the project team lacked mechanisms through which engagement could be mandated. Fourth, working relationships within practices impacted on engagement. Those seeking to implement interventions in primary care need to consider the particular context if they are to secure successful implementation. We suggest that there are particular kinds of interventions, which may be best suited to the primary care context. © The Author 2016. Published by Oxford University Press.

General practitioner views on the determinants of test ordering: a theory-based qualitative approach to the development of an intervention to improve immunoglobulin requests in primary care.

PubMed

Cadogan, S L; McHugh, S M; Bradley, C P; Browne, J P; Cahill, M R

2016-07-19

Research suggests that variation in laboratory requesting patterns may indicate unnecessary test use. Requesting patterns for serum immunoglobulins vary significantly between general practitioners (GPs). This study aims to explore GP's views on testing to identify the determinants of behaviour and recommend feasible intervention strategies for improving immunoglobulin test use in primary care. Qualitative semi-structured interviews were conducted with GPs requesting laboratory tests at Cork University Hospital or University Hospital Kerry in the South of Ireland. GPs were identified using a Health Service Executive laboratory list of GPs in the Cork-Kerry region. A random sample of GPs (stratified by GP requesting patterns) was generated from this list. GPs were purposively sampled based on the criteria of location (urban/rural); length of time qualified; and practice size (single-handed/group). Interviews were carried out between December 2014 and February 2015. Interviews were transcribed verbatim using NVivo 10 software and analysed using the framework analysis method. Emerging themes were mapped to the theoretical domains framework (TDF), which outlines 12 domains that can enable or inhibit behaviour change. The behaviour change wheel and behaviour change technique (BCT) taxonomy were then used to identify potential intervention strategies. Sixteen GPs were interviewed (ten males and six females). Findings suggest that intervention strategies should specifically target the key barriers to effective test ordering, while considering the context of primary care practice. Seven domains from the TDF were perceived to influence immunoglobulin test ordering behaviours and were identified as 'mechanisms for change' (knowledge, environmental context and resources, social/professional role and identity, beliefs about capabilities, beliefs about consequences, memory, attention and decision-making processes and behavioural regulation). Using these TDF domains, seven BCTs emerged as feasible 'intervention content' for targeting GPs' ordering behaviour. These included instructions on how to effectively request the test (how to perform behaviour), information on GPs' use of the test (feedback on behaviour), information about patient consequences resulting from not doing the test (information about health consequences), laboratory/consultant-based advice/education (credible source), altering the test ordering form (restructuring the physical environment), providing guidelines (prompts/cues) and adding interpretive comments to the results (adding objects to the environment). These BCTs aligned to four intervention functions: education, persuasion, environmental restructuring and enablement. This study has effectively applied behaviour change theory to identify feasible strategies for improving immunoglobulin test use in primary care using the TDF, 'behaviour change wheel' and BCT taxonomy. The identified BCTs will form the basis of a theory-based intervention to improve the use of immunoglobulin tests among GPs. Future research will involve the development and evaluation of this intervention.

'I can actually talk to them now': qualitative results of an educational intervention for emergency nurses caring for clients who self-injure.

PubMed

McAllister, Margaret; Moyle, Wendy; Billett, Stephen; Zimmer-Gembeck, Melanie

2009-10-01

This Australian study evaluated the effectiveness of a solution-focused education intervention in extending and improving emergency nursing responses to patients who present because of self-injury. Emergency nurses commonly report lack of training and feeling unskilled in managing people who present because of self-harm. Most educational interventions have provided content knowledge, yet rarely have they focused on conveying the value of health promotion strategies such as proactive skills and coping strategies. A mixed method pretest-posttest group design was used. Nurses (n = 36) were interviewed to examine differences in professional identity, awareness of self-injury and clinical reasoning. The qualitative results are presented in this paper and these showed improvements in knowledge and understanding of self-harm, self-belief in nurses' capacity to positively influence clients and the value of health promotion skills. The intervention produced a positive attitudinal shift towards clients and an expressed intention to act in ways that were more person-centred and change oriented. The solution-focused education intervention appears to show promise as an intervention for enabling nurses to value their unique contribution to providing a health service that is more proactive and health-promoting. Interactive education bringing psychosocial skills to technical nursing staff builds confidence, competence and more person-focused care.

Implementing a web-based home monitoring system within an academic health care network: barriers and facilitators to innovation diffusion.

PubMed

Pelletier, Alexandra C; Jethwani, Kamal; Bello, Heather; Kvedar, Joseph; Grant, Richard W

2011-01-01

The practice of outpatient type 2 diabetes management is gradually moving from the traditional visit-based, fee-for-service model to a new, health information communication technology (ICT)-supported model that can enable non-visit-based diabetes care. To date, adoption of innovative health ICT tools for diabetes management has been slowed by numerous barriers, such as capital investment costs, lack of reliable reimbursement mechanisms, design defects that have made some systems time-consuming and inefficient to use, and the need to integrate new ICT tools into a system not primarily designed for their use. Effective implementation of innovative diabetes health ICT interventions must address local practice heterogeneity and the interaction of this heterogeneity with clinical care delivery. The Center for Connected Health at Partners Healthcare has implemented a new ICT intervention, Diabetes Connect (DC), a Web-based glucose home monitoring and clinical messaging system. Using the framework of the diffusion of innovation theory, we review the implementation and examine lessons learned as we continue to deploy DC across the health care network. © 2010 Diabetes Technology Society.

Automatic identification of comparative effectiveness research from Medline citations to support clinicians’ treatment information needs

PubMed Central

Zhang, Mingyuan; Fiol, Guilherme Del; Grout, Randall W.; Jonnalagadda, Siddhartha; Medlin, Richard; Mishra, Rashmi; Weir, Charlene; Liu, Hongfang; Mostafa, Javed; Fiszman, Marcelo

2014-01-01

Online knowledge resources such as Medline can address most clinicians’ patient care information needs. Yet, significant barriers, notably lack of time, limit the use of these sources at the point of care. The most common information needs raised by clinicians are treatment-related. Comparative effectiveness studies allow clinicians to consider multiple treatment alternatives for a particular problem. Still, solutions are needed to enable efficient and effective consumption of comparative effectiveness research at the point of care. Objective Design and assess an algorithm for automatically identifying comparative effectiveness studies and extracting the interventions investigated in these studies. Methods The algorithm combines semantic natural language processing, Medline citation metadata, and machine learning techniques. We assessed the algorithm in a case study of treatment alternatives for depression. Results Both precision and recall for identifying comparative studies was 0.83. A total of 86% of the interventions extracted perfectly or partially matched the gold standard. Conclusion Overall, the algorithm achieved reasonable performance. The method provides building blocks for the automatic summarization of comparative effectiveness research to inform point of care decision-making. PMID:23920677

Utilization and management of maternal and child health funds in rural Nepal.

PubMed

Morrison, Joanna; Thapa, Rita; Sen, Aman; Neupane, Rishi; Borghi, Jo; Tumbahangphe, Kirti Man; Osrin, David; Manandhar, Dharma; Costello, Anthony

2010-01-01

Maternal and neonatal mortality rates are highest in the poorest countries, and financial barriers impede access to health care. Community loan funds can increase access to cash in rural areas, thereby reducing delays in care seeking. As part of a participatory intervention in rural Nepal, community women's groups initiated and managed local funds. We explore the factors affecting utilization and management of these funds and the role of the funds in the success of the women's group intervention. We conducted a qualitative study using focus group discussions, group interviews and unstructured observations. Funds may increase access to care for members of trusted 'insider' families adjudged as able to repay loans. Sustainability and sufficiency of funds was a concern but funds increased women's independence and enabled timely care seeking. Conversely, the perceived necessity to contribute may have deterred poorer women. While funds were integral to group success and increased women's autonomy, they may not be the most effective way of supporting the poorest, as the risk pool is too small to allow for repayment default.

Kangaroo mother care: a systematic review of barriers and enablers

PubMed Central

Labar, Amy S; Wall, Stephen; Atun, Rifat

2016-01-01

Abstract Objective To investigate factors influencing the adoption of kangaroo mother care in different contexts. Methods We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization’s regional databases, for studies on “kangaroo mother care” or “kangaroo care” or “skin-to-skin care” from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems. Findings We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption. Conclusion Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake. PMID:26908962

Optimizing nonpharmacological management following an acute exacerbation of chronic obstructive pulmonary disease.

PubMed

Harrison, Samantha L; Goldstein, Roger; Desveaux, Laura; Tulloch, Verity; Brooks, Dina

2014-01-01

Though the guidelines for the optimal management of chronic obstructive pulmonary disease (COPD) following an acute exacerbation (AE) are well established, issues associated with poor adherence to nonpharmacological interventions such as self-management advice and pulmonary rehabilitation will impact on hospital readmission rates and health care costs. Systems developed for clinically stable patients with COPD may not be sufficient for those who are post-exacerbation. A redesign of the manner in which such interventions are delivered to patients following an AECOPD is necessary. Addressing two or more components of the chronic care model is effective in reducing health care utilization in patients with COPD, with self-management support contributing a key role. By refining self-management support to incorporate the identification and treatment of psychological symptoms and by providing health care professionals adequate time and training to deliver respiratory-specific advice and self-management strategies, adherence to nonpharmacological therapies following an AE may be enhanced. Furthermore, following up patients in their own homes allows for the tailoring of advice and for the delivery of consistent health care messages which may enable knowledge to be retained. By refining the delivery of nonpharmacological therapies following an AECOPD according to components of the chronic care model, adherence may be improved, resulting in better disease management and possibly reducing health care utilization.

[Nursing Care Sistematization: accident by Loxosceles gaucho].

PubMed

Kamimura, Helayne Mika; Paiva, Bianca Sakamoto Ribeiro; Ayres, Jairo Aparecido

2009-01-01

Experience report carried out at a university hospital involving a patient victimized by an accident with a spider of the Loxosceles gaucho genus. This type of accident can be classified as mild, moderate and severe, depending on the period of time elapsed between the occurrence of the accident and the moment of care provision. We aimed at applying nursing care systematization in a comprehensive and humanized manner. The following nursing diagnoses were established: acute pain, damaged skin integrity, risks for infection, constipation and low self-esteem. The therapeutic relationship favored student/patient interactions and enabled the recognition of the needs that deserved nursing interventions. The nursing process was a valuable instrument and provided important elements for the patient's daily development and planning adjustment by prioritizing care quality.

A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program.

PubMed

Pearsall, Emily A; Meghji, Zahida; Pitzul, Kristen B; Aarts, Mary-Anne; McKenzie, Marg; McLeod, Robin S; Okrainec, Allan

2015-01-01

Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients. ERAS programs include perioperative interventions that when used together have led to decreased length of stay while increasing patient recovery and satisfaction. Despite the known benefits of ERAS programs, uptake remains slow. Semistructured interviews were conducted with general surgeons, anesthesiologists, and ward nurses at 7 University of Toronto-affiliated hospitals to identify potential barriers and enablers to adoption of 18 ERAS interventions. Grounded theory was used to thematically analyze the transcribed interviews. Nineteen general surgeons, 18 anesthesiologists, and 18 nurses participated. The mean time of each interview was 18 minutes. Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential. Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto-affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.

In what ways do communities support optimal antiretroviral treatment in Zimbabwe?

PubMed

Scott, K; Campbell, C; Madanhire, C; Skovdal, M; Nyamukapa, C; Gregson, S

2014-12-01

Little research has been conducted on how pre-existing indigenous community resources, especially social networks, affect the success of externally imposed HIV interventions. Antiretroviral treatment (ART), an externally initiated biomedical intervention, is being rolled out across sub-Saharan Africa. Understanding the ways in which community networks are working to facilitate optimal ART access and adherence will enable policymakers to better engage with and bolster these pre-existing resources. We conducted 67 interviews and eight focus group discussions with 127 people from three key population groups in Manicaland, eastern Zimbabwe: healthcare workers, adults on ART and carers of children on ART. We also observed over 100 h of HIV treatment sites at local clinics and hospitals. Our research sought to determine how indigenous resources were enabling people to achieve optimal ART access and adherence. We analysed data transcripts using thematic network technique, coding references to supportive community networks that enable local people to achieve ART access and adherence. People on ART or carers of children on ART in Zimbabwe report drawing support from a variety of social networks that enable them to overcome many obstacles to adherence. Key support networks include: HIV groups; food and income support networks; home-based care, church and women's groups; family networks; and relationships with healthcare providers. More attention to the community context in which HIV initiatives occur will help ensure that interventions work with and benefit from pre-existing social capital. © The Author (2013). Published by Oxford University Press.

In what ways do communities support optimal antiretroviral treatment in Zimbabwe?

PubMed Central

Scott, K.; Campbell, C.; Madanhire, C.; Skovdal, M.; Nyamukapa, C.; Gregson, S.

2014-01-01

Little research has been conducted on how pre-existing indigenous community resources, especially social networks, affect the success of externally imposed HIV interventions. Antiretroviral treatment (ART), an externally initiated biomedical intervention, is being rolled out across sub-Saharan Africa. Understanding the ways in which community networks are working to facilitate optimal ART access and adherence will enable policymakers to better engage with and bolster these pre-existing resources. We conducted 67 interviews and eight focus group discussions with 127 people from three key population groups in Manicaland, eastern Zimbabwe: healthcare workers, adults on ART and carers of children on ART. We also observed over 100 h of HIV treatment sites at local clinics and hospitals. Our research sought to determine how indigenous resources were enabling people to achieve optimal ART access and adherence. We analysed data transcripts using thematic network technique, coding references to supportive community networks that enable local people to achieve ART access and adherence. People on ART or carers of children on ART in Zimbabwe report drawing support from a variety of social networks that enable them to overcome many obstacles to adherence. Key support networks include: HIV groups; food and income support networks; home-based care, church and women's groups; family networks; and relationships with healthcare providers. More attention to the community context in which HIV initiatives occur will help ensure that interventions work with and benefit from pre-existing social capital. PMID:23503291

Decrease social inequalities return-to-work: development and design of a randomised controlled trial among women with breast cancer.

PubMed

Vidor, Clémence; Leroyer, Ariane; Christophe, Véronique; Seillier, Mélanie; Foncel, Jérome; Van de Maële, Justine; Bonneterre, Jacques; Fantoni, Sophie

2014-04-17

Despite the improvement in the care management, women cancer patients who are still in employment find themselves for the most part obliged to stop working while they are having treatment. Their return-to-work probability is impacted by numerous psychosocial factors. The objective is to describe the development and the content of an intervention aimed to facilitate the return to work of female breast cancer patients and in particular the women in the most precarious situations through early active individualised psychosocial support (APAPI). The intervention proposed is made up of 4 interviews with a psychologist at the hospital, distributed over the year according to the diagnosis and conducted on the same day as a conventional follow-up consultation, then a consultation with a specialist job retention physician. We expect, in the first instance, that this intervention will reduce the social inequalities of the return-to-work rate at 12 months. The EPICES score will enable the population to be broken down according to the level of social precariousness. The other expected results are the reduction of the social inequalities in the quality of the return to work at 18 and 24 months and the disparities between the individual and collective resources of the patients. This intervention is assessed in the context of a controlled and randomised multi-centre study. The patients eligible are women aged between 18 and 55 years with a unilateral breast cancer with local extension exclusively, having received surgery followed by adjuvant chemotherapy, in employment at the time of the diagnosis and dealt with by one of the 2 investigating centres. It is essential to assess this type of intervention before envisaging its generalisation. The study set in place will enable us to measure the impact of this intervention aiming to facilitate the return to work of breast cancer patients, in particular for those who suffer from social fragility, compared with the standard care.

Enabling healthy living: Experiences of people with severe mental illness in psychiatric outpatient services.

PubMed

Blomqvist, Marjut; Sandgren, Anna; Carlsson, Ing-Marie; Jormfeldt, Henrika

2018-02-01

It is well known that people with severe mental illness have a reduced life expectancy and a greater risk of being affected by preventable physical illnesses such as metabolic syndrome, cardiovascular disease and type 2 diabetes. There are still, however, only a few published studies focusing on what enables healthy living for this group. This study thus aimed to describe what enables healthy living among people with severe mental illness in psychiatric outpatient services. The data were collected in qualitative interviews (n = 16) and content analysis was used to analyze the data. The interviews resulted in an overall theme "Being regarded as a whole human being by self and others", which showed the multidimensional nature of health and the issues that enable healthy living among people with severe mental illness. Three categories emerged: (i) everyday structure (ii), motivating life events and (iii) support from significant others. The results indicate that a person with severe mental illness needs to be encountered as a whole person if healthy living is to be enabled. Attaining healthy living requires collaboration between the providers of care, help and support. Health care organizations need to work together to develop and provide interventions to enable healthy living and to reduce poor physical health among people with severe mental illness. © 2017 Australian College of Mental Health Nurses Inc.

Managerial leadership for research use in nursing and allied health care professions: a narrative synthesis protocol

PubMed Central

2014-01-01

Background Nurses and allied health care professionals (physiotherapists, occupational therapists, speech and language pathologists, dietitians) form more than half of the clinical health care workforce and play a central role in health service delivery. There is a potential to improve the quality of health care if these professionals routinely use research evidence to guide their clinical practice. However, the use of research evidence remains unpredictable and inconsistent. Leadership is consistently described in implementation research as critical to enhancing research use by health care professionals. However, this important literature has not yet been synthesized and there is a lack of clarity on what constitutes effective leadership for research use, or what kinds of intervention effectively develop leadership for the purpose of enabling and enhancing research use in clinical practice. We propose to synthesize the evidence on leadership behaviours amongst front line and senior managers that are associated with research evidence by nurses and allied health care professionals, and then determine the effectiveness of interventions that promote these behaviours. Methods/Design Using an integrated knowledge translation approach that supports a partnership between researchers and knowledge users throughout the research process, we will follow principles of knowledge synthesis using a systematic method to synthesize different types of evidence involving: searching the literature, study selection, data extraction and quality assessment, and analysis. A narrative synthesis will be conducted to explore relationships within and across studies and meta-analysis will be performed if sufficient homogeneity exists across studies employing experimental randomized control trial designs. Discussion With the engagement of knowledge users in leadership and practice, we will synthesize the research from a broad range of disciplines to understand the key elements of leadership that supports and enables research use by health care practitioners, and how to develop leadership for the purpose of enhancing research use in clinical practice. Trial registration PROSPERO CRD42014007660. PMID:24903267

Managerial leadership for research use in nursing and allied health care professions: a narrative synthesis protocol.

PubMed

Gifford, Wendy A; Holyoke, Paul; Squires, Janet E; Angus, Douglas; Brosseau, Lucie; Egan, Mary; Graham, Ian D; Miller, Carol; Wallin, Lars

2014-06-05

Nurses and allied health care professionals (physiotherapists, occupational therapists, speech and language pathologists, dietitians) form more than half of the clinical health care workforce and play a central role in health service delivery. There is a potential to improve the quality of health care if these professionals routinely use research evidence to guide their clinical practice. However, the use of research evidence remains unpredictable and inconsistent. Leadership is consistently described in implementation research as critical to enhancing research use by health care professionals. However, this important literature has not yet been synthesized and there is a lack of clarity on what constitutes effective leadership for research use, or what kinds of intervention effectively develop leadership for the purpose of enabling and enhancing research use in clinical practice. We propose to synthesize the evidence on leadership behaviours amongst front line and senior managers that are associated with research evidence by nurses and allied health care professionals, and then determine the effectiveness of interventions that promote these behaviours. Using an integrated knowledge translation approach that supports a partnership between researchers and knowledge users throughout the research process, we will follow principles of knowledge synthesis using a systematic method to synthesize different types of evidence involving: searching the literature, study selection, data extraction and quality assessment, and analysis. A narrative synthesis will be conducted to explore relationships within and across studies and meta-analysis will be performed if sufficient homogeneity exists across studies employing experimental randomized control trial designs. With the engagement of knowledge users in leadership and practice, we will synthesize the research from a broad range of disciplines to understand the key elements of leadership that supports and enables research use by health care practitioners, and how to develop leadership for the purpose of enhancing research use in clinical practice. PROSPERO CRD42014007660.

Supportive care for older people with frailty in hospital: An integrative review.

PubMed

Nicholson, Caroline; Morrow, Elizabeth M; Hicks, Allan; Fitzpatrick, Joanne

2017-01-01

Growing numbers of older people living with frailty and chronic health conditions are being referred to hospitals with acute care needs. Supportive care is a potentially highly relevant and clinically important approach which could bridge the practice gap between curative models of care and palliative care. However, future interventions need to be informed and underpinned by existing knowledge of supportive care. To identify and build upon existing theories and evidence about supportive care, specifically in relation to the hospital care of older people with frailty, to inform future interventions and their evaluation. An integrative review was used to identify and integrate theory and evidence. Electronic databases (Cochrane Medline, EMBASE and CIHAHL) were searched using the key term 'supportive care'. Screening identified studies employing qualitative and/or quantitative methods published between January 1990 and December 2015. Citation searches, reference checking and searches of the grey literature were also undertaken. Literature searches identified 2733 articles. After screening, and applying eligibility criteria based on relevance to the research question, studies were subject to methodological quality appraisal. Findings from included articles (n=52) were integrated using synthesis of themes. Relevant evidence was identified across different research literatures, on clinical conditions and contexts. Seven distinct themes of the synthesis were identified, these were: Ensuring fundamental aspects of care are met, Communicating and connecting with the patient, Carer and family engagement, Building up a picture of the person and their circumstances, Decisions and advice about best care for the person, Enabling self-help and connection to wider support, and Supporting patients through transitions in care. A tentative integrative model of supportive care for frail older people is developed from the findings. The findings and model developed here will inform future interventions and can help staff and hospital managers to develop appropriate strategies, staff training and resource allocation models to improve the quality of health care for older people. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Feasibility Testing and Refinement of a Supportive Educational Intervention for Carers of Patients with High-Grade Glioma - a Pilot Study.

PubMed

Halkett, Georgia K B; Lobb, Elizabeth A; Miller, Lisa; Shaw, Thérèse; Moorin, Rachael; Long, Anne; King, Anne; Clarke, Jenny; Fewster, Stephanie; Nowak, Anna K

2017-02-11

The aim of this pilot study was to test the feasibility and acceptability of a family carer intervention for carers of patients with high-grade glioma (HGG). The intervention consisted of: (1) an initial telephone assessment of carer needs; (2) a personalised tabbed resource file; (3) nurse-led home visit; and (4) ongoing telephone support. Two consumer representatives reviewed the intervention resources. The intervention was then piloted with participants who were the primary carer for patients undergoing treatment for HGG in Western Australia. Two consumers provided feedback on the resource, and 10 carers participated in the pilot. Positive feedback was received about the resource manual and intervention. Suggestions were also made for changes which were implemented into the trial. The surveys were shortened based on feedback. Participants identified a large range of issues during nursing assessments which would not otherwise be identified or addressed for carers receiving routine care. As a result of providing the intervention, the nurse was able to make referrals to address needs that were identified. This pilot study enabled us to refine and test the Care-IS intervention and test the feasibility and acceptability of proposed survey instruments. We were also able to estimate recruitment and retention and the overall study timeline required for the randomised controlled trial we are now conducting. It has also demonstrated the role of the nurse who delivered the intervention and allowed us to refine communication and referral pathways.

Using the Medical Research Council framework for development and evaluation of complex interventions in a low resource setting to develop a theory-based treatment support intervention delivered via SMS text message to improve blood pressure control.

PubMed

Bobrow, Kirsten; Farmer, Andrew; Cishe, Nomazizi; Nwagi, Ntobeko; Namane, Mosedi; Brennan, Thomas P; Springer, David; Tarassenko, Lionel; Levitt, Naomi

2018-01-23

Several frameworks now exist to guide intervention development but there remains only limited evidence of their application to health interventions based around use of mobile phones or devices, particularly in a low-resource setting. We aimed to describe our experience of using the Medical Research Council (MRC) Framework on complex interventions to develop and evaluate an adherence support intervention for high blood pressure delivered by SMS text message. We further aimed to describe the developed intervention in line with reporting guidelines for a structured and systematic description. We used a non-sequential and flexible approach guided by the 2008 MRC Framework for the development and evaluation of complex interventions. We reviewed published literature and established a multi-disciplinary expert group to guide the development process. We selected health psychology theory and behaviour change techniques that have been shown to be important in adherence and persistence with chronic medications. Semi-structured interviews and focus groups with various stakeholders identified ways in which treatment adherence could be supported and also identified key features of well-regarded messages: polite tone, credible information, contextualised, and endorsed by identifiable member of primary care facility staff. Direct and indirect user testing enabled us to refine the intervention including refining use of language and testing of interactive components. Our experience shows that using a formal intervention development process is feasible in a low-resource multi-lingual setting. The process enabled us to pre-test assumptions about the intervention and the evaluation process, allowing the improvement of both. Describing how a multi-component intervention was developed including standardised descriptions of content aimed to support behaviour change will enable comparison with other similar interventions and support development of new interventions. Even in low-resource settings, funders and policy-makers should provide researchers with time and resources for intervention development work and encourage evaluation of the entire design and testing process. The trial of the intervention is registered with South African National Clinical Trials Register number (SANCTR DOH-27-1212-386; 28/12/2012); Pan Africa Trial Register (PACTR201411000724141; 14/12/2013); ClinicalTrials.gov ( NCT02019823 ; 24/12/2013).

A model to evaluate quality and effectiveness of disease management.

PubMed

Lemmens, K M M; Nieboer, A P; van Schayck, C P; Asin, J D; Huijsman, R

2008-12-01

Disease management has emerged as a new strategy to enhance quality of care for patients suffering from chronic conditions, and to control healthcare costs. So far, however, the effects of this strategy remain unclear. Although current models define the concept of disease management, they do not provide a systematic development or an explanatory theory of how disease management affects the outcomes of care. The objective of this paper is to present a framework for valid evaluation of disease-management initiatives. The evaluation model is built on two pillars of disease management: patient-related and professional-directed interventions. The effectiveness of these interventions is thought to be affected by the organisational design of the healthcare system. Disease management requires a multifaceted approach; hence disease-management programme evaluations should focus on the effects of multiple interventions, namely patient-related, professional-directed and organisational interventions. The framework has been built upon the conceptualisation of these disease-management interventions. Analysis of the underlying mechanisms of these interventions revealed that learning and behavioural theories support the core assumptions of disease management. The evaluation model can be used to identify the components of disease-management programmes and the mechanisms behind them, making valid comparison feasible. In addition, this model links the programme interventions to indicators that can be used to evaluate the disease-management programme. Consistent use of this framework will enable comparisons among disease-management programmes and outcomes in evaluation research.

A theory led narrative review of one-to-one health interventions: the influence of attachment style and client-provider relationship on client adherence.

PubMed

Nanjappa, S; Chambers, S; Marcenes, W; Richards, D; Freeman, R

2014-10-01

A theory-led narrative approach was used to unpack the complexities of the factors that enable successful client adherence following one-to-one health interventions. Understanding this could prepare the provider to anticipate different adherence behaviours by clients, allowing them to tailor their interventions to increase the likelihood of adherence. The review was done in two stages. A theoretical formulation was proposed to explore factors which influence the effectiveness of one-to-one interventions to result in client adherence. The second stage tested this theory using a narrative synthesis approach. Eleven studies across the health care arena were included in the synthesis and explored the interplay between client attachment style, client-provider interaction and client adherence with health interventions. It emerged that adherence results substantially because of the relationship that the client has with the provider, which is amplified or diminished by the client's own attachment style. This occurs because the client's attachment style shapes how they perceive and behave in relationships with the health-care providers, who become the 'secure base' from which the client accepts, assimilates and adheres with the recommended health intervention. The pathway from one-to-one interventions to adherence is explained using moderated mediation and mediated moderation models. © The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.

MODEM: A comprehensive approach to modelling outcome and costs impacts of interventions for dementia. Protocol paper.

PubMed

Comas-Herrera, Adelina; Knapp, Martin; Wittenberg, Raphael; Banerjee, Sube; Bowling, Ann; Grundy, Emily; Jagger, Carol; Farina, Nicolas; Lombard, Daniel; Lorenz, Klara; McDaid, David

2017-01-11

The MODEM project (A comprehensive approach to MODelling outcome and costs impacts of interventions for DEMentia) explores how changes in arrangements for the future treatment and care of people living with dementia, and support for family and other unpaid carers, could result in better outcomes and more efficient use of resources. MODEM starts with a systematic mapping of the literature on effective and (potentially) cost-effective interventions in dementia care. Those findings, as well as data from a cohort, will then be used to model the quality of life and cost impacts of making these evidence-based interventions more widely available in England over the period from now to 2040. Modelling will use a suite of models, combining microsimulation and macrosimulation methods, modelling the costs and outcomes of care, both for an individual over the life-course from the point of dementia diagnosis, and for individuals and England as a whole in a particular year. Project outputs will include an online Dementia Evidence Toolkit, making evidence summaries and a literature database available free to anyone, papers in academic journals and other written outputs, and a MODEM Legacy Model, which will enable local commissioners of services to apply the model to their own populations. Modelling the effects of evidence-based cost-effective interventions and making this information widely available has the potential to improve the health and quality of life both of people with dementia and their carers, while ensuring that resources are used efficiently.

Translating and testing the ENABLE: CHF-PC concurrent palliative care model for older adults with heart failure and their family caregivers.

PubMed

Dionne-Odom, J Nicholas; Kono, Alan; Frost, Jennifer; Jackson, Lisa; Ellis, Daphne; Ahmed, Ali; Azuero, Andres; Bakitas, Marie

2014-09-01

Heart failure (HF) and palliative care (PC) organizations recommend early PC to improve the quality of life of patients living with HF. We conducted a two-phase formative evaluation study to translate a cancer-focused concurrent PC intervention into one that would be appropriate for rural-dwelling adults with New York Heart Association Class III-IV HF and their primary caregivers. Phase I: We tailored the intervention for an HF population via literature review, expert consultation, and clinician (N=15) small group interviews. Phase II: We enrolled 11 patient/caregiver dyads to assess intervention feasibility and satisfaction. We assessed participants' experiences and satisfaction after session/week three and session/week six via digitally recorded interviews. Clinician and participant interviews were transcribed and content analyzed. Outcome measures were evaluated for completion rates and effect sizes. Phase I: Clinicians described barriers to initiating PC in HF, triggers for initiating PC, and suggestions for intervention improvement. Phase II: Participants were able to complete the majority of study sessions, measures, and interviews. Satisfaction interviews revealed the content to be relevant and comprehensive in addressing HF patient and caregiver primary concerns; however, participants unanimously suggested making the intervention available earlier in the illness trajectory. Efficacy measures demonstrated small to medium effect sizes. We tailored and demonstrated feasibility of providing an early, concurrent palliative care intervention to patients with advanced HF and their caregivers. Based on this experience we are now conducting an efficacy trial in a racially diverse sample.

Review of electronic decision-support tools for diabetes care: a viable option for low- and middle-income countries?

PubMed

Ali, Mohammed K; Shah, Seema; Tandon, Nikhil

2011-05-01

Diabetes care is complex, requiring motivated patients, providers, and systems that enable guideline-based preventative care processes, intensive risk-factor control, and positive lifestyle choices. However, care delivery in low- and middle-income countries (LMIC) is hindered by a compendium of systemic and personal factors. While electronic medical records (EMR) and computerized clinical decision-support systems (CDSS) have held great promise as interventions that will overcome system-level challenges to improving evidence-based health care delivery, evaluation of these quality improvement interventions for diabetes care in LMICs is lacking. OBJECTIVE AND DATA SOURCES: We reviewed the published medical literature (systematic search of MEDLINE database supplemented by manual searches) to assess the quantifiable and qualitative impacts of combined EMR-CDSS tools on physician performance and patient outcomes and their applicability in LMICs. Inclusion criteria prespecified the population (type 1 or 2 diabetes patients), intervention (clinical EMR-CDSS tools with enhanced functionalities), and outcomes (any process, self-care, or patient-level data) of interest. Case, review, or methods reports and studies focused on nondiabetes, nonclinical, or in-patient uses of EMR-CDSS were excluded. Quantitative and qualitative data were extracted from studies by separate single reviewers, respectively, and relevant data were synthesized. Thirty-three studies met inclusion criteria, originating exclusively from high-income country settings. Among predominantly experimental study designs, process improvements were consistently observed along with small, variable improvements in risk-factor control, compared with baseline and/or control groups (where applicable). Intervention benefits varied by baseline patient characteristics, features of the EMR-CDSS interventions, motivation and access to technology among patients and providers, and whether EMR-CDSS tools were combined with other quality improvement strategies (e.g., workflow changes, case managers, algorithms, incentives). Patients shared experiences of feeling empowered and benefiting from increased provider attention and feedback but also frustration with technical difficulties of EMR-CDSS tools. Providers reported more efficient and standardized processes plus continuity of care but also role tensions and "mechanization" of care. This narrative review supports EMR-CDSS tools as innovative conduits for structuring and standardizing care processes but also highlights setting and selection limitations of the evidence reviewed. In the context of limited resources, individual economic hardships, and lack of structured systems or trained human capital, this review reinforces the need for well-designed investigations evaluating the role and feasibility of technological interventions (customized to each LMIC's locality) in clinical decision making for diabetes care. © 2011 Diabetes Technology Society.

Making it local: Beacon Communities use health information technology to optimize care management.

PubMed

Allen, Amy; Des Jardins, Terrisca R; Heider, Arvela; Kanger, Chatrian R; Lobach, David F; McWilliams, Lee; Polello, Jennifer M; Rein, Alison L; Schachter, Abigail A; Singh, Ranjit; Sorondo, Barbara; Tulikangas, Megan C; Turske, Scott A

2014-06-01

Care management aims to provide cost-effective, coordinated, non-duplicative care to improve care quality, population health, and reduce costs. The 17 communities receiving funding from the Office of the National Coordinator for Health Information Technology through the Beacon Community Cooperative Agreement Program are leaders in building and strengthening their health information technology (health IT) infrastructure to provide more effective and efficient care management. This article profiles 6 Beacon Communities' health IT-enabled care management programs, highlighting the influence of local context on program strategy and design, and describing challenges, lessons learned, and policy implications for care delivery and payment reform. The unique needs (eg, disease burden, demographics), community partnerships, and existing resources and infrastructure all exerted significant influence on the overall priorities and design of each community's care management program. Though each Beacon Community needed to engage in a similar set of care management tasks--including patient identification, stratification, and prioritization; intervention; patient engagement; and evaluation--the contextual factors helped shape the specific strategies and tools used to carry out these tasks and achieve their objectives. Although providers across the country are striving to deliver standardized, high-quality care, the diverse contexts in which this care is delivered significantly influence the priorities, strategies, and design of community-based care management interventions. Gaps and challenges in implementing effective community-based care management programs include: optimizing allocation of care management services; lack of available technology tailored to care management needs; lack of standards and interoperability; integrating care management into care settings; evaluating impact; and funding and sustainability.

Smartphone application for multi-phasic interventional trials in psychiatry: Technical design of a smart server.

PubMed

Zhang, Melvyn W B; Ho, Roger C M

2017-01-01

Smartphones and their accompanying applications are currently widely utilized in various healthcare interventions. Prior to the deployment of these tools for healthcare intervention, typically, proof of concept feasibility studies, as well as randomized trials are conducted to determine that these tools are efficacious prior to their actual implementation. In the field of psychiatry, most of the current interventions seek to compare smartphone based intervention against conventional care. There remains a paucity of research evaluating different forms of interventions using a single smartphone application. In the field of nutrition, there has been recent pioneering research demonstrating how a multi-phasic randomized controlled trial could be conducted using a single smartphone application. Despite the innovativeness of the previous smartphone conceptualization, there remains a paucity of technical information underlying the conceptualization that would support a multi-phasic interventional trial. It is thus the aim of the current technical note to share insights into an innovative server design that would enable the delivery of multi-phasic trials.

Behaviour change interventions to influence antimicrobial prescribing: a cross-sectional analysis of reports from UK state-of-the-art scientific conferences.

PubMed

Rawson, T M; Moore, L S P; Tivey, A M; Tsao, A; Gilchrist, M; Charani, E; Holmes, A H

2017-01-01

To improve the quality of antimicrobial stewardship (AMS) interventions the application of behavioural sciences supported by multidisciplinary collaboration has been recommended. We analysed major UK scientific research conferences to investigate AMS behaviour change intervention reporting. Leading UK 2015 scientific conference abstracts for 30 clinical specialties were identified and interrogated. All AMS and/or antimicrobial resistance(AMR) abstracts were identified using validated search criteria. Abstracts were independently reviewed by four researchers with reported behavioural interventions classified using a behaviour change taxonomy. Conferences ran for 110 days with >57,000 delegates. 311/12,313(2.5%) AMS-AMR abstracts (oral and poster) were identified. 118/311(40%) were presented at the UK's infectious diseases/microbiology conference. 56/311(18%) AMS-AMR abstracts described behaviour change interventions. These were identified across 12/30(40%) conferences. The commonest abstract reporting behaviour change interventions were quality improvement projects [44/56 (79%)]. In total 71 unique behaviour change functions were identified. Policy categories; "guidelines" (16/71) and "service provision" (11/71) were the most frequently reported. Intervention functions; "education" (6/71), "persuasion" (7/71), and "enablement" (9/71) were also common. Only infection and primary care conferences reported studies that contained multiple behaviour change interventions. The remaining 10 specialties tended to report a narrow range of interventions focusing on "guidelines" and "enablement". Despite the benefits of behaviour change interventions on antimicrobial prescribing, very few AMS-AMR studies reported implementing them in 2015. AMS interventions must focus on promoting behaviour change towards antimicrobial prescribing. Greater focus must be placed on non-infection specialties to engage with the issue of behaviour change towards antimicrobial use.

A prospective randomized trial examining health care utilization in individuals using multiple smartphone-enabled biosensors.

PubMed

Bloss, Cinnamon S; Wineinger, Nathan E; Peters, Melissa; Boeldt, Debra L; Ariniello, Lauren; Kim, Ju Young; Sheard, Judith; Komatireddy, Ravi; Barrett, Paddy; Topol, Eric J

2016-01-01

Background. Mobile health and digital medicine technologies are becoming increasingly used by individuals with common, chronic diseases to monitor their health. Numerous devices, sensors, and apps are available to patients and consumers-some of which have been shown to lead to improved health management and health outcomes. However, no randomized controlled trials have been conducted which examine health care costs, and most have failed to provide study participants with a truly comprehensive monitoring system. Methods. We conducted a prospective randomized controlled trial of adults who had submitted a 2012 health insurance claim associated with hypertension, diabetes, and/or cardiac arrhythmia. The intervention involved receipt of one or more mobile devices that corresponded to their condition(s) (hypertension: Withings Blood Pressure Monitor; diabetes: Sanofi iBGStar Blood Glucose Meter; arrhythmia: AliveCor Mobile ECG) and an iPhone with linked tracking applications for a period of 6 months; the control group received a standard disease management program. Moreover, intervention study participants received access to an online health management system which provided participants detailed device tracking information over the course of the study. This was a monitoring system designed by leveraging collaborations with device manufacturers, a connected health leader, health care provider, and employee wellness program-making it both unique and inclusive. We hypothesized that health resource utilization with respect to health insurance claims may be influenced by the monitoring intervention. We also examined health-self management. Results & Conclusions. There was little evidence of differences in health care costs or utilization as a result of the intervention. Furthermore, we found evidence that the control and intervention groups were equivalent with respect to most health care utilization outcomes. This result suggests there are not large short-term increases or decreases in health care costs or utilization associated with monitoring chronic health conditions using mobile health or digital medicine technologies. Among secondary outcomes there was some evidence of improvement in health self-management which was characterized by a decrease in the propensity to view health status as due to chance factors in the intervention group.

A prospective randomized trial examining health care utilization in individuals using multiple smartphone-enabled biosensors

PubMed Central

Peters, Melissa; Boeldt, Debra L.; Ariniello, Lauren; Kim, Ju Young; Sheard, Judith; Komatireddy, Ravi; Barrett, Paddy

2016-01-01

Background. Mobile health and digital medicine technologies are becoming increasingly used by individuals with common, chronic diseases to monitor their health. Numerous devices, sensors, and apps are available to patients and consumers–some of which have been shown to lead to improved health management and health outcomes. However, no randomized controlled trials have been conducted which examine health care costs, and most have failed to provide study participants with a truly comprehensive monitoring system. Methods. We conducted a prospective randomized controlled trial of adults who had submitted a 2012 health insurance claim associated with hypertension, diabetes, and/or cardiac arrhythmia. The intervention involved receipt of one or more mobile devices that corresponded to their condition(s) (hypertension: Withings Blood Pressure Monitor; diabetes: Sanofi iBGStar Blood Glucose Meter; arrhythmia: AliveCor Mobile ECG) and an iPhone with linked tracking applications for a period of 6 months; the control group received a standard disease management program. Moreover, intervention study participants received access to an online health management system which provided participants detailed device tracking information over the course of the study. This was a monitoring system designed by leveraging collaborations with device manufacturers, a connected health leader, health care provider, and employee wellness program–making it both unique and inclusive. We hypothesized that health resource utilization with respect to health insurance claims may be influenced by the monitoring intervention. We also examined health-self management. Results & Conclusions. There was little evidence of differences in health care costs or utilization as a result of the intervention. Furthermore, we found evidence that the control and intervention groups were equivalent with respect to most health care utilization outcomes. This result suggests there are not large short-term increases or decreases in health care costs or utilization associated with monitoring chronic health conditions using mobile health or digital medicine technologies. Among secondary outcomes there was some evidence of improvement in health self-management which was characterized by a decrease in the propensity to view health status as due to chance factors in the intervention group. PMID:26788432

Laying a Firm Foundation: Embedding Evidence-Based Emergent Literacy Practices Into Early Intervention and Preschool Environments.

PubMed

Terrell, Pamela; Watson, Maggie

2018-04-05

As part of this clinical forum on curriculum-based intervention, the goal of this tutorial is to share research about the importance of language and literacy foundations in natural environments during emergent literacy skill development, from infancy through preschool. Following an overview of intervention models in schools by Powell (2018), best practices at home, in child care, and in preschool settings are discussed. Speech-language pathologists in these settings will be provided a toolbox of best emergent literacy practices. A review of published literature in speech-language pathology, early intervention, early childhood education, and literacy was completed. Subsequently, an overview of the impact of early home and preschool literacy experiences are described. Research-based implementation of best practice is supported with examples of shared book reading and child-led literacy embedded in play within the coaching model of early intervention. Finally, various aspects of emergent literacy skill development in the preschool years are discussed. These include phonemic awareness, print/alphabet awareness, oral language skills, and embedded/explicit literacy. Research indicates that rich home literacy environments and exposure to rich oral language provide an important foundation for the more structured literacy environments of school. Furthermore, there is a wealth of evidence to support a variety of direct and indirect intervention practices in the home, child care, and preschool contexts to support and enhance all aspects of oral and written literacy. Application of this "toolbox" of strategies should enable speech-language pathologists to address the prevention and intervention of literacy deficits within multiple environments during book and play activities. Additionally, clinicians will have techniques to share with parents, child care providers, and preschool teachers for evidence-based literacy instruction within all settings during typical daily activities.

The role of a behavioural medicine intervention in physiotherapy for the effects of rehabilitation outcomes in exercise-based cardiac rehabilitation (ECRA) - the study protocol of a randomised, controlled trial.

PubMed

Borg, Sabina; Öberg, Birgitta; Nilsson, Lennart; Söderlund, Anne; Bäck, Maria

2017-05-25

To help patients with coronary artery disease (CAD) benefit from the positive health effects attained by exercise-based cardiac rehabilitation (CR), adherence to these programmes according to international guidelines is important. Strategies to increase adherence to exercise-based CR are mainly an unexplored area. The objective of this study is to investigate the effects of a behavioural medicine intervention in physiotherapy, containing goal-setting, self-monitoring and feedback, with the aim of improving rehabilitation outcomes for exercise-based CR, compared with usual care. This is a randomised, controlled trial. A total of 160 patients with CAD will be included consecutively at the Coronary Care Unit at a university hospital in Sweden. Patients are randomised 1:1 using sealed envelopes to usual care or a behavioural medicine intervention in physiotherapy, in addition to usual care for 4 months. Outcome assessment at baseline, 4 and 12 months includes submaximal aerobic capacity (primary outcome), exercise adherence, muscle endurance, level of physical activity, biomarkers, anxiety and depression, health-related quality of life, patient enablement and self-efficacy (secondary outcomes). This is the first study to evaluate the role of an integrated behavioural medicine intervention in exercise-based CR in the effects of rehabilitation outcomes. The results of this study will provide valuable information about the effect of these interventions in exercise-based CR and it has the potential to inform and assist in further treatment in secondary prevention for patients with CAD. The study include all items from the World Health Organization Trial Registration Data Set. NCT02895451, 2016-08-16, retrospectively registered.

Developing an Unguided Internet-Delivered Intervention for Emotional Distress in Primary Care Patients: Applying Common Factor and Person-Based Approaches.

PubMed

Geraghty, Adam Wa; Muñoz, Ricardo F; Yardley, Lucy; Mc Sharry, Jennifer; Little, Paul; Moore, Michael

2016-12-20

Developing effective, unguided Internet interventions for mental health represents a challenge. Without structured human guidance, engagement with these interventions is often limited and the effectiveness reduced. If their effectiveness can be increased, they have great potential for broad, low-cost dissemination. Improving unguided Internet interventions for mental health requires a renewed focus on the proposed underlying mechanisms of symptom improvement and the involvement of target users from the outset. The aim of our study was to develop an unguided e-mental health intervention for distress in primary care patients, drawing on meta-theory of psychotherapeutic change and utilizing the person-based approach (PBA) to guide iterative qualitative piloting with patients. Common factors meta-theory informed the selection and structure of therapeutic content, enabling flexibility whilst retaining the proposed necessary ingredients for effectiveness. A logic model was designed outlining intervention components and proposed mechanisms underlying improvement. The PBA provided a framework for systematically incorporating target-user perspective into the intervention development. Primary care patients (N=20) who had consulted with emotional distress in the last 12 months took part in exploratory qualitative interviews, and a subsample (n=13) undertook think-aloud interviews with a prototype of the intervention. A flexible intervention was developed, to be used as and when patients need, diverting from a more traditional, linear approach. Based on the in-depth qualitative findings, disorder terms such as "depression" were avoided, and discussions of psychological symptoms were placed in the context of stressful life events. Think-aloud interviews showed that patients were positive about the design and structure of the intervention. On the basis of patient feedback, modifications were made to increase immediate access to all therapeutic techniques. Detailing theoretical assumptions underlying Internet interventions for mental health, and integrating this approach with systematic in-depth qualitative research with target patients is important. These strategies may provide novel ways for addressing the challenges of unguided delivery. The resulting intervention, Healthy Paths, will be evaluated in primary care-based randomized controlled trials, and deployed as a massive open online intervention (MOOI). ©Adam WA Geraghty, Ricardo F Muñoz, Lucy Yardley, Jennifer Mc Sharry, Paul Little, Michael Moore. Originally published in JMIR Mental Health (http://mental.jmir.org), 20.12.2016.

Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF).

PubMed

Craig, Louise E; McInnes, Elizabeth; Taylor, Natalie; Grimley, Rohan; Cadilhac, Dominique A; Considine, Julie; Middleton, Sandy

2016-11-28

Clinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED. Studies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy. Five qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of "environmental, context and resources" (such as stressful working conditions or lack of resources) and "knowledge" (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of "knowledge" (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and "skills" (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were "focus on past success" and "information about health consequences." Barriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs.

Delays in Cancer Care Among Low-Income Minorities Despite Access

PubMed Central

Nonzee, Narissa J.; Ragas, Daiva M.; Ha Luu, Thanh; Phisuthikul, Ava M.; Tom, Laura; Dong, XinQi

2015-01-01

Abstract Introduction: Narrowing the racial/ethnic and socioeconomic disparities in breast and cervical cancer requires an in-depth understanding of motivation for adherence to cancer screening and follow-up care. To inform patient-centered interventions, this study aimed to identify reasons why low-income women adhered to or delayed breast or cervical cancer screening, follow-up and treatment despite access to cancer care-related services. Methods: Semistructured qualitative interviews were conducted among women with access to cancer care-related services receiving care at an academic cancer center, federally qualified health centers, or free clinics in the Chicago metropolitan area. Transcripts were coded and analyzed for themes related to rationales for adherence. Results: Among 138 participants, most were African American (46%) or Hispanic (36%), English speaking (70%), and between ages 41 and 65 years (64%). Primary drivers of nonadherence included lack of knowledge of resources, denial or fear, competing obligations, and embarrassment. Facilitators included abnormality identification, patient activation, provider-initiated actions, and motivation from family or friends. Conclusions: Interventions targeting increased adherence to care among low-income and ethnic minority women should direct efforts to proactive, culturally and patient-informed education that enables patients to access resources and use the health care system, address misconceptions about cancer, ensure health care providers' communication of screening guidelines, and leverage the patient's social support network. PMID:26070037

Development of an optimised 1:1 physiotherapy intervention post first-time lumbar discectomy: a mixed-methods study

PubMed Central

Rushton, A; White, L; Heap, A; Heneghan, N; Goodwin, P

2016-01-01

Objectives To develop an optimised 1:1 physiotherapy intervention that reflects best practice, with flexibility to tailor management to individual patients, thereby ensuring patient-centred practice. Design Mixed-methods combining evidence synthesis, expert review and focus groups. Setting Secondary care involving 5 UK specialist spinal centres. Participants A purposive panel of clinical experts from the 5 spinal centres, comprising spinal surgeons, inpatient and outpatient physiotherapists, provided expert review of the draft intervention. Purposive samples of patients (n=10) and physiotherapists (n=10) (inpatient/outpatient physiotherapists managing patients with lumbar discectomy) were invited to participate in the focus groups at 1 spinal centre. Methods A draft intervention developed from 2 systematic reviews; a survey of current practice and research related to stratified care was circulated to the panel of clinical experts. Lead physiotherapists collaborated with physiotherapy and surgeon colleagues to provide feedback that informed the intervention presented at 2 focus groups investigating acceptability to patients and physiotherapists. The focus groups were facilitated by an experienced facilitator, recorded in written and tape-recorded forms by an observer. Tape recordings were transcribed verbatim. Data analysis, conducted by 2 independent researchers, employed an iterative and constant comparative process of (1) initial descriptive coding to identify categories and subsequent themes, and (2) deeper, interpretive coding and thematic analysis enabling concepts to emerge and overarching pattern codes to be identified. Results The intervention reflected best available evidence and provided flexibility to ensure patient-centred care. The intervention comprised up to 8 sessions of 1:1 physiotherapy over 8 weeks, starting 4 weeks postsurgery. The intervention was acceptable to patients and physiotherapists. Conclusions A rigorous process informed an optimised 1:1 physiotherapy intervention post-lumbar discectomy that reflects best practice. The developed intervention was agreed on by the 5 spinal centres for implementation in a randomised controlled trial to evaluate its effectiveness. PMID:26916690

Non-operative advances: what has happened in the last 50 years in paediatric surgery?

PubMed

Holland, Andrew J A; McBride, Craig A

2015-01-01

Paediatric surgeons remain paediatric clinicians who have the unique skill set to treat children with surgical problems that may require operative intervention. Many of the advances in paediatric surgical care have occurred outside the operating theatre and have involved significant input from medical, nursing and allied health colleagues. The establishment of neonatal intensive care units, especially those focusing on the care of surgical infants, has greatly enhanced the survival rates and long-term outcomes of those infants with major congenital anomalies requiring surgical repair. Educational initiatives such as the advanced trauma life support and emergency management of severe burns courses have facilitated improved understanding and clinical care. Paediatric surgeons have led with the non-operative management of solid organ injury following blunt abdominal trauma. Nano-crystalline burn wound dressings have enabled a reduced frequency of painful dressing changes in addition to effective antimicrobial efficacy and enhanced burn wound healing. Burns care has evolved so that many children may now be treated almost exclusively in an ambulatory care setting or as day case-only patients, with novel technologies allowing accurate prediction of burn would outcome and planning of elective operative intervention to achieve burn wound closure. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Causal Structure of Brain Physiology after Brain Injury from Subarachnoid Hemorrhage.

PubMed

Claassen, Jan; Rahman, Shah Atiqur; Huang, Yuxiao; Frey, Hans-Peter; Schmidt, J Michael; Albers, David; Falo, Cristina Maria; Park, Soojin; Agarwal, Sachin; Connolly, E Sander; Kleinberg, Samantha

2016-01-01

High frequency physiologic data are routinely generated for intensive care patients. While massive amounts of data make it difficult for clinicians to extract meaningful signals, these data could provide insight into the state of critically ill patients and guide interventions. We develop uniquely customized computational methods to uncover the causal structure within systemic and brain physiologic measures recorded in a neurological intensive care unit after subarachnoid hemorrhage. While the data have many missing values, poor signal-to-noise ratio, and are composed from a heterogeneous patient population, our advanced imputation and causal inference techniques enable physiologic models to be learned for individuals. Our analyses confirm that complex physiologic relationships including demand and supply of oxygen underlie brain oxygen measurements and that mechanisms for brain swelling early after injury may differ from those that develop in a delayed fashion. These inference methods will enable wider use of ICU data to understand patient physiology.

Developing a prenatal nursing care International Classification for Nursing Practice catalogue.

PubMed

Liu, L; Coenen, A; Tao, H; Jansen, K R; Jiang, A L

2017-09-01

This study aimed to develop a prenatal nursing care catalogue of International Classification for Nursing Practice. As a programme of the International Council of Nurses, International Classification for Nursing Practice aims to support standardized electronic nursing documentation and facilitate collection of comparable nursing data across settings. This initiative enables the study of relationships among nursing diagnoses, nursing interventions and nursing outcomes for best practice, healthcare management decisions, and policy development. The catalogues are usually focused on target populations. Pregnant women are the nursing population addressed in this project. According to the guidelines for catalogue development, three research steps have been adopted: (a) identifying relevant nursing diagnoses, interventions and outcomes; (b) developing a conceptual framework for the catalogue; (c) expert's validation. This project established a prenatal nursing care catalogue with 228 terms in total, including 69 nursing diagnosis, 92 nursing interventions and 67 nursing outcomes, among them, 57 nursing terms were newly developed. All terms in the catalogue were organized by a framework with two main categories, i.e. Expected Changes of Pregnancy and Pregnancy at Risk. Each category had four domains, representing the physical, psychological, behavioral and environmental perspectives of nursing practice. This catalogue can ease the documentation workload among prenatal care nurses, and facilitate storage and retrieval of standardized data for many purposes, such as quality improvement, administration decision-support and researches. The documentations of prenatal care provided data that can be more fluently communicated, compared and evaluated across various healthcare providers and clinic settings. © 2016 International Council of Nurses.

Supporting family caregivers to identify their own needs in end-of-life care: Qualitative findings from a stepped wedge cluster trial.

PubMed

Aoun, Samar; Deas, Kathleen; Toye, Chris; Ewing, Gail; Grande, Gunn; Stajduhar, Kelli

2015-06-01

The Carer Support Needs Assessment Tool encompasses the physical, psychological, social, practical, financial, and spiritual support needs that government policies in many countries emphasize should be assessed and addressed for family caregivers during end-of-life care. To describe the experience of family caregivers of terminally ill people of the Carer Support Needs Assessment Tool intervention in home-based palliative care. This study was conducted during 2012-2014 in Silver Chain Hospice Care Service in Western Australia. This article reports on one part of a three-part evaluation of a stepped wedge cluster trial. All 233 family caregivers receiving the Carer Support Needs Assessment Tool intervention provided feedback on their experiences via brief end-of-trial semi-structured telephone interviews. Data were subjected to a thematic analysis. The overwhelming majority reported finding the Carer Support Needs Assessment Tool assessment process straightforward and easy. Four key themes were identified: (1) the practicality and usefulness of the systematic assessment; (2) emotional responses to caregiver reflection; (3) validation, reassurance, and empowerment; and (4) accessing support and how this was experienced. Family caregivers appreciated the value of the Carer Support Needs Assessment Tool intervention in engaging them in conversations about their needs, priorities, and solutions. The Carer Support Needs Assessment Tool presented a simple, yet potentially effective intervention to help palliative care providers systematically assess and address family caregivers' needs. The Carer Support Needs Assessment Tool provided a formal structure to facilitate discussions with family caregivers to enable needs to be addressed. Such discussions can also inform an evidence base for the ongoing development of services for family caregivers, ensuring that new or improved services are designed to meet the explicit needs of family caregivers. © The Author(s) 2015.

A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation.

PubMed

Matthews, James; Hall, Amanda M; Hernon, Marian; Murray, Aileen; Jackson, Ben; Taylor, Ian; Toner, John; Guerin, Suzanne; Lonsdale, Chris; Hurley, Deirdre A

2015-07-05

Clinical practice guidelines for the treatment of low back pain suggest the inclusion of a biopsychosocial approach in which patient self-management is prioritized. While many physiotherapists recognise the importance of evidence-based practice, there is an evidence practice gap that may in part be due to the fact that promoting self-management necessitates change in clinical behaviours. Evidence suggests that a patient's motivation and maintenance of self-management behaviours can be positively influenced by the clinician's use of an autonomy supportive communication style. Therefore, the aim of this study was to develop and pilot-test the feasibility of a theoretically derived implementation intervention to support physiotherapists in using an evidence-based autonomy supportive communication style in practice for promoting patient self-management in clinical practice. A systematic process was used to develop the intervention and pilot-test its feasibility in primary care physiotherapy. The development steps included focus groups to identify barriers and enablers for implementation, the theoretical domains framework to classify determinants of change, a behaviour change technique taxonomy to select appropriate intervention components, and forming a testable theoretical model. Face validity and acceptability of the intervention was pilot-tested with two physiotherapists and monitoring their communication with patients over a three-month timeframe. Using the process described above, eight barriers and enablers for implementation were identified. To address these barriers and enablers, a number of intervention components were selected ranging from behaviour change techniques such as, goal-setting, self-monitoring and feedback to appropriate modes of intervention delivery (i.e. continued education meetings and audit and feedback focused coaching). Initial pilot-testing revealed the acceptability of the intervention to recipients and highlighted key areas for refinement prior to scaling up for a definitive trial. The development process utilised in this study ensured the intervention was theory-informed and evidence-based, with recipients signalling its relevance and benefit to their clinical practice. Future research should consider additional intervention strategies to address barriers of social support and those beyond the clinician level.

Transformative Learning: Patterns of Psychophysiologic Response and Technology-Enabled Learning and Intervention Systems

DTIC Science & Technology

2008-09-01

Psychophysiologic Response and Technology -Enabled Learning and Intervention Systems PRINCIPAL INVESTIGATOR: Leigh W. Jerome, Ph.D...NUMBER Transformative Learning : Patterns of Psychophysiologic Response and Technology - Enabled Learning and Intervention Systems 5b. GRANT NUMBER...project entitled “Transformative Learning : Patterns of Psychophysiologic Response in Technology Enabled Learning and Intervention Systems.” The

Barriers and facilitators to the implementation of person-centred care in different healthcare contexts.

PubMed

Moore, Lucy; Britten, Nicky; Lydahl, Doris; Naldemirci, Öncel; Elam, Mark; Wolf, Axel

2017-12-01

To empower patients and improve the quality of care, policy-makers increasingly adopt systems to enhance person-centred care. Although models of person-centredness and patient-centredness vary, respecting the needs and preferences of individuals receiving care is paramount. In Sweden, as in other countries, healthcare providers seek to improve person-centred principles and address gaps in practice. Consequently, researchers at the University of Gothenburg Centre for Person-Centred Care are currently delivering person-centred interventions employing a framework that incorporates three routines. These include eliciting the patient's narrative, agreeing a partnership with shared goals between patient and professional, and safeguarding this through documentation. To explore the barriers and facilitators to the delivery of person-centred care interventions, in different contexts. Qualitative interviews were conducted with a purposeful sample of 18 researchers from seven research studies across contrasting healthcare settings. Interviews were transcribed, translated and thematically analysed, adopting some basic features of grounded theory. The ethical code of conduct was followed and conformed to the ethical guidelines adopted by the Swedish Research Council. Barriers to the implementation of person-centred care covered three themes: traditional practices and structures; sceptical, stereotypical attitudes from professionals; and factors related to the development of person-centred interventions. Facilitators included organisational factors, leadership and training and an enabling attitude and approach by professionals. Trained project managers, patients taking an active role in research and adaptive strategies by researchers all helped person-centred care delivery. At the University of Gothenburg, a model of person-centred care is being initiated and integrated into practice through research. Knowledgeable, well-trained professionals facilitate the routines of narrative elicitation and partnership. Strong leadership and adaptive strategies are important for overcoming existing practices, routines and methods of documentation. This study provides guidance for practitioners when delivering and adapting person-centred care in different contexts. © 2016 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.

eHealth Advances in Support of People with Complex Care Needs: Case Examples from Canada, Scotland and the US.

PubMed

Gray, Carolyn Steele; Mercer, Stewart; Palen, Ted; McKinstry, Brian; Hendry, Anne

2016-01-01

Information technology (IT) in healthcare, also referred to as eHealth technologies, may offer a promising solution to the provision of better care and support for people who have multiple conditions and complex care needs, and their caregivers. eHealth technologies can include electronic medical records, telemonitoring systems and web-based portals, and mobile health (mHealth) technologies that enable information sharing between providers, patients, clients and their families. IT often acts as an enabler of improved care delivery, rather than being an intervention per se. But how are different countries seeking to leverage adoption of these technologies to support people who have chronic conditions and complex care needs? This article presents three case examples from Ontario (Canada), Scotland and Kaiser Permanente Colorado (United States) to identify how these jurisdictions are currently using technology to address multimorbidity. A SWOT (strengths, weaknesses, opportunities, threats) analysis is presented for each case and a final discussion addresses the future of eHealth for complex care needs. The case reports presented in this manuscript mark the foundational work of the Multi-National eHealth Research Partnership Supporting Complex Chronic Disease and Disability (the eCCDD Network); a CIHR-funded project intended to support the international development and uptake of eHealth tools for people with complex care needs.

Description of a novel telemedicine-enabled comprehensive system of care: drip and ship plus drip and keep within a system of stroke care delivery.

PubMed

Commiskey, Patricia; Afshinnik, Arash; Cothren, Elizabeth; Gropen, Toby; Iwuchukwu, Ifeanyi; Jennings, Bethany; McGrade, Harold C; Mora-Guillot, Julia; Sabharwal, Vivek; Vidal, Gabriel A; Zweifler, Richard M; Gaines, Kenneth

2017-04-01

United States (US) and worldwide telestroke programs frequently focus only on emergency room hyper-acute stroke management. This article describes a comprehensive, telemedicine-enabled, stroke care delivery system that combines "drip and ship" and "drip and keep" models with a comprehensive stroke center primary hub at Ochsner Medical Center in New Orleans, advanced stroke-capable regional hubs, and geographically-aligned, "stroke-ready" spokes. The primary hub provides vascular neurology expertise via telemedicine and monitors care for patients remaining at regional hubs and spokes using a multidisciplinary team approach. By 2014, primary hub telestroke consults grew to ≈1000/year with 16 min average door to consult initiation and 20 min to completion, and 29% of ischemic stroke patients received recombinant tissue-type plasminogen activator (rtPA), increasing 275%. Most patients remained in hospitals close to home, but neurointensive care and interventional procedures were common reasons for primary hub transfer. Given the time sensitivity and expert consultation needed for complex acute stroke care delivery paradigms, telestroke programs are effective for fulfilling unmet care needs. Combining drip and ship and drip and keep management allows more patients to stay "local," limiting primary hub transfer unless more advanced services are required. Post admission telestroke management at spokes increases personnel efficiency and can positively impact stroke outcomes.

Parent education programmes for special health care needs children: a systematic review.

PubMed

Jackson, Alun C; Liang, Rachel P-T; Frydenberg, Erica; Higgins, Rosemary O; Murphy, Barbara M

2016-06-01

The aim of this review was to examine parent education programmes for families with children with special health care needs, to better design interventions focusing on the psychosocial aspects of living with a child's chronic condition. Studies of familial coping with children with special health care needs indicate high levels of parenting stress, with families with children with special health care needs at risk of major psychological and social disturbances and financial strain. Despite increased knowledge of the factors affecting children with special health care needs themselves, evidence for the effectiveness of preventative and treatment interventions in the form of parent education programmes remains limited. Systematic review using PRISMA guidelines. Multi database Boolean searches in EBSCO Discovery Services using the search terms 'complex/special health care needs children', 'child/pediatric/congenital heart disease', 'chronic illness (including diabetes, cancer and cystic fibrosis)', 'family coping', 'siblings' AND 'parenting/family support programs' were conducted. Analysis of 13 included studies showed evidence for the effectiveness of both mixed-health condition and condition-specific parenting programmes delivered in a variety of modes. Three common core intervention approaches were: use of narrative therapy enabling families to tell their own stories, thus facilitating emotional processing and (co-) construction of meaning; a focus on strengthening protective factors such as enhancing parents' skills in communication, and behavioural management and provision of psycho-education to deepen parents' understanding of their child's condition and associated developmental challenges. Irrespective of the type of outcome measures used in the studies, the review showed that there were positive gains and improvements across a range of areas of family functioning such as mental health, parenting, communication and problem-solving skills postprogramme. Identification of what programme characteristics enhance functioning for families with children with special health care needs should encourage the design of effective interventions. © 2016 John Wiley & Sons Ltd.

Activity groups for people with schizophrenia: a randomized controlled trial.

PubMed

Dean, Madeleine; Weston, Adam R W; Osborn, David P; Willis, Suzie; Patterson, Sue; Killaspy, Helen; Leurent, Baptiste; Crawford, Mike J

2014-08-01

UK guidelines recommend that patients with schizophrenia are offered access to social activities, however, the impact of such interventions have not been examined in a large randomized trial. To investigate the effect of an activity group intervention on mental health and global functioning 12 months after randomization compared to standard care alone. Secondary analysis of data from the MATISSE study. Primary outcomes were global functioning, assessed using the Global Assessment of Functioning (GAF), and mental health symptoms measured using the Positive and Negative Syndrome Scale (PANSS). About 140 participants were randomized to activity groups and 137 to standard care alone. Follow-up data were collected from 242 (87%) participants. Mental health improved significantly among those offered activity groups (change in PANSS score = -6.0, 95% CI -2.3 to -9.8) but global functioning did not (change in GAF score = 0.8, 95% CI -1.7 to 3.3). No significant differences were found between treatment arms. Offering activity groups to patients with schizophrenia was not associated with any additional clinical benefits. There was poor uptake and attendance at activity groups. Interventions that aim to improve negative symptoms may be useful in enabling engagement in psychosocial interventions.

Costs of a motivational enhancement therapy coupled with cognitive behavioral therapy versus brief advice for pregnant substance users.

PubMed

Xu, Xiao; Yonkers, Kimberly A; Ruger, Jennifer P

2014-01-01

To determine and compare costs of a nurse-administered behavioral intervention for pregnant substance users that integrated motivational enhancement therapy with cognitive behavioral therapy (MET-CBT) to brief advice (BA) administered by an obstetrical provider. Both interventions were provided concurrent with prenatal care. We conducted a micro-costing study that prospectively collected detailed resource utilization and unit cost data for each of the two intervention arms (MET-CBT and BA) within the context of a randomized controlled trial. A three-step approach for identifying, measuring and valuing resource utilization was used. All cost estimates were inflation adjusted to 2011 U.S. dollars. A total of 82 participants received the MET-CBT intervention and 86 participants received BA. From the societal perspective, the total cost (including participants' time cost) of the MET-CBT intervention was $120,483 or $1,469 per participant. In contrast, the total cost of the BA intervention was $27,199 or $316 per participant. Personnel costs (nurse therapists and obstetric providers) for delivering the intervention sessions and supervising the program composed the largest share of the MET-CBT intervention costs. Program set up costs, especially intervention material design and training costs, also contributed substantially to the overall cost. Implementation of an MET-CBT program to promote drug abstinence in pregnant women is associated with modest costs. Future cost effectiveness and cost benefit analyses integrating costs with outcomes and benefits data will enable a more comprehensive understanding of the intervention in improving the care of substance abusing pregnant women.

Home and Online Management and Evaluation of Blood Pressure (HOME BP) digital intervention for self-management of uncontrolled, essential hypertension: a protocol for the randomised controlled HOME BP trial

PubMed Central

Morton, Katherine; Stuart, Beth; Raftery, James; Bradbury, Katherine; Yao, Guiqing Lily; Zhu, Shihua; Little, Paul; Yardley, Lucy

2016-01-01

Introduction Self-management of hypertension, including self-monitoring and antihypertensive medication titration, lowers blood pressure (BP) at 1 year compared to usual care. The aim of the current trial is to assess the effectiveness of the Home and Online Management and Evaluation of Blood Pressure (HOME BP) intervention for the self-management of hypertension in primary care. Methods and analysis The HOME BP trial will be a randomised controlled trial comparing BP self-management—consisting of the HOME BP online digital intervention with self-monitoring, lifestyle advice and antihypertensive drug titration—with usual care for people with uncontrolled essential hypertension. Eligible patients will be recruited from primary care and randomised to usual care or to self-management using HOME BP. The primary outcome will be the difference in mean systolic BP (mm Hg) at 12-month follow-up between the intervention and control groups adjusting for baseline BP and covariates. Secondary outcomes (also adjusted for baseline and covariates where appropriate) will be differences in mean BP at 6 months and diastolic BP at 12 months; patient enablement; quality of life, and economic analyses including all key resources associated with the intervention and related services, adopting a broad societal perspective to include NHS, social care and patient costs, considered within trial and modelled with a lifetime horizon. Medication beliefs, adherence and changes; self-efficacy; perceived side effects and lifestyle changes will be measured for process analyses. Qualitative analyses will explore patient and healthcare professional experiences of HOME BP to gain insights into the factors affecting acceptability, feasibility and adherence. Ethics and dissemination This study has received NHS ethical approval (REC reference 15/SC/0082). The findings from HOME BP will be disseminated widely through peer-reviewed publications, scientific conferences and workshops. If successful, HOME BP will be directly applicable to UK primary care management of hypertension. Trial registration number ISRCTN13790648; pre-results. PMID:27821598

Cost Effectiveness of Potential ART Adherence Monitoring Interventions in Sub-Saharan Africa.

PubMed

Phillips, Andrew N; Cambiano, Valentina; Nakagawa, Fumiyo; Bansi-Matharu, Loveleen; Sow, Papa Salif; Ehrenkranz, Peter; Ford, Deborah; Mugurungi, Owen; Apollo, Tsitsi; Murungu, Joseph; Bangsberg, David R; Revill, Paul

2016-01-01

Interventions based around objective measurement of adherence to antiretroviral drugs for HIV have potential to improve adherence and to enable differentiation of care such that clinical visits are reduced in those with high adherence. It would be useful to understand the approximate upper limit of cost that could be considered for such interventions of a given effectiveness in order to be cost effective. Such information can guide whether to implement an intervention in the light of a trial showing a certain effectiveness and cost. An individual-based model, calibrated to Zimbabwe, which incorporates effects of adherence and resistance to antiretroviral therapy, was used to model the potential impact of adherence monitoring-based interventions on viral suppression, death rates, disability adjusted life years and costs. Potential component effects of the intervention were: enhanced average adherence when on ART, reduced risk of ART discontinuation, and reduced risk of resistance acquisition. We considered a situation in which viral load monitoring is not available and one in which it is. In the former case, it was assumed that care would be differentiated based on the adherence level, with fewer clinic visits in those demonstrated to have high adherence. In the latter case, care was assumed to be primarily differentiated according to viral load level. The maximum intervention cost required to be cost effective was calculated based on a cost effectiveness threshold of $500 per DALY averted. In the absence of viral load monitoring, an adherence monitoring-based intervention which results in a durable 6% increase in the proportion of ART experienced people with viral load < 1000 cps/mL was cost effective if it cost up to $50 per person-year on ART, mainly driven by the cost savings of differentiation of care. In the presence of viral load monitoring availability, an intervention with a similar effect on viral load suppression was cost-effective when costing $23-$32 per year, depending on whether the adherence intervention is used to reduce the level of need for viral load measurement. The cost thresholds identified suggest that there is clear scope for adherence monitoring-based interventions to provide net population health gain, with potential cost-effective use in situations where viral load monitoring is or is not available. Our results guide the implementation of future adherence monitoring interventions found in randomized trials to have health benefit.

Cost Effectiveness of Potential ART Adherence Monitoring Interventions in Sub-Saharan Africa

PubMed Central

Cambiano, Valentina; Nakagawa, Fumiyo; Bansi-Matharu, Loveleen; Sow, Papa Salif; Ehrenkranz, Peter; Ford, Deborah; Mugurungi, Owen; Apollo, Tsitsi; Murungu, Joseph; Bangsberg, David R.; Revill, Paul

2016-01-01

Background Interventions based around objective measurement of adherence to antiretroviral drugs for HIV have potential to improve adherence and to enable differentiation of care such that clinical visits are reduced in those with high adherence. It would be useful to understand the approximate upper limit of cost that could be considered for such interventions of a given effectiveness in order to be cost effective. Such information can guide whether to implement an intervention in the light of a trial showing a certain effectiveness and cost. Methods An individual-based model, calibrated to Zimbabwe, which incorporates effects of adherence and resistance to antiretroviral therapy, was used to model the potential impact of adherence monitoring-based interventions on viral suppression, death rates, disability adjusted life years and costs. Potential component effects of the intervention were: enhanced average adherence when on ART, reduced risk of ART discontinuation, and reduced risk of resistance acquisition. We considered a situation in which viral load monitoring is not available and one in which it is. In the former case, it was assumed that care would be differentiated based on the adherence level, with fewer clinic visits in those demonstrated to have high adherence. In the latter case, care was assumed to be primarily differentiated according to viral load level. The maximum intervention cost required to be cost effective was calculated based on a cost effectiveness threshold of $500 per DALY averted. Findings In the absence of viral load monitoring, an adherence monitoring-based intervention which results in a durable 6% increase in the proportion of ART experienced people with viral load < 1000 cps/mL was cost effective if it cost up to $50 per person-year on ART, mainly driven by the cost savings of differentiation of care. In the presence of viral load monitoring availability, an intervention with a similar effect on viral load suppression was cost-effective when costing $23-$32 per year, depending on whether the adherence intervention is used to reduce the level of need for viral load measurement. Conclusion The cost thresholds identified suggest that there is clear scope for adherence monitoring-based interventions to provide net population health gain, with potential cost-effective use in situations where viral load monitoring is or is not available. Our results guide the implementation of future adherence monitoring interventions found in randomized trials to have health benefit. PMID:27977702

Caring for people with dementia in hospital: findings from a survey to identify barriers and facilitators to implementing best practice dementia care.

PubMed

Tropea, Joanne; LoGiudice, Dina; Liew, Danny; Roberts, Carol; Brand, Caroline

2017-03-01

Best practice dementia care is not always provided in the hospital setting. Knowledge, attitudes and motivation, practitioner behavior, and external factors can influence uptake of best practice and quality care. The aim of this study was to determine hospital staff perceived barriers and enablers to implementing best practice dementia care. A 17-item survey was administered at two Australian hospitals between July and September 2014. Multidisciplinary staff working in the emergency departments and general medical wards were invited to participate in the survey. The survey collected data about the respondents' current role, work area, and years of experience, their perceived level of confidence and knowledge in dementia care and common symptoms of dementia, barriers and enablers to implementing best practice dementia care, job satisfaction in caring for people with dementia, and to rate the hospital's capacity and available resources to support best practice dementia care. A total of 112 survey responses were received. The environment, inadequate staffing levels and workload, time, and staff knowledge and skills were identified as barriers to implementing best practice dementia care. Most respondents rated their knowledge of dementia care and common symptoms of dementia, and confidence in recognizing whether a person has dementia, as moderate or high dementia. Approximately, half the respondents rated access to training and equipment as low or very low. The survey findings highlighted hospital staff perceived barriers to implementing best practice dementia care that can be used to inform locally tailored improvement interventions.

Coaching Family Caregivers to become Better Problem Solvers when Caring for Persons with Advanced Cancer

PubMed Central

Dionne-Odom, J. Nicholas; Lyons, Kathleen D.; Akyar, Imatullah; Bakitas, Marie

2016-01-01

Family caregivers of persons with advanced cancer often take on responsibilities that present daunting and complex problems. Serious problems that go unresolved may be burdensome and result in negative outcomes for caregivers’ psychological and physical health and affect the quality of care delivered to the care recipients with cancer, especially at the end of life. Formal problem-solving training approaches have been developed over the past several decades to assist individuals with managing problems faced in daily life. Several of these problem-solving principles and techniques were incorporated into ENABLE (Educate, Nurture, Advise, Before Life End), an ‘early’ palliative care telehealth intervention for individuals diagnosed with advanced cancer and their family caregivers. A hypothetical case resembling the situations of actual caregiver participants in ENABLE that exemplifies the complex problems that caregivers face is presented followed by presentation of an overview of ENABLE’s problem-solving key principles, techniques and steps in problem-solving support. Though more research is needed to formally test the use of problem-solving support in social work practice, social workers can easily incorporate these techniques into everyday practice. PMID:27143574

The role and structure of the multidisciplinary team in the management of advanced Parkinson’s disease with a focus on the use of levodopa–carbidopa intestinal gel

PubMed Central

Pedersen, Stephen W; Suedmeyer, Martin; Liu, Louis W C; Domagk, Dirk; Forbes, Alison; Bergmann, Lars; Onuk, Koray; Yegin, Ashley; van Laar, Teus

2017-01-01

A multidisciplinary team (MDT) approach is increasingly recommended in Parkinson’s disease (PD) treatment guidelines, but no standard of care exists for such an approach, and the guidelines do not provide clarification on how it should be implemented. This paper reviews evidence of MDT interventions in people with PD and provides expert clinical perspectives for an MDT approach, with a focus on advanced PD and levodopa–carbidopa intestinal gel (carbidopa–levodopa enteral suspension in the USA). The key recommendations are to enable the best possible treatment of people with PD locally by facilitating a close structured collaboration of different health care professionals working in a fixed network structure; to refer people with PD to established MDT centers in a timely manner; to establish regular meetings for the MDT enabling interdisciplinary exchange and learning; to optimize individual treatment and carefully evaluate available treatment options; to ensure treatment decisions are agreed jointly between people with PD, their caregivers, family, and health care professional; and to include specialists outside of neurology from adjuvant medical departments as necessary when implementing advanced therapies. PMID:28115853

[The psychosocial challenges of epilepsy and the role of the clinical nurse specialist].

PubMed

Chartrand, Dominic

2015-01-01

Epilepsy in children is a complex disease with significant psychosocial consequences for the child and their family. The intervention of a multidisciplinary team enables the care to be adapted and provides support for the families. At Sainte-Justine Hospital in Montreal, Canada, the nurse clinician specialised in epilepsy plays a key role in this team. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Feasibility and effectiveness of the implementation of a primary prevention programme for type 2 diabetes in routine primary care practice: a phase IV cluster randomised clinical trial

PubMed Central

2012-01-01

Background The objective of this study is to perform an independent evaluation of the feasibility and effectiveness of an educational programme for the primary prevention of type 2 diabetes (DM2) in high risk populations in primary care settings, implanted within the Basque Health Service - Osakidetza. Methods/design This is a prospective phase IV cluster clinical trial conducted under routine conditions in 14 primary health care centres of Osakidetza, randomly assigned to an intervention or control group. We will recruit a total sample of 1089 individuals, aged between 45 and 70 years old, without diabetes but at high risk of developing the condition (Finnish Diabetes Risk Score, FINDRISC ≥ 14) and follow them up for 2 years. Primary health care nursing teams of the intervention centres will implement DE-PLAN, a structured educational intervention program focused on changing healthy lifestyles (diet and physical activity); while the patients in the control centres will receive the usual care for the prevention and treatment of DM2 currently provided in Osakidetza. The effectiveness attributable to the programme will be assessed by comparing the changes observed in patients exposed to the intervention and those in the control group, with respect to the risk of developing DM2 and lifestyle habits. In terms of feasibility, we will assess indicators of population coverage and programme implementation. Discussion The aim of this study is to provide the scientific basis for disseminate the programme to the remaining primary health centres in Osakidetza, as a novel way of addressing prevention of DM2. The study design will enable us to gather information on the effectiveness of the intervention as well as the feasibility of implementing it in routine practice. Trial registration ClinicalTrials.gov NCT01365013 PMID:23158830

Pathways to ambulatory sensitive hospitalisations for Māori in the Auckland and Waitemata regions.

PubMed

Barker, Carol; Crengle, Sue; Bramley, Dale; Bartholomew, Karen; Bolton, Patricia; Walsh, Michael; Wignall, Jean

2016-10-28

Ambulatory Sensitive Hospitalisations (ASH) are a group of conditions potentially preventable through interventions delivered in the primary health care setting. ASH rates are consistently higher for Māori compared with non-Māori. This study aimed to establish Māori experience of factors driving the use of hospital services for ASH conditions, including barriers to accessing primary care. A telephone questionnaire exploring pathways to ASH was administered to Māori (n=150) admitted to Auckland and Waitemata District Health Board (DHB) hospitals with an ASH condition between January 1st-June 30th 2015. A cohort of 1,013 participants were identified; 842 (83.1%) were unable to be contacted. Of the 171 people contactable, 150 agreed to participate, giving an overall response rate of 14.8% and response rate of contactable patients of 87.7%. Results demonstrated high rates of self-reported enrolment, utilisation and preference for primary care. Many participants demonstrated appropriate health seeking behaviour and accurate recall of diagnoses. While financial barriers to accessing primary care were reported, non-financial barriers including lack of after-hours provision (12.6% adults, 37.7% children), appointment availability (7.4% adults, 17.0% children) and lack of transport (13.7% adults, 20.8% children) also featured in participant responses. Interventions to reduce Māori ASH include: timely access to primary care through electronic communications, increased appointment availability, extended opening hours, low cost after-hours care and consistent best management of ASH conditions in general practice through clinical pathways. Facilitated enrolment of ASH patients with no general practitioner could also reduce ASH. Research into transport barriers and enablers for Māori accessing primary care is required to support future interventions.

The Arab American Experience with Diabetes: Perceptions, Myths and Implications for Culturally-Specific Interventions

PubMed Central

Bertran, Elizabeth A; Pinelli, Nicole R; Sills, Stephen J; Jaber, Linda A

2016-01-01

Aims Culturally-specific lifestyle diabetes prevention programs require an assessment of population disease perceptions and cultural influences on health beliefs and behaviors. The primary objectives were to assess Arab Americans’ knowledge and perceptions of diabetes and their preferences for a lifestyle intervention. Methods Sixty-nine self-identified Arab or Arab Americans ≥ 30 years of age and without diabetes participated in 8 focus groups. Results Emerging themes from the data included myths about diabetes etiology, folk remedies, and social stigma. The main barrier to healthcare was lack of health insurance and/or cost of care. Intervention preferences included gender-specific exercise, group-delivered education featuring religious ideology, inclusion of the family, and utilization of community facilities. Conclusion Lifestyle interventions for Arab Americans need to address cultural preferences, diabetes myths, and folk remedies. Interventions should incorporate Arabic cultural content and gender-specific group education and exercise. Utilization of family support and religious centers will enable culturally-acceptable and cost-effective interventions. PMID:27460886

Use of the Internet and Mobile Phones for Self-Management of Severe Mental Health Problems: Qualitative Study of Staff Views

PubMed Central

Bucci, Sandra; Lobban, Fiona

2017-01-01

Background Researchers are currently investigating the feasibility, acceptability, and efficacy of digital health interventions for people who experience severe mental health problems such as psychosis and bipolar disorder. Although the acceptability of digital health interventions for severe mental health problems appears to be relatively high and some people report successfully using the Internet and mobile phones to manage their mental health, the attitudes of mental health care staff toward such approaches have yet to be considered. Objective The aim of this study was to explore mental health care staff experiences of clients with severe mental health problems engaging with the Internet and mobile phones to self-manage their mental health and their views toward these behaviors. The study also sought to examine the opinions expressed by mental health care staff toward digital health interventions for severe mental health problems to identify potential facilitators and barriers to implementation. Methods Four focus groups were conducted with 20 staff working in mental health care services in the North West of the England using a topic guide. Focus groups involved 12 staff working in secondary care psychological services (7 participants in focus group 1 and 5 participants in focus group 4), 4 staff working in a rehabilitation unit (focus group 2), and 4 staff working in a community mental health team (focus group 3). Focus groups were transcribed verbatim, and transcripts were analyzed thematically to identify key themes that emerged from the data. Results Four overarching themes, two with associated subthemes, were identified: (1) staff have conflicting views about the pros and cons of using Web-based resources and digital health interventions to manage mental health; (2) digital health interventions could increase access to mental health support options for severe mental health problems but may perpetuate the digital divide; (3) digital health interventions’ impact on staff roles and responsibilities; and (4) digital health interventions should be used to enhance, not replace, face-to-face support. Conclusions This study is the first, to our knowledge, to qualitatively explore the experiences and attitudes of mental health care staff toward individuals with severe mental health problems using the Internet, mobile phones, and digital health interventions to self-manage their mental health. Understanding the positive and negative experiences and views shared by staff toward both current and potential digital health intervention use has enabled the identification of several considerations for implementation. Additionally, the findings suggest mental health care staff need clear guidance and training in relation to their responsibilities in recommending reputable and secure websites, forums, and digital health interventions and in how to manage professional boundaries on the Internet. Overall, the study highlights that digital health interventions could be well received by staff working in mental health services but importantly, such management options must be presented to frontline staff as an avenue to enhance care and extend choice, rather than as a method to reduce costs. PMID:29092809

Divisions of general practice in Australia: how do they measure up in the international context?

PubMed Central

Smith, Judith; Sibthorpe, Beverly

2007-01-01

Background Since the late 1980s, there has been evidence of an international trend towards more organised primary care. This has taken a number of forms including the emergence of primary care organisations. Underpinning such developments is an inherent belief in evidence that suggests that well-developed primary care is associated with improved health outcomes and greater cost-effectiveness within health systems. In Australia, primary care organisations have emerged as divisions of general practice. These are professionally-led, regionally-based, and largely government-funded voluntary associations of general practitioners that seek to co-ordinate local primary care services, and improve the quality of care and health outcomes for local communities. Discussion In this paper, we examine and debate the development of divisions in the international context, using six roles of primary care organisations outlined in published research. The six roles that are used as the basis for the critique are the ability of primary care organisations to: improve health outcomes; manage demand and control costs; engage primary care physicians; enable greater integration of health services; develop more accessible services in community and primary care settings; and enable greater scrutiny and assurance of quality of primary care services. Summary We conclude that there has been an evolutionary approach to divisions' development and they now appear embedded as geographically-based planning and development organisations within the Australian primary health care system. The Australian Government has to date been cautious in its approach to intervention in divisions' direction and performance. However, options for the next phase include: making greater use of contracts between government and divisions; introducing and extending proposed national quality targets for divisions, linked with financial or other incentives for performance; government sub-contracting with state-based organisations to act as purchasers of care; pursuing a fund-holding approach within divisions; and developing divisions as a form of health maintenance organisation. The challenge for the Australian Government, should it wish to see divisions' role expand, is to find mechanisms to enable this without compromising the relatively strong GP engagement that increasingly distinguishes divisions of general practice within the international experience of primary care organisations. PMID:17626642

Linking clinic and home: a randomized, controlled clinical effectiveness trial of real-time, wireless blood pressure monitoring for older patients with kidney disease and hypertension.

PubMed

Rifkin, Dena E; Abdelmalek, Joseph A; Miracle, Cynthia M; Low, Chai; Barsotti, Ryan; Rios, Phil; Stepnowsky, Carl; Agha, Zia

2013-02-01

Older adults with chronic kidney disease have a high rate of uncontrolled hypertension. Home monitoring of blood pressure (BP) is an integral part of management, but requires that patients bring records to clinic visits. Telemonitoring interventions, however, have not targeted older, less technologically-skilled populations. Veterans with stage 3 or greater chronic kidney disease and uncontrolled hypertension were randomized to a novel telemonitoring device pairing a Bluetooth-enabled BP cuff with an Internet-enabled hub, which wirelessly transmitted readings (n=28), or usual care (n=15). Home recordings were reviewed weekly and telemonitoring participants were contacted if BP was above goal. The prespecified primary endpoints were improved data exchange and device acceptability. Secondary endpoint was BP change. Forty-three participants (average age 68 years, 75% white) completed the 6-month study. Average start-of-study BP was 147/78 mmHg. Those in the intervention arm had a median of 29 (IQR 22, 53) transmitted BP readings per month, with 78% continuing to use the device regularly, whereas only 20% of those in the usual care group brought readings to in-person visits. The median number of telephone contacts triggered by the wireless monitoring was 2 (IQR 1, 4) per patient. Both groups had a significant improvement in systolic BP (P<0.05, for both changes); systolic BP fell a median of 13 mmHg in monitored participants compared with 8.5 mmHg in usual care participants (P for comparison 0.31). This low-cost wireless monitoring strategy led to greater sharing of data between patients and clinic and produced a trend toward improvements in BP control over usual care at 6 months.

Evaluation of international case studies within 'Live.Learn.Laugh.': a unique global public-private partnership to promote oral health.

PubMed

Dugdill, Lindsey; Pine, Cynthia M

2011-08-01

The partnership between the Féderation Dentaire International (FDI), and Unilever Oral Care, aims to raise awareness of oral health globally; to enable FDI member associations to promote oral health; and to increase the visibility of the FDI and authority of Unilever oral care brands worldwide. Country Projects between National Dental Associations (NDAs), the member associations of FDI, and Unilever Oral Care local companies have been established as a key strand of the partnership. This paper reports on the evaluation of an in-depth sample of Country Projects (n=5) to determine their potential to impact on oral health. Five country sites were selected as being indicative of different programme delivery types. Each site received a two-day visit during Spring-Summer 2009, which enabled the evaluators to audit what was delivered in practice compared with the original written project briefs and to undertake interviews of study site staff. 39 projects in 36 countries have been initiated. In those examined by site visits, clear evidence was found of capacity building to deliver oral health. In some countries, widespread population reach had been prioritised. Effectiveness of partnership working varied depending on the strength of the relationship between the NDA and local Unilever Oral Care representatives and alignment with national marketing strategy. The quality of internal evaluation varied considerably. Over a million people had been reached directly by Country Projects and this public-private partnership has made a successful start. To move towards improving oral health rather than only awareness raising; future Country Projects would benefit from being limited to certain evidence-based intervention designs, and using an agreed core indicator set in order to allow cross-country comparison of intervention outcomes. © 2011 FDI World Dental Federation.

ValuedCare program: a population health model for the delivery of evidence-based care across care continuum for hip fracture patients in Eastern Singapore.

PubMed

Mittal, Chikul; Lee, Hsien Chieh Daniel; Goh, Kiat Sern; Lau, Cheng Kiang Adrian; Tay, Leeanna; Siau, Chuin; Loh, Yik Hin; Goh, Teck Kheng Edward; Sandi, Chit Lwin; Lee, Chien Earn

2018-05-30

To test a population health program which could, through the application of process redesign, implement multiple evidence-based practices across the continuum of care in a functionally integrated health delivery system and deliver highly reliable and consistent evidence-based surgical care for patients with fragility hip fractures in an acute tertiary general hospital. The ValuedCare (VC) program was developed in three distinct phases as an ongoing collaboration between the Geisinger Health System (GHS), USA, and Changi General Hospital (CGH), Singapore, modelled after the GHS ProvenCare® Fragile Hip Fracture Program. Clinical outcome data on consecutive hip fracture patients seen in 12 months pre-intervention were then compared with the post-intervention group. Both pre- and post-intervention groups were followed up across the continuum of care for a period of 12 months. VC patients showed significant improvement in median time to surgery (97 to 50.5 h), as well as proportion of patients operated within 48 h from hospital admission (48% from 18.8%) as compared to baseline pre-intervention data. These patients also had significant reduction (p value < 0.001) of acute inpatient complications such as delirium, pneumonia, urinary tract infections, and pressure sores. VC program has shown significant reduction in median length of stay for acute hospital (13 to 9 days) as well as median combined length of stay for acute and sub-acute rehabilitation hospital (46 to 39 days), thus reducing the total duration of hospitalization and saving total hospital bed days. Operative and inpatient mortality, together with readmission rates, remained low and comparable to international Geriatric Fracture Centers (GFCs). The implementation of VC methodology has enabled consistent delivery of high-quality, reliable and comprehensive evidence-based care for hip fracture patients at Changi General Hospital. This has also reflected successful change management and interdisciplinary collaboration within the organization through the program. There is potential for testing this methodology as a quality improvement framework replicable to other disease groups in a functionally integrated healthcare system.

Annual Research Review: Improved nutrition--pathway to resilience.

PubMed

Yousafzai, Aisha K; Rasheed, Muneera A; Bhutta, Zulfiqar A

2013-04-01

Early child nutritional deficiencies are prevalent in low- and middle-countries with consequences linked not only to poor survival and growth, but also to poor development outcomes. Children in disadvantaged communities face multiple risks for nutritional deficiencies, yet some children may be less susceptible or may recover more quickly from malnutrition. A greater understanding is needed about factors which moderate the effects of nutrition-related risks and foster resilience to protect against or ameliorate poor development outcomes. A literature review was undertaken from August to December 2011 and updated in August 2012. Key word searches using terms Nutrition, Malnutrition, Child Development, Responsive Care, Stimulation, Low and Middle Income Countries and Resilience were undertaken using PubMed and Psychinfo. Dietary adequacy is critical for growth and development, but current evidence indicates that nutrition supplementation alone is insufficient to foster resilience to protect against, mitigate, and recover from nutritional threats and to promote healthy development. The combination of nutrition interventions with stimulation and responsive care is necessary. Combined nutrition and psychosocial stimulation approaches can potentially work effectively together to promote protective factors and mitigate risks for poor cognitive, motor, social, and affective functioning helping children to adapt in times of adversity. However, there are gaps in our existing knowledge to combine nutrition and psychosocial stimulation interventions effectively and promote these interventions at scale. Research needs to address barriers at the level of family, community, programme, and policy which have prevented thus far the uptake of combined nutrition and psychosocial intervention strategies. Further investigations are needed on how to provide support to caregivers, enabling them to implement appropriate care for feeding and stimulation. Finally, the effect of combined interventions on pathways of care and protective mediators that foster resilience need to be better understood to determine focus areas for content of combined intervention curricula which help families in high-risk settings. © 2012 The Authors. Journal of Child Psychology and Psychiatry © 2012 Association for Child and Adolescent Mental Health.

PRagmatic trial Of Video Education in Nursing homes: The design and rationale for a pragmatic cluster randomized trial in the nursing home setting.

PubMed

Mor, Vincent; Volandes, Angelo E; Gutman, Roee; Gatsonis, Constantine; Mitchell, Susan L

2017-04-01

Background/Aims Nursing homes are complex healthcare systems serving an increasingly sick population. Nursing homes must engage patients in advance care planning, but do so inconsistently. Video decision support tools improved advance care planning in small randomized controlled trials. Pragmatic trials are increasingly employed in health services research, although not commonly in the nursing home setting to which they are well-suited. This report presents the design and rationale for a pragmatic cluster randomized controlled trial that evaluated the "real world" application of an Advance Care Planning Video Program in two large US nursing home healthcare systems. Methods PRagmatic trial Of Video Education in Nursing homes was conducted in 360 nursing homes (N = 119 intervention/N = 241 control) owned by two healthcare systems. Over an 18-month implementation period, intervention facilities were instructed to offer the Advance Care Planning Video Program to all patients. Control facilities employed usual advance care planning practices. Patient characteristics and outcomes were ascertained from Medicare Claims, Minimum Data Set assessments, and facility electronic medical record data. Intervention adherence was measured using a Video Status Report embedded into electronic medical record systems. The primary outcome was the number of hospitalizations/person-day alive among long-stay patients with advanced dementia or cardiopulmonary disease. The rationale for the approaches to facility randomization and recruitment, intervention implementation, population selection, data acquisition, regulatory issues, and statistical analyses are discussed. Results The large number of well-characterized candidate facilities enabled several unique design features including stratification on historical hospitalization rates, randomization prior to recruitment, and 2:1 control to intervention facilities ratio. Strong endorsement from corporate leadership made randomization prior to recruitment feasible with 100% participation of facilities randomized to the intervention arm. Critical regulatory issues included minimal risk determination, waiver of informed consent, and determination that nursing home providers were not engaged in human subjects research. Intervention training and implementation were initiated on 5 January 2016 using corporate infrastructures for new program roll-out guided by standardized training elements designed by the research team. Video Status Reports in facilities' electronic medical records permitted "real-time" adherence monitoring and corrective actions. The Centers for Medicare and Medicaid Services Virtual Research Data Center allowed for rapid outcomes ascertainment. Conclusion We must rigorously evaluate interventions to deliver more patient-focused care to an increasingly frail nursing home population. Video decision support is a practical approach to improve advance care planning. PRagmatic trial Of Video Education in Nursing homes has the potential to promote goal-directed care among millions of older Americans in nursing homes and establish a methodology for future pragmatic randomized controlled trials in this complex healthcare setting.

Strategic factors for the sustainability of a health intervention at municipal level of Brazil.

PubMed

Oliveira, Sydia Rosana de Araujo; Medina, Maria Guadalupe; Figueiró, Ana Cláudia; Potvin, Louise

2017-07-27

The present study aims to describe the evolution of an intervention, using a methodology that adopts the critical event as the unit of analysis, and to identify strategic factors that facilitate the continuation of the interventions. Six critical events were identified: dispute care models for health; area of advice: dispute field; change policy; break of interorganizational relations; lack of physical structure and turnover of staff; difficulty in organizing practices in the work process. these are developed into strategic factors: enabling network of allies; meetings and educational activities/building capacity; benefits perceived by community members; mobilization of key actors; intervention's compatibility with the government's vision; restoration of interrelationship; and stability of the workforce. These strategic factors form a group of interrelated conditions that provide the strengthened linkages between elements in the intervention, supporting the hypothesis that they collaborate for the sustainability of the interventions in health. Tracking down the transformations of an intervention set by the critical events, it was verified that these factors performed a protective role at times of changes in the intervention process.

A narrative of resistance: presentation of self when parenting children with asthma.

PubMed

Cohn, Ellen S; Cortés, Dharma E; Hook, Julie M; Yinusa-Nyahkoon, Leanne S; Solomon, Jeffrey L; Bokhour, Barbara

2009-01-01

Using a social constructivist perspective and narrative analysis, the purpose of this paper is to illustrate how an understanding of self-presentation in interactions may inform health care interventions. We examine how a single African American mother, living in poverty, presents her sense of self in the context of obtaining and providing asthma care for her children. By analyzing four separate encounters--two interviews with the children's mother, the clinical encounter between the mother and her children's doctor, and an interview with the doctor, we gain an understanding of the mother's self-presentation and identity and the doctor's view of the mother. The analyses reveal the mother's consistent desire to protect her children in an unpredictable social world. By examining self-presentation, behavior that is typically construed as non-adherence is reframed as resilience, one mother's attempt to assert control. We argue that an understanding of identity production may enable practitioners and patients to create collaborative interventions. The analysis presented in this paper points to the need for a co-constructed intervention that allows for choice and control and honors the mother's sense of self.

Automated Detection of Sepsis Using Electronic Medical Record Data: A Systematic Review.

PubMed

Despins, Laurel A

Severe sepsis and septic shock are global issues with high mortality rates. Early recognition and intervention are essential to optimize patient outcomes. Automated detection using electronic medical record (EMR) data can assist this process. This review describes automated sepsis detection using EMR data. PubMed retrieved publications between January 1, 2005 and January 31, 2015. Thirteen studies met study criteria: described an automated detection approach with the potential to detect sepsis or sepsis-related deterioration in real or near-real time; focused on emergency department and hospitalized neonatal, pediatric, or adult patients; and provided performance measures or results indicating the impact of automated sepsis detection. Detection algorithms incorporated systemic inflammatory response and organ dysfunction criteria. Systems in nine studies generated study or care team alerts. Care team alerts did not consistently lead to earlier interventions. Earlier interventions did not consistently translate to improved patient outcomes. Performance measures were inconsistent. Automated sepsis detection is potentially a means to enable early sepsis-related therapy but current performance variability highlights the need for further research.

Making It Local: Beacon Communities Use Health Information Technology to Optimize Care Management

PubMed Central

Allen, Amy; Des Jardins, Terrisca R.; Heider, Arvela; Kanger, Chatrian R.; Lobach, David F.; McWilliams, Lee; Polello, Jennifer M.; Schachter, Abigail A.; Singh, Ranjit; Sorondo, Barbara; Tulikangas, Megan C.; Turske, Scott A.

2014-01-01

Abstract Care management aims to provide cost-effective, coordinated, non-duplicative care to improve care quality, population health, and reduce costs. The 17 communities receiving funding from the Office of the National Coordinator for Health Information Technology through the Beacon Community Cooperative Agreement Program are leaders in building and strengthening their health information technology (health IT) infrastructure to provide more effective and efficient care management. This article profiles 6 Beacon Communities' health IT-enabled care management programs, highlighting the influence of local context on program strategy and design, and describing challenges, lessons learned, and policy implications for care delivery and payment reform. The unique needs (eg, disease burden, demographics), community partnerships, and existing resources and infrastructure all exerted significant influence on the overall priorities and design of each community's care management program. Though each Beacon Community needed to engage in a similar set of care management tasks—including patient identification, stratification, and prioritization; intervention; patient engagement; and evaluation—the contextual factors helped shape the specific strategies and tools used to carry out these tasks and achieve their objectives. Although providers across the country are striving to deliver standardized, high-quality care, the diverse contexts in which this care is delivered significantly influence the priorities, strategies, and design of community-based care management interventions. Gaps and challenges in implementing effective community-based care management programs include: optimizing allocation of care management services; lack of available technology tailored to care management needs; lack of standards and interoperability; integrating care management into care settings; evaluating impact; and funding and sustainability. (Population Health Management 2014;17:149–158) PMID:24476558

Applying a participatory approach to the promotion of a culture of respect during childbirth.

PubMed

Ratcliffe, Hannah L; Sando, David; Mwanyika-Sando, Mary; Chalamilla, Guerino; Langer, Ana; McDonald, Kathleen P

2016-07-18

Disrespect and abuse (D&A) during facility-based childbirth is a topic of growing concern and attention globally. Several recent studies have sought to quantify the prevalence of D&A, however little evidence exists about effective interventions to mitigate disrespect and abuse, and promote respectful maternity care. In an accompanying article, we describe the process of selecting, implementing, and evaluating a package of interventions designed to prevent and reduce disrespect and abuse in a large urban hospital in Tanzania. Though that study was not powered to detect a definitive impact on reducing D&A, the results showed important changes in intermediate outcomes associated with this goal. In this commentary, we describe the factors that enabled this effect, especially the participatory approach we adopted to engage key stakeholders throughout the planning and implementation of the program. Based on our experience and findings, we conclude that a visible, sustained, and participatory intervention process; committed facility leadership; management support; and staff engagement throughout the project contributed to a marked change in the culture of the hospital to one that values and promotes respectful maternity care. For these changes to translate into dignified care during childbirth for all women in a sustainable fashion, institutional commitment to providing the necessary resources and staff will be needed.

Barriers and facilitators to self-care in chronic heart failure: a meta-synthesis of qualitative studies.

PubMed

Siabani, Soraya; Leeder, Stephen R; Davidson, Patricia M

2013-01-01

Chronic heart failure (CHF) is a costly condition that places large demands on self-care. Failure to adhere with self-care recommendations is common and associated with frequent hospitalization. Understanding the factors that enable or inhibit self-care is essential in developing effective health care interventions. This qualitative review was conducted to address the research question, "What are the barriers and facilitators to self-care among patients with CHF?" Electronic databases including Medline, EMBASE, CINAHL, Web of Science, Scopus and Google scholar were searched. Articles were included if they were peer reviewed (1995 to 2012), in English language and investigated at least one contextual or individual factor impacting on self-care in CHF patients > 18years. The criteria defined by Kuper et al. including clarity and appropriateness of sampling, data collection and data analysis were used to appraise the quality of articles. Twenty-three articles met the inclusion criteria. Factors impacting on self-care were included factors related to symptoms of CHF and the self-care process; factors related to personal characteristics; and factors related to environment and self-care system. Important factors such as socioeconomic situation and education level have not been explored extensively and there were minimal data on the influence of age, gender, self-confidence and duration of disease. Although there is an emerging literature, further research is required to address the barriers and facilitators to self-care in patients with CHF in order to provide an appropriate guide for intervention strategies to improve self-care in CHF.

Designing clinically valuable telehealth resources: processes to develop a community-based palliative care prototype.

PubMed

Tieman, Jennifer Joy; Morgan, Deidre Diane; Swetenham, Kate; To, Timothy Hong Man; Currow, David Christopher

2014-09-04

Changing population demography and patterns of disease are increasing demands on the health system. Telehealth is seen as providing a mechanism to support community-based care, thus reducing pressure on hospital services and supporting consumer preferences for care in the home. This study examined the processes involved in developing a prototype telehealth intervention to support palliative care patients involved with a palliative care service living in the community. The challenges and considerations in developing the palliative care telehealth prototype were reviewed against the Center for eHealth Research (CeHRes) framework, a telehealth development model. The project activities to develop the prototype were specifically mapped against the model's first four phases: multidisciplinary project management, contextual inquiry, value specification, and design. This project has been developed as part of the Telehealth in the Home: Aged and Palliative Care in South Australia initiative. Significant issues were identified and subsequently addressed during concept and prototype development. The CeHRes approach highlighted the implicit diversity in views and opinions among participants and stakeholders and enabled issues to be considered, resolved, and incorporated during design through continuous engagement. The CeHRes model provided a mechanism that facilitated "better" solutions in the development of the palliative care prototype by addressing the inherent but potentially unrecognized differences in values and beliefs of participants. This collaboration enabled greater interaction and exchange among participants resulting in a more useful and clinically valuable telehealth prototype.

Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records-REDUCE Trial study original protocol.

PubMed

Juszczyk, Dorota; Charlton, Judith; McDermott, Lisa; Soames, Jamie; Sultana, Kirin; Ashworth, Mark; Fox, Robin; Hay, Alastair D; Little, Paul; Moore, Michael V; Yardley, Lucy; Prevost, A Toby; Gulliford, Martin C

2016-08-04

Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. ISRCTN95232781; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Balancing student/trainee learning with the delivery of patient care in the healthcare workplace: a protocol for realist synthesis.

PubMed

Sholl, Sarah; Ajjawi, Rola; Allbutt, Helen; Butler, Jane; Jindal-Snape, Divya; Morrison, Jill; Rees, Charlotte

2016-04-26

A national survey was recently conducted to explore medical education research priorities in Scotland. The identified themes and underlying priority areas can be linked to current medical education drivers in the UK. The top priority area rated by stakeholders was: 'Understanding how to balance service and training conflicts'. Despite its perceived importance, a preliminary scoping exercise revealed the least activity with respect to published literature reviews. This protocol has therefore been developed so as to understand how patient care, other service demands and student/trainee learning can be simultaneously facilitated within the healthcare workplace. The review will identify key interventions designed to balance patient care and student/trainee learning, to understand how and why such interventions produce their effects. Our research questions seek to address how identified interventions enable balanced patient care-trainee learning within the healthcare workplace, for whom, why and under what circumstances. Pawson's five stages for undertaking a realist review underpin this protocol. These stages may progress in a non-linear fashion due to the iterative nature of the review process. We will: (1) clarify the scope of the review, identifying relevant interventions and existing programme theories, understanding how interventions act to produce their intended outcomes; (2) search journal articles and grey literature for empirical evidence from 1998 (introduction of the European Working Time Directive) on the UK multidisciplinary team working concerning these interventions, theories and outcomes, using databases such as ERIC, Scopus and CINAHL; (3) assess study quality; (4) extract data; and (5) synthesise data, drawing conclusions. A formal ethical review is not required. These findings should provide an important understanding of how workplace-based interventions influence the balance of trainee learning and service provision. They should benefit various stakeholders involved in workplace-based learning interventions, and inform the medical education research agenda in the UK. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Essential childbirth and postnatal interventions for improved maternal and neonatal health

PubMed Central

2014-01-01

Childbirth and the postnatal period, spanning from right after birth to the following several weeks, presents a time in which the number of deaths reported still remain alarmingly high. Worldwide, about 800 women die from pregnancy- or childbirth-related complications daily while almost 75% of neonatal deaths occur within the first seven days of delivery and a vast majority of these occur in the first 24 hours. Unfortunately, this alarming trend of mortality persists, as287,000 women lost their lives to pregnancy and childbirth related causes in 2010. Almost all of these deaths were preventable and occurred in low-resource settings, pointing towards dearth of adequate facilities in these parts of the world. The main objective of this paper is to review the evidence based childbirth and post natal interventions which have a beneficial impact on maternal and newborn outcomes. It is a compilation of existing, new and updated interventions designed to help physicians and policy makers and enable them to reduce the burden of maternal and neonatal morbidities and mortalities. Interventions during the post natal period that were found to be associated with a decrease in maternal and neonatal morbidity and mortality included: advice and support of family planning, support and promotion of early initiation and continued breastfeeding; thermal care or kangaroo mother care for preterm and/or low birth weight babies; hygienic care of umbilical cord and skin following delivery, training health personnel in basic neonatal resuscitation; and postnatal visits. Adequate delivery of these interventions is likely to bring an unprecedented decrease in the number of deaths reported during childbirth. PMID:25177795

Developing, implementing and evaluating a model for an outpatient self-harm service.

PubMed

Brand, Fiona; Lascelles, Karen

2017-05-10

Aim To reduce the incidence of self-harming behaviour and improve well-being and experience of care for individuals who present regularly to the emergency department in one hospital following self-harm, by providing outpatient care. Method This was a 12-month nurse-led practice development project to develop, implement and evaluate a brief-intervention outpatient service for individuals who presented to the emergency department following self-harm and who were identified as being at risk of further self-harm. The service improvement was informed by an action research process and the principles of appreciative inquiry. Findings The project provided a short-term outpatient follow-up service, known as Brief Interventions in Repeat Self Harm (BIRSH), to patients who presented to the emergency department following self-harm, and who were considered at risk of further self-harm. The intervention enabled the clinician to validate the patient's distress and offer them short-term outpatient follow-up care. The BIRSH sessions were offered to 38 patients. A total of 26 patients attended one or more BIRSH session, and all of these individuals showed a reduction in the number of presentations to the emergency department following self-harm in the six months following the intervention, compared to the six months before the intervention. Conclusion The BIRSH outpatient service appears to have been a contributory factor in reducing self-harm for patients who engaged with the service. The service improvement was informed by an action research process and the principles of appreciative inquiry, which provided a positive, focused approach to the practice development project.

Longitudinal cystic fibrosis care.

PubMed

Antunovic, S S; Lukac, M; Vujovic, D

2013-01-01

Cystic fibrosis is a complex disease entity that presents considerable lifelong challenges. Implementation of medical and surgical treatment options involves multisystem interventions to prevent and treat lung and gastrointestinal manifestations of cystic fibrosis and associated comorbidities. From birth through adulthood, cystic fibrosis care entails a longitudinal regimen aimed at achieving relief of disease symptoms and enhanced life expectancy. With increased knowledge of the molecular behavior of the cystic fibrosis transmembrane conductance regulator (CFTR) in health and disease, clinical practice has been enriched by the prospect of novel strategies, including mutation-specific drug and gene therapy targeting restoration of corrupted transepithelial ion transport. Emerging paradigms of comprehensive care increasingly enable personalized solutions to address the root cause of disease-transforming management options for individuals with cystic fibrosis.

The N-of-1 Clinical Trial: A Timely Research Opportunity in Homeopathy.

PubMed

Ulbrich-Zürni, Susanne; Teut, Michael; Roll, Stephanie; Mathie, Robert T

2018-02-01

 The randomised controlled trial (RCT) is considered the 'gold standard' for establishing treatment efficacy or effectiveness of an intervention, but its data do not infer response in an individual patient. Individualised clinical care, a fundamental principle in complementary and alternative medicine (CAM), including homeopathy, seems well disposed in principle to being researched by single-patient (N-of-1) study design. Guidelines for reporting N-of-1 trials have recently been developed.  To overview the current status in the literature of the N-of-1 method and its application in medicine, including CAM. To consider whether the N-of-1 trial design offers an opportunity for novel research in homeopathy. N-OF-1 TRIAL DESIGN:  The N-of-1 trial applies the principles of the conventional crossover, blinded, RCT design. The treatment under study and the comparator are repeated in a randomised order, and with suitable washout time, over a defined period. N-of-1 design is constrained for use in chronic stable conditions, and for interventions that have quick onset and cessation of effect, with modest or negligible carryover. Outcome data can be aggregated and interpreted for the individual subject; they can also be pooled with data from several similar N-of-1 trials, enabling more generalisable conclusions. THE N-OF-1 TRIAL IN CAM: The typical individualisation of patient care can be accommodated in N-of-1 study design if the patient and the specific therapeutic intervention are selected within the constraints of the method. Application of the N-of-1 method in CAM has been advocated but has been mainly limited, in practice, to a small number of studies in herbal and traditional Chinese medicine. THE N-OF-1 TRIAL IN HOMEOPATHY:  Individualised homeopathy can be accommodated for investigation within the same methodological constraints; less in-depth homeopathic approaches to prescribing are also amendable to investigation using the N-of-1 method. No such studies have been published. We identify three main targets in its ready applicability to homeopathy: (1) to optimise clinical care in an individual patient; (2) to investigate whether the outcomes of treatment using homeopathy differ from those of placebo; (3) to aggregate data from a series of N-of-1 trials to enable broader conclusions about a group of patients or intervention.  The N-of-1 trial design offers important new investigative possibilities in homeopathy and should be explored as a means to optimise individualised health care or investigate effectiveness of the homeopathic intervention compared with placebo in individual subjects. The Faculty of Homeopathy.

Pharmaceutical care in smoking cessation

PubMed Central

Marín Armero, Alicia; Calleja Hernandez, Miguel A; Perez-Vicente, Sabina; Martinez-Martinez, Fernando

2015-01-01

As a determining factor in various diseases and the leading known cause of preventable mortality and morbidity, tobacco use is the number one public health problem in developed countries. Facing this health problem requires authorities and health professionals to promote, via specific programs, health campaigns that improve patients’ access to smoking cessation services. Pharmaceutical care has a number of specific characteristics that enable the pharmacist, as a health professional, to play an active role in dealing with smoking and deliver positive smoking cessation interventions. The objectives of the study were to assess the efficacy of a smoking cessation campaign carried out at a pharmaceutical care center and to evaluate the effects of pharmaceutical care on patients who decide to try to stop smoking. The methodology was an open, analytical, pre–post intervention, quasi-experimental clinical study performed with one patient cohort. The results of the study were that the promotional campaign for the smoking cessation program increased the number of patients from one to 22, and after 12 months into the study, 43.48% of the total number of patients achieved total smoking cessation. We can conclude that advertising of a smoking cessation program in a pharmacy increases the number of patients who use the pharmacy’s smoking cessation services, and pharmaceutical care is an effective means of achieving smoking cessation. PMID:25678779

Pharmaceutical care in smoking cessation.

PubMed

Marín Armero, Alicia; Calleja Hernandez, Miguel A; Perez-Vicente, Sabina; Martinez-Martinez, Fernando

2015-01-01

As a determining factor in various diseases and the leading known cause of preventable mortality and morbidity, tobacco use is the number one public health problem in developed countries. Facing this health problem requires authorities and health professionals to promote, via specific programs, health campaigns that improve patients' access to smoking cessation services. Pharmaceutical care has a number of specific characteristics that enable the pharmacist, as a health professional, to play an active role in dealing with smoking and deliver positive smoking cessation interventions. The objectives of the study were to assess the efficacy of a smoking cessation campaign carried out at a pharmaceutical care center and to evaluate the effects of pharmaceutical care on patients who decide to try to stop smoking. The methodology was an open, analytical, pre-post intervention, quasi-experimental clinical study performed with one patient cohort. The results of the study were that the promotional campaign for the smoking cessation program increased the number of patients from one to 22, and after 12 months into the study, 43.48% of the total number of patients achieved total smoking cessation. We can conclude that advertising of a smoking cessation program in a pharmacy increases the number of patients who use the pharmacy's smoking cessation services, and pharmaceutical care is an effective means of achieving smoking cessation.

Living Well With a Long-Term Condition: Service Users' Perspectives of a Self-Management Intervention.

PubMed

Stenberg, Nicola; Furness, Penny J

2017-03-01

The outcomes of self-management interventions are commonly assessed using quantitative measurement tools, and few studies ask people with long-term conditions to explain, in their own words, what aspects of the intervention they valued. In this Grounded Theory study, a Health Trainers service in the north of England was evaluated based on interviews with eight service-users. Open, focused, and theoretical coding led to the development of a preliminary model explaining participants' experiences and perceived impact of the service. The model reflects the findings that living well with a long-term condition encompassed social connectedness, changed identities, acceptance, and self-care. Health trainers performed four related roles that were perceived to contribute to these outcomes: conceptualizer, connector, coach, and champion. The evaluation contributes a grounded theoretical understanding of a personalized self-management intervention that emphasizes the benefits of a holistic approach to enable cognitive, behavioral, emotional, and social adjustments.

Domestic violence in the pregnant patient: obstetric and behavioral interventions.

PubMed

Mayer, L; Liebschutz, J

1998-10-01

Every day, obstetric providers treat patients experiencing domestic violence. Domestic violence can have both dramatic and subtle impacts on maternal and fetal morbidity and mortality. This article enumerates patient risk factors for and obstetric consequences of domestic violence. It describes adaptations to the assessment and treatment of pregnancy complications occurring in the context of domestic violence and presents behavioral interventions that can be performed within existing obstetric care delivery systems. Behavioral interventions include assessments of a patient's readiness for change and her emotional responses to the violence. Obstetric interventions include an assessment of risk of physical harm to a pregnant woman and her fetus from domestic violence. Interviewing techniques include educating the patient about the effects of abuse and, over time, validating a patient's efforts to change. Reliance on a team approach and use of community resources are emphasized. All of these mechanisms enable obstetric providers to assist pregnant women in taking steps to end the abuse.

Enhancing Supportive-Educative Nursing Systems to Reduce Risk of Post-Breast Cancer Lymphedema

PubMed Central

Armer, Jane M.; Shook, Robin P.; Schneider, Melanie K; Brooks, Constance W.; Peterson, Julie; Stewart, Bob R

2010-01-01

This study describes the use of data regarding self-care agency to enhance a supportive-educative nursing system for breast cancer survivors to reduce the risk of developing lymphedema post surgery. Impetus for this study came from the analysis of participant feedback from a parent study (Lance Armstrong Foundation pilot study) that sought to plan an educational program for nurses that will improve their supportive-educative nursing system when working with breast cancer survivors. The goal is to enable these women to reduce the risk of lymphedema post surgery. The parent study examined a bundled behavioral-educative intervention, which included standard lymphedema education coupled with Modified Manual Lymph Drainage (MMLD) to reduce the risk of developing lymphedema in newly-diagnosed breast cancer survivors. Based upon the feedback received from the parent study, the research team recognized that many of the participants were not fully following the recommendations of the intervention protocol. In order for nurses to help patients develop self-care agency (SCA) (Orem, 2001) to engage in actions that addressed the self-care requisites associated with post-breast cancer surgery, these nurses needed to refine their intervention skills. Prior to the development of a program for the nurses, the research team conducted a study to explore the state of power related to SCA of the study participants. The information obtained from this was then used in the development of an educational program for bundled intervention. Both motivational interviewing (Miller & Rollnick, 2002) and solution-focused therapy (Berg & DeJong, 1996) were incorporated into the educational program for the research nurse team to strengthen and improve supportive-educative nursing systems. Supportive-educative systems of care that integrate self-care deficit nursing theory, motivational interviewing, and solution-focused therapy can assist patients to develop and sustain self-care agency. PMID:22872189

Combining administrative data feedback, reflection and action planning to engage primary care professionals in quality improvement: qualitative assessment of short term program outcomes.

PubMed

Vachon, Brigitte; Désorcy, Bruno; Gaboury, Isabelle; Camirand, Michel; Rodrigue, Jean; Quesnel, Louise; Guimond, Claude; Labelle, Martin; Huynh, Ai-Thuy; Grimshaw, Jeremy

2015-09-18

Improving primary care for chronic disease management requires a coherent, integrated approach to quality improvement. Evidence in the continuing professional development (CPD) field suggests the importance of using strategies such as feedback delivery, reflective practice and action planning to facilitate recognition of gaps and service improvement needs. Our study explored the outcomes of a CPD intervention, named the COMPAS Project, which consists of a three-hour workshop composed of three main activities: feedback, critical reflection and action planning. The feedback intervention is delivered face-to-face and presents performance indicators extracted from clinical-administrative databases. This aim of this study was to assess the short term outcomes of this intervention to engage primary care professional in continuous quality improvement (QI). In order to develop an understanding of our intervention and of its short term outcomes, a program evaluation approach was used. Ten COMPAS workshops on diabetes management were directly observed and qualitative data was collected to assess the intervention short term outcomes. Data from both sources were combined to describe the characteristics of action plans developed by professionals. Two independent coders analysed the content of these plans to assess if they promoted engagement in QI and interprofessional collaboration. During the ten workshops held, 26 interprofessional work teams were formed. Twenty-two of them developed a QI project they could implement themselves and that targeted aspects of their own practice they perceived in need of change. Most frequently prioritized strategies for change were improvement of systematic clientele follow-up, medication compliance, care pathway and support to improve adoption of healthier life habits. Twenty-one out of 22 action plans were found to target some level of improvement of interprofessional collaboration in primary care. Our study results demonstrate that the COMPAS intervention enabled professionals to target priorities for practice improvements and to develop action plans that promote interprofessional collaboration. The COMPAS intervention aims to increase capability for continuous QI, readiness to implement process of care changes and team shared goals but available resources, climate and culture for change and leadership, are also important required conditions to successfully implement these practice changes. We think that the proposed approach can be very useful to support and engage primary care professionals in the planning stage of quality improvement projects since it combines key successful ingredients: feedback, reflection and planning of action.

Barriers and enablers of kangaroo mother care implementation from a health systems perspective: a systematic review

PubMed Central

Chan, Grace; Bergelson, Ilana; Smith, Emily R; Skotnes, Tobi; Wall, Stephen

2017-01-01

Abstract Kangaroo Mother Care (KMC) is an evidence-based intervention that reduces neonatal morbidity and mortality. However, adoption among health systems has varied. Understanding the interaction between health system functions—leadership, financing, healthcare workers (HCWs), technologies, information and research, and service delivery—and KMC is essential to understanding KMC adoption. We present a systematic review of the barriers and enablers of KMC implementation from the perspective of health systems, with a focus on HCWs and health facilities. Using the search terms ‘kangaroo mother care’, ‘skin to skin (STS) care’ and ‘kangaroo care’, we searched Embase, Scopus, Web of Science, Pubmed, and World Health Organization Regional Databases. Reports and hand searched references from publications were also included. Screening and data abstraction were conducted by two independent reviewers using standardized forms. A conceptual model to assess KMC adoption themes was developed using NVivo software. Our search strategy yielded 2875 studies. We included 86 studies with qualitative data on KMC implementation from the perspective of HCWs and/or facilities. Six themes emerged on barriers and enablers to KMC adoption: buy-in and bonding; social support; time; medical concerns; training; and cultural norms. Analysis of interactions between HCWs and facilities yielded further barriers and enablers in the areas of training, communication, and support. HCWs and health facilities serve as two important adopters of Kangaroo Mother Care within a health system. The complex components of KMC lead to multifaceted barriers and enablers to integration, which inform facility, regional, and country-level recommendations for increasing adoption. Further research of methods to promote context-specific adoption of KMC at the health systems level is needed. PMID:28973515

Making Longevity in an Aging Society: Linking Ethical Sensibility and Medicare Spending

PubMed Central

Kaufman, Sharon R.

2010-01-01

An aging U.S. society, a growing array of life-extending medical interventions, Medicare policy and an ethic of individual decision-making together contribute to the deepening societal tension between controlling health care costs and enabling health consumer use of life-sustaining technologies. The activities that constitute longevity making, like so many other socio-medical practices, constitute a site for the governing of life and the emergence of new forms of ethical comportment and social participation. Those activities – including the necessity of treating risk, the difficulty of saying ‘no’ to evidence-based interventions and the responsibility of choosing among clinical options -- also lie at the heart of debates about health care rationing and reform. Cardiac procedures, organ transplantation and cancer treatments are three examples of medicine’s success in extending life and are emblematic of the existential and societal quandaries that result. A perspective from medical anthropology shows the ways in which the making of life is linked to health care spending and the ongoing debates about age-based rationing. PMID:20182967

Learning to deal constructively with troubled conscience related to care providers' perceptions of deficient teamwork in residential care of older people--a participatory action research study.

PubMed

Ericson-Lidman, Eva; Strandberg, Gunilla

2015-06-01

Conscience can be perceived as an asset that helps care providers to provide good care, but it can also be a burden that generates stress of conscience (stress related to a troubled conscience). Participatory action research (PAR) has been shown to be successful in supporting care providers in residential care of older people to learn to deal with their troubled conscience in challenging and demanding care situations. The aim of the study was to describe an intervention process to assist care providers in residential care of older people to constructively deal with their troubled conscience related to perceptions of deficient teamwork. The study design was grounded in PAR. Nine enrolled nurses (ENs), two nursing aids (NAs), one Registered Nurse (RN) and their manager participated in 12 PAR sessions. All sessions were tape-recorded, and a domain analysis of the transcriptions was performed. Findings show that a PAR-based intervention can support care providers to understand, handle and take measures against deficient teamwork. Using troubled conscience as a driving force can increase the opportunities to improve quality of care in residential care for older people. During the PAR process, participants raised their awareness of the need to view the team in a wider sense and that the manager and the Registered Nurse should also be members of the team to improve team outcome. To improve clinical practice, we suggest that teams in residential care of older people should be enabled to share and reflect on challenging situations that generate troubled conscience. However, as shown in this study, care providers might need support in order to facilitate and promote sharing and reflecting on what their conscience tells them. © 2014 Nordic College of Caring Science.

Care and Service at Home for Persons With Dementia in Europe.

PubMed

Bökberg, Christina; Ahlström, Gerd; Leino-Kilpi, Helena; Soto-Martin, Maria E; Cabrera, Esther; Verbeek, Hilde; Saks, Kai; Stephan, Astrid; Sutcliffe, Caroline; Karlsson, Staffan

2015-09-01

To describe available and utilized formal care and service at home for persons with dementia, from diagnosis to end-of-life stage, in eight European countries. A descriptive cross-country design concerning eight European countries as a part of the European research project RightTimePlaceCare. The research team in each country used a mapping system to collect country-specific information concerning dementia care and service system. The mapping system consists of 50 types of care and service activities. Sixteen of the 50 predefined activities concerning care and service at home were selected for this study and subdivided into three categories, following the stages of dementia. Availability was reported to be higher than utilization, and the findings indicated more similarities than differences among the eight countries involved. Even though there were several available activities of "basic care and services" and "healthcare interventions," they were utilized by few in most countries. Furthermore, "specialized dementia care and services" were sparsely available and even more sparsely utilized in the participating countries. The findings indicated that persons with dementia in Europe received formal care and service on a general, basic level but seldom adjusted to their specific needs. This study describes the gap between service provision and utilization enabling nurses to develop individually adjusted care plans for persons with dementia during the progress of the disease. The findings do not include matters of quality of care or how to best organize effective care and services. However, the activities of care and services presented here should shed light on what room there is for improvement when it comes to enabling persons with dementia to go on living at home. © 2015 Sigma Theta Tau International.

Key ingredients for implementing intensive outpatient programs within patient-centered medical homes: A literature review and qualitative analysis.

PubMed

Breland, Jessica Y; Asch, Steven M; Slightam, Cindie; Wong, Ava; Zulman, Donna M

2016-03-01

Intensive outpatient programs aim to transform care while conserving resources for high-need, high-cost patients, but little is known about factors that influence their implementation within patient-centered medical homes (PCMHs). In this mixed-methods study, we reviewed the literature to identify factors affecting intensive outpatient program implementation, then used semi-structured interviews to determine how these factors influenced the implementation of an intensive outpatient program within the Veterans Affairs' (VA) PCMH. Interviewees included facility leadership and clinical staff who were involved in a pilot Intensive Management Patient Aligned Care Team (ImPACT) intervention for high-need, high-cost VA PCMH patents. We classified implementation factors in the literature review and qualitative analysis using the Consolidated Framework for Implementation Research (CFIR). The literature review (n=9 studies) and analyses of interviews (n=15) revealed key implementation factors in three CFIR domains. First, the Inner Setting (i.e., the organizational and PCMH environment), mostly enabled implementation through a culture of innovation, good networks and communication, and positive tension for change. Second, Characteristics of Individuals, including creativity, flexibility, and interpersonal skills, allowed program staff to augment existing PCMH services. Finally, certain Intervention Characteristics (e.g., adaptability) enabled implementation, while others (e.g., complexity) generated implementation barriers. Resources and structural features common to PCMHs can facilitate implementation of intensive outpatient programs, but program success is also dependent on staff creativity and flexibility, and intervention adaptations to meet patient and organizational needs. Established PCMHs likely provide resources and environments that permit accelerated implementation of intensive outpatient programs. V. Published by Elsevier Inc.

Use of the Internet and Mobile Phones for Self-Management of Severe Mental Health Problems: Qualitative Study of Staff Views.

PubMed

Berry, Natalie; Bucci, Sandra; Lobban, Fiona

2017-11-01

Researchers are currently investigating the feasibility, acceptability, and efficacy of digital health interventions for people who experience severe mental health problems such as psychosis and bipolar disorder. Although the acceptability of digital health interventions for severe mental health problems appears to be relatively high and some people report successfully using the Internet and mobile phones to manage their mental health, the attitudes of mental health care staff toward such approaches have yet to be considered. The aim of this study was to explore mental health care staff experiences of clients with severe mental health problems engaging with the Internet and mobile phones to self-manage their mental health and their views toward these behaviors. The study also sought to examine the opinions expressed by mental health care staff toward digital health interventions for severe mental health problems to identify potential facilitators and barriers to implementation. Four focus groups were conducted with 20 staff working in mental health care services in the North West of the England using a topic guide. Focus groups involved 12 staff working in secondary care psychological services (7 participants in focus group 1 and 5 participants in focus group 4), 4 staff working in a rehabilitation unit (focus group 2), and 4 staff working in a community mental health team (focus group 3). Focus groups were transcribed verbatim, and transcripts were analyzed thematically to identify key themes that emerged from the data. Four overarching themes, two with associated subthemes, were identified: (1) staff have conflicting views about the pros and cons of using Web-based resources and digital health interventions to manage mental health; (2) digital health interventions could increase access to mental health support options for severe mental health problems but may perpetuate the digital divide; (3) digital health interventions' impact on staff roles and responsibilities; and (4) digital health interventions should be used to enhance, not replace, face-to-face support. This study is the first, to our knowledge, to qualitatively explore the experiences and attitudes of mental health care staff toward individuals with severe mental health problems using the Internet, mobile phones, and digital health interventions to self-manage their mental health. Understanding the positive and negative experiences and views shared by staff toward both current and potential digital health intervention use has enabled the identification of several considerations for implementation. Additionally, the findings suggest mental health care staff need clear guidance and training in relation to their responsibilities in recommending reputable and secure websites, forums, and digital health interventions and in how to manage professional boundaries on the Internet. Overall, the study highlights that digital health interventions could be well received by staff working in mental health services but importantly, such management options must be presented to frontline staff as an avenue to enhance care and extend choice, rather than as a method to reduce costs. ©Natalie Berry, Sandra Bucci, Fiona Lobban. Originally published in JMIR Mental Health (http://mental.jmir.org), 01.11.2017.

Duplex DNA-Invading γ-Modified Peptide Nucleic Acids Enable Rapid Identification of Bloodstream Infections in Whole Blood

PubMed Central

Nölling, Jörk; Rapireddy, Srinivas; Amburg, Joel I.; Crawford, Elizabeth M.; Prakash, Ranjit A.; Rabson, Arthur R.

2016-01-01

ABSTRACT Bloodstream infections are a leading cause of morbidity and mortality. Early and targeted antimicrobial intervention is lifesaving, yet current diagnostic approaches fail to provide actionable information within a clinically viable time frame due to their reliance on blood culturing. Here, we present a novel pathogen identification (PID) platform that features the use of duplex DNA-invading γ-modified peptide nucleic acids (γPNAs) for the rapid identification of bacterial and fungal pathogens directly from blood, without culturing. The PID platform provides species-level information in under 2.5 hours while reaching single-CFU-per-milliliter sensitivity across the entire 21-pathogen panel. The clinical utility of the PID platform was demonstrated through assessment of 61 clinical specimens, which showed >95% sensitivity and >90% overall correlation to blood culture findings. This rapid γPNA-based platform promises to improve patient care by enabling the administration of a targeted first-line antimicrobial intervention. PMID:27094328

The enabling effect of food assistance in improving adherence and/or treatment completion for antiretroviral therapy and tuberculosis treatment: a literature review.

PubMed

de Pee, Saskia; Grede, Nils; Mehra, Divya; Bloem, Martin W

2014-10-01

Socioeconomic costs of HIV and TB and the difficulty of maintaining optimal treatment are well documented. Social protection measures such as food assistance may be required to offset some of the treatment related costs as well as to ensure food security and maintain good health of the affected individual and household. Programmes have started placing greater emphasis on treatment adherence and are looking for proven interventions that can optimize it. This paper looks at the effect of food assistance for enabling treatment adherence and reviews studies that used food assistance to promote adherence. Eight of ten studies found that provision of food can improve adherence and/or treatment completion for HIV care and treatment, ART and TB-DOTS. This indicates that food provision is not only a biological, but also a behavioural intervention, and underscores that unresolved food insecurity can be an impediment to treatment adherence and consequently to good treatment outcomes.

A new type of swaddling clothing improved development of preterm infants in neonatal intensive care units.

PubMed

Kitase, Yuma; Sato, Yoshiaki; Takahashi, Hirokazu; Shimizu, Misaki; Ishikawa, Chie; Yamamoto, Hikaru; Hayakawa, Masahiro

2017-09-01

Preterm infants undergo stress owing to essential treatments and exposure to the extrauterine environment in neonatal intensive care units. The aim of this study was to enable preterm infants to maintain adequate positioning with a newly developed swaddling clothing, in order to improve low muscle tone and sleep quality, and to confirm the safety of the clothing. This prospective clinical trial included an intervention group (preterm infants wearing bag-shaped clothing, allowing only exposure of the head, n=27), and a control group (preterm infants managed only with conventional swaddling, n=12). We used the Dubowitz method to analyze behavior, recorded the frequency of vomiting and apnea in both groups, and assessed the sleep state in the intervention group. Muscle tone and total score for the Dubowitz method significantly improved in the intervention group, compared with those in the control group. We evaluated the sleep state before and after the introduction of the device in the intervention group, and State 1 increased from 53.5% to 69.2% after introduction. No significant difference was seen in the frequency of vomiting and apnea between the groups. The new swaddling clothing with enhanced stretch capacity improved the muscle tone and increased sleep time by decreasing the state level of preterm infants. This is an effective tool to assist in infant development in neonatal intensive care units. Copyright © 2017 Elsevier B.V. All rights reserved.

Mobile health for early retention in HIV care: a qualitative study in Kenya (WelTel Retain)

PubMed Central

Smillie, Kirsten; Van Borek, Natasha; van der Kop, Mia L; Lukhwaro, Abigael; Li, Neville; Karanja, Sarah; Patel, Anik R; Ojakaa, David; Lester, Richard T

2017-01-01

Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT), WelTel Kenya1, demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain, an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis, we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care, the use of cell phones in everyday life, and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured, qualitative interviews were conducted and recorded, transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis, structural and individual barriers including poverty, depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone, and most were comfortable communicating through text messages, or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems, leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis. PMID:25555099

Mobile health for early retention in HIV care: a qualitative study in Kenya (WelTel Retain).

PubMed

Smillie, Kirsten; Van Borek, Natasha; van der Kop, Mia L; Lukhwaro, Abigael; Li, Neville; Karanja, Sarah; Patel, Anik R; Ojakaa, David; Lester, Richard T

2014-01-01

Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT), WelTel Kenya1, demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain, an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis, we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care, the use of cell phones in everyday life, and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured, qualitative interviews were conducted and recorded, transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis, structural and individual barriers including poverty, depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone, and most were comfortable communicating through text messages, or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems, leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis.

Development and piloting of a plan for integrating mental health in primary care in Sehore district, Madhya Pradesh, India

PubMed Central

Shidhaye, Rahul; Shrivastava, Sanjay; Murhar, Vaibhav; Samudre, Sandesh; Ahuja, Shalini; Ramaswamy, Rohit; Patel, Vikram

2016-01-01

Background The large treatment gap for mental disorders in India underlines the need for integration of mental health in primary care. Aims To operationalise the delivery of the World Health Organization Mental Health Gap Action Plan interventions for priority mental disorders and to design an integrated mental healthcare plan (MHCP) comprising packages of care for primary healthcare in one district. Method Mixed methods were used including theory of change workshops, qualitative research to develop the MHCP and piloting of specific packages of care in a single facility. Results The MHCP comprises three enabling packages: programme management, capacity building and community mobilisation; and four service delivery packages: awareness for mental disorders, identification, treatment and recovery. Challenges were encountered in training primary care workers to improve identification and treatment. Conclusions There are a number of challenges to integrating mental health into primary care, which can be addressed through the injection of new resources and collaborative care models. PMID:26447172

Exploring barriers and enablers for scaling up a community-based grain bank intervention for improved infant and young child feeding in Ethiopia: A qualitative process evaluation.

PubMed

Sako, Binta; Leerlooijer, Joanne N; Lelisa, Azeb; Hailemariam, Abebe; Brouwer, Inge D; Tucker Brown, Amal; Osendarp, Saskia J M

2018-04-01

Child malnutrition remains high in Ethiopia, and inadequate complementary feeding is a contributing factor. In this context, a community-based intervention was designed to provide locally made complementary food for children 6-23 months, using a bartering system, in four Ethiopian regions. After a pilot phase, the intervention was scaled up from 8 to 180 localities. We conducted a process evaluation to determine enablers and barriers for the scaling up of this intervention. Eight study sites were selected to perform 52 key informant interviews and 31 focus group discussions with purposely selected informants. For analysis, we used a framework describing six elements of successful scaling up: socio-political context, attributes of the intervention, attributes of the implementers, appropriate delivery strategy, the adopting community, and use of research to inform the scale-up process. A strong political will, alignment of the intervention with national priorities, and integration with the health care system were instrumental in the scaling up. The participatory approach in decision-making reinforced ownership at community level, and training about complementary feeding motivated mothers and women's groups to participate. However, the management of the complex intervention, limited human resources, and lack of incentives for female volunteers proved challenging. In the bartering model, the barter rate was accepted, but the bartering was hindered by unavailability of cereals and limited financial and material resources to contribute, threatening the project's sustainability. Scaling up strategies for nutrition interventions require sufficient time, thorough planning, and assessment of the community's capacity to contribute human, financial, and material resources. © 2017 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.

Exploring barriers and enablers for scaling up a community‐based grain bank intervention for improved infant and young child feeding in Ethiopia: A qualitative process evaluation

PubMed Central

Sako, Binta; Leerlooijer, Joanne N.; Lelisa, Azeb; Hailemariam, Abebe; Brouwer, Inge D.; Tucker Brown, Amal

2017-01-01

Abstract Child malnutrition remains high in Ethiopia, and inadequate complementary feeding is a contributing factor. In this context, a community‐based intervention was designed to provide locally made complementary food for children 6–23 months, using a bartering system, in four Ethiopian regions. After a pilot phase, the intervention was scaled up from 8 to 180 localities. We conducted a process evaluation to determine enablers and barriers for the scaling up of this intervention. Eight study sites were selected to perform 52 key informant interviews and 31 focus group discussions with purposely selected informants. For analysis, we used a framework describing six elements of successful scaling up: socio‐political context, attributes of the intervention, attributes of the implementers, appropriate delivery strategy, the adopting community, and use of research to inform the scale‐up process. A strong political will, alignment of the intervention with national priorities, and integration with the health care system were instrumental in the scaling up. The participatory approach in decision‐making reinforced ownership at community level, and training about complementary feeding motivated mothers and women's groups to participate. However, the management of the complex intervention, limited human resources, and lack of incentives for female volunteers proved challenging. In the bartering model, the barter rate was accepted, but the bartering was hindered by unavailability of cereals and limited financial and material resources to contribute, threatening the project's sustainability. Scaling up strategies for nutrition interventions require sufficient time, thorough planning, and assessment of the community's capacity to contribute human, financial, and material resources. PMID:29063698

Multidimensional team-based intervention using musical cues to reduce odds of facility-acquired pressure ulcers in long-term care: a paired randomized intervention study.

PubMed

Yap, Tracey L; Kennerly, Susan M; Simmons, Mark R; Buncher, Charles R; Miller, Elaine; Kim, Jay; Yap, Winston Y

2013-09-01

To test the effectiveness of a pressure ulcer (PU) prevention intervention featuring musical cues to remind all long-term care (LTC) staff (nursing and ancillary) to help every resident move or reposition every 2 hours. Twelve-month paired-facility two-arm (with one-arm crossover) randomized intervention trial. Ten midwestern U.S. LTC facilities. Four treatment facilities received intervention during Months 1 to 12, four comparison facilities received intervention during Months 7 to 12, and two pseudo-control facilities received no intervention. LTC facility residents (N = 1,928). All facility staff received in-person education, video, and handouts, and visiting family members received informational pamphlets on PU prevention and an intervention featuring musical cues. Nurse-led multidisciplinary staff teams presented the cues as prompts for staff and family to reposition residents or remind them to move. Musical selections (with and without lyrics) customized to facility preferences were played daily over the facility intercom or public address system every 2 hours for the 12-hour daytime period. Primary outcome measure was the frequency of new facility-acquired PUs divided by the total number of facility Minimum Data Set (MDS) resident assessments conducted during the study period. Odds of a new PU were lower in intervention facilities (P = .08) for MDS 2.0 assessments and were significantly lower (P = .05) for MDS 3.0. Mean odds ratios suggested intervention facility residents were 45% less likely than comparison facility residents to develop a new PU. Customized musical cues that prompt multidisciplinary staff teams to encourage or enable movement of all residents hold promise for reducing facility-acquired PUs in LTC settings. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Selecting services for a service robot: evaluating the problematic activities threatening the independence of elderly persons.

PubMed

Bedaf, Sandra; Gelderblom, Gert Jan; de Witte, Luc; Syrdal, Dag; Lehmann, Hagen; Amirabdollahian, Farshid; Dautenhahn, Kerstin; Hewson, David

2013-06-01

Sustaining independent living for the elderly is desirable both for the individual as well as for societies as a whole. Substantial care interventions are provided to citizens supporting their independent living. Currently, such interventions are primarily based on human care provision, but due to demographic changes the demand for such support is continuously increasing. Assistive Robotics has the potential to answer this growing demand. The notions research towards service robots that support the independence of elderly people has been given increased attention. The challenge is to develop robots that are able to adequately support with those activities that pose the greatest problems for elderly people seeking to remain independent. In order to develop the capabilities of the Care-O-bot 3 in the ACCOMPANY project, problematic activities that may threaten continued independent living of elderly people were studied. Focus groups were conducted in the Netherlands, UK, and France and included three separate user groups: (1) elderly (N=41), (2) formal caregivers (N=40), and (3) informal caregivers (N=32). This resulted in a top 3 of problematic activity domains that received the highest priority: (1) Mobility, (2) Self-care, and (3) Social isolation. The findings inform the further development of the Care-O-bot. In the ACCOMPANY project the Care-O-bot 3 will be developed further to enable it to support independently living older persons in one of these domains.

Successful chronic disease care for Aboriginal Australians requires cultural competence.

PubMed

Liaw, Siaw Teng; Lau, Phyllis; Pyett, Priscilla; Furler, John; Burchill, Marlene; Rowley, Kevin; Kelaher, Margaret

2011-06-01

To review the literature to determine the attributes of culturally appropriate healthcare to inform the design of chronic disease management (CDM) models for Aboriginal patients in urban general practice. A comprehensive conceptual framework, drawing on the Access to Care, Pathway to Care, Chronic Care, Level of Connectedness, and Cultural Security, Cultural Competency and Cultural Respect models, was developed to define the search strategy, inclusion criteria and appraisal methods for the literature review. Selected papers were reviewed in detail if they examined a chronic disease intervention for an Aboriginal population and reported on its evaluation, impacts or outcomes. In the 173 papers examined, only 11 programs met the inclusion criteria. All were programs conducted in rural and remote Aboriginal community-controlled health services. Successful chronic disease care and interventions require adequate Aboriginal community engagement, utilising local knowledge, strong leadership, shared responsibilities, sustainable resources and integrated data and systems. These success factors fitted within the conceptual framework developed. Research and development of culturally appropriate CDM models concurrently in both urban and rural settings will enable more rigorous evaluation, leading to stronger evidence for best practice. A partnership of mainstream and Aboriginal-controlled health services is essential to successfully 'close the gap'. Findings will inform and guide the development, implementation and evaluation of culturally appropriate CDM in mainstream general practice and primary care. © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia.

Technological Health Intervention in Population Aging to Assist People to Work Smarter not Harder: Qualitative Study

PubMed Central

2018-01-01

Background Technology-based health care has been promoted as an effective tool to enable clinicians to work smarter. However, some health stakeholders believe technology will compel users to work harder by creating extra work. Objective The objective of this study was to investigate how and why electronic health (eHealth) has been applied in Taiwan and to suggest implications that may inspire other countries facing similar challenges. Methods A qualitative methodology was adopted to obtain insightful inputs from deeper probing. Taiwan was selected as a typical case study, given its aging population, advanced technology, and comprehensive health care system. This study investigated 38 stakeholders in the health care ecosystem through in-depth interviews and focus groups, which provides an open, flexible, and enlightening way to study complex, dynamic, and interactive situations through informal conversation or a more structured, directed discussion. Results First, respondents indicated that the use of technology can enable seamless patient care and clinical benefits such as flexibility in time management. Second, the results suggested that a leader’s vision, authority, and management skills might influence success in health care innovation. Finally, the results implied that both internal and external organizational governance are highly relevant for implementing technology-based innovation in health care. Conclusions This study provided Taiwanese perspectives on how to intelligently use technology to benefit health care and debated the perception that technology prevents human interaction between clinicians and patients. PMID:29301736

Functions of behavior change interventions when implementing multi-professional teamwork at an emergency department: a comparative case study

PubMed Central

2014-01-01

Background While there is strong support for the benefits of working in multi-professional teams in health care, the implementation of multi-professional teamwork is reported to be complex and challenging. Implementation strategies combining multiple behavior change interventions are recommended, but the understanding of how and why the behavior change interventions influence staff behavior is limited. There is a lack of studies focusing on the functions of different behavior change interventions and the mechanisms driving behavior change. In this study, applied behavior analysis is used to analyze the function and impact of different behavior change interventions when implementing multi-professional teamwork. Methods A comparative case study design was applied. Two sections of an emergency department implemented multi-professional teamwork involving changes in work processes, aimed at increasing inter-professional collaboration. Behavior change interventions and staff behavior change were studied using observations, interviews and document analysis. Using a hybrid thematic analysis, the behavior change interventions were categorized according to the DCOM® model. The functions of the behavior change interventions were then analyzed using applied behavior analysis. Results The two sections used different behavior change interventions, resulting in a large difference in the degree of staff behavior change. The successful section enabled staff performance of teamwork behaviors with a strategy based on ongoing problem-solving and frequent clarification of directions. Managerial feedback initially played an important role in motivating teamwork behaviors. Gradually, as staff started to experience positive outcomes of the intervention, motivation for teamwork behaviors was replaced by positive task-generated feedback. Conclusions The functional perspective of applied behavior analysis offers insight into the behavioral mechanisms that describe how and why behavior change interventions influence staff behavior. The analysis demonstrates how enabling behavior change interventions, managerial feedback and task-related feedback interact in their influence on behavior and have complementary functions during different stages of implementation. PMID:24885212

Interventions to improve antibiotic prescribing practices for hospital inpatients.

PubMed

Davey, Peter; Marwick, Charis A; Scott, Claire L; Charani, Esmita; McNeil, Kirsty; Brown, Erwin; Gould, Ian M; Ramsay, Craig R; Michie, Susan

2017-02-09

Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias.More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence).Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence).There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomesWe analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions.

An embedded longitudinal multi-faceted qualitative evaluation of a complex cluster randomized controlled trial aiming to reduce clinically important errors in medicines management in general practice.

PubMed

Cresswell, Kathrin M; Sadler, Stacey; Rodgers, Sarah; Avery, Anthony; Cantrill, Judith; Murray, Scott A; Sheikh, Aziz

2012-06-08

There is a need to shed light on the pathways through which complex interventions mediate their effects in order to enable critical reflection on their transferability. We sought to explore and understand key stakeholder accounts of the acceptability, likely impact and strategies for optimizing and rolling-out a successful pharmacist-led information technology-enabled (PINCER) intervention, which substantially reduced the risk of clinically important errors in medicines management in primary care. Data were collected at two geographical locations in central England through a combination of one-to-one longitudinal semi-structured telephone interviews (one at the beginning of the trial and another when the trial was well underway), relevant documents, and focus group discussions following delivery of the PINCER intervention. Participants included PINCER pharmacists, general practice staff, researchers involved in the running of the trial, and primary care trust staff. PINCER pharmacists were interviewed at three different time-points during the delivery of the PINCER intervention. Analysis was thematic with diffusion of innovation theory providing a theoretical framework. We conducted 52 semi-structured telephone interviews and six focus group discussions with 30 additional participants. In addition, documentary data were collected from six pharmacist diaries, along with notes from four meetings of the PINCER pharmacists and feedback meetings from 34 practices. Key findings that helped to explain the success of the PINCER intervention included the perceived importance of focusing on prescribing errors to all stakeholders, and the credibility and appropriateness of a pharmacist-led intervention to address these shortcomings. Central to this was the face-to-face contact and relationship building between pharmacists and a range of practice staff, and pharmacists' explicitly designated role as a change agent. However, important concerns were identified about the likely sustainability of this new model of delivering care, in the absence of an appropriate support network for pharmacists and career development pathways. This embedded qualitative inquiry has helped to understand the complex organizational and social environment in which the trial was undertaken and the PINCER intervention was delivered. The longitudinal element has given insight into the dynamic changes and developments over time. Medication errors and ways to address these are high on stakeholders' agendas. Our results further indicate that pharmacists were, because of their professional standing and skill-set, able to engage with the complex general practice environment and able to identify and manage many clinically important errors in medicines management. The transferability of the PINCER intervention approach, both in relation to other prescribing errors and to other practices, is likely to be high.

An embedded longitudinal multi-faceted qualitative evaluation of a complex cluster randomized controlled trial aiming to reduce clinically important errors in medicines management in general practice

PubMed Central

2012-01-01

Background There is a need to shed light on the pathways through which complex interventions mediate their effects in order to enable critical reflection on their transferability. We sought to explore and understand key stakeholder accounts of the acceptability, likely impact and strategies for optimizing and rolling-out a successful pharmacist-led information technology-enabled (PINCER) intervention, which substantially reduced the risk of clinically important errors in medicines management in primary care. Methods Data were collected at two geographical locations in central England through a combination of one-to-one longitudinal semi-structured telephone interviews (one at the beginning of the trial and another when the trial was well underway), relevant documents, and focus group discussions following delivery of the PINCER intervention. Participants included PINCER pharmacists, general practice staff, researchers involved in the running of the trial, and primary care trust staff. PINCER pharmacists were interviewed at three different time-points during the delivery of the PINCER intervention. Analysis was thematic with diffusion of innovation theory providing a theoretical framework. Results We conducted 52 semi-structured telephone interviews and six focus group discussions with 30 additional participants. In addition, documentary data were collected from six pharmacist diaries, along with notes from four meetings of the PINCER pharmacists and feedback meetings from 34 practices. Key findings that helped to explain the success of the PINCER intervention included the perceived importance of focusing on prescribing errors to all stakeholders, and the credibility and appropriateness of a pharmacist-led intervention to address these shortcomings. Central to this was the face-to-face contact and relationship building between pharmacists and a range of practice staff, and pharmacists’ explicitly designated role as a change agent. However, important concerns were identified about the likely sustainability of this new model of delivering care, in the absence of an appropriate support network for pharmacists and career development pathways. Conclusions This embedded qualitative inquiry has helped to understand the complex organizational and social environment in which the trial was undertaken and the PINCER intervention was delivered. The longitudinal element has given insight into the dynamic changes and developments over time. Medication errors and ways to address these are high on stakeholders’ agendas. Our results further indicate that pharmacists were, because of their professional standing and skill-set, able to engage with the complex general practice environment and able to identify and manage many clinically important errors in medicines management. The transferability of the PINCER intervention approach, both in relation to other prescribing errors and to other practices, is likely to be high. PMID:22682095

Public preferences for prioritizing preventive and curative health care interventions: a discrete choice experiment.

PubMed

Luyten, Jeroen; Kessels, Roselinde; Goos, Peter; Beutels, Philippe

2015-03-01

Setting fair health care priorities counts among the most difficult ethical challenges our societies are facing. To elicit through a discrete choice experiment the Belgian adult population's (18-75 years; N = 750) preferences for prioritizing health care and investigate whether these preferences are different for prevention versus cure. We used a Bayesian D-efficient design with partial profiles, which enables considering a large number of attributes and interaction effects. We included the following attributes: 1) type of intervention (cure vs. prevention), 2) effectiveness, 3) risk of adverse effects, 4) severity of illness, 5) link between the illness and patient's health-related lifestyle, 6) time span between intervention and effect, and 7) patient's age group. All attributes were statistically significant contributors to the social value of a health care program, with patient's lifestyle and age being the most influential ones. Interaction effects were found, showing that prevention was preferred to cure for disease in young adults, as well as for severe and lethal disease in people of any age. However, substantial differences were found in the preferences of respondents from different age groups, with different lifestyles and different health states. Our study suggests that according to the Belgian public, contextual factors of health gains such as patient's age and health-related lifestyle should be considered in priority setting decisions. The studies, however, revealed substantial disagreement in opinion between different population subgroups. Copyright © 2015 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Protocol for a randomised controlled trial of chronic disease self-management support for older Australians with multiple chronic diseases.

PubMed

Reed, Richard L; Battersby, Malcolm; Osborne, Richard H; Bond, Malcolm J; Howard, Sara L; Roeger, Leigh

2011-11-01

The prevalence of older Australians with multiple chronic diseases is increasing and now accounts for a large proportion of total health care utilisation. Chronic disease self-management support (CDSMS) has become a core service component of many community based health programs because it is considered a useful tool in improving population health outcomes and reducing the financial burden of chronic disease care. However, the evidence base to justify these support programs is limited, particularly for older people with multiple chronic diseases. We describe an ongoing trial examining the effectiveness of a particular CDSMS approach called the Flinders Program. The Flinders Program is a clinician-led generic self-management intervention that provides a set of tools and a structured process that enables health workers and patients to collaboratively assess self-management behaviours, identify problems, set goals, and develop individual care plans covering key self-care, medical, psychosocial and carer issues. A sample of 252 older Australians that have two or more chronic conditions will be randomly assigned to receive either CDSMS or an attention control intervention (health information only) for 6 months. Outcomes will be assessed using self-reported health measures taken at baseline and post-intervention. This project will be the first comprehensive evaluation of CDSMS in this population. Findings are expected to guide consumers, clinicians and policymakers in the use of CDSMS, as well as facilitate prioritisation of public monies towards evidence-based services. Copyright © 2011 Elsevier Inc. All rights reserved.

Decrease social inequalities return-to-work: development and design of a randomised controlled trial among women with breast cancer

PubMed Central

2014-01-01

Background Despite the improvement in the care management, women cancer patients who are still in employment find themselves for the most part obliged to stop working while they are having treatment. Their return-to-work probability is impacted by numerous psychosocial factors. The objective is to describe the development and the content of an intervention aimed to facilitate the return to work of female breast cancer patients and in particular the women in the most precarious situations through early active individualised psychosocial support (APAPI). Methods The intervention proposed is made up of 4 interviews with a psychologist at the hospital, distributed over the year according to the diagnosis and conducted on the same day as a conventional follow-up consultation, then a consultation with a specialist job retention physician. We expect, in the first instance, that this intervention will reduce the social inequalities of the return-to-work rate at 12 months. The EPICES score will enable the population to be broken down according to the level of social precariousness. The other expected results are the reduction of the social inequalities in the quality of the return to work at 18 and 24 months and the disparities between the individual and collective resources of the patients. This intervention is assessed in the context of a controlled and randomised multi-centre study. The patients eligible are women aged between 18 and 55 years with a unilateral breast cancer with local extension exclusively, having received surgery followed by adjuvant chemotherapy, in employment at the time of the diagnosis and dealt with by one of the 2 investigating centres. Discussion It is essential to assess this type of intervention before envisaging its generalisation. The study set in place will enable us to measure the impact of this intervention aiming to facilitate the return to work of breast cancer patients, in particular for those who suffer from social fragility, compared with the standard care. PMID:24742314

[Surface Cleaning and Disinfection in the Hospital. Improvement by Objective Monitoring and Intervention].

PubMed

Woltering, R; Hoffmann, G; Isermann, J; Heudorf, U

2016-11-01

Background and Objective: An assessment of cleaning and disinfection in hospitals by the use of objective surveillance and review of mandatory corrective measures was undertaken. Methods: A prospective examination of the cleaning and disinfection of surfaces scheduled for daily cleaning in 5 general care hospitals by use of an ultraviolet fluorescence targeting method (UVM) was performed, followed by structured educational and procedural interventions. The survey was conducted in hospital wards, operating theatres and intensive care units. Cleaning performance was measured by complete removal of UVM. Training courses and reinforced self-monitoring were implemented after the first evaluation. 6 months later, we repeated the assessment for confirmation of success. Results: The average cleaning performance was 34% (31/90) at base-line with significant differences between the 5 hospitals (11-67%). The best results were achieved in intensive care units (61%) and operating theatres (58%), the worst results in hospital wards (22%). The intervention significantly improved cleaning performance up to an average of 69% (65/94; +34.7%; 95% confidence interval (CI): 21.2-48.3; p<0.05), with differences between the hospitals (20-95%). The largest increase was achieved in hospital wards (+45%; CI 29.2-60.8; p<0.05). Improvements in operating theatres (+22.9%; CI 10.9-56.7) and intensive care units (+5.6%; CI 25.8-36.9) were statistically not significant. Conclusions: The monitoring of cleaning and disinfection of surfaces by fluorescence targeting is appropriate for evaluating hygiene regulations. An intervention can lead to a significant improvement of cleaning performance. As part of a strategy to improve infection control in hospitals, fluorescence targeting enables a simple inexpensive and effective surveillance of the cleaning performance and corrective measures. © Georg Thieme Verlag KG Stuttgart · New York.

The Norwegian Healthy Life Study: protocol for a pragmatic RCT with longitudinal follow-up on physical activity and diet for adults.

PubMed

Abildsnes, Eirik; Meland, Eivind; Mildestvedt, Thomas; Stea, Tonje H; Berntsen, Sveinung; Samdal, Gro Beate

2017-01-05

The Norwegian Directorate of Health recommends that Healthy Life Centres (HLCs) be established in primary health care to support behaviour change and reduce the risk of non-communicable diseases. The aim of the present study protocol is to present the rationale, design and methods of a combined pragmatic randomized controlled trial (RCT) and longitudinal cohort study of the effects of attending HLCs concerning physical activity, sedentary behaviour and diet and to explore how psychological well-being and motivational factors may mediate short- and long-term effects. The present study will combine a 6-month RCT with a longitudinal cohort study (24 months from baseline) conducted at six HLCs from June 2014 to Sept 2017. Participants are randomized to behavioural change interventions or a 6-month waiting list control group. A randomized trial of interventions in HLCs has the potential to influence the development of policy and practice for behaviour change interventions and patient education programmes in Norway. We discuss some of the important preconditions for obtaining valid results from a complex intervention and outline some of the characteristics of ecological approaches in health care research that can enable a pragmatic intervention study. The study was retrospectively registered on September 19, 2014 and is available online at ClinicalTrials.gov (ID: NCT02247219 ).

Developing a complex intervention to support timely engagement with palliative care for patients with advanced cancer in primary and secondary care in the UK: a study protocol.

PubMed

Hackett, Julia; Bekker, Hilary; Bennett, Michael I; Carder, Paul; Gallagher, Jean; Henry, Claire; Kite, Suzanne; Taylor, Sally; Velikova, Galina; Ziegler, Lucy

2018-05-14

For patients with advanced cancer, timely access to palliative care can improve quality of life and enable patients to participate in decisions about their end-of-life care. However, in a UK population of 2500 patients who died from cancer, one-third did not receive specialist palliative care, and of those who did, the duration of involvement was too short to maximise the benefits. Initiating a conversation about palliative care is challenging for some health professionals and patients often have unmet information needs and misconceptions about palliative care. We will work closely with patients and health professionals to develop a patient decision aid and health professional training module designed to facilitate a timely and informed conversation about palliative care. This study is being conducted over 24 months from November 2017 to October 2019 and follows the UK Medical Research Council framework for developing complex interventions and the International Patient Decision Aids Guideline. The Ottawa Decision Support Framework underpins the study. The Supporting Timely Engagement with Palliative care (STEP) intervention will be developed though an iterative process informed by interviews and focus groups with patients with advanced cancer, oncologists, general practitioners and palliative care doctors. An expert panel will also review each iteration. The expert panel will consist of a patient representative with experience of palliative care, health professionals who are involved in advanced cancer care decision-making, a medical education expert and the National Council for Palliative Care director of transformation. The feasibility and acceptability of the decision aid and doctor training will be tested in oncology and general practice settings. Ethical approval for the study has been granted by the Office for Research Ethics Committees Northern Ireland (ORECNI), approval reference 17/NI/0249. Dissemination and knowledge transfer will be conducted via publications, national bodies and networks, and patient and family groups. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

A hospital-based child protection programme evaluation instrument: a modified Delphi study.

PubMed

Wilson, Denise; Koziol-McLain, Jane; Garrett, Nick; Sharma, Pritika

2010-08-01

Refine instrument for auditing hospital-based child abuse and neglect violence intervention programmes prior to field-testing. A modified Delphi study to identify and rate items and domains indicative of an effective and quality child abuse and neglect intervention programme. Experts participated in four Delphi rounds: two surveys, a one-day workshop and the opportunity to comment on the penultimate instrument. New Zealand. Twenty-four experts in the field of care and protection of children. Items with panel agreement >or=85% and mean importance rating >or=4.0 (scale from 1 (not important) to 5 (very important)). There was high-level consensus on items across Rounds 1 and 2 (89% and 85%, respectively). In Round 3 an additional domain (safety and security) was agreed upon and cultural issues, alert systems for children at risk, and collaboration among primary care, community, non-government and government agencies were discussed. The final instrument included nine domains ('policies and procedures', 'safety and security', 'collaboration', 'cultural environment', 'training of providers', 'intervention services', 'documentation' 'evaluation' and 'physical environment') and 64 items. The refined instrument represents the hallmarks of an ideal child abuse and neglect programme given current knowledge and experience. The instrument enables rigorous evaluations of hospital-based child abuse and neglect intervention programmes for quality improvement and benchmarking with other programmes.

The PULSAR primary care protocol: a stepped-wedge cluster randomized controlled trial to test a training intervention for general practitioners in recovery-oriented practice to optimize personal recovery in adult patients.

PubMed

Enticott, Joanne C; Shawyer, Frances; Brophy, Lisa; Russell, Grant; Fossey, Ellie; Inder, Brett; Mazza, Danielle; Vasi, Shiva; Weller, Penelope June; Wilson-Evered, Elisabeth; Edan, Vrinda; Meadows, Graham

2016-12-20

General practitioners (GPs) in Australia play a central role in the delivery of mental health care. This article describes the PULSAR (Principles Unite Local Services Assisting Recovery) Primary Care protocol, a novel mixed methods evaluation of a training intervention for GPs in recovery-oriented practice. The aim of the intervention is to optimize personal recovery in patients consulting study GPs for mental health issues. The intervention mixed methods design involves a stepped-wedge cluster randomized controlled trial testing the outcomes of training in recovery-oriented practice, together with an embedded qualitative study to identify the contextual enablers and challenges to implementing recovery-oriented practice. The project is conducted in Victoria, Australia between 2013 and 2017. Eighteen general practices and community health centers are randomly allocated to one of two steps (nine months apart) to start an intervention comprising GP training in the delivery of recovery-oriented practice. Data collection consists of cross-sectional surveys collected from patients of participating GPs at baseline, and again at the end of Steps 1 and 2. The primary outcome is improvement in personal recovery using responses to the Questionnaire about the Process of Recovery. Secondary outcomes are improvements in patient-rated measures of personal recovery and wellbeing, and of the recovery-oriented practice they have received, using the INSPIRE questionnaire, the Warwick-Edinburgh Mental Well-being Scale, and the Kessler Psychological Distress Scale. Participant data will be analyzed in the group that the cluster was assigned to at each study time point. Another per-protocol dataset will contain all data time-stamped according to the date of intervention received at each cluster site. Qualitative interviews with GPs and patients at three and nine months post-training will investigate experiences and challenges related to implementing recovery-oriented practice in primary care. Recovery-oriented practice is gaining increasing prominence in mental health service delivery and the outcomes of such an approach within the primary care sector for the first time will be evaluated in this project. If findings are positive, the intervention has the potential to extend recovery-oriented practice to GPs throughout the community. Australian and New Zealand Clinical Trial Registry ( ACTRN12614001312639 ). Registered: 8 August 2014.

Implementation of shared decision-making in oncology: development and pilot study of a nurse-led decision-coaching programme for women with ductal carcinoma in situ.

PubMed

Berger-Höger, Birte; Liethmann, Katrin; Mühlhauser, Ingrid; Steckelberg, Anke

2017-12-06

To implement informed shared decision-making (ISDM) in breast care centres, we developed and piloted an inter-professional complex intervention. We developed an intervention consisting of three components: an evidence-based patient decision aid (DA) for women with ductal carcinoma in situ, a decision-coaching led by specialised nurses (breast care nurses and oncology nurses) and structured physician encounters. In order to enable professionals to gain ISDM competencies, we developed and tested a curriculum-based training programme for specialised nurses and a workshop for physicians. After successful testing of the components, we conducted a pilot study to test the feasibility of the entire revised intervention in two breast care centres. Here the acceptance of the intervention by women and professionals, the applicability to the breast care centres' procedures, women's knowledge, patient involvement in treatment decision-making assessed with the MAPPIN'SDM-observer instrument MAPPIN'O dyad, and barriers to and facilitators of the implementation were taken into consideration. We used questionnaires, structured verbal and written feedback and video recordings. Qualitative data were analysed descriptively, and mean values and ranges of quantitative data were calculated. To test the DA, focus groups and individual interviews were conducted with 27 women. Six expert reviews were obtained. The components of the nurse training were tested with 18 specialised nurses and 19 health science students. The development and piloting of the components were successful. The pilot test of the entire intervention included seven patients. In general, the intervention is applicable. Patients attained adequate knowledge (range of correct answers: 9-11 of 11). On average, a basic level of patient involvement in treatment decision-making was observed for nurses and patient-nurse dyads (M(MAPPIN-O dyad ): 2.15 and M(MAPPIN-O nurse ): 1.90). Relevant barriers were identified; physicians barely tolerated women's preferences that were not in line with the medical recommendation. Classifying women as inappropriate for ISDM due to age or education led physicians to neglect eligible women during the recruitment phase. Decision-coaching is feasible. Nevertheless, there are some indications that structural changes are needed for long-term implementation. We are currently evaluating the intervention in a cluster randomised controlled trial in 16 breast care centres.

Development of an optimised 1:1 physiotherapy intervention post first-time lumbar discectomy: a mixed-methods study.

PubMed

Rushton, A; White, L; Heap, A; Calvert, M; Heneghan, N; Goodwin, P

2016-02-25

To develop an optimised 1:1 physiotherapy intervention that reflects best practice, with flexibility to tailor management to individual patients, thereby ensuring patient-centred practice. Mixed-methods combining evidence synthesis, expert review and focus groups. Secondary care involving 5 UK specialist spinal centres. A purposive panel of clinical experts from the 5 spinal centres, comprising spinal surgeons, inpatient and outpatient physiotherapists, provided expert review of the draft intervention. Purposive samples of patients (n=10) and physiotherapists (n=10) (inpatient/outpatient physiotherapists managing patients with lumbar discectomy) were invited to participate in the focus groups at 1 spinal centre. A draft intervention developed from 2 systematic reviews; a survey of current practice and research related to stratified care was circulated to the panel of clinical experts. Lead physiotherapists collaborated with physiotherapy and surgeon colleagues to provide feedback that informed the intervention presented at 2 focus groups investigating acceptability to patients and physiotherapists. The focus groups were facilitated by an experienced facilitator, recorded in written and tape-recorded forms by an observer. Tape recordings were transcribed verbatim. Data analysis, conducted by 2 independent researchers, employed an iterative and constant comparative process of (1) initial descriptive coding to identify categories and subsequent themes, and (2) deeper, interpretive coding and thematic analysis enabling concepts to emerge and overarching pattern codes to be identified. The intervention reflected best available evidence and provided flexibility to ensure patient-centred care. The intervention comprised up to 8 sessions of 1:1 physiotherapy over 8 weeks, starting 4 weeks postsurgery. The intervention was acceptable to patients and physiotherapists. A rigorous process informed an optimised 1:1 physiotherapy intervention post-lumbar discectomy that reflects best practice. The developed intervention was agreed on by the 5 spinal centres for implementation in a randomised controlled trial to evaluate its effectiveness. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Evidence-based practice in physiotherapy: a systematic review of barriers, enablers and interventions.

PubMed

Scurlock-Evans, Laura; Upton, Penney; Upton, Dominic

2014-09-01

Despite clear benefits of the Evidence-Based Practice (EBP) approach to ensuring quality and consistency of care, its uptake within physiotherapy has been inconsistent. Synthesise the findings of research into EBP barriers, facilitators and interventions in physiotherapy and identify methods of enhancing adoption and implementation. Literature concerning physiotherapists' practice between 2000 and 2012 was systematically searched using: Academic Search Complete, Cumulative Index of Nursing and Allied Health Literature Plus, American Psychological Association databases, Medline, Journal Storage, and Science Direct. Reference lists were searched to identify additional studies. Thirty-two studies, focusing either on physiotherapists' EBP knowledge, attitudes or implementation, or EBP interventions in physiotherapy were included. One author undertook all data extraction and a second author reviewed to ensure consistency and rigour. Synthesis was organised around the themes of EBP barriers/enablers, attitudes, knowledge/skills, use and interventions. Many physiotherapists hold positive attitudes towards EBP. However, this does not necessarily translate into consistent, high-quality EBP. Many barriers to EBP implementation are apparent, including: lack of time and skills, and misperceptions of EBP. Only studies published in the English language, in peer-reviewed journals were included, thereby introducing possible publication bias. Furthermore, narrative synthesis may be subject to greater confirmation bias. There is no "one-size fits all" approach to enhancing EBP implementation; assessing organisational culture prior to designing interventions is crucial. Although some interventions appear promising, further research is required to explore the most effective methods of supporting physiotherapists' adoption of EBP. Copyright © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Redesigning inpatient care: Testing the effectiveness of an accountable care team model.

PubMed

Kara, Areeba; Johnson, Cynthia S; Nicley, Amy; Niemeier, Michael R; Hui, Siu L

2015-12-01

US healthcare underperforms on quality and safety metrics. Inpatient care constitutes an immense opportunity to intervene to improve care. Describe a model of inpatient care and measure its impact. A quantitative assessment of the implementation of a new model of care. The graded implementation of the model allowed us to follow outcomes and measure their association with the dose of the implementation. Inpatient medical and surgical units in a large academic health center. Eight interventions rooted in improving interprofessional collaboration (IPC), enabling data-driven decisions, and providing leadership were implemented. Outcome data from August 2012 to December 2013 were analyzed using generalized linear mixed models for associations with the implementation of the model. Length of stay (LOS) index, case-mix index-adjusted variable direct costs (CMI-adjusted VDC), 30-day readmission rates, overall patient satisfaction scores, and provider satisfaction with the model were measured. The implementation of the model was associated with decreases in LOS index (P < 0.0001) and CMI-adjusted VDC (P = 0.0006). We did not detect improvements in readmission rates or patient satisfaction scores. Most providers (95.8%, n = 92) agreed that the model had improved the quality and safety of the care delivered. Creating an environment and framework in which IPC is fostered, performance data are transparently available, and leadership is provided may improve value on both medical and surgical units. These interventions appear to be well accepted by front-line staff. Readmission rates and patient satisfaction remain challenging. © 2015 Society of Hospital Medicine.

Pre-Visit Prioritization for Complex Patients with Diabetes: Randomized Trial Design and Implementation within an Integrated Health Care System

PubMed Central

Grant, Richard W; Uratsu, Connie S; Hansen, Karen R; Altschuler, Andrea; Kim, Eileen; Fireman, Bruce; Adams, Alyce S; Schmittdiel, Julie A; Heisler, Michele

2016-01-01

Background/Aims Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care. Methods We designed a controlled, cluster-randomized, multi-site intervention (Pre-Visit Prioritization for Complex Patients with Diabetes) that enables patients with poorly controlled type 2 diabetes to identify their top priorities prior to a scheduled visit and sends these priorities to the primary care physician progress note in the electronic medical record. In this paper, we describe strategies to address challenges to implementing our health IT-based intervention study within a large health care system. Results This study is being conducted in 30 primary care practices within a large integrated care delivery system in Northern California. Over a 12-week period (3/1/2015 – 6/6/2015), 146 primary care physicians consented to enroll in the study (90.1%) and approved contact with 2496 of their patients (97.6%). Implementation challenges included: (1) Navigating research vs. quality improvement requirements; (2) Addressing informed consent considerations; and (3) Introducing a new clinical tool into a highly time-constrained workflow. Strategies for successfully initiating this study included engagement with institutional leaders, Institutional Review Board members, and clinical stakeholders at multiple stages both before and after notice of Federal funding; flexibility by the research team in study design; and strong support from institutional leadership for “self-learning health system” research. Conclusions By paying careful attention to identifying and collaborating with a wide range of key clinical stakeholders, we have shown that researchers embedded within a learning care system can successfully apply rigorous clinical trial methods to test new care innovations. PMID:26820612

Pre-Visit Prioritization for complex patients with diabetes: Randomized trial design and implementation within an integrated health care system.

PubMed

Grant, Richard W; Uratsu, Connie S; Estacio, Karen R; Altschuler, Andrea; Kim, Eileen; Fireman, Bruce; Adams, Alyce S; Schmittdiel, Julie A; Heisler, Michele

2016-03-01

Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care. We designed a controlled, cluster-randomized, multi-site intervention (Pre-Visit Prioritization for Complex Patients with Diabetes) that enables patients with poorly controlled type 2 diabetes to identify their top priorities prior to a scheduled visit and sends these priorities to the primary care physician progress note in the electronic medical record. In this paper, we describe strategies to address challenges to implementing our health IT-based intervention study within a large health care system. This study is being conducted in 30 primary care practices within a large integrated care delivery system in Northern California. Over a 12-week period (3/1/2015-6/6/2015), 146 primary care physicians consented to enroll in the study (90.1%) and approved contact with 2496 of their patients (97.6%). Implementation challenges included: (1) navigating research vs. quality improvement requirements; (2) addressing informed consent considerations; and (3) introducing a new clinical tool into a highly time-constrained workflow. Strategies for successfully initiating this study included engagement with institutional leaders, Institutional Review Board members, and clinical stakeholders at multiple stages both before and after notice of Federal funding; flexibility by the research team in study design; and strong support from institutional leadership for "self-learning health system" research. By paying careful attention to identifying and collaborating with a wide range of key clinical stakeholders, we have shown that researchers embedded within a learning care system can successfully apply rigorous clinical trial methods to test new care innovations. Copyright © 2016 Elsevier Inc. All rights reserved.

OA38 From service delivery to community enablement: a public health approach to palliative care.

PubMed

McLoughlin, Kathleen; Rhatigan, Jim; Richardson, Marie; Lloyd, Rebecca

2015-04-01

: Milford Care Centre is the only hospice in Ireland to make a strategic decision to embrace a public health approach to palliative care, through the development, implementation and evaluation of the Compassionate Communities Project. This presentation seeks to examine why Milford made the decision to move toward a community enablement model, describes the development and implementation of the Compassionate Communities Project to date, presents key findings from recent evaluations and highlights our plans for the future. The presentation uses a reflective, story telling approach to meet it's aims, coupled with data and statistics gathered from the evaluations, and includes a new short film 'Tell Me' developed by recent Computer Science graduates for the Project to use to engage with communities during Café Conversations. The presentation will highlight the relevance of Health Promoting Palliative Care theory to the development of a three-tier model of programme activity, examine the challenges in implementing such an approach and will discuss the impact of upstream intervention to downstream service provision using case studies. © 2015, 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.

Obstructive sleep apnoea in adults: a common chronic condition in need of a comprehensive chronic condition management approach.

PubMed

Heatley, Emer M; Harris, Melanie; Battersby, Malcolm; McEvoy, R Doug; Chai-Coetzer, Ching Li; Antic, Nicholas A

2013-10-01

Obstructive sleep apnoea (OSA) is a common disorder that has all the characteristics of a chronic condition. As with other chronic conditions, OSA requires ongoing management of treatments and problems, such as residual symptoms, deficits and co-morbidities. Also, many OSA patients have modifiable lifestyle factors that contribute to their disease, which could be improved with intervention. As health systems are in the process of developing more comprehensive chronic care structures and supports, tools such as chronic condition management programs are available to enable OSA patients and their health care providers to further engage and collaborate in health management. This review explains why the OSA patient group requires a more comprehensive approach to disease management, describes the chronic care model as a platform for management of chronic conditions, and assesses the suitability of particular chronic disease management programs in relation to the needs of the OSA population. Implementation of an evidence-based health-professional-led chronic condition management program into OSA patient care is likely to provide a context in which health risks are properly acknowledged and addressed. Such programs present an important opportunity to enable more optimal health outcomes than is possible by device-focused management alone. Copyright © 2012 Elsevier Ltd. All rights reserved.

A rehabilitation model as key to comprehensive care in the era of HIV as a chronic disease in South Africa.

PubMed

Chetty, Verusia; Hanass-Hancock, Jill

2016-01-01

In the era of widespread access to antiretroviral therapy, people living with HIV survive; however, this comes with new experiences of comorbidities and HIV-related disability posing new challenges to rehabilitation professionals and an already fragile health system in Southern Africa. Public health approaches to HIV need to include not only prevention, treatment and support but also rehabilitation. While some well-resourced countries have developed rehabilitation approaches for HIV, resource-poor settings of Southern Africa lack a model of care that includes rehabilitation approaches providing accessible and comprehensive care for people living with HIV. In this study, a learning in action approach was used to conceptualize a comprehensive model of care that addresses HIV-related disability and a feasible rehabilitation framework for resource-poor settings. The study used qualitative methods in the form of a focus group discussion with thirty participants including people living with HIV, the multidisciplinary healthcare team and community outreach partners at a semi-rural health facility in South Africa. The discussion focused on barriers and enablers of access to rehabilitation. Participants identified barriers at various levels, including transport, physical access, financial constraints and poor multi-stakeholder team interaction. The results of the group discussions informed the design of an inclusive model of HIV care. This model was further informed by established integrated rehabilitation models. Participants emphasized that objectives need to respond to policy, improve access to patient-centered care and maintain a multidisciplinary team approach. They proposed that guiding principles should include efficient communication, collaboration of all stakeholders and leadership in teams to enable staff to implement the model. Training of professional staff and lay personnel within task-shifting approaches was seen as an essential enabler to implementation. The health facility as well as outreach services such as intermediate clinics, home-based care, outreach and community-based rehabilitation was identified as important structures for potential rehabilitation interventions.

Health professionals' views on health literacy issues for culturally and linguistically diverse women in maternity care: barriers, enablers and the need for an integrated approach.

PubMed

Hughson, Jo-Anne; Marshall, Fiona; Daly, Justin Oliver; Woodward-Kron, Robyn; Hajek, John; Story, David

2018-02-01

Objective To identify health literacy issues when providing maternity care to culturally and linguistically diverse (CALD) women, and the strategies needed for health professionals to collaboratively address these issues. Methods A qualitative case study design was undertaken at one large metropolitan Australian hospital serving a highly CALD population. Semistructured interviews were conducted with a range of maternity healthcare staff. The data were analysed thematically. The study is informed by a framework of cultural competence education interventions for health professionals and a health literacy framework. Results Eighteen clinicians participated in the interviews (seven midwives, five obstetricians, five physiotherapists, one social worker, and one occupational therapist). Emergent themes of health literacy-related issues were: patient-based factors (communication and cultural barriers, access issues); provider-based factors (time constraints, interpreter issues); and enablers (cultural awareness among staff, technology). Conclusions There are significant health literacy and systemic issues affecting the hospital's provision of maternity care for CALD women. These findings, mapped onto the four domains of cultural competence education interventions will inform a technology-delivered health literacy intervention for CALD maternity patients. This approach may be applied to other culturally diverse healthcare settings to foster patient health literacy. What is known about the topic? There are health inequities for pregnant women of culturally and linguistically diverse (CALD) backgrounds. Low health literacy compounded by language and cultural factors contribute to these inequities and access to interpreters in pregnancy care remains an ongoing issue. Pregnancy smart phone applications are a popular source of health information for pregnant women yet these apps are not tailored for CALD women nor are they part of a regulated industry. What does this paper add? This paper provides clinician and language service staff perspectives on key health literacy issues that are both patient-based and provider-based. This research confirms that the complex interplay of social and practical factors contributes to and perpetuates low health literacy, creating barriers to health access; it also highlights several enablers for increasing CALD health literacy and access. These include greater health practitioner awareness and accommodation of CALD women's needs and the provision of culturally and linguistically appropriate eHealth resources. What are the implications for practitioners? eHealth resources are emerging as valuable enabling tools to address the health literacy and information needs of pregnant women. However, these resources need to be used adjunctively with health practitioner communication. Both resource developers and health practitioners need to understand issues affecting CALD patients and their needs. Developers need to consider how the resource addresses these needs. Training of health professionals about culture-specific issues may help to enhance communication with, and therefore health literacy among, individual cultural groups. Further, formalised language and interpreting training of bi- or multilingual health professionals is advised to ensure that they are able to interpret to a professional standard when called on to do so.

A Study of the Association Between Multidisciplinary Home Care and Home Death Among Thai Palliative Care Patients.

PubMed

Nagaviroj, Kittiphon; Anothaisintawee, Thunyarat

2017-06-01

Many terminally ill patients would prefer to stay and die in their own homes, but unfortunately, some may not be able to do so. Although there are many factors associated with successful home deaths, receiving palliative home visits from the multidisciplinary care teams is one of the key factors that enable patients to die at home. Our study was aimed to find whether there was any association between our palliative home care program and home death. A retrospective study was conducted in the Department of Family Medicine at Ramathibodi Hospital between January 2012 and May 2014. All of the patients who were referred to multidisciplinary palliative care teams were included. The data set comprised of patient's profile, disease status, functional status, patient's symptoms, preferred place of death, frequency of home visits, types of team interventions, and patient's actual place of death. Multiple logistic regression was applied in order to determine the association between the variables and the probability of dying at home. A total of 142 patients were included into the study. At the end of the study, 50 (35.2%) patients died at home and 92 (64.8%) patients died in the hospital. The multivariate logistic regression analysis demonstrated a strong association between multidisciplinary home care and home death (odds ratio 6.57, 95% confidence interval [CI] 2.48-17.38). Palliative home care was a significant factor enabling patients who want to die at home. We encourage health policy makers to promote the development of community-based palliative care programs in Thailand.

Directions for the International Society for Research on Internet Interventions (ISRII).

PubMed

Ritterband, Lee M; Andersson, Gerhard; Christensen, Helen M; Carlbring, Per; Cuijpers, Pim

2006-09-29

In 2004, the International Society for Research on Internet Interventions (ISRII) was formed to encourage eHealth researchers to collaborate in their efforts to further the science behind developing, testing, and disseminating Web-based treatment programs. The group held its second meeting (April 2006) to clarify the Society's direction and identify key issues that need addressing in the field. These issues are identified and examined in the current paper. Given the success of using the Internet to treat a range of medical and mental health problems, and the growing need for better dissemination of health care, Internet interventions will almost certainly play a prominent role in global health. ISRII plans to provide the necessary venue to ensure the science driving this field is strong, enabling researchers to conduct the highest quality research and permitting meaningful conclusions from completed studies.

A business case evaluation of workplace engineering noise control: a net-cost model.

PubMed

Lahiri, Supriya; Low, Colleen; Barry, Michael

2011-03-01

This article provides a convenient tool for companies to determine the costs and benefits of alternative interventions to prevent noise-induced hearing loss (NIHL). Contextualized for Singapore and in collaboration with Singapore's Ministry of Manpower, the Net-Cost model evaluates costs of intervention for equipment and labor, avoided costs of productivity losses and medical care, and productivity gains from the employer's economic perspective. To pilot this approach, four case studies are presented, with varying degrees of economic benefits to the employer, including one in which multifactor productivity is the main driver. Although compliance agencies may not require economic analysis of NIHL, given scarce resources in a market-driven economy, this tool enables stakeholders to understand and compare the costs and benefits of NIHL interventions comprehensively and helps in determining risk management strategies.

Gender-informed, psychoeducational programme for couples to prevent postnatal common mental disorders among primiparous women: cluster randomised controlled trial.

PubMed

Fisher, Jane; Rowe, Heather; Wynter, Karen; Tran, Thach; Lorgelly, Paula; Amir, Lisa H; Proimos, Jenny; Ranasinha, Sanjeeva; Hiscock, Harriet; Bayer, Jordana; Cann, Warren

2016-03-07

Interventions to prevent postpartum common mental disorders (PCMD) among unselected populations of women have had limited success. The aim was to determine whether What Were We Thinking (WWWT) a gender-informed, psychoeducational programme for couples and babies can prevent PCMD among primiparous women 6 months postpartum. Cluster-randomised controlled trial. 48 Maternal and Child Health Centres (MCHCs) from 6 Local Government Areas in Melbourne, Australia were allocated randomly to usual care (24) or usual care plus WWWT (24). English-speaking primiparous women receiving primary care at trial MCHCs were recruited to the intervention (204) and control (196) conditions. Of these, 187 (91.7%) and 177 (90.3%) provided complete data. WWWT is a manualised programme comprising primary care from a trained nurse, print materials and a face-to-face seminar. Data sources were standardised and study-specific measures collected in blinded computer-assisted telephone interviews at 6 and 26 weeks postpartum. The primary outcome was PCMD assessed by Composite International Diagnostic Interviews and Patient Health Questionnaire (PHQ) Depression and Generalised Anxiety Disorder modules. In intention-to-treat analyses the adjusted OR (AOR) of PCMD in the intervention compared to the usual care group was 0.78 (95% CI 0.38 to 1.63, ns), but mild to moderate anxiety symptoms (AOR 0.58, 95% CI 0.35 to 0.97) and poor self-rated health (AOR 0.46, 95% CI 0.22 to 0.97) were significantly lower. In a per protocol analysis, comparing the full (three component) intervention and usual care groups, the AOR of PCMD was 0.36, (95% CI 0.14 to 0.95). The WWWT seminar was appraised as salient, comprehensible and useful by >85% participants. No harms were detected. WWWT is readily integrated into primary care, enables inclusion of fathers and addresses modifiable risks for PCMD directly. The full intervention appears a promising programme for preventing PCMD, optimising family functioning, and as the first component of a stepped approach to mental healthcare. ACTRN12613000506796; Results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Using internet enabled mobile devices and social networking technologies to promote exercise as an intervention for young first episode psychosis patients.

PubMed

Killackey, Eoin; Anda, Anna Lee; Gibbs, Martin; Alvarez-Jimenez, Mario; Thompson, Andrew; Sun, Pamela; Baksheev, Gennady N

2011-05-12

Young people with first episode psychosis are at an increased risk for a range of poor health outcomes. In contrast to the growing body of evidence that suggests that exercise therapy may benefit the physical and mental health of people diagnosed with schizophrenia, there are no studies to date that have sought to extend the use of exercise therapy among patients with first episode psychosis. The aim of the study is to test the feasibility and acceptability of an exercise program that will be delivered via internet enabled mobile devices and social networking technologies among young people with first episode psychosis. This study is a qualitative pilot study being conducted at Orygen Youth Health Research Centre in Melbourne, Australia. Participants are young people aged 15-24 who are receiving clinical care at a specialist first episode psychosis treatment centre. Participants will also comprise young people from the general population. The exercise intervention is a 9-week running program, designed to gradually build a person's level of fitness to be able to run 5 kilometres (3 miles) towards the end of the program. The program will be delivered via an internet enabled mobile device. Participants will be asked to post messages about their running experiences on the social networking website, and will also be asked to attend three face-to-face interviews. This paper describes the development of a qualitative study to pilot a running program coupled with the use of internet enabled mobile devices among young people with first episode psychosis. If the program is found to be feasible and acceptable to patients, it is hoped that further rigorous evaluations will ultimately lead to the introduction of exercise therapy as part of an evidence-based, multidisciplinary approach in routine clinical care.

A Systematic Review of Health System Barriers and Enablers for Antiretroviral Therapy (ART) for HIV-Infected Pregnant and Postpartum Women

PubMed Central

Colvin, Christopher J.; Konopka, Sarah; Chalker, John C.; Jonas, Edna; Albertini, Jennifer; Amzel, Anouk; Fogg, Karen

2014-01-01

Background Despite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, particularly in much of Africa. Lifelong antiretroviral therapy (ART) appears to be the most effective way to prevent these deaths, but the rates of three key outcomes—ART initiation, retention in care, and long-term ART adherence—remain low. This systematic review synthesized evidence on health systems factors affecting these outcomes in pregnant and postpartum women living with HIV. Methods Searches were conducted for studies addressing the population of interest (HIV-infected pregnant and postpartum women), the intervention of interest (ART), and the outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. A four-stage narrative synthesis design was used to analyze findings. Review findings from 42 included studies were categorized according to five themes: 1) models of care, 2) service delivery, 3) resource constraints and governance challenges, 4) patient-health system engagement, and 5) maternal ART interventions. Results Low prioritization of maternal ART and persistent dropout along the maternal ART cascade were key findings. Service delivery barriers included poor communication and coordination among health system actors, poor clinical practices, and gaps in provider training. The few studies that assessed maternal ART interventions demonstrated the importance of multi-pronged, multi-leveled interventions. Conclusions There has been a lack of emphasis on the experiences, needs and vulnerabilities particular to HIV-infected pregnant and postpartum women. Supporting these women to successfully traverse the maternal ART cascade requires carefully designed and targeted interventions throughout the steps. Careful design of integrated service delivery models is of critical importance in this effort. Key knowledge gaps and research priorities were also identified, including definitions and indicators of adherence rates, and the importance of cumulative measures of dropout along the maternal ART cascade. PMID:25303241

Developing a response to family violence in primary health care: the New Zealand experience.

PubMed

Gear, Claire; Koziol-McLain, Jane; Wilson, Denise; Clark, Faye

2016-08-20

Despite primary health care being recognised as an ideal setting to effectively respond to those experiencing family violence, responses are not widely integrated as part of routine health care. A lack of evidence testing models and approaches for health sector integration, alongside challenges of transferability and sustainability, means the best approach in responding to family violence is still unknown. The Primary Health Care Family Violence Responsiveness Evaluation Tool was developed as a guide to implement a formal systems-led response to family violence within New Zealand primary health care settings. Given the difficulties integrating effective, sustainable responses to family violence, we share the experience of primary health care sites that embarked on developing a response to family violence, presenting the enablers, barriers and resources required to maintain, progress and sustain family violence response development. In this qualitative descriptive study data were collected from two sources. Firstly semi-structured focus group interviews were conducted during 24-month follow-up evaluation visits of primary health care sites to capture the enablers, barriers and resources required to maintain, progress and sustain a response to family violence. Secondly the outcomes of a group activity to identify response development barriers and implementation strategies were recorded during a network meeting of primary health care professionals interested in family violence prevention and intervention; findings were triangulated across the two data sources. Four sites, representing three PHOs and four general practices participated in the focus group interviews; 35 delegates from across New Zealand attended the network meeting representing a wider perspective on family violence response development within primary health care. Enablers and barriers to developing a family violence response were identified across four themes: 'Getting started', 'Building effective relationships', 'Sourcing funding' and 'Shaping a national approach to family violence'. The strong commitment of key people dedicated to addressing family violence is essential for response sustainability and would be strengthened by prioritising family violence response as a national health target with dedicated resourcing. Further analysis of the health care system as a complex adaptive system may provide insight into effective approaches to response development and health system integration.

Evaluating a complex system-wide intervention using the difference in differences method: the Delivering Choice Programme

PubMed Central

Round, Jeff; Drake, Robyn; Kendall, Edward; Addicott, Rachael; Agelopoulos, Nicky; Jones, Louise

2015-01-01

Objectives We report the use of difference in differences (DiD) methodology to evaluate a complex, system-wide healthcare intervention. We use the worked example of evaluating the Marie Curie Delivering Choice Programme (DCP) for advanced illness in a large urban healthcare economy. Methods DiD was selected because a randomised controlled trial was not feasible. The method allows for before and after comparison of changes that occur in an intervention site with a matched control site. This enables analysts to control for the effect of the intervention in the absence of a local control. Any policy, seasonal or other confounding effects over the test period are assumed to have occurred in a balanced way at both sites. Data were obtained from primary care trusts. Outcomes were place of death, inpatient admissions, length of stay and costs. Results Small changes were identified between pre- and post-DCP outputs in the intervention site. The proportion of home deaths and median cost increased slightly, while the number of admissions per patient and the average length of stay per admission decreased slightly. None of these changes was statistically significant. Conclusions Effects estimates were limited by small numbers accessing new services and selection bias in sample population and comparator site. In evaluating the effect of a complex healthcare intervention, the choice of analysis method and output measures is crucial. Alternatives to randomised controlled trials may be required for evaluating large scale complex interventions and the DiD approach is suitable, subject to careful selection of measured outputs and control population. PMID:24644163

Rationale and design of the Study of a Tele-pharmacy Intervention for Chronic diseases to Improve Treatment adherence (STIC2IT): A cluster-randomized pragmatic trial.

PubMed

Choudhry, Niteesh K; Isaac, Thomas; Lauffenburger, Julie C; Gopalakrishnan, Chandrasekar; Khan, Nazleen F; Lee, Marianne; Vachon, Amy; Iliadis, Tanya L; Hollands, Whitney; Doheny, Scott; Elman, Sandra; Kraft, Jacqueline M; Naseem, Samrah; Gagne, Joshua J; Jackevicius, Cynthia A; Fischer, Michael A; Solomon, Daniel H; Sequist, Thomas D

2016-10-01

Approximately half of patients with chronic cardiometabolic conditions are nonadherent with their prescribed medications. Interventions to improve adherence have been only modestly effective because they often address single barriers to adherence, intervene at single points in time, or are imprecisely targeted to patients who may not need adherence assistance. To evaluate the effect of a multicomponent, behaviorally tailored pharmacist-based intervention to improve adherence to medications for diabetes, hypertension, and hyperlipidemia. The STIC2IT trial is a cluster-randomized pragmatic trial testing the impact of a pharmacist-led multicomponent intervention that uses behavioral interviewing, text messaging, mailed progress reports, and video visits. Targeted patients are those who are nonadherent to glucose-lowering, antihypertensive, or statin medications and who also have evidence of poor disease control. The intervention is tailored to patients' individual health barriers and their level of health activation. We cluster-randomized 14 practice sites of a large multispecialty group practice to receive either the pharmacist-based intervention or usual care. STIC2IT has enrolled 4,076 patients who will be followed up for 12months after randomization. The trial's primary outcome is medication adherence, assessed using pharmacy claims data. Secondary outcomes are disease control and health care resource utilization. This trial will determine whether a technologically enabled, behaviorally targeted pharmacist-based intervention results in improved adherence and disease control. If effective, this strategy could be a scalable method of offering tailored adherence support to those with the greatest clinical need. Copyright © 2016 Elsevier Inc. All rights reserved.

Beyond quality improvement: exploring why primary care teams engage in a voluntary audit and feedback program.

PubMed

Wagner, Daniel J; Durbin, Janet; Barnsley, Jan; Ivers, Noah M

2017-12-02

Despite its popularity, the effectiveness of audit and feedback in support quality improvement efforts is mixed. While audit and feedback-related research efforts have investigated issues relating to feedback design and delivery, little attention has been directed towards factors which motivate interest and engagement with feedback interventions. This study explored the motivating factors that drove primary care teams to participate in a voluntary audit and feedback initiative. Interviews were conducted with leaders of primary care teams who had participated in at least one iteration of the audit and feedback program. This intervention was developed by an organization which advocates for high-quality, team-based primary care in Ontario, Canada. Interview transcripts were coded using the Consolidated Framework for Implementation Research and the resulting framework was analyzed inductively to generate key themes. Interviews were completed with 25 individuals from 18 primary care teams across Ontario. The majority were Executive Directors (14), Physician leaders (3) and support staff for Quality Improvement (4). A range of motivations for participating in the audit and feedback program beyond quality improvement were emphasized. Primarily, informants believed that the program would eventually become a best-in-class audit and feedback initiative. This reflected concerns regarding existing initiatives in terms of the intervention components and intentions as well as the perception that an initiative by primary care, for primary care would better reflect their own goals and better support desired patient outcomes. Key enablers included perceived obligations to engage and provision of support for the work involved. No teams cited an evidence base for A&F as a motivating factor for participation. A range of motivating factors, beyond quality improvement, contributed to participation in the audit and feedback program. Findings from this study highlight that efforts to understand how and when the intervention works best cannot be limited to factors within developers' control. Clinical teams may more readily engage with initiatives with the potential to address their own long-term system goals. Aligning motivations for participation with the goals of the audit and feedback initiative may facilitate both engagement and impact.

Clarifying self-harm through evolutionary concept analysis.

PubMed

Tofthagen, Randi; Fagerstrøm, Lisbeth

2010-09-01

Clarification of the concept self-harm is needed in order to enable research and theory development and facilitate the development and evaluation of medical interventions and nursing care for individuals who self-harm. This study presents such a conceptual analysis. Articles from 1997 to 2007 were sought from the Medline, PubMed, Cinahl, and PsychINFO search engines by entering the search words 'self-harm', 'self-harming', and 'psychiatric care'. 25 medicine and 23 nursing science articles were chosen for inclusion and analysed. Rodgers' evolutionary concept analysis process was used to delineate and clarify the concept's context, surrogate terms, antecedents, attributes, and consequences, as well as to determine implications for further research. Attributes of self-harm may include repetitive injury of mouth or exterior body, that is to say the infliction of physical pain to alleviate mental pain, and time spent self-harming. Antecedents may be gender, mental pain, substance abuse and relational problems. Consequences often include the need for medication and help with altering coping behaviour. Some self-harm patients met with negative attitudes from nurses. Individualized care and treatment is recommended. Accordingly, inter-professional collaboration and postgraduate education is needed in order to provide better care and treatment for self-harm patients. Furthermore, better understanding is needed to help enable health care personnel understand why individuals self-harm. The conceptual analysis presented in this study may be helpful as regards theory development within this still rather unexplored field. © 2010 The Authors. Journal compilation © 2010 Nordic College of Caring Science.

Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study.

PubMed

Saronga, Happiness Pius; Duysburgh, Els; Massawe, Siriel; Dalaba, Maxwell Ayindenaba; Wangwe, Peter; Sukums, Felix; Leshabari, Melkizedeck; Blank, Antje; Sauerborn, Rainer; Loukanova, Svetla

2017-08-07

QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009.

From concept to application: the impact of a community-wide intervention to improve the delivery of preventive services to children.

PubMed

Margolis, P A; Stevens, R; Bordley, W C; Stuart, J; Harlan, C; Keyes-Elstein, L; Wisseh, S

2001-09-01

To improve health outcomes of children, the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practices and more coordination between practices and community-based agencies. However, applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them. To improve the way that preventive health care services are organized and delivered in 1 community, we designed, implemented, and assessed the impact of a health care system-level approach, which involved addressing multiple care delivery processes, at multiple levels in the community, the practice, and the family. Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community, with particular attention to health outcomes for low-income mothers and infants. Observational intervention study in 1 North Carolina county (population 182 000) involving low- income pregnant mothers and their infants, primary care practices, and departments of health and mental health. An interrupted time-series design was used to assess rates of preventive services in office practices before and after the intervention, and a historical cohort design was used to compare maternal and child health outcomes for women enrolled in an intensive home visiting program with women who sought prenatal care during the 9 months before the program's initiation. Outcomes were assessed when the infants reached 12 months of age. Our primary objective was to achieve changes in the process of care delivery at the level of the clinical interaction between care providers and patients that would lead to improved health and developmental outcomes for families. We selected interventions that were directed toward major risk factors (eg, poverty, ineffective care systems for preventive care in office practices) and for which there was existing evidence of efficacy. The interventions involved community-, practice-, and family-level strategies to improve processes of care delivery to families and children. The objectives of the community-level intervention were: 1) to achieve policy level changes that would result in changes in resources available at the level of clinical care, 2) to engage multiple practice organizations in the intervention to achieve an effect on most, if not all, families in the community, and 3) to enhance communication between, among, and within public and private practice organizations to improve coordination and avoid duplication of services. The objective of the practice-level interventions was to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered. To assist the health department in implementing the family-level intervention, we provided assistance in hiring and training staff and ongoing consultation on staff supervision, including the use of structured protocols for care delivery, and regular feedback data about implementation of the program. Interventions with primary care practices focused on the design of the delivery system within the office and the use of teamwork and data in an "office systems" approach to improving clinical preventive care. All practices (N = 8) that enrolled at least 5 infants/month received help in assessing performance and developing systems (eg, preventive services flow sheets) for preventive services delivery. Family-level interventions addressed the process of care delivery to high-risk pregnant women (<100% poverty) and their infants. Mothers were recruited for the home visiting intervention when they first sought prenatal care at the community health center, the county's largest provider of prenatal care to underserved women. The home visiting intervention involved teams of nurses and educators and involved 2 to 4 visits per month through the infant's first year of life to provide parental education on fetal and infant health and development, enhance parents' informal support systems, and link parents with needed health and human services. We included training in injury prevention and discipline, and home visitors assisted mothers in obtaining care from one of the primary care offices. There were high levels of participation, changes in the organization of the delivery system, and improvements in preventive health outcomes. Agencies cooperated in joint contracting, staff training, and defining program eligibility. All 8 eligible practices agreed to participate and 7/8 implemented at least 1 new office system element. Of eligible women, 89% agreed to participate, and outcome data were available on 80% (180/225). After adjusting for differences in baseline characteristics, intervention group women were significantly more likely than comparison group women to use contraceptives (69% vs 47%), not smoke tobacco (27% vs 54%) and have a safe and stimulating home environment for their children. Intervention group children were more likely to have had an appropriate number of well-child care visits (57% vs 37%) and less likely to be injured (2% vs 7%). Intervention mothers also received Aid to Families with Dependent Children for fewer months after the birth of their child (7.7 months vs 11.3 months). We observed a number of positive effects at all 3 levels of intervention. Policy-level changes at the state and community led to lasting changes in the organization and financing of care, which enabled changes in clinical services to take place. These changes have now been expanded beyond this community to other communities in the state. We were also able to engage multiple practice organizations, reduce duplication, and improve the coordination of care. Changes in the process of preventive services delivery were noted in participating practices. Finally, the outcomes of the family-level intervention were comparable in direction and magnitude to the outcomes of previous randomized trials of the intervention. All the changes were achieved over a relatively brief 3-year study period, and many have been sustained since the project was completed. Tiered, interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children.

Using novel Canadian resources to improve medication reconciliation at discharge: study protocol for a randomized controlled trial.

PubMed

Tamblyn, Robyn; Huang, Allen R; Meguerditchian, Ari N; Winslade, Nancy E; Rochefort, Christian; Forster, Alan; Eguale, Tewodros; Buckeridge, David; Jacques, André; Naicker, Kiyuri; Reidel, Kristen E

2012-08-27

Adverse drug events are responsible for up to 7% of all admissions to acute care hospitals. At least 58% of these are preventable, resulting from incomplete drug information, prescribing or dispensing errors, and overuse or underuse of medications. Effective implementation of medication reconciliation is considered essential to reduce preventable adverse drug events occurring at transitions between community and hospital care. An electronically enabled discharge reconciliation process represents an innovative approach to this problem. Participants will be recruited in Quebec and are eligible for inclusion if they are using prescription medication at admission, covered by the Quebec drug insurance plan, admitted from the community, 18 years or older, admitted to a general or intensive care medical or surgical unit, and discharged alive. A sample size of 3,714 will be required to detect a 5% reduction in adverse drug events. The intervention will comprise electronic retrieval of the community drug list, combined with an electronic discharge reconciliation module and an electronic discharge communication module. The primary outcomes will be adverse drug events occurring 30 days post-discharge, identified by a combination of patient self-report and chart abstraction. All emergency room visits and hospital readmission during this period will be measured as secondary outcomes. A cluster randomization approach will be used to allocate 16 medical and 10 surgical units to electronic discharge reconciliation and communication versus usual care. An intention-to-treat approach will be used to analyse data. Logistic regression will be undertaken within a generalized estimating equation framework to account for clustering within units. The goal of this prospective trial is to determine if electronically enabled discharge reconciliation will reduce the risk of adverse drug events, emergency room visits and readmissions 30 days post-discharge compared with usual care. We expect that this intervention will improve adherence to medication reconciliation at discharge, the accuracy of the community-based drug history and effective communication of hospital-based treatment changes to community care providers. The results may support policy-directed investments in computerizing and training of hospital staff, generate key requirements for future hospital accreditation standards, and highlight functional requirements for software vendors. NCT01179867.

Point of Care Technologies for HIV

PubMed Central

Hewlett, Indira K.

2014-01-01

Effective prevention of HIV/AIDS requires early diagnosis, initiation of therapy, and regular plasma viral load monitoring of the infected individual. In addition, incidence estimation using accurate and sensitive assays is needed to facilitate HIV prevention efforts in the public health setting. Therefore, more affordable and accessible point-of-care (POC) technologies capable of providing early diagnosis, HIV viral load measurements, and CD4 counts in settings where HIV is most prevalent are needed to enable appropriate intervention strategies and ultimately stop transmission of the virus within these populations to achieve the future goal of an AIDS-free generation. This review discusses the available and emerging POC technologies for future application to these unmet public health needs. PMID:24579041

Cell phone intervention to improve adherence: cystic fibrosis care team, patient, and parent perspectives.

PubMed

Marciel, Kristen K; Saiman, Lisa; Quittell, Lynne M; Dawkins, Kevin; Quittner, Alexandra L

2010-02-01

Treatment regimens for patients with cystic fibrosis (CF) are time-consuming and complex, resulting in consistently low adherence rates. To date, few studies have evaluated innovative technologies to improve adherence in this population. Current infection control guidelines for patients with CF seek to minimize patient-to-patient transmission of potential pathogens. Thus, interventions must avoid face-to-face contact and be delivered individually, limiting opportunities for peer support. This study aimed to develop and assess a web-enabled cell phone, CFFONE, designed to provide CF information and social support to improve adherence in adolescents with CF. The acceptability, feasibility, and utility of CFFONE were evaluated with health care professionals (n = 17) adolescents with CF aged 11-18 years old (n = 12), adults with CF aged 21-36 years old (n = 6), parents of adolescents with CF (n = 12), and technology experts (n = 8). Adolescents also tested a prototype of CFFONE (n = 9). Qualitative and quantitative data were collected. Focus group data with health care professionals indicated a need for this intervention, and indicated that CFFONE would be likely to improve knowledge and social support, and somewhat likely to improve adherence. Adolescent, adults, and parents all rated CFFONE as likely to improve adherence. Technology experts rated the prototype design and format as appropriate. The current study provided some support from key stakeholders for this intervention to improve adherence in adolescents with CF. Next steps include a multi-center trial of the efficacy and safety of CFFONE. (c) 2010 Wiley-Liss, Inc.

Improving Nursing Home Care through Feedback On PerfoRMance Data (INFORM): Protocol for a cluster-randomized trial.

PubMed

Hoben, Matthias; Norton, Peter G; Ginsburg, Liane R; Anderson, Ruth A; Cummings, Greta G; Lanham, Holly J; Squires, Janet E; Taylor, Deanne; Wagg, Adrian S; Estabrooks, Carole A

2017-01-10

Audit and feedback is effective in improving the quality of care. However, methods and results of international studies are heterogeneous, and studies have been criticized for a lack of systematic use of theory. In TREC (Translating Research in Elder Care), a longitudinal health services research program, we collect comprehensive data from care providers and residents in Canadian nursing homes to improve quality of care and life of residents, and quality of worklife of caregivers. The study aims are to a) systematically feed back TREC research data to nursing home care units, and b) compare the effectiveness of three different theory-based feedback strategies in improving performance within care units. INFORM (Improving Nursing Home Care through Feedback On PerfoRMance Data) is a 3.5-year pragmatic, three-arm, parallel, cluster-randomized trial. We will randomize 67 Western Canadian nursing homes with 203 care units to the three study arms, a standard feedback strategy and two assisted and goal-directed feedback strategies. Interventions will target care unit managerial teams. They are based on theory and evidence related to audit and feedback, goal setting, complex adaptive systems, and empirical work on feeding back research results. The primary outcome is the increased number of formal interactions (e.g., resident rounds or family conferences) involving care aides - non-registered caregivers providing up to 80% of direct care. Secondary outcomes are a) other modifiable features of care unit context (improved feedback, social capital, slack time) b) care aides' quality of worklife (improved psychological empowerment, job satisfaction), c) more use of best practices, and d) resident outcomes based on the Resident Assessment Instrument - Minimum Data Set 2.0. Outcomes will be assessed at baseline, immediately after the 12-month intervention period, and 18 months post intervention. INFORM is the first study to systematically assess the effectiveness of different strategies to feed back research data to nursing home care units in order to improve their performance. Results of this study will enable development of a practical, sustainable, effective, and cost-effective feedback strategy for routine use by managers, policy makers and researchers. The results may also be generalizable to care settings other than nursing homes. ClinicalTrials.gov Identifier: NCT02695836 . Date of registration: 24 February 2016.

Design of a trial-based economic evaluation on the cost-effectiveness of employability interventions among work disabled employees or employees at risk of work disability: The CASE-study

PubMed Central

2012-01-01

Background In the Netherlands, absenteeism and reduced productivity due to work disability lead to high yearly costs reaching almost 5% of the gross national product. To reduce the economic burden of sick leave and reduced productivity, different employability interventions for work-disabled employees or employees at risk of work disability have been developed. Within this study, called 'CASE-study' (Cost-effectiveness Analysis of Sustainable Employability), five different employability interventions directed at work disabled employees with divergent health complaints will be analysed on their effectiveness and cost-effectiveness. This paper describes a consistent and transparent methodological design to do so. Methods/design Per employability intervention 142 participants are needed whereof approximately 66 participants receiving the intervention will be compared with 66 participants receiving usual care. Based on the intervention-specific characteristics, a randomized control trial or a quasi-experiment with match-criteria will be conducted. Notwithstanding the study design, eligible participants will be employees aged 18 to 63, working at least 12 h per week, and at risk of work disability, or already work-disabled due to medical restrictions. The primary outcome will be the duration of sick leave. Secondary outcomes are health status and quality of life. Outcomes will be assessed at baseline and then 6, 12 and 18 months later. Economic costs will consist of healthcare costs and cost of lost production due to work disability, and will be evaluated from a societal perspective. Discussion The CASE-study is the first to conduct economic evaluations of multiple different employability interventions based on a similar methodological framework. The cost-effectiveness results for every employability intervention will be published in 2014, but the methods, strengths and weaknesses of the study protocol are discussed in this paper. To contribute to treatment options in occupational health practice and enable the development of guidelines on how to conduct economic evaluation better suited to this field; this paper provides an important first step. Trial registration Four trials involved in the CASE-study are registered with the Netherlands Trial Registry: Care for Work (NTR2886), Health and Motion (NTR3111), Guidance to Excel in Return to Work (NTR3151), Care for Companies/Second Care (NTR3136). PMID:22257557

Resuscitation and Obstetrical Care to Reduce Intrapartum-Related Neonatal Deaths: A MANDATE Study.

PubMed

Kamath-Rayne, Beena D; Griffin, Jennifer B; Moran, Katelin; Jones, Bonnie; Downs, Allan; McClure, Elizabeth M; Goldenberg, Robert L; Rouse, Doris; Jobe, Alan H

2015-08-01

To evaluate the impact of neonatal resuscitation and basic obstetric care on intrapartum-related neonatal mortality in low and middle-income countries, using the mathematical model, Maternal and Neonatal Directed Assessment of Technology (MANDATE). Using MANDATE, we evaluated the impact of interventions for intrapartum-related events causing birth asphyxia (basic neonatal resuscitation, advanced neonatal care, increasing facility birth, and emergency obstetric care) when implemented in home, clinic, and hospital settings of sub-Saharan African and India for 2008. Total intrapartum-related neonatal mortality (IRNM) was acute neonatal deaths from intrapartum-related events plus late neonatal deaths from ongoing intrapartum-related injury. Introducing basic neonatal resuscitation in all settings had a large impact on decreasing IRNM. Increasing facility births and scaling up emergency obstetric care in clinics and hospitals also had a large impact on decreasing IRNM. Increasing prevalence and utilization of advanced neonatal care in hospital settings had limited impact on IRNM. The greatest improvement in IRNM was seen with widespread advanced neonatal care and basic neonatal resuscitation, scaled-up emergency obstetric care in clinics and hospitals, and increased facility deliveries, resulting in an estimated decrease in IRNM to 2.0 per 1,000 live births in India and 2.5 per 1,000 live births in sub-Saharan Africa. With more deliveries occurring in clinics and hospitals, the scale-up of obstetric care can have a greater effect than if modeled individually. Use of MANDATE enables health leaders to direct resources towards interventions that could prevent intrapartum-related deaths. A lack of widespread implementation of basic neonatal resuscitation, increased facility births, and emergency obstetric care are missed opportunities to save newborn lives.

Technological Health Intervention in Population Aging to Assist People to Work Smarter not Harder: Qualitative Study.

PubMed

Chen, Sonia Chien-I

2018-01-04

Technology-based health care has been promoted as an effective tool to enable clinicians to work smarter. However, some health stakeholders believe technology will compel users to work harder by creating extra work. The objective of this study was to investigate how and why electronic health (eHealth) has been applied in Taiwan and to suggest implications that may inspire other countries facing similar challenges. A qualitative methodology was adopted to obtain insightful inputs from deeper probing. Taiwan was selected as a typical case study, given its aging population, advanced technology, and comprehensive health care system. This study investigated 38 stakeholders in the health care ecosystem through in-depth interviews and focus groups, which provides an open, flexible, and enlightening way to study complex, dynamic, and interactive situations through informal conversation or a more structured, directed discussion. First, respondents indicated that the use of technology can enable seamless patient care and clinical benefits such as flexibility in time management. Second, the results suggested that a leader's vision, authority, and management skills might influence success in health care innovation. Finally, the results implied that both internal and external organizational governance are highly relevant for implementing technology-based innovation in health care. This study provided Taiwanese perspectives on how to intelligently use technology to benefit health care and debated the perception that technology prevents human interaction between clinicians and patients. ©Sonia Chien-I Chen. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.01.2018.

TRAK App Suite: A Web-Based Intervention for Delivering Standard Care for the Rehabilitation of Knee Conditions.

PubMed

Spasić, Irena; Button, Kate; Divoli, Anna; Gupta, Satyam; Pataky, Tamas; Pizzocaro, Diego; Preece, Alun; van Deursen, Robert; Wilson, Chris

2015-10-16

Standard care for the rehabilitation of knee conditions involves exercise programs and information provision. Current methods of rehabilitation delivery struggle to keep up with large volumes of patients and the length of treatment required to maximize the recovery. Therefore, the development of novel interventions to support self-management is strongly recommended. Such interventions need to include information provision, goal setting, monitoring, feedback, and support groups, but the most effective methods of their delivery are poorly understood. The Internet provides a medium for intervention delivery with considerable potential for meeting these needs. The objective of this study was to demonstrate the feasibility of a Web-based app and to conduct a preliminary review of its practicability as part of a complex medical intervention in the rehabilitation of knee disorders. This paper describes the development, implementation, and usability of such an app. An interdisciplinary team of health care professionals and researchers, computer scientists, and app developers developed the TRAK app suite. The key functionality of the app includes information provision, a three-step exercise program based on a standard care for the rehabilitation of knee conditions, self-monitoring with visual feedback, and a virtual support group. There were two types of stakeholders (patients and physiotherapists) that were recruited for the usability study. The usability questionnaire was used to collect both qualitative and quantitative information on computer and Internet usage, task completion, and subjective user preferences. A total of 16 patients and 15 physiotherapists participated in the usability study. Based on the System Usability Scale, the TRAK app has higher perceived usability than 70% of systems. Both patients and physiotherapists agreed that the given Web-based approach would facilitate communication, provide information, help recall information, improve understanding, enable exercise progression, and support self-management in general. The Web app was found to be easy to use and user satisfaction was very high. The TRAK app suite can be accessed at http://apps.facebook.com/kneetrak/. The usability study suggests that a Web-based intervention is feasible and acceptable in supporting self-management of knee conditions.

TRAK App Suite: A Web-Based Intervention for Delivering Standard Care for the Rehabilitation of Knee Conditions

PubMed Central

Divoli, Anna; Gupta, Satyam; Pataky, Tamas; Pizzocaro, Diego; Preece, Alun; van Deursen, Robert; Wilson, Chris

2015-01-01

Background Standard care for the rehabilitation of knee conditions involves exercise programs and information provision. Current methods of rehabilitation delivery struggle to keep up with large volumes of patients and the length of treatment required to maximize the recovery. Therefore, the development of novel interventions to support self-management is strongly recommended. Such interventions need to include information provision, goal setting, monitoring, feedback, and support groups, but the most effective methods of their delivery are poorly understood. The Internet provides a medium for intervention delivery with considerable potential for meeting these needs. Objective The objective of this study was to demonstrate the feasibility of a Web-based app and to conduct a preliminary review of its practicability as part of a complex medical intervention in the rehabilitation of knee disorders. This paper describes the development, implementation, and usability of such an app. Methods An interdisciplinary team of health care professionals and researchers, computer scientists, and app developers developed the TRAK app suite. The key functionality of the app includes information provision, a three-step exercise program based on a standard care for the rehabilitation of knee conditions, self-monitoring with visual feedback, and a virtual support group. There were two types of stakeholders (patients and physiotherapists) that were recruited for the usability study. The usability questionnaire was used to collect both qualitative and quantitative information on computer and Internet usage, task completion, and subjective user preferences. Results A total of 16 patients and 15 physiotherapists participated in the usability study. Based on the System Usability Scale, the TRAK app has higher perceived usability than 70% of systems. Both patients and physiotherapists agreed that the given Web-based approach would facilitate communication, provide information, help recall information, improve understanding, enable exercise progression, and support self-management in general. The Web app was found to be easy to use and user satisfaction was very high. The TRAK app suite can be accessed at http://apps.facebook.com/kneetrak/. Conclusions The usability study suggests that a Web-based intervention is feasible and acceptable in supporting self-management of knee conditions. PMID:26474643

The role of the occupational therapist in the care of people living with lung cancer.

PubMed

White, Kahren M

2016-06-01

This paper aims to explore the vital role occupational therapists play in enabling people living with lung cancer to continue to actively live. Core assessments and interventions employed by occupational therapists are described in a case study. It will demonstrate how people living with lung cancer can continue to participate in meaningful and chosen life roles, even in the face of functional decline. Skilled management by the occupational therapist of the refractory symptoms of advanced lung cancer supports this participation.

Mechanisms that Trigger a Good Health-Care Response to Intimate Partner Violence in Spain. Combining Realist Evaluation and Qualitative Comparative Analysis Approaches.

PubMed

Goicolea, Isabel; Vives-Cases, Carmen; Hurtig, Anna-Karin; Marchal, Bruno; Briones-Vozmediano, Erica; Otero-García, Laura; García-Quinto, Marta; San Sebastian, Miguel

2015-01-01

Health care professionals, especially those working in primary health-care services, can play a key role in preventing and responding to intimate partner violence. However, there are huge variations in the way health care professionals and primary health care teams respond to intimate partner violence. In this study we tested a previously developed programme theory on 15 primary health care center teams located in four different Spanish regions: Murcia, C Valenciana, Castilla-León and Cantabria. The aim was to identify the key combinations of contextual factors and mechanisms that trigger a good primary health care center team response to intimate partner violence. A multiple case-study design was used. Qualitative and quantitative information was collected from each of the 15 centers (cases). In order to handle the large amount of information without losing familiarity with each case, qualitative comparative analysis was undertaken. Conditions (context and mechanisms) and outcomes, were identified and assessed for each of the 15 cases, and solution formulae were calculated using qualitative comparative analysis software. The emerging programme theory highlighted the importance of the combination of each team's self-efficacy, perceived preparation and women-centredness in generating a good team response to intimate partner violence. The use of the protocol and accumulated experience in primary health care were the most relevant contextual/intervention conditions to trigger a good response. However in order to achieve this, they must be combined with other conditions, such as an enabling team climate, having a champion social worker and having staff with training in intimate partner violence. Interventions to improve primary health care teams' response to intimate partner violence should focus on strengthening team's self-efficacy, perceived preparation and the implementation of a woman-centred approach. The use of the protocol combined with a large working experience in primary health care, and other factors such as training, a good team climate, and having a champion social worker on the team, also played a key role. Measures to sustain such interventions and promote these contextual factors should be encouraged.

Factors contributing to the effectiveness of physical activity counselling in primary care: a realist systematic review.

PubMed

Gagliardi, Anna R; Abdallah, Flavia; Faulkner, Guy; Ciliska, Donna; Hicks, Audrey

2015-04-01

Physical activity (PA) counselling in primary care increases PA but is not consistently practiced. This study examined factors that optimise the delivery and impact of PA counselling. A realist systematic review based on the PRECEDE-PROCEED model and RAMESES principles was conducted to identify essential components of PA counselling. MEDLINE, EMBASE, Cochrane Library, PsycINFO, and Physical Education Index were searched from 2000 to 2013 for studies that evaluated family practice PA counselling. Of 1546 articles identified, 10 were eligible for review (3 systematic reviews, 5 randomised controlled trials, 2 observational studies). Counselling provided by clinicians or counsellors alone that explored motivation increased self-reported PA at least 12 months following intervention. Multiple sessions may sustain increased PA beyond 12 months. Given the paucity of eligible studies and limited detail reported about interventions, further research is needed to establish the optimal design and delivery of PA counselling. Research and planning should consider predisposing, reinforcing and enabling design features identified in these studies. Since research shows that PA counselling promotes PA but is not widely practiced, primary care providers will require training and tools to operationalize PA counselling. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Cost-utility analysis of an advanced pressure ulcer management protocol followed by trained wound, ostomy, and continence nurses.

PubMed

Kaitani, Toshiko; Nakagami, Gojiro; Iizaka, Shinji; Fukuda, Takashi; Oe, Makoto; Igarashi, Ataru; Mori, Taketoshi; Takemura, Yukie; Mizokami, Yuko; Sugama, Junko; Sanada, Hiromi

2015-01-01

The high prevalence of severe pressure ulcers (PUs) is an important issue that requires to be highlighted in Japan. In a previous study, we devised an advanced PU management protocol to enable early detection of and intervention for deep tissue injury and critical colonization. This protocol was effective for preventing more severe PUs. The present study aimed to compare the cost-effectiveness of the care provided using an advanced PU management protocol, from a medical provider's perspective, implemented by trained wound, ostomy, and continence nurses (WOCNs), with that of conventional care provided by a control group of WOCNs. A Markov model was constructed for a 1-year time horizon to determine the incremental cost-effectiveness ratio of advanced PU management compared with conventional care. The number of quality-adjusted life-years gained, and the cost in Japanese yen (¥) ($US1 = ¥120; 2015) was used as the outcome. Model inputs for clinical probabilities and related costs were based on our previous clinical trial results. Univariate sensitivity analyses were performed. Furthermore, a Bayesian multivariate probability sensitivity analysis was performed using Monte Carlo simulations with advanced PU management. Two different models were created for initial cohort distribution. For both models, the expected effectiveness for the intervention group using advanced PU management techniques was high, with a low expected cost value. The sensitivity analyses suggested that the results were robust. Intervention by WOCNs using advanced PU management techniques was more effective and cost-effective than conventional care. © 2015 by the Wound Healing Society.

What helps or hinders the transformation from a major tertiary center to a major trauma center? Identifying barriers and enablers using the Theoretical Domains Framework.

PubMed

Roberts, Neil; Lorencatto, Fabiana; Manson, Joanna; Brundage, Susan I; Jansen, Jan O

2016-03-12

Major Trauma Centers (MTCs), as part of a trauma system, improve survival and functional outcomes from injury. Developing such centers from current teaching hospitals is likely to generate diverse beliefs amongst staff. These may act as barriers or enablers. Prior identification of these may make the service development process more efficient. The importance of applying theory to systematically identify barriers and enablers to changing clinical practice in emergency medicine has been emphasized. This study systematically explored theory-based barriers and enablers towards implementing the transformation of a tertiary hospital into a MTC. Our goal was to demonstrate the use of a replicable method to identify targets that could be addressed to achieve a successful transformation from an organization evolved to provide a particular type of clinical care into a clinical system with different demands, requirements and expectations. The Theoretical Domains Framework (TDF) is a tool designed to elicit and analyze beliefs affecting behavior. Semi-structured interviews based around the TDF were conducted in a major tertiary hospital in Scotland due to become a MTC with a purposive sample of major stakeholders including clinicians and nurses from specialties involved in trauma care, clinical managers and administration. Belief statements were identified through qualitative analysis, and assessed for importance according to prevalence, discordance and evidence base. 1728 utterances were recorded and coded into 91 belief statements. 58 were classified as important barriers/enablers. There were major concerns about resource demands, with optimism conditional on these being met. Distracting priorities abound within the Emergency Department. Better communication is needed. Staff motivation is high and they should be engaged in skills development and developing performance improvement processes. This study presents a systematic and replicable method of identifying theory-based barriers and enablers towards complex service development. It identifies multiple barriers/enablers that may serve as a basis for developing an implementation intervention to enhance the development of MTCs. This method can be used to address similar challenges in developing specialist centers or implementing clinical practice change in emergency care across both developing and developed countries.

Kangaroo mother care: using formative research to design an acceptable community intervention.

PubMed

Mazumder, Sarmila; Upadhyay, Ravi Prakash; Hill, Zelee; Taneja, Sunita; Dube, Brinda; Kaur, Jasmine; Shekhar, Medha; Ghosh, Runa; Bisht, Shruti; Martines, Jose Carlos; Bahl, Rajiv; Sommerfelt, Halvor; Bhandari, Nita

2018-03-02

Low and middle income countries (LMICs), including India, contribute to a major proportion of low birth weight (LBW) infants globally. These infants require special care. Kangaroo Mother Care (KMC) in hospitals is a cost effective and efficacious intervention. In institutional deliveries, the duration of facility stay is often short. In LMICs, a substantial proportion of deliveries still occur at home and access to health care services is limited. In these circumstances, a pragmatic choice may be to initiate KMC at home for LBW babies. However, evidence is lacking on benefits of community-initiated KMC (cKMC). Promoting KMC at home without an understanding of its acceptability may lead to limited success. We conducted formative research to assess the feasibility, acceptability and adoption of cKMC with the aim of designing an intervention package for a randomised controlled trial in LBW infants in Haryana, India. Qualitative methods included 40 in-depth interviews with recently delivered women and 6 focus group discussions, two each with fathers and grandfathers, grandmothers, and community health workers. A prototype intervention package to promote cKMC was developed and tested in 28 mother-infant pairs (of them, one mother had twins), using Household (HH) trials. We found that most mothers in the community recognized that babies born small required special care. In spite of not being aware of the practice of KMC, respondents felt that creating awareness of KMC benefits will promote practice. They expressed concerns about doing KMC for long periods because mothers needed rest after delivery. However, the cultural practice of recently delivered women not expected to be doing household chores and availability of other family members were identified as enablers. HH trials provided an opportunity to test the intervention package and showed high acceptability for KMC. Most mothers perceived benefits such as weight gain and increased activity in the infant. Community-initiated KMC is acceptable by mothers and adoption rates are high. Formative research is essential for developing a strategy for delivery of an intervention. Trial registration number CTRI/2015/10/006267 . Name of Registry: Clinical Trials Registry - India. URL of Registry: http://ctri.nic.in/Clinicaltrials/login.php Date of Registration: 15/10/2015. Date of enrolment of the first participant to the trial: 18/04/2015.

Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial.

PubMed

Haas, Jennifer S; Linder, Jeffrey A; Park, Elyse R; Gonzalez, Irina; Rigotti, Nancy A; Klinger, Elissa V; Kontos, Emily Z; Zaslavsky, Alan M; Brawarsky, Phyllis; Marinacci, Lucas X; St Hubert, Stella; Fleegler, Eric W; Williams, David R

2015-02-01

Widening socioeconomic disparities in mortality in the United States are largely explained by slower declines in tobacco use among smokers of low socioeconomic status (SES) than among those of higher SES, which points to the need for targeted tobacco cessation interventions. Documentation of smoking status in electronic health records (EHRs) provides the tools for health systems to proactively offer tobacco treatment to socioeconomically disadvantaged smokers. To evaluate a proactive tobacco cessation strategy that addresses sociocontextual mediators of tobacco use for low-SES smokers. This prospective, randomized clinical trial included low-SES adult smokers who described their race and/or ethnicity as black, Hispanic, or white and received primary care at 1 of 13 practices in the greater Boston area (intervention group, n = 399; control group, n = 308). We analyzed EHRs to identify potentially eligible participants and then used interactive voice response (IVR) techniques to reach out to them. Consenting patients were randomized to either receive usual care from their own health care team or enter an intervention program that included (1) telephone-based motivational counseling, (2) free nicotine replacement therapy (NRT) for 6 weeks, (3) access to community-based referrals to address sociocontextual mediators of tobacco use, and (4) integration of all these components into their normal health care through the EHR system. Self-reported past-7-day tobacco abstinence 9 months after randomization ("quitting"), assessed by automated caller or blinded study staff. The intervention group had a higher quit rate than the usual care group (17.8% vs 8.1%; odds ratio, 2.5; 95% CI, 1.5-4.0; number needed to treat, 10). We examined whether use of intervention components was associated with quitting among individuals in the intervention group: individuals who participated in the telephone counseling were more likely to quit than those who did not (21.2% vs 10.4%; P < .001). There was no difference in quitting by use of NRT. Quitting did not differ by a request for a community referral, but individuals who used their referral were more likely to quit than those who did not (43.6% vs 15.3%; P < .001). Proactive, IVR-facilitated outreach enables engagement with low-SES smokers. Providing counseling, NRT, and access to community-based resources to address sociocontextual mediators among smokers reached in this setting is effective. clinicaltrials.gov Identifier: NCT01156610.

The feasibility of implementing recovery, psychosocial and pharmacological interventions for psychosis: comparison study.

PubMed

van der Krieke, Lian; Bird, Victoria; Leamy, Mary; Bacon, Faye; Dunn, Rebecca; Pesola, Francesca; Janosik, Monika; Le Boutillier, Clair; Williams, Julie; Slade, Mike

2015-05-23

Clinical guidelines for the treatment of people experiencing psychosis have existed for over a decade, but implementation of recommended interventions is limited. Identifying influences on implementation may help to reduce this translational gap. The Structured Assessment of Feasibility (SAFE) measure is a standardised assessment of implementation blocks and enablers. The aim of this study was to characterise and compare the implementation blocks and enablers for recommended psychosis interventions. SAFE was used to evaluate and compare three groups of interventions recommended in the 2014 NICE psychosis guideline: pharmacological (43 trials testing 5 interventions), psychosocial (65 trials testing 5 interventions), and recovery (19 trials testing 5 interventions). The 127 trial reports rated with SAFE were supplemented by published intervention manuals, research protocols, trial registrations and design papers. Differences in the number of blocks and enablers across the three interventions were tested statistically, and feasibility profiles were generated. There was no difference between psychosocial and recovery interventions in the number of blocks or enablers to implementation. Pharmacological interventions (a) had fewer blocks than both psychosocial interventions (χ (2)(3) = 133.77, p < 0.001) and recovery interventions (χ (2)(3) = 104.67, p < 0.001) and (b) did not differ in number of enablers from recovery interventions (χ (2)(3) = 0.74, p = 0.863) but had fewer enablers than psychosocial interventions (χ (2)(3) = 28.92, p < 0.001). Potential adverse events associated with the intervention tend to be a block for pharmacological interventions, whereas complexity of the intervention was the most consistent block for recovery and psychosocial interventions. Feasibility profiles show that pharmacological interventions are relatively easy to implement but can sometimes involve risks. Psychosocial and recovery interventions are relatively complex but tend to be more flexible and more often manualised. SAFE ratings can contribute to tackling the current implementation challenges in mental health services, by providing a reporting guideline structure for researchers to maximise the potential for implementation and by informing prioritisation decisions by clinical guideline developers and service managers.

Self-Care for Health in Rural Hispanic Women at Risk for Postpartum Depression.

PubMed

Kim, Younglee; Dee, Vivien

2017-01-01

To determine factors that affect self-care of rural Hispanic women at risk for postpartum depression (PPD). This study was a descriptive cross-sectional design based on the key concepts of Orem's Self-care Deficit Nursing theory. Data were collected from 223 Hispanic postpartum women residing in Mecca, North Shore, and Thermal in California by an interviewer-administered survey. Four instruments were utilized: Edinburgh Postnatal Depression Scale (EPDS) for PPD, Multidimensional Scale of Perceived Social Support for social support, Duke University Religion Index (DUREL) for spirituality, and Self Rated Abilities for Health Practices for self-care. The prevalence of women at risk for PPD was about 43 %. Social support, spirituality, and self-care ability were significantly correlated in women with PPD. Social support was a strong factor in predicting self-care ability for 'Nutrition', 'Psychological well-being', 'Exercise', and 'Responsible Health Practices' in the rural Hispanic women at risk for PPD. The study findings can enable nurses and healthcare professionals to develop effective tailored interventions to assist rural Hispanic women's abilities to perform self-care for health, and in particular, during the postpartum period.

Design of Economic Evaluations of Mindfulness-Based Interventions: Ten Methodological Questions of Which to Be Mindful.

PubMed

Edwards, Rhiannon Tudor; Bryning, Lucy; Crane, Rebecca

Mindfulness-based interventions (MBIs) are being increasingly applied in a variety of settings. A growing body of evidence to support the effectiveness of these interventions exists and there are a few published cost-effectiveness studies. With limited resources available within public sectors (health care, social care, and education), it is necessary to build in concurrent economic evaluations alongside trials in order to inform service commissioning and policy. If future research studies are well-designed, they have strong potential to investigate the economic impact of MBIs. The particular challenge to the health economist is how best to capture the ways that MBIs help people adjust to or build resilience to difficult life circumstances, and to disseminate effectively to enable policy makers to judge the value of the contribution that MBIs can make within the context of the limited resourcing of public services. In anticipation of more research worldwide evaluating MBIs in various settings, this article suggests ten health economics methodological design questions that researchers may want to consider prior to conducting MBI research. These questions draw on both published standards of good methodological practice in economic evaluation of medical interventions, and on the authors' knowledge and experience of mindfulness-based practice. We argue that it is helpful to view MBIs as both complex interventions and as public health prevention initiatives. Our suggestions for well-designed economic evaluations of MBIs in health and other settings, mirror current thinking on the challenges and opportunities of public health economics.

The expert's guide to mealtime interventions - A Delphi method survey.

PubMed

Conchin, Simone; Carey, Sharon

2017-09-27

Prevalence of malnutrition and a myriad of barriers to adequate oral diet in hospitalised patients warrants further investment to improve the patient mealtime experience. The aim of this study was to explore barriers and enablers to implementing effective mealtime interventions and develop a process framework to guide clinicians and researchers in the area. Potential experts in the area of hospital mealtime intervention were identified as having published in this field of work within the Australasian setting. Further information was sought by email and telephone communication on professional background; research experience; interest; and capacity to participate. Recruited participants were surveyed using a modified Delphi method to establish opinion and experience in the area of mealtime interventions. Results were collated and content was coded using a thematic analysis approach by the primary researcher and two additional reviewers. Thirty-two Australian authors in the area of mealtime interventions within the hospital environment were identified from publication. Twenty-one participants were able to be contacted and nineteen of these consented to enrol in the study. Participants included those from a dietetic (n = 14), nursing (n = 4) and medical (n = 1) background. Participants were deemed to have expert knowledge if they had significant involvement in the published research and demonstrated a deep level of understanding of hospital mealtime interventions. All participants provided key insights into barriers to oral intake in the hospital environment and suggestions for interventions to address these barriers. From the survey, an eight step framework to guide mealtime interventions was developed. Hospital mealtime interventions are complex processes. Interventions should be implemented after careful consideration of the local context and baseline data; and tailored to address barriers. Roles and responsibilities for nutrition care should be clear and consistent. Implementation planning is recommended to ensure that an ongoing process is in place to engage executive support and staff involvement, foster project team resilience and ensure sustainability of interventions. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Directions for the International Society for Research on Internet Interventions (ISRII)

PubMed Central

Andersson, Gerhard; Christensen, Helen M; Carlbring, Per; Cuijpers, Pim

2006-01-01

In 2004, the International Society for Research on Internet Interventions (ISRII) was formed to encourage eHealth researchers to collaborate in their efforts to further the science behind developing, testing, and disseminating Web-based treatment programs. The group held its second meeting (April 2006) to clarify the Society’s direction and identify key issues that need addressing in the field. These issues are identified and examined in the current paper. Given the success of using the Internet to treat a range of medical and mental health problems, and the growing need for better dissemination of health care, Internet interventions will almost certainly play a prominent role in global health. ISRII plans to provide the necessary venue to ensure the science driving this field is strong, enabling researchers to conduct the highest quality research and permitting meaningful conclusions from completed studies. PMID:17032639

Patient-Centered Tablet Application for Improving Medication Adherence after a Drug-Eluting Stent.

PubMed

Shah, Vicki; Dileep, Anandu; Dickens, Carolyn; Groo, Vicki; Welland, Betty; Field, Jerry; Baumann, Matthew; Flores, Jose D; Shroff, Adhir; Zhao, Zhongsheng; Yao, Yingwei; Wilkie, Diana J; Boyd, Andrew D

2016-01-01

This study's objective was to evaluate a patient-centered educational electronic tablet application, "My Interventional Drug-Eluting Stent Educational App" (MyIDEA) to see if there was an increase in patient knowledge about dual antiplatelet therapy (DAPT) and medication possession ratio (MPR) compared to treatment as usual. In a pilot project, 24 elderly (≥50 years old) research participants were recruited after a drug-eluting stent. Eleven were randomized to the control arm and 13 to the interventional arm. All the participants completed psychological and knowledge questionnaires. Adherence was assessed through MPR, which was calculated at 3 months for all participants who were scheduled for second and third follow-up visits. Relative to control, the interventional group had a 10% average increase in MPR. As compared to the interventional group, more patients in the control group had poor adherence (<80% MPR). The psychological data revealed a single imbalance in anxiety between the control and interventional groups. On average, interventional participants spent 21 min using MyIDEA. Consumer health informatics has enabled us to engage patients with their health data using novel methods. Consumer health technology needs to focus more on patient knowledge and engagement to improve long-term health. MyIDEA takes a unique approach in targeting DAPT from the onset. MyIDEA leverages patient-centered information with clinical care and the electronic health record highlighting the patients' role as a team member in their own health care. The patients think critically about adverse events and how to solve issues before leaving the hospital.

The effectiveness of learning portfolios in learning participation and learners' perceptions of skills and confidence in the mother of preterm infant.

PubMed

Cheng, Yi-Chuan; Chen, Li-Li; Chang, Yu-Shan; Li, Tsai-Chung; Chen, Ching-Ju; Huang, Li-Chi

2018-03-22

The purpose of this study was to investigate the effectiveness of preterm infant learning portfolios in enabling mothers to develop infant care knowledge and skills, as well as confidence in their abilities. This study used a quasi-experimental design. The sample consisted of 52 mothers with preterm infants recruited at a neonatal intermediate unit of a medical centre in central Taiwan. Among those, 26 participants in the control group received regular health education and 26 participants in the experimental group received learning portfolios and regular care. The Preterm Infant Care Learning Portfolio (PICLP) is a semi-structured learning portfolio which was provided by nurses. Intervention started with 15 min of instructions on how to use PICLP, including a list of learning task and methods of self-assessment. Follow-up sessions of 5-10 min were conducted after each learning task. The frequency of learning skills could be adjusted depending on participants' learning needs. Self-administered questionnaires regarding knowledge of and skills in preterm infant care and maternal confidence were used to evaluate the effectiveness of the intervention; the questionnaires were conducted before the intervention, 1 day before discharge and 1 month after discharge. We also tracked the frequency with which participants attended instructional sessions before discharged. Mothers' preterm infant care knowledge and skills and confidence improved in both groups after the intervention. The experimental group showed greater improvement than the control group by post-test 2; there was no statistical difference between groups at 1 day before discharge and 1 month after discharge. However, participants in the experimental group came for instructional sessions on baby care for more frequently than the control group. The frequency of learning sessions attended was a predictor of improved scores of the skill assessment before discharge. Both programmes led to improvements in preterm infant care knowledge and skills and maternal confidence. Giving mothers learning portfolios appears to stimulate significantly greater participation in hospital-based instructional programmes, which should in turn lead to greater long-term retention of learning. The learning portfolios may have an additional benefit in promoting acquisition of care abilities for mothers with preterm infant before hospital discharge and application of these abilities at home. At-home care for preterm infants requires specialized care skills and confidence. Learning portfolios can be used as an effective learner-centred strategy for teaching these health care abilities. Copyright © 2018 Elsevier Ltd. All rights reserved.

Evaluation of a multi-pronged intervention to improve access to safe abortion care in two districts in Jharkhand

PubMed Central

2014-01-01

Background Despite the adoption of the Medical Termination of Pregnancy Act in 1972, access to safe abortion services remains limited in India. Awareness of the legality of abortion also remains low, leading many women to seek services outside the health system. Medical abortion (MA) is an option that has the potential to expand access to safe abortion services. A multi-pronged intervention covering a population of 161,000 in 253 villages in the Silli and Khunti blocks of Jharkhand was conducted between 2007 and 2009, seeking to improve medical abortion services and create awareness at the community level by providing information through community intermediaries and creating an enabling environment through a behavior change communication campaign. The study evaluates the changes in knowledge about abortion-related issues, changes in abortion care-seeking, and service utilization as a result of this intervention. Methods A baseline cross-sectional survey was conducted pre-intervention (n = 1,253) followed by an endline survey (n = 1,290) one year after the completion of the intervention phase. In addition, monitoring data from intervention facilities was collected monthly over the study period. Results Nearly 85% of respondents reported being exposed to safe abortion messaging as a result of the intervention. Awareness of the legality of abortion increased significantly from 19.7% to 57.6% for women, as did awareness of the specific conditions for which abortion is allowed. Results were similar for men. There was also a significant increase in the proportion of men and women who knew of a legal and safe provider and place from where abortion services could be obtained. Multivariate analysis showed positive associations between exposure to any component of the intervention and increased knowledge about legality and gestational age limits, however only interpersonal communication was associated with a significant increase in knowledge of where to obtain safe services (OR 4.8, SE 0.67). Utilization of safe abortion services, and in particular MA, increased at all intervention sites over the duration of the intervention with a shift towards women seeking care earlier in pregnancy. Conclusion The evaluation demonstrates the success of the intervention and its potential for replication in similar contexts within India. PMID:24886273

Evaluation of a multi-pronged intervention to improve access to safe abortion care in two districts in Jharkhand.

PubMed

Banerjee, Sushanta K; Andersen, Kathryn L; Baird, Traci L; Ganatra, Bela; Batra, Sangeeta; Warvadekar, Janardan

2014-05-21

Despite the adoption of the Medical Termination of Pregnancy Act in 1972, access to safe abortion services remains limited in India. Awareness of the legality of abortion also remains low, leading many women to seek services outside the health system. Medical abortion (MA) is an option that has the potential to expand access to safe abortion services. A multi-pronged intervention covering a population of 161,000 in 253 villages in the Silli and Khunti blocks of Jharkhand was conducted between 2007 and 2009, seeking to improve medical abortion services and create awareness at the community level by providing information through community intermediaries and creating an enabling environment through a behavior change communication campaign. The study evaluates the changes in knowledge about abortion-related issues, changes in abortion care-seeking, and service utilization as a result of this intervention. A baseline cross-sectional survey was conducted pre-intervention (n = 1,253) followed by an endline survey (n = 1,290) one year after the completion of the intervention phase. In addition, monitoring data from intervention facilities was collected monthly over the study period. Nearly 85% of respondents reported being exposed to safe abortion messaging as a result of the intervention. Awareness of the legality of abortion increased significantly from 19.7% to 57.6% for women, as did awareness of the specific conditions for which abortion is allowed. Results were similar for men. There was also a significant increase in the proportion of men and women who knew of a legal and safe provider and place from where abortion services could be obtained. Multivariate analysis showed positive associations between exposure to any component of the intervention and increased knowledge about legality and gestational age limits, however only interpersonal communication was associated with a significant increase in knowledge of where to obtain safe services (OR 4.8, SE 0.67). Utilization of safe abortion services, and in particular MA, increased at all intervention sites over the duration of the intervention with a shift towards women seeking care earlier in pregnancy. The evaluation demonstrates the success of the intervention and its potential for replication in similar contexts within India.

Living Long and Well: Prospects for a Personalized Approach to the Medicine of Ageing.

PubMed

Fuellen, Georg; Schofield, Paul; Flatt, Thomas; Schulz, Ralf-Joachim; Boege, Fritz; Kraft, Karin; Rimbach, Gerald; Ibrahim, Saleh; Tietz, Alexander; Schmidt, Christian; Köhling, Rüdiger; Simm, Andreas

2016-01-01

Research into ageing and its underlying molecular basis enables us to develop and implement targeted interventions to ameliorate or cure its consequences. However, the efficacy of interventions often differs widely between individuals, suggesting that populations should be stratified or even individualized. Large-scale cohort studies in humans, similar systematic studies in model organisms as well as detailed investigations into the biology of ageing can provide individual validated biomarkers and mechanisms, leading to recommendations for targeted interventions. Human cohort studies are already ongoing, and they can be supplemented by in silico simulations. Systematic studies in animal models are made possible by the use of inbred strains or genetic reference populations of mice. Combining the two, a comprehensive picture of the various determinants of ageing and 'health span' can be studied in detail, and an appreciation of the relevance of results from model organisms to humans is emerging. The interactions between genotype and environment, particularly the psychosocial environment, are poorly studied in both humans and model organisms, presenting serious challenges to any approach to a personalized medicine of ageing. To increase the success of preventive interventions, we argue that there is a pressing need for an individualized evaluation of interventions such as physical exercise, nutrition, nutraceuticals and calorie restriction mimetics as well as psychosocial and environmental factors, separately and in combination. The expected extension of the health span enables us to refocus health care spending on individual prevention, starting in late adulthood, and on the brief period of morbidity at very old age. © 2015 S. Karger AG, Basel.

A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test.

PubMed

Maina, Ivy W; Belton, Tanisha D; Ginzberg, Sara; Singh, Ajit; Johnson, Tiffani J

2018-02-01

Disparities in the care and outcomes of US racial/ethnic minorities are well documented. Research suggests that provider bias plays a role in these disparities. The implicit association test enables measurement of implicit bias via tests of automatic associations between concepts. Hundreds of studies have examined implicit bias in various settings, but relatively few have been conducted in healthcare. The aim of this systematic review is to synthesize the current knowledge on the role of implicit bias in healthcare disparities. A comprehensive literature search of several databases between May 2015 and September 2016 identified 37 qualifying studies. Of these, 31 found evidence of pro-White or light-skin/anti-Black, Hispanic, American Indian or dark-skin bias among a variety of HCPs across multiple levels of training and disciplines. Fourteen studies examined the association between implicit bias and healthcare outcomes using clinical vignettes or simulated patients. Eight found no statistically significant association between implicit bias and patient care while six studies found that higher implicit bias was associated with disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy. All seven studies that examined the impact of implicit provider bias on real-world patient-provider interaction found that providers with stronger implicit bias demonstrated poorer patient-provider communication. Two studies examined the effect of implicit bias on real-world clinical outcomes. One found an association and the other did not. Two studies tested interventions aimed at reducing bias, but only one found a post-intervention reduction in implicit bias. This review reveals a need for more research exploring implicit bias in real-world patient care, potential modifiers and confounders of the effect of implicit bias on care, and strategies aimed at reducing implicit bias and improving patient-provider communication. Future studies have the opportunity to build on this current body of research, and in doing so will enable us to achieve equity in healthcare and outcomes. Copyright © 2017 Elsevier Ltd. All rights reserved.

Learning that leads to action: impact and characteristics of a professional education approach to improve the care of critically ill children and their families.

PubMed

Solomon, Mildred Z; Browning, David M; Dokken, Deborah L; Merriman, Melanie P; Rushton, Cynda H

2010-04-01

To determine the impact of an innovative professional educational approach on clinicians' confidence and ability to make institutional improvements in pediatric palliative care. Evaluation to assess impact of educational intervention on participants and participant institutions. Retreats lasting 2.5 days. Physicians, nurses, psychosocial staff, and bereaved parents. "Relational learning across boundaries" pedagogy. Analysis of participant questionnaires (n = 782, response rate of 84%), team leader surveys (n = 72, response rate of 71%), and follow-up interview with subsample (n = 21, response rate of 81%). Outcomes included confidence to act and institutional improvements achieved. Seventy-four percent of team leaders reported significant or moderate improvement in pediatric palliative care after the retreat; only 1% reported no improvement. Ninety-one percent credited the retreat experience as being somewhat or very instrumental to the improvements, which included the establishment of pediatric palliative care and bereavement programs, improvements in interdisciplinary communication, care coordination, clinician-family interaction at the bedside, and educational programs. Participants attributed the impact of the 2.5-day retreat to its key pedagogical features, involvement of family members as equal participants and participation of colleagues from other disciplines and care settings, as well as the ground rules used for the small group seminars. The intervention was successful in improving clinicians' confidence and catalyzed improvements in pediatric palliative care within participating institutions. Relational learning holds promise for professional learning, especially when the educational goal is tied to enabling a shift in social and ethical norms.

Predictors of non-drug psychiatric/psychotherapeutic treatment in children and adolescents with mental or behavioural disorders.

PubMed

Abbas, Sascha; Ihle, Peter; Adler, Jürgen-Bernhard; Engel, Susanne; Günster, Christian; Holtmann, Martin; Kortevoss, Axel; Linder, Roland; Maier, Werner; Lehmkuhl, Gerd; Schubert, Ingrid

2017-04-01

Children and adolescents with mental health problems need effective and safe therapies to support their emotional and social development and to avoid functional impairment and progress of social deficits. Though psychotropic drugs seem to be the preferential treatment, psychotherapy and psychosocial interventions are essential in mental health care. For Germany, current data on the utilization of psychotherapy and psychosocial interventions in children with mental health problems is lacking. To analyse why certain children and adolescents with mental or behavioural disorders do and others do not receive non-drug treatment, we assessed predictors associated with specific non-drug psychiatric/psychotherapeutic treatment including psychosocial interventions, psychotherapy and other non-drug treatments. The study is based on data of two large German health insurance funds, AOK and TK, comprising 30 % of the German child and adolescent population. Predictors of non-drug psychiatric/psychotherapeutic treatment were analysed for 23,795 cases and two controls for every case of the same age and sex in children aged 0-17 years following a new diagnosis of mental or behavioural disorder in 2010. Predictors were divided according to Andersen's behavioural model into predisposing, need and enabling factors. The most prominent and significant predictors positively associated with non-drug psychiatric/psychotherapeutic treatment were the residential region as predisposing factor; specific, both ex- and internalizing, mental and behavioural disorders, psychiatric co-morbidity and psychotropic drug use as need factors; and low area deprivation and high accessibility to outpatient physicians and inpatient institutions with non-drug psychiatric/psychotherapeutic department as enabling factors. In conclusion, the present study suggests that the residential region as proxy for supply of therapist and socioeconomic situation is an influencing factor for the use of psychotherapy. The analysis sheds further light on predisposing, need and enabling factors as predictors of non-drug psychotherapeutic/psychiatric treatment in children and adolescents with mental or behavioural health disorders in Germany. More research is needed to further understand the factors promoting the gap between the need and utilization of mental health care.

Pathways into mental health care for UK veterans: a qualitative study.

PubMed

Mellotte, Harriet; Murphy, Dominic; Rafferty, Laura; Greenberg, Neil

2017-01-01

Background : It is well established that veterans suffering from mental health difficulties under use mental health services. Objective : This study aimed to understand more about the barriers that prevent veterans from seeking professional help and the enablers that assist veterans in seeking professional help. It also aimed to explore potential mechanisms to improve veterans' help-seeking and pathways to care. Method : The study employed a qualitative design whereby 17 veterans who had recently attended specialist veteran mental health services took part in semi-structured interviews. The resultant data were analysed using grounded theory. Results : Participants described two distinct stages to their help-seeking: initial help-seeking and pathways through treatment. Specific barriers and enablers to help-seeking were identified at each stage. Initial barriers included recognizing that there is a problem, self-stigma and anticipated public stigma. Initial enablers included being in crisis, social support, motivation and the media. Treatment pathway barriers included practical factors and negative beliefs about health services and professionals. Treatment pathway enablers included having a diagnosis, being seen in a veteran-specific service and establishing a good therapeutic relationship. Participants provided some suggestions for interventions to improve veterans' help-seeking in future; these focussed on enhancing both veterans and health professionals' knowledge regarding mental health difficulties. Conclusions : This study identified a number of barriers and enablers that may impact a veteran's journey in seeking help from professional services for mental health difficulties. Enablers such as reaching a crisis point, social support, the media, having a diagnosis of PTSD and veteran-specific mental health services appeared to be important in opposing stigma-related beliefs and in supporting veterans to engage in help-seeking behaviours.

Pathways into mental health care for UK veterans: a qualitative study

PubMed Central

Mellotte, Harriet; Murphy, Dominic; Rafferty, Laura; Greenberg, Neil

2017-01-01

ABSTRACT Background: It is well established that veterans suffering from mental health difficulties under use mental health services. Objective: This study aimed to understand more about the barriers that prevent veterans from seeking professional help and the enablers that assist veterans in seeking professional help. It also aimed to explore potential mechanisms to improve veterans’ help-seeking and pathways to care. Method: The study employed a qualitative design whereby 17 veterans who had recently attended specialist veteran mental health services took part in semi-structured interviews. The resultant data were analysed using grounded theory. Results: Participants described two distinct stages to their help-seeking: initial help-seeking and pathways through treatment. Specific barriers and enablers to help-seeking were identified at each stage. Initial barriers included recognizing that there is a problem, self-stigma and anticipated public stigma. Initial enablers included being in crisis, social support, motivation and the media. Treatment pathway barriers included practical factors and negative beliefs about health services and professionals. Treatment pathway enablers included having a diagnosis, being seen in a veteran-specific service and establishing a good therapeutic relationship. Participants provided some suggestions for interventions to improve veterans’ help-seeking in future; these focussed on enhancing both veterans and health professionals’ knowledge regarding mental health difficulties. Conclusions: This study identified a number of barriers and enablers that may impact a veteran’s journey in seeking help from professional services for mental health difficulties. Enablers such as reaching a crisis point, social support, the media, having a diagnosis of PTSD and veteran-specific mental health services appeared to be important in opposing stigma-related beliefs and in supporting veterans to engage in help-seeking behaviours. PMID:29163864

Barriers and enablers of kangaroo mother care practice: a systematic review.

PubMed

Seidman, Gabriel; Unnikrishnan, Shalini; Kenny, Emma; Myslinski, Scott; Cairns-Smith, Sarah; Mulligan, Brian; Engmann, Cyril

2015-01-01

Kangaroo mother care (KMC) is an evidence-based approach to reducing mortality and morbidity in preterm infants. Although KMC is a key intervention package in newborn health initiatives, there is limited systematic information available on the barriers to KMC practice that mothers and other stakeholders face while practicing KMC. This systematic review sought to identify the most frequently reported barriers to KMC practice for mothers, fathers, and health practitioners, as well as the most frequently reported enablers to practice for mothers. We searched nine electronic databases and relevant reference lists for publications reporting barriers or enablers to KMC practice. We identified 1,264 unique publications, of which 103 were included based on pre-specified criteria. Publications were scanned for all barriers / enablers. Each publication was also categorized based on its approach to identification of barriers / enablers, and more weight was assigned to publications which had systematically sought to understand factors influencing KMC practice. Four of the top five ranked barriers to KMC practice for mothers were resource-related: "Issues with the facility environment / resources," "negative impressions of staff attitudes or interactions with staff," "lack of help with KMC practice or other obligations," and "low awareness of KMC / infant health." Considering only publications from low- and middle-income countries, "pain / fatigue" was ranked higher than when considering all publications. Top enablers to practice were included "mother-infant attachment" and "support from family, friends, and other mentors." Our findings suggest that mother can understand and enjoy KMC, and it has benefits for mothers, infants, and families. However, continuous KMC may be physically and emotionally difficult, and often requires support from family members, health practitioners, or other mothers. These findings can serve as a starting point for researchers and program implementers looking to improve KMC programs.

Applying the COM-B model to creation of an IT-enabled health coaching and resource linkage program for low-income Latina moms with recent gestational diabetes: the STAR MAMA program.

PubMed

Handley, Margaret A; Harleman, Elizabeth; Gonzalez-Mendez, Enrique; Stotland, Naomi E; Althavale, Priyanka; Fisher, Lawrence; Martinez, Diana; Ko, Jocelyn; Sausjord, Isabel; Rios, Christina

2016-05-18

One of the fastest growing risk groups for early onset of diabetes is women with a recent pregnancy complicated by gestational diabetes, and for this group, Latinas are the largest at-risk group in the USA. Although evidence-based interventions, such as the Diabetes Prevention Program (DPP), which focuses on low-cost changes in eating, physical activity and weight management can lower diabetes risk and delay onset, these programs have yet to be tailored to postpartum Latina women. This study aims to tailor a IT-enabled health communication program to promote DPP-concordant behavior change among postpartum Latina women with recent gestational diabetes. The COM-B model (incorporating Capability, Opportunity, and Motivational behavioral barriers and enablers) and the Behavior Change Wheel (BCW) framework, convey a theoretically based approach for intervention development. We combined a health literacy-tailored health IT tool for reaching ethnic minority patients with diabetes with a BCW-based approach to develop a health coaching intervention targeted to postpartum Latina women with recent gestational diabetes. Current evidence, four focus groups (n = 22 participants), and input from a Regional Consortium of health care providers, diabetes experts, and health literacy practitioners informed the intervention development. Thematic analysis of focus group data used the COM-B model to determine content. Relevant cultural, theoretical, and technological components that underpin the design and development of the intervention were selected using the BCW framework. STAR MAMA delivers DPP content in Spanish and English using health communication strategies to: (1) validate the emotions and experiences postpartum women struggle with; (2) encourage integration of prevention strategies into family life through mothers becoming intergenerational custodians of health; and (3) increase social and material supports through referral to social networks, health coaches, and community resources. Feasibility, acceptability, and health-related outcomes (weight loss, physical activity, consumption of healthy foods, breastfeeding, and glucose screening) will be evaluated at 9 months postpartum using a randomized controlled trial design. STAR MAMA provides a DPP-based intervention that integrates theory-based design steps. Through systematic use of behavioral theory to inform intervention development, STAR MAMA may represent a strategy to develop health IT intervention tools to meet the needs of diverse populations. ClinicalTrials.gov NCT02240420.

Feasibility of a mobile and web-based intervention to support self-management in outpatients with cancer pain.

PubMed

Hochstenbach, Laura M J; Zwakhalen, Sandra M G; Courtens, Annemie M; van Kleef, Maarten; de Witte, Luc P

2016-08-01

Cancer pain is a prevalent and distressing symptom. To enhance self-management in outpatients, a multi-component intervention was developed, integrating patient self-management and professional care through healthcare technology. This article describes feasibility of the intervention in everyday practice. Patients with moderate to severe cancer pain (n = 11) and registered nurses specialized in pain and palliative care (n = 3) participated in a four-week study. The intervention involved daily monitoring, graphical feedback, education, and advice by means of a mobile application for patients and a web application for nurses. Learnability, usability and desirability were measured in patients with a 20-item questionnaire (1-5 scale), higher scores indicating better feasibility. Patients' adherence was based on completion rates from server logs. Single semi-structured interviews with patients and a focus group interview with nurses provided insight into experiences. Questionnaire findings confirmed learnability (4.8), usability (4.8) and desirability (4.6) of the application for patients. Average completion rates were 76.8% for pain monitoring, 50.4% for medication monitoring and 100% for education sessions. Interviews revealed that patients were pleased with the simplicity of the mobile application and appreciated different components. Nurses agreed upon the added value and were mostly positive about the possibilities of the web application. Patients and nurses provided ideas for improvements relating to the content and technical performance of the intervention. Study results demonstrate feasibility of the intervention in everyday practice. Provided that content-related and technical adjustments are made, the intervention enables patients with cancer pain to practice self-management and nurses to remotely support these patients. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Evaluating a complex system-wide intervention using the difference in differences method: the Delivering Choice Programme.

PubMed

Round, Jeff; Drake, Robyn; Kendall, Edward; Addicott, Rachael; Agelopoulos, Nicky; Jones, Louise

2015-03-01

We report the use of difference in differences (DiD) methodology to evaluate a complex, system-wide healthcare intervention. We use the worked example of evaluating the Marie Curie Delivering Choice Programme (DCP) for advanced illness in a large urban healthcare economy. DiD was selected because a randomised controlled trial was not feasible. The method allows for before and after comparison of changes that occur in an intervention site with a matched control site. This enables analysts to control for the effect of the intervention in the absence of a local control. Any policy, seasonal or other confounding effects over the test period are assumed to have occurred in a balanced way at both sites. Data were obtained from primary care trusts. Outcomes were place of death, inpatient admissions, length of stay and costs. Small changes were identified between pre- and post-DCP outputs in the intervention site. The proportion of home deaths and median cost increased slightly, while the number of admissions per patient and the average length of stay per admission decreased slightly. None of these changes was statistically significant. Effects estimates were limited by small numbers accessing new services and selection bias in sample population and comparator site. In evaluating the effect of a complex healthcare intervention, the choice of analysis method and output measures is crucial. Alternatives to randomised controlled trials may be required for evaluating large scale complex interventions and the DiD approach is suitable, subject to careful selection of measured outputs and control population. 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.

Improving detection and initial management of gestational diabetes through the primary level of care in Morocco: protocol for a cluster randomized controlled trial.

PubMed

Utz, Bettina; Assarag, Bouchra; Essolbi, Amina; Barkat, Amina; El Ansari, Nawal; Fakhir, Bouchra; Delamou, Alexandre; De Brouwere, Vincent

2017-06-19

Morocco is facing a growing prevalence of diabetes and according to latest figures of the World Health Organization, already 12.4% of the population are affected. A similar prevalence has been reported for gestational diabetes (GDM) and although it is not yet high on the national agenda, immediate and long-term complications threaten the health of mothers and future generations. A situational analysis on GDM conducted in 2015 revealed difficulties in access to screening and delays in receiving appropriate care. This implementation study has as objective to evaluate a decentralized GDM detection and management approach through the primary level of care and assess its potential for scaling up. We will conduct a hybrid effectiveness-implementation research using a cluster randomized controlled trial design in two districts of Morocco. Using the health center as unit of randomization we randomly selected 20 health centers with 10 serving as intervention and 10 as control facilities. In the intervention arm, providers will screen pregnant women attending antenatal care for GDM by capillary glucose testing during antenatal care. Women tested positive will receive nutritional counselling and will be followed up through the health center. In the control facilities, screening and initial management of GDM will follow standard practice. Primary outcome will be birthweight with weight gain during pregnancy, average glucose levels and pregnancy outcomes including mode of delivery, presence or absence of obstetric or newborn complications and the prevalence of GDM at health center level as secondary outcomes. Furthermore we will assess the quality of life /care experienced by the women in both arms. Qualitative methods will be applied to evaluate the feasibility of the intervention at primary level and its adoption by the health care providers. In Morocco, gestational diabetes screening and its initial management is fragmented and coupled with difficulties in access and treatment delays. Implementation of a strategy that enables detection, management and follow-up of affected women at primary health care level is expected to positively impact on access to care and medical outcomes. The trial has been registered on clininicaltrials.gov ; identifier NCT02979756 ; retrospectively registered 22 November 2016.

Sustaining Nurse-Led Task-Shifting Strategies for Hypertension Control: A Concept Mapping Study to Inform Evidence-Based Practice.

PubMed

Blackstone, Sarah; Iwelunmor, Juliet; Plange-Rhule, Jacob; Gyamfi, Joyce; Quakyi, Nana Kofi; Ntim, Micheal; Ogedegbe, Gbenga

2017-10-01

The use of task-shifting is an increasingly widespread delivery approach for health interventions targeting prevention, treatment, and control of hypertension in adults living in sub-Saharan Africa (SSA). Addressing a gap in the literature, this research examined the sustainability of an ongoing task-shifting strategy for hypertension (TASSH) from the perspectives of community health nurses (CHNs) implementing the program. We used concept-mapping, a mixed-methods participatory approach to understand CHNs' perceptions of barriers and enablers to sustaining a task-shifting program. Participants responded to focal prompts, eliciting statements regarding perceived barriers and enablers to sustaining TASSH, and then rated these ideas based on importance to the research questions and feasibility to address. Twenty-eight community health nurses (21 women, 7 men) from the Ashanti region of Ghana completed the concept-mapping process. Factors influencing sustainability were grouped into five categories: Limited Drug Supply, Financial Support, Provision of Primary Health Care, Personnel Training, and Patient-Provider Communication. The limited supply of antihypertensive medication was considered by CHNs as the most important item to address, while providing training for intervention personnel was considered most feasible to address. This study's findings highlight the importance of examining nurses' perceptions of factors likely to influence the sustainability of evidence-based, task-shifting interventions. Nurses' perceptions can guide the widespread uptake and dissemination of these interventions in resource-limited settings. © 2017 Sigma Theta Tau International.

Nudging socially isolated people towards well-being with the 'Happiness Route': design of a randomized controlled trial for the evaluation of a happiness-based intervention.

PubMed

Weiss, Laura A; Westerhof, Gerben J; Bohlmeijer, Ernst T

2013-09-20

The Happiness Route is an innovative intervention that uses a happiness-based approach for people with an accumulation of risk factors for low well-being: socially isolated people with health impairments and a low socioeconomic status. The goal of this intervention is to improve well-being by engaging participants in intrinsically motivated activities with methods from positive psychology. We hypothesize that the primary outcome measure, emotional, social and psychological well-being of participants of the Happiness Route, will increase in comparison to the traditional and commonly-used problem-based approach. Secondary outcome measures are health-related quality of life, psychosocial functioning and health care consumption. Participants will be socially isolated people with health problems and a low socioeconomic status. Participants will be recruited in ten Dutch communities and candidates will be signed up by intermediaries, professionals from the health and social sector. Randomly assigned, half of the participants will follow the Happiness Route and half of the participants will follow the active, problem-focused control group 'Customized Care'. In total, 256 participants will be included. In both conditions, participants will receive counseling sessions from trained counselors. In the control group, participants will talk about their problems and the care they get and counselors help to optimize their care. In the Happiness Route, the counselor ask questions such as "How do you want to live your life?". The intervention helps people to find their 'passion', i.e., a positive goal-engaged and intrinsically motivated activity. It enables them to follow their passion through by a once-only personal happiness budget (maximal €500). We use well-validated and reliable questionnaires to measure primary and secondary outcome measures at baseline, directly after the intervention and at a nine-month follow-up. Shortcomings of earlier intervention studies in positive psychology will be tackled with this study, such as having a target group who is especially vulnerable for low well-being. The practice-based setting is especially interesting, as it can give valuable insights in how positive psychology interventions work in practice, but can also give rise to several challenges. Dutch Trial Register, trial registration number TC=3377NTR.http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3377.

Stakeholder analysis for a maternal and newborn health project in Eastern Uganda.

PubMed

Namazzi, Gertrude; N, Kiwanuka Suzanne; Peter, Waiswa; John, Bua; Olico, Okui; A, Allen Katharine; A, Hyder Adnan; Elizabeth, Ekirapa Kiracho

2013-03-04

Based on the realization that Uganda is not on track to achieving Millennium Development Goals 4 and 5, Makerere University School of Public Health in collaboration with other partners proposed to conduct two community based maternal/newborn care interventions aimed at increasing access to health facility care through transport vouchers and use of community health workers to promote ideal family care practices. Prior to the implementation, a stakeholder analysis was undertaken to assess and map stakeholders' interests, influence/power and position in relation to the interventions; their views regarding the success and sustainability; and how this research can influence policy formulation in the country. A stakeholder analysis was carried out in March 2011 at national level and in four districts of Eastern Uganda where the proposed interventions would be conducted. At the national level, four key informant interviews were conducted with the ministry of health representative, Member of Parliament, and development partners. District health team members were interviewed and also engaged in a workshop; and at community level, twelve focus group discussions were conducted among women, men and motorcycle transporters. This analysis revealed that district and community level stakeholders were high level supporters of the proposed interventions but not drivers. At community level the mothers, their spouses and transporters were of low influence due to the limited funds they possessed. National level and district stakeholders believed that the intervention is costly and cannot be affordably scaled up. They advised the study team to mobilize and sensitize the communities to contribute financially from the start in order to enhance sustainability beyond the study period. Stakeholders believed that the proposed interventions will influence policy through modeling on how to improve the quality of maternal/newborn health services, male involvement, and improved accessibility of services. Most of the stakeholders interviewed were supporters of the proposed maternal and newborn care intervention because of the positive benefits of the intervention. The analysis highlighted stakeholder concerns that will be included in the final project design and that could also be useful in countries of similar setting that are planning to set up programmes geared at increasing access to maternal and new born interventions. Key among these concerns was the need to use both human and financial resources that are locally available in the community, to address supply side barriers that influence access to maternal and child healthcare. Research to policy translation, therefore, will require mutual trust, continued dialogue and engagement of the researchers, implementers and policy makers to enable scale up.

Stakeholder analysis for a maternal and newborn health project in Eastern Uganda

PubMed Central

2013-01-01

Background Based on the realization that Uganda is not on track to achieving Millennium Development Goals 4 and 5, Makerere University School of Public Health in collaboration with other partners proposed to conduct two community based maternal/newborn care interventions aimed at increasing access to health facility care through transport vouchers and use of community health workers to promote ideal family care practices. Prior to the implementation, a stakeholder analysis was undertaken to assess and map stakeholders’ interests, influence/power and position in relation to the interventions; their views regarding the success and sustainability; and how this research can influence policy formulation in the country. Methods A stakeholder analysis was carried out in March 2011 at national level and in four districts of Eastern Uganda where the proposed interventions would be conducted. At the national level, four key informant interviews were conducted with the ministry of health representative, Member of Parliament, and development partners. District health team members were interviewed and also engaged in a workshop; and at community level, twelve focus group discussions were conducted among women, men and motorcycle transporters. Results This analysis revealed that district and community level stakeholders were high level supporters of the proposed interventions but not drivers. At community level the mothers, their spouses and transporters were of low influence due to the limited funds they possessed. National level and district stakeholders believed that the intervention is costly and cannot be affordably scaled up. They advised the study team to mobilize and sensitize the communities to contribute financially from the start in order to enhance sustainability beyond the study period. Stakeholders believed that the proposed interventions will influence policy through modeling on how to improve the quality of maternal/newborn health services, male involvement, and improved accessibility of services. Conclusion Most of the stakeholders interviewed were supporters of the proposed maternal and newborn care intervention because of the positive benefits of the intervention. The analysis highlighted stakeholder concerns that will be included in the final project design and that could also be useful in countries of similar setting that are planning to set up programmes geared at increasing access to maternal and new born interventions. Key among these concerns was the need to use both human and financial resources that are locally available in the community, to address supply side barriers that influence access to maternal and child healthcare. Research to policy translation, therefore, will require mutual trust, continued dialogue and engagement of the researchers, implementers and policy makers to enable scale up. PMID:23497057

Medication-use evaluation with a Web application.

PubMed

Burk, Muriel; Moore, Von; Glassman, Peter; Good, Chester B; Emmendorfer, Thomas; Leadholm, Thomas C; Cunningham, Francesca

2013-12-15

A Web-based application for coordinating medication-use evaluation (MUE) initiatives within the Veterans Affairs (VA) health care system is described. The MUE Tracker (MUET) software program was created to improve VA's ability to conduct national medication-related interventions throughout its network of 147 medical centers. MUET initiatives are centrally coordinated by the VA Center for Medication Safety (VAMedSAFE), which monitors the agency's integrated databases for indications of suboptimal prescribing or drug therapy monitoring and adverse treatment outcomes. When a pharmacovigilance signal is detected, VAMedSAFE identifies "trigger groups" of at-risk veterans and uploads patient lists to the secure MUET application, where locally designated personnel (typically pharmacists) can access and use the data to target risk-reduction efforts. Local data on patient-specific interventions are stored in a centralized database and regularly updated to enable tracking and reporting for surveillance and quality-improvement purposes; aggregated data can be further analyzed for provider education and benchmarking. In a three-year pilot project, the MUET program was found effective in promoting improved prescribing of erythropoiesis-stimulating agents (ESAs) and enhanced laboratory monitoring of ESA-treated patients in all specified trigger groups. The MUET initiative has since been expanded to target other high-risk drugs, and efforts are underway to refine the tool for broader utility. The MUET application has enabled the increased standardization of medication safety initiatives across the VA system and may serve as a useful model for the development of pharmacovigilance tools by other large integrated health care systems.

An exploratory study to examine intentions to adopt an evidence-based HIV linkage-to-care intervention among state health department AIDS directors in the United States.

PubMed

Norton, Wynne E

2012-04-02

Widespread dissemination and implementation of evidence-based human immunodeficiency virus (HIV) linkage-to-care (LTC) interventions is essential for improving HIV-positive patients' health outcomes and reducing transmission to uninfected others. To date, however, little work has focused on identifying factors associated with intentions to adopt LTC interventions among policy makers, including city, state, and territory health department AIDS directors who play a critical role in deciding whether an intervention is endorsed, distributed, and/or funded throughout their region. Between December 2010 and February 2011, we administered an online questionnaire with state, territory, and city health department AIDS directors throughout the United States to identify factors associated with intentions to adopt an LTC intervention. Guided by pertinent theoretical frameworks, including the Diffusion of Innovations and the "push-pull" capacity model, we assessed participants' attitudes towards the intervention, perceived organizational and contextual demand and support for the intervention, likelihood of adoption given endorsement from stakeholder groups (e.g., academic researchers, federal agencies, activist organizations), and likelihood of enabling future dissemination efforts by recommending the intervention to other health departments and community-based organizations. Forty-four participants (67% of the eligible sample) completed the online questionnaire. Approximately one-third (34.9%) reported that they intended to adopt the LTC intervention for use in their city, state, or territory in the future. Consistent with prior, related work, these participants were classified as LTC intervention "adopters" and were compared to "nonadopters" for data analysis. Overall, adopters reported more positive attitudes and greater perceived demand and support for the intervention than did nonadopters. Further, participants varied with their intention to adopt the LTC intervention in the future depending on endorsement from different key stakeholder groups. Most participants indicated that they would support the dissemination of the intervention by recommending it to other health departments and community-based organizations. Findings from this exploratory study provide initial insight into factors associated with public health policy makers' intentions to adopt an LTC intervention. Implications for future research in this area, as well as potential policy-related strategies for enhancing the adoption of LTC interventions, are discussed.

Telecare for diabetes, CHF or COPD: effect on quality of life, hospital use and costs. A randomised controlled trial and qualitative evaluation.

PubMed

Kenealy, Timothy W; Parsons, Matthew J G; Rouse, A Paul B; Doughty, Robert N; Sheridan, Nicolette F; Hindmarsh, Jennifer K Harré; Masson, Sarah C; Rea, Harry H

2015-01-01

To assess the effect of telecare on health related quality of life, self-care, hospital use, costs and the experiences of patients, informal carers and health care professionals. Patients were randomly assigned either to usual care or to additionally entering their data into a commercially-available electronic device that uploaded data once a day to a nurse-led monitoring station. Patients had congestive heart failure (Site A), chronic obstructive pulmonary disease (Site B), or any long-term condition, mostly diabetes (Site C). Site C contributed only intervention patients - they considered a usual care option to be unethical. The study took place in New Zealand between September 2010 and February 2012, and lasted 3 to 6 months for each patient. The primary outcome was health-related quality of life (SF36). Data on experiences were collected by individual and group interviews and by questionnaire. There were 171 patients (98 intervention, 73 control). Quality of life, self-efficacy and disease-specific measures did not change significantly, while anxiety and depression both decreased significantly with the intervention. Hospital admissions, days in hospital, emergency department visits, outpatient visits and costs did not differ significantly between the groups. Patients at all sites were universally positive. Many felt safer and more cared-for, and said that they and their family had learned more about managing their condition. Staff could all see potential benefits of telecare, and, after some initial technical problems, many staff felt that telecare enabled them to effectively monitor more patients. Strongly positive patient and staff experiences and attitudes complement and contrast with small or non-significant quantitative changes. Telecare led to patients and families taking a more active role in self-management. It is likely that subgroups of patients benefitted in ways that were not measured or visible within the quantitative data, especially feelings of safety and being cared-for. Australian New Zealand Clinical Trials Registry ACTRN12610000269033.

Enablers and challenges to occupational therapists’ research engagement: A qualitative study

PubMed Central

Di Bona, Laura; Wenborn, Jennifer; Field, Becky; Hynes, Sinéad M; Ledgerd, Ritchard; Mountain, Gail; Swinson, Tom

2017-01-01

Introduction To develop occupational therapy’s evidence base and improve its clinical outcomes, occupational therapists must increase their research involvement. Barriers to research consumption and leadership are well documented, but those relating to delivering research interventions, less so. Yet, interventions need to be researched within practice to demonstrate their clinical effectiveness. This study aims to improve understanding of challenges and enablers experienced by occupational therapists who deliver interventions within research programmes. Method Twenty-eight occupational therapists who participated in the Valuing Active Life in Dementia (VALID) research programme reported their experiences in five focus groups. Data were analysed thematically to identify key and subthemes. Results Occupational therapists reported that overwhelming paperwork, use of videos, recruitment and introducing a new intervention challenged their research involvement, whereas support, protected time and a positive attitude enabled it. The impact of these challenges and enablers varied between therapists and organisations. Conclusion Challenges and enablers to research involvement can be identified but must be addressed within individual and organisational contexts. Multifaceted collective action to minimise challenges and maximise enablers can facilitate clinicians’ involvement in research. Using this approach should enable occupational therapists to increase their research involvement, thus demonstrating the clinical effectiveness of their interventions. PMID:29170592

Application of PACE Principles for Population Health Management of Frail Older Adults.

PubMed

Stefanacci, Richard G; Reich, Shelley; Casiano, Alex

2015-10-01

To determine which practices would have the most impact on reducing hospital and emergency department admissions and nursing home placement among older adults with multiple comorbid conditions, a literature search and survey were conducted to identify and prioritize comprehensive care principles as practiced in the Program of All-inclusive Care for the Elderly (PACE). PACE medical directors and members of the PACE interdisciplinary team (IDT) were surveyed to gain their insights on the most impactful practices, which were identified as: End-of-Life Management, Caregiver Support, Management of Red Flags, Medication Management, Participant and Caregiver Health Care System Literacy, and Care Coordination. In addition, this research evaluated measures that could be used to assess an organization's level of success with regard to each of the 6 PACE practices identified. The results reported in this article, found through a survey with PACE medical directors and IDT members concerning effective interventions, can be viewed as strategies to improve care for older adults, enabling them to maintain their independence in the community, avoid the expense of facility-based care, and enhance their quality of life.

Barriers within the health care system to dealing with sexualized violence: a literature review.

PubMed

Rönnberg, A K; Hammarström, A

2000-09-01

The aim of this study was to review the literature about possible barriers to recognition and intervention regarding women exposed to sexualized violence, in their interactions with the health care system. The barriers, as reported by the health care staff, were: lack of education; the stereotype of a "typical battered woman"; too close identification with the victim/abuser; time constraints; fear of offending the victim/abuser; and feelings of hopelessness and non-responsibility. The barriers, as reported by the victims, were: negative experiences of and structural limitations within the health care system; fear of retaliation from the abusive partner; and psychological effects of the normalization process. We conclude that the barriers within the health care sector have to be dealt with on three different levels: the structural level in order to diminish male power in society; the organizational level in order to initiate screening and to allow the staff time for dealing with the victims; and on the individual level, health care staff need to acquire the knowledge and skills to enable them to address sexualized violence.

High-risk population health management--achieving improved patient outcomes and near-term financial results.

PubMed

Lynch, J P; Forman, S A; Graff, S; Gunby, M C

2000-07-01

A managed care organization sought to achieve efficiencies in care delivery and cost savings by anticipating and better caring for its frail and least stable members. Time sequence case study of program intervention across an entire managed care population in its first year compared with the prior baseline year. Key attributes of the intervention included predictive registries of at-risk members based on existing data, relentless focus on the high-risk group, an integrated clinical and psychosocial approach to assessments and are planning, a reengineered care management process, secured Internet applications enabling rapid implementation and broad connectivity, and population-based outcomes metrics derived from widely used measures of resource utilization and functional status. Concentrating on the highest-risk group, which averaged just 1.1% prevalence in the total membership, yielded bottom line results. When the year before program implementation (July 1997 through June 1998) was compared with the subsequent year, the total population's annualized commercial admission rate was reduced 5.3%, and seniors' was reduced 3.0%. A claims-paid analysis exclusively of the highest-risk group revealed that their efficiencies and savings overwhelmingly contributed to the membershipwide effect. This subgroup's costs dropped 35.7% from preprogram levels of $2590 per member per month (excluding pharmaceuticals). During the same time, patient-derived cross-sectional functional status rose 12.5%. A sharply focused, Internet-deployed case management strategy achieved economic and functional status results on a population basis and produced systemwide savings in its first year of implementation.

Web-based self-management for patients with multiple sclerosis: a practical, randomized trial.

PubMed

Miller, Deborah M; Moore, Shirley M; Fox, Robert J; Atreja, Ashish; Fu, Alex Z; Lee, Jar-Chi; Saupe, Welf; Stadtler, Maria; Chakraborty, Swati; Harris, C M; Rudick, Richard A

2011-01-01

No studies have addressed the use of electronic personal health records (e-PHRs) for self-management in complex neurological disorders. We assessed and tested an Internet-based self-management system that utilized the e-PHR and determined its impact on self-assessed well-being, clinician-assessed well-being, and healthcare utilization in patients with multiple sclerosis (MS). Subjects were randomized to usual care (a secure Web-based messaging system) or active intervention, which included secure messaging, self-monitoring, self-management of MS symptoms, and communication about upcoming clinic visits. Computers and Internet access were provided. Subjects were included if they had MS, lived within the county or region surrounding our MS center, had at least two appointments at our center in the previous 12 months, and demonstrated basic typing and computer skills. Study duration was 12 months. Of 220 subjects completing informed consent, 206 met the inclusion criteria. At the study's end, 83 subjects remained in the usual care group and 84 in the enhanced care group. Both groups used the available system components. The groups did not significantly differ on the primary endpoints or healthcare utilization. Self-management support is an emerging aspect of chronic care management. We established the feasibility of conducting a randomized, controlled trial using e-PHRs for patient self-management. We did not find that e-PHR-enabled self-management augmented multidisciplinary MS center-based care, possibly because the differences between interventions were not great enough.

Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events.

PubMed

Olson, Andrew P J; Graber, Mark L; Singh, Hardeep

2018-01-29

Diagnostic error is a prevalent, harmful, and costly phenomenon. Multiple national health care and governmental organizations have recently identified the need to improve diagnostic safety as a high priority. A major barrier, however, is the lack of standardized, reliable methods for measuring diagnostic safety. Given the absence of reliable and valid measures for diagnostic errors, we need methods to help establish some type of baseline diagnostic performance across health systems, as well as to enable researchers and health systems to determine the impact of interventions for improving the diagnostic process. Multiple approaches have been suggested but none widely adopted. We propose a new framework for identifying "undesirable diagnostic events" (UDEs) that health systems, professional organizations, and researchers could further define and develop to enable standardized measurement and reporting related to diagnostic safety. We propose an outline for UDEs that identifies both conditions prone to diagnostic error and the contexts of care in which these errors are likely to occur. Refinement and adoption of this framework across health systems can facilitate standardized measurement and reporting of diagnostic safety.

Getting evidence-based pressure ulcer prevention into practice: a process evaluation of a multifaceted intervention in a hospital setting.

PubMed

Sving, Eva; Fredriksson, Lennart; Gunningberg, Lena; Mamhidir, Anna-Greta

2017-10-01

To describe registered nurses', assistant nurses' and first-line managers' experiences and perceptions of a multifaceted hospital setting intervention focused on implementing evidence-based pressure ulcer prevention. Pressure ulcer prevention is deficient. Different models exist to support implementation of evidence-based care. Little is known about implementation processes. A descriptive qualitative approach. Five focus-group nurse interviews and five individual first-line manager interviews were conducted at five Swedish hospital units. Qualitative content analysis was used. The findings support that the intervention and the implementation process changed the understanding and way of working with pressure ulcer prevention: from treating to preventing. This became possible as 'Changed understanding enables changed actions - through one's own performance and reflection on pressure ulcer prevention'. Having a common outlook on pressure ulcer prevention, easy access to pressure-reducing equipment, and external and internal facilitator support were described as important factors for changed practices. Bedside support, feedback and discussions on current results increased the awareness of needed improvements. The multifaceted intervention approach and the participants' positive attitudes seemed to be crucial for changing understanding and working more preventatively. The strategies used and the skills of the facilitators need to be tailored to the problems surrounding the context. Feedback discussions among the staff regarding the results of the care provided also appear to be vital. It is crucial that dedicated facilitators are involved to promote the implementation process. A preventative mindset should be strived for. Creating an implementation plan with an outcome and a process evaluation should be emphasised. It is important to give the staff regular feedback on the quality of care and on those occasions allocate time for discussion and reflection. © 2016 John Wiley & Sons Ltd.

Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial.

PubMed

Yotebieng, Marcel; Behets, Frieda; Kawende, Bienvenu; Ravelomanana, Noro Lantoniaina Rosa; Tabala, Martine; Okitolonda, Emile W

2017-04-26

Despite the rapid adoption of the World Health Organization's 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum. The aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics. If proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation. The protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669 .

Case management by nurses in primary care: analysis of 73 'success stories'.

PubMed

Elwyn, Glyn; Williams, Meryl; Roberts, Catherine; Newcombe, Robert G; Vincent, Judith

2008-01-01

There is interest as to whether case management reduces unplanned patient admission to hospital. However, very little is known about how the intervention is delivered and what the most salient outcome measures are. Qualitative study embedded in a wider evaluation. Primary health care. Analysis of case manager case reports in a service innovation evaluation study. Case management provides home-based care to frail elderly patients using a process of assessment and medication review. This often leads to new diagnoses, to the co-ordination of further care and the tailoring of services to suit the needs of individuals. The benefits reported are complex and relate to improving a patient's quality of life more than the prevention or otherwise of admission to hospital. The type of attention provided by these roles seems to be absent from current NHS arrangements. The role enables time to be spent assessing the individual needs of patients who live at the margins of independent living. The case managers describe having the time and the skills to assess a mix of clinical and social problems, and then accessing the correct networks to help elderly people with multiple illnesses navigate a complex system of providers. More weight should be given to the ability of this intervention to result in improved quality of life for patients, and to the investigation of costs and benefits.

Operational challenges in conducting a community-based technology-enabled mental health services delivery model for rural India: Experiences from the SMART Mental Health Project.

PubMed

Maulik, Pallab K; Kallakuri, Sudha; Devarapalli, Siddhardha

2018-01-01

Background: There are large gaps in the delivery of mental health care in low- and middle-income countries such as India, and the problems are even more acute in rural settings due to lack of resources, remoteness, and lack of infrastructure, amongst other factors. The Systematic Medical Appraisal Referral and Treatment (SMART) Mental Health Project was conceived as a mental health services delivery model using technology-based solutions for rural India. This paper reports on the operational strategies used to facilitate the implementation of the intervention. Method: Key components of the SMART Mental Health Project included delivering an anti-stigma campaign, training of primary health workers in screening, diagnosing and managing stress, depression and increased suicide risk and task sharing of responsibilities in delivering care; and using mobile technology based electronic decision support systems to support delivery of algorithm based care for such disorders. The intervention was conducted in 42 villages across two sites in the state of Andhra Pradesh in south India. A pre-post mixed methods evaluation was done, and in this paper operational challenges are reported. Results: Both quantitative and qualitative results from the evaluation from one site covering about 5000 adults showed that the intervention was feasible and acceptable, and initial results indicated that it was beneficial in increasing access to mental health care and reducing depression and anxiety symptoms. A number of strategies were initiated in response to operational challenges to ensure smoother conduct of the project and facilitated the project to be delivered as envisaged. Conclusions: The operational strategies initiated for this project were successful in ensuring the delivery of the intervention. Those, coupled with other more systematic processes have informed the researchers to understand key processes that need to be in place to develop a more robust study, that could eventually be scaled up.

Implementation of an evidence-based intervention to improve the wellbeing of people with dementia and their carers: study protocol for 'Care of People with dementia in their Environments (COPE)' in the Australian context.

PubMed

Clemson, Lindy; Laver, Kate; Jeon, Yun-Hee; Comans, Tracy A; Scanlan, Justin; Rahja, Miia; Culph, Jennifer; Low, Lee-Fay; Day, Sally; Cations, Monica; Crotty, Maria; Kurrle, Susan; Piersol, Catherine; Gitlin, Laura N

2018-05-09

There are effective non-pharmacological treatment programs that reduce functional disability and changed behaviours in people with dementia. However, these programs (such as the Care of People with dementia in their Environments (COPE) program) are not widely available. The primary aim of this study is to determine the strategies and processes that enable the COPE program to be implemented into existing dementia care services in Australia. This study uses a mixed methods approach to test an implementation strategy. The COPE intervention (up to ten consultations with an occupational therapist and up to two consultations with a nurse) will be implemented using a number of strategies including planning (such as developing and building relationships with dementia care community service providers), educating (training nurses and occupational therapists in how to apply the intervention), restructuring (organisations establishing referral systems; therapist commitment to provide COPE to five clients following training) and quality management (coaching, support, reminders and fidelity checks). Qualitative and quantitative data will contribute to understanding how COPE is adopted and implemented. Feasibility, fidelity, acceptability, uptake and service delivery contexts will be explored and a cost/benefit evaluation conducted. Client outcomes of activity engagement and caregiver wellbeing will be assessed in a pragmatic pre-post evaluation. While interventions that promote independence and wellbeing are effective and highly valued by people with dementia and their carers, access to such programs is limited. Barriers to translation that have been previously identified are addressed in this study, including limited training opportunities and a lack of confidence in clinicians working with complex symptoms of dementia. A strength of the study is that it involves implementation within different types of existing services, such as government and private providers, so the study will provide useful guidance for further future rollout. 16 February 2017; ACTRN12617000238370 .

Dementia care initiative in primary practice – study protocol of a cluster randomized trial on dementia management in a general practice setting

PubMed Central

Holle, Rolf; Gräßel, Elmar; Ruckdäschel, Stefan; Wunder, Sonja; Mehlig, Hilmar; Marx, Peter; Pirk, Olaf; Butzlaff, Martin; Kunz, Simone; Lauterberg, Jörg

2009-01-01

Background Current guidelines for dementia care recommend the combination of drug therapy with non-pharmaceutical measures like counselling and social support. However, the scientific evidence concerning non-pharmaceutical interventions for dementia patients and their informal caregivers remains inconclusive. Targets of modern comprehensive dementia care are to enable patients to live at home as long and as independent as possible and to reduce the burden of caregivers. The objective of the study is to compare a complex intervention including caregiver support groups and counselling against usual care in terms of time to nursing home placement. In this paper the study protocol is described. Methods/Design The IDA (Initiative Demenzversorgung in der Allgemeinmedizin) project is designed as a three armed cluster-randomized trial where dementia patients and their informal caregivers are recruited by general practitioners. Patients in the study region of Middle Franconia, Germany, are included if they have mild or moderate dementia, are at least 65 years old, and are members of the German AOK (Allgemeine Ortskrankenkasse) sickness fund. In the control group patients receive regular treatment, whereas in the two intervention groups general practitioners participate in a training course in evidence based dementia treatment, recommend support groups and offer counseling to the family caregivers either beginning at baseline or after the 1-year follow-up. The study recruitment and follow-up took place from July 2005 to January 2009. 303 general practitioners were randomized of which 129 recruited a total of 390 patients. Time to nursing home admission within the two year intervention and follow-up period is the primary endpoint. Secondary endpoints are cognitive status, activities of daily living, burden of care giving as well as healthcare costs. For an economic analysis from the societal perspective, data are collected from caregivers as well as by the use of routine data from statutory health insurance and long-term care insurance. Discussion From a public health perspective, the IDA trial is expected to lead to evidence based results on the community effectiveness of non-pharmaceutical support measures for dementia patients and their caregivers in the primary care sector. For health policy makers it is necessary to make their decisions about financing new services based on strong knowledge about the acceptance of measures in the population and their cost-effectiveness. Trial registration ISRCTN68329593 PMID:19500383

Implementing Self-Management within a Group Counseling Context: Effects on Academic Enabling Behaviors

ERIC Educational Resources Information Center

Briesch DuBois, Jacquelyn M.; Briesch, Amy M.; Hoffman, Jessica A.; Struzziero, Joan; Toback, Robin

2017-01-01

Self-management interventions have been adapted to serve as targeted interventions to increase academic enabling behaviors in groups of students. However, a trade-off exists between adapting these interventions to feasibly fit group contexts and maintaining theoretical intervention components. This study examines the use of self-management within…

Introducing PALETTE: an iterative method for conducting a literature search for a review in palliative care.

PubMed

Zwakman, Marieke; Verberne, Lisa M; Kars, Marijke C; Hooft, Lotty; van Delden, Johannes J M; Spijker, René

2018-06-02

In the rapidly developing specialty of palliative care, literature reviews have become increasingly important to inform and improve the field. When applying widely used methods for literature reviews developed for intervention studies onto palliative care, challenges are encountered such as the heterogeneity of palliative care in practice (wide range of domains in patient characteristics, stages of illness and stakeholders), the explorative character of review questions, and the poorly defined keywords and concepts. To overcome the challenges and to provide guidance for researchers to conduct a literature search for a review in palliative care, Palliative cAre Literature rEview iTeraTive mEthod (PALLETE), a pragmatic framework, was developed. We assessed PALETTE with a detailed description. PALETTE consists of four phases; developing the review question, building the search strategy, validating the search strategy and performing the search. The framework incorporates different information retrieval techniques: contacting experts, pearl growing, citation tracking and Boolean searching in a transparent way to maximize the retrieval of literature relevant to the topic of interest. The different components and techniques are repeated until no new articles are qualified for inclusion. The phases within PALETTE are interconnected by a recurrent process of validation on 'golden bullets' (articles that undoubtedly should be part of the review), citation tracking and concept terminology reflecting the review question. To give insight in the value of PALETTE, we compared PALETTE with the recommended search method for reviews of intervention studies. By using PALETTE on two palliative care literature reviews, we were able to improve our review questions and search strategies. Moreover, in comparison with the recommended search for intervention reviews, the number of articles needed to be screened was decreased whereas more relevant articles were retrieved. Overall, PALETTE helped us in gaining a thorough understanding of the topic of interest and made us confident that the included studies comprehensively represented the topic. PALETTE is a coherent and transparent pragmatic framework to overcome the challenges of performing a literature review in palliative care. The method enables researchers to improve question development and to maximise both sensitivity and precision in their search process.

Team working in intensive care: current evidence and future endeavors.

PubMed

Richardson, Joanne; West, Michael A; Cuthbertson, Brian H

2010-12-01

It has recently been argued that the future of intensive care medicine will rely on high quality management and teamwork. Therefore, this review takes an organizational psychology perspective to examine the most recent research on the relationship between teamwork, care processes, and patient outcomes in intensive care. Interdisciplinary communication within a team is crucial for the development of negotiated shared treatment goals and short-team patient outcomes. Interventions for maximizing team communication have received substantial interest in recent literature. Intensive care coordination is not a linear process, and intensive care teams often fail to discuss how to implement goals, trigger and align activities, or reflect on their performance. Despite a move toward interdisciplinary team working, clinical decision-making is still problematic and continues to be perceived as a top-down and authoritative process. The topic of team leadership in intensive care is underexplored and requires further research. Based on findings from the most recent research evidence in medicine and management, four principles are identified for improving the effectiveness of team working in intensive care: engender professional efficacy, create stable teams and leaders, develop trust and participative safety, and enable frequent team reflexivity.

Women’s Sleep Disorders: Integrative Care

PubMed Central

Frange, Cristina; Banzoli, Carolina Vicente; Colombo, Ana Elisa; Siegler, Marcele; Coelho, Glaury; Bezerra, Andréia Gomes; Csermak, Marcelo; Naufel, Maria Fernanda; Cesar-Netto, Cristiana; Andersen, Monica Levy; Girão, Manoel João Batista Castelo; Tufik, Sergio; Hachul, Helena

2017-01-01

The integrative care model is rooted in a biopsychosocial approach. Integrative is a term which refers to increasing the harmony and coherence of your whole being, and integrative care is therefore focused on the person, not on either the disease or a therapy. It is provided collaboratively by a health team comprising physicians, psychologists, physiotherapists, acupuncturists, and meditation, nutrition, and floral therapy. Previous studies have demonstrated that interventions based on the integrative care model improved womens lifestyle and quality of life. Our aim was to describe the use of complementary and alternative medicine (CAM) alongside traditional medicine among women with sleep conditions in our Womens Sleep Disorders Integrative Treatment Outpatient Clinic. We are sharing our experiences and clinical practice as the model we developed seems to have both physical and psychological benefits for women with sleep problems. We discuss the wide range of benefits that result from this type of complex intervention, and the contextual factors that may influence these benefits. This will inform future practitioners and we hope to contribute to quantitative research in the clinical setting. The study highlights the importance of treating sleep complaints with a caring relationship and a CAM approach, alongside conventional medicine. Exploration of the lived experience of CAM and its meaning enables healthcare professionals to gain insights into the patients needs, preferences, and values. Gynecologists, clinicians, and health care providers should support and guide patients in their decision to use CAM by providing evidence-based and comprehensive advice on the potential benefits, risks and related safety issues of this approach. PMID:29410750

A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia.

PubMed

Wenger, Neil S; Roth, Carol P; Shekelle, Paul G; Young, Roy T; Solomon, David H; Kamberg, Caren J; Chang, John T; Louie, Rachel; Higashi, Takahiro; MacLean, Catherine H; Adams, John; Min, Lillian C; Ransohoff, Kurt; Hoffing, Marc; Reuben, David B

2009-03-01

To determine whether a practice-based intervention can improve care for falls, urinary incontinence, and cognitive impairment. Controlled trial. Two community medical groups. Community-dwelling patients (357 at intervention sites and 287 at control sites) aged 75 and older identified as having difficulty with falls, incontinence, or cognitive impairment. Intervention and control practices received condition case-finding, but only intervention practices received a multicomponent practice-change intervention. Percentage of quality indicators satisfied measured using a 13-month medical record abstraction. Before the intervention, the quality of care was the same in intervention and control groups. Screening tripled the number of patients identified as needing care for falls, incontinence, or cognitive impairment. During the intervention, overall care for the three conditions was better in the intervention than the control group (41%, 95% confidence interval (CI)=35-46% vs 25%, 95% CI=20-30%, P<.001). Intervention group patients received better care for falls (44% vs 23%, P<.001) and incontinence (37% vs 22%, P<.001) but not for cognitive impairment (44% vs 41%, P=.67) than control group patients. The intervention was more effective for conditions identified by screening than for conditions identified through usual care. A practice-based intervention integrated into usual clinical care can improve primary care for falls and urinary incontinence, although even with the intervention, less than half of the recommended care for these conditions was provided. More-intensive interventions, such as embedding intervention components into an electronic medical record, will be needed to adequately improve care for falls and incontinence.

Agent-based human-robot interaction of a combat bulldozer

NASA Astrophysics Data System (ADS)

Granot, Reuven; Feldman, Maxim

2004-09-01

A small-scale supervised autonomous bulldozer in a remote site was developed to experience agent based human intervention. The model is based on Lego Mindstorms kit and represents combat equipment, whose job performance does not require high accuracy. The model enables evaluation of system response for different operator interventions, as well as for a small colony of semiautonomous dozers. The supervising human may better react than a fully autonomous system to unexpected contingent events, which are a major barrier to implement full autonomy. The automation is introduced as improved Man Machine Interface (MMI) by developing control agents as intelligent tools to negotiate between human requests and task level controllers as well as negotiate with other elements of the software environment. Current UGVs demand significant communication resources and constant human operation. Therefore they will be replaced by semi-autonomous human supervisory controlled systems (telerobotic). For human intervention at the low layers of the control hierarchy we suggest a task oriented control agent to take care of the fluent transition between the state in which the robot operates and the one imposed by the human. This transition should take care about the imperfections, which are responsible for the improper operation of the robot, by disconnecting or adapting them to the new situation. Preliminary conclusions from the small-scale experiments are presented.

Population-based breast cancer screening in a primary care network

PubMed Central

Atlas, Steven J.; Ashburner, Jeffrey M.; Chang, Yuchiao; Lester, William T.; Barry, Michael J.; Grant, Richard W.

2013-01-01

Objective To assess up to 3-year follow-up of a health information technology system that facilitated population-based breast cancer screening. Study Design Cohort study with 2-year follow-up after completing a 1-year cluster randomized trial. Methods Women 42-69 years old receiving care within a 12-practice primary care network. The trial tested an integrated, non-visit-based population management informatics system that: 1) identified women overdue for mammograms, 2) connected them to primary care providers using a Web-based tool, 3) created automatically-generated outreach letters for patients specified by providers, 4) monitored for subsequent mammography scheduling and completion, and 5) provided practice delegates a list of women remaining unscreened for reminder phone calls. All practices also provided visit-based cancer screening reminders. Eligible women overdue for a mammogram during a one-year study period included those overdue at study start (prevalent cohort) or becoming overdue during follow-up (incident cohort). The main outcome measure was mammography completion rates over three years. Results Among 32,688 eligible women, 9,795 (30%) were overdue for screening including 4,487 in intervention and 5,308 in control practices. Intervention patients were somewhat younger, more likely to be non-Hispanic white, and have health insurance compared to control patients. Among patients in the prevalent cohort (n=6,697), adjusted completion rates were significantly higher among intervention compared to control patients after 3 years (51.7% vs. 45.8%, p=0.002). For patients in the incident cohort (n=3,098), adjusted completion rates after 2 years were 53.8% vs. 48.7%, p=0.052, respectively. Conclusions Population-based informatics systems can enable sustained increases in mammography screening rates beyond that seen with office-based visit reminders. PMID:23286611

Forging a pediatric primary care-community partnership to support food-insecure families.

PubMed

Beck, Andrew F; Henize, Adrienne W; Kahn, Robert S; Reiber, Kurt L; Young, John J; Klein, Melissa D

2014-08-01

Academic primary care clinics often care for children from underserved populations affected by food insecurity. Clinical-community collaborations could help mitigate such risk. We sought to design, implement, refine, and evaluate Keeping Infants Nourished and Developing (KIND), a collaborative intervention focused on food-insecure families with infants. Pediatricians and community collaborators codeveloped processes to link food-insecure families with infants to supplementary infant formula, educational materials, and clinic and community resources. Intervention evaluation was done prospectively by using time-series analysis and descriptive statistics to characterize and enumerate those served by KIND during its first 2 years. Analyses assessed demographic, clinical, and social risk outcomes, including completion of preventive services and referral to social work or our medical-legal partnership. Comparisons were made between those receiving and not receiving KIND by using χ2 statistics. During the 2-year study period, 1042 families with infants received KIND. Recipients were more likely than nonrecipients to have completed a lead test and developmental screen (both P < .001), and they were more likely to have received a full set of well-infant visits by 14 months (42.0% vs. 28.7%; P < .0001). Those receiving KIND also were significantly more likely to have been referred to social work (29.2% vs. 17.6%; P < .0001) or the medical-legal partnership (14.8% vs. 5.7%; P < .0001). Weight-for-length at 9 months did not statistically differ between groups. A clinical-community collaborative enabled pediatric providers to address influential social determinants of health. This food insecurity-focused intervention was associated with improved preventive care outcomes for the infants served. Copyright © 2014 by the American Academy of Pediatrics.

The present and future of cardiac arrest care: international experts reach out to caregivers and healthcare authorities.

PubMed

Nolan, Jerry P; Berg, Robert A; Callaway, Clifton W; Morrison, Laurie J; Nadkarni, Vinay; Perkins, Gavin D; Sandroni, Claudio; Skrifvars, Markus B; Soar, Jasmeet; Sunde, Kjetil; Cariou, Alain

2018-06-02

The purpose of this review is to describe the epidemiology of out-of-hospital cardiac arrest (OHCA), disparities in organisation and outcome, recent advances in treatment and ongoing controversies. We also outline the standard of care that should be provided by the critical care specialist and propose future directions for cardiac arrest research. Narrative review with contributions from international resuscitation experts. Although it is recognised that survival rates from OHCA are increasing there is considerable scope for improvement and many countries have implemented national strategies in an attempt to achieve this goal. More resources are required to enable high-quality randomised trials in resuscitation. Increasing international collaboration should facilitate resuscitation research and knowledge translation. The International Liaison Committee on Resuscitation (ILCOR) has adopted a continuous evidence review process, which facilitate the implementation of resuscitation interventions proven to improve patient outcomes.

GEROM – Developing a Contemporary On-line Master’s Degree Curriculum in Gerontology

PubMed Central

Kokol, Peter; Blažun, Helena

2012-01-01

Demographic changes have profoundly influenced the structure of present and future populations in terms of the number of older people requiring nursing care, the nature and settings of the nursing care provided, and finally, each individual, e. g., nursing care providers. The aim of the paper is to present the results of the EU Erasmus project GEROM, which, among other things, resulted in an on-line gerontological master’s degree curriculum which is globally focused, flexible, innovative, diverse, contemporary and ICT-based. It focuses on meeting the needs of older people and their carers. An innovative aspect in the curriculum implementation is a virtual environment for clinical practice, enabling students to practice clinical and nursing interventions and diagnosing on-line, based on an adaptive, individualized and personalized blended-learning approach. During the pilot implementation of three randomly selected subjects, the students evaluated the program and were satisfied with both content and implementation. PMID:24199089

Enabling sense-making for patients receiving outpatient palliative treatment: A participatory action research driven model for person-centered communication.

PubMed

Öhlén, J; Carlsson, G; Jepsen, A; Lindberg, I; Friberg, F

2016-06-01

In clinical palliative cancer care, the diversity of patient concerns over time makes information provision a critical issue, the demands of information-seeking patients presenting a challenge to both the communicative and organizational skills of the health provider. This study puts forward a practice model for communication between patients, their family members, and professional health providers during ongoing palliative chemotherapy; a model which supports the providers in enabling person-centered communication. A constant comparative analysis adapted to participatory action research was applied. The model was developed step-wise in three interrelated cycles, with results from previous studies from palliative cancer care processed in relation to professional health providers' experience-based clinical knowledge. In doing this, focus group discussions were carried out with providers and patients to develop and revise the model. The Enabling Sense Making model for person-centered communication gave rise to three domains (which are also the major communicative actors in palliative care): the patient, the family, and the provider. These actors were placed in the context of a communicative arena. The three respective domains were built up in different layers discriminating between significant aspects of person-centered communication, from the manifest that is most usually explicated in dialogues, to the latent that tends to be implicitly mediated. The model intends to facilitate timely reorientation of care from curative treatment or rehabilitation to palliation, as well as the introduction of appropriate palliative interventions over time during palliative phases. In this way the model is to be regarded a frame for directing the awareness of the professionals, which focuses on how to communicate and how to consider the patient's way of reasoning. The model could be used as a complement to other strategic initiatives for the advancement of palliative care communication. It needs to be further evaluated in regard to practice evidence.

Barriers and enablers in primary care clinicians' management of osteoarthritis: protocol for a systematic review and qualitative evidence synthesis.

PubMed

Egerton, T; Diamond, L; Buchbinder, R; Bennell, K; Slade, S C

2016-05-27

Osteoarthritis is a highly prevalent and disabling condition. Primary care management of osteoarthritis is generally suboptimal despite evidence for several modestly effective interventions and the availability of high-quality clinical practice guidelines. This report describes a planned study to synthesise the views of primary care clinicians on the barriers and enablers to following recommended management of osteoarthritis, with the aim of providing new interpretations that may facilitate the uptake of recommended treatments, and in turn improve patient care. A systematic review and meta-synthesis of qualitative studies. 5 databases will be searched using key search terms for qualitative research, evidence-based practice, clinical practice guidelines, osteoarthritis, beliefs, perceptions, barriers, enablers and adherence. A priori inclusion/exclusion criteria include availability of data from primary care clinicians, reports on views regarding management of osteoarthritis, and studies using qualitative methods for both data collection and analysis. At least 2 independent reviewers will identify eligible reports, conduct a critical appraisal of study conduct, extract data and synthesise reported findings and interpretations. Synthesis will follow thematic analysis within a grounded theory framework of inductive coding and iterative theme identification. The reviewers plus co-authors will contribute to the meta-synthesis to find new themes and theories. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach will be used to determine a confidence profile of each finding from the meta-synthesis. The protocol has been registered on PROSPERO and is reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P) guidelines. Ethical approval is not required. The systematic review will be published in a peer-reviewed journal. The results will help to inform policy and practice and assist in the optimisation of management for people with osteoarthritis. CRD42015027543. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals.

PubMed

Chaves, N J; Cheng, A C; Runnegar, N; Kirschner, J; Lee, T; Buising, K

2014-06-01

Antimicrobial stewardship programmes aim to optimise use of antibiotics and are now mandatory in all Australian hospitals. We aimed to identify barriers to and enablers of appropriate antimicrobial prescribing among hospital doctors. Two paper-based and one web-based surveys were administered at three Australian university teaching hospitals from March 2010 to May 2011. The 18-item questionnaire recorded doctors’ level of experience, their knowledge regarding the use of common antimicrobials and their attitudes regarding antimicrobial prescribing. Local survey modifications allowed inclusion of specific questions on: infections in intensive care unit patients, clinical microbiology and use of local guidelines. The respondents (n = 272) were comprised of 96 (35%) registrars, 67 (25%)residents, 57 (21%) interns and 47 (17%) consultant hospital doctors. Forty-one per cent were working in a medical specialty. Identified barriers included: gaps in antimicrobial prescribing knowledge (especially among interns), a lack of awareness about which antimicrobials were restricted and a reliance on senior colleagues to make antimicrobial prescribing decisions. Enablers of optimal prescribing included: an acknowledgement of the need for assistance in prescribing and reported readiness to consult national prescribing guidelines. These results were used to help guide and prioritise interventions to improve prescribing practices. A transferable knowledge and attitudes survey tool can be used to highlight barriers and facilitators to optimal hospital antimicrobial prescribing in order to inform tailored antimicrobial stewardship interventions.

Data Collection and Harmonization in HIV Research: The Seek, Test, Treat, and Retain Initiative at the National Institute on Drug Abuse.

PubMed

Chandler, Redonna K; Kahana, Shoshana Y; Fletcher, Bennett; Jones, Dionne; Finger, Matthew S; Aklin, Will M; Hamill, Kathleen; Webb, Candace

2015-12-01

Large-scale, multisite data sets offer the potential for exploring the public health benefits of biomedical interventions. Data harmonization is an emerging strategy to increase the comparability of research data collected across independent studies, enabling research questions to be addressed beyond the capacity of any individual study. The National Institute on Drug Abuse recently implemented this novel strategy to prospectively collect and harmonize data across 22 independent research studies developing and empirically testing interventions to effectively deliver an HIV continuum of care to diverse drug-abusing populations. We describe this data collection and harmonization effort, collectively known as the Seek, Test, Treat, and Retain Data Collection and Harmonization Initiative, which can serve as a model applicable to other research endeavors.

Personalized In Vitro and In Vivo Cancer Models to Guide Precision Medicine | Office of Cancer Genomics

Cancer.gov

Precision medicine is an approach that takes into account the influence of individuals' genes, environment, and lifestyle exposures to tailor interventions. Here, we describe the development of a robust precision cancer care platform that integrates whole-exome sequencing with a living biobank that enables high-throughput drug screens on patient-derived tumor organoids. To date, 56 tumor-derived organoid cultures and 19 patient-derived xenograft (PDX) models have been established from the 769 patients enrolled in an Institutional Review Board-approved clinical trial.

Optimal patient education for cancer pain: a systematic review and theory-based meta-analysis.

PubMed

Marie, N; Luckett, T; Davidson, P M; Lovell, M; Lal, S

2013-12-01

Previous systematic reviews have found patient education to be moderately efficacious in decreasing the intensity of cancer pain, but variation in results warrants analysis aimed at identifying which strategies are optimal. A systematic review and meta-analysis was undertaken using a theory-based approach to classifying and comparing educational interventions for cancer pain. The reference lists of previous reviews and MEDLINE, PsycINFO, and CENTRAL were searched in May 2012. Studies had to be published in a peer-reviewed English language journal and compare the effect on cancer pain intensity of education with usual care. Meta-analyses used standardized effect sizes (ES) and a random effects model. Subgroup analyses compared intervention components categorized using the Michie et al. (Implement Sci 6:42, 2011) capability, opportunity, and motivation behavior (COM-B) model. Fifteen randomized controlled trials met the criteria. As expected, meta-analysis identified a small-moderate ES favoring education versus usual care (ES, 0.27 [-0.47, -0.07]; P = 0.007) with substantial heterogeneity (I² = 71 %). Subgroup analyses based on the taxonomy found that interventions using "enablement" were efficacious (ES, 0.35 [-0.63, -0.08]; P = 0.01), whereas those lacking this component were not (ES, 0.18 [-0.46, 0.10]; P = 0.20). However, the subgroup effect was nonsignificant (P = 0.39), and heterogeneity was not reduced. Factoring in the variable of individualized versus non-individualized influenced neither efficacy nor heterogeneity. The current meta-analysis follows a trend in using theory to understand the mechanisms of complex interventions. We suggest that future efforts focus on interventions that target patient self-efficacy. Authors are encouraged to report comprehensive details of interventions and methods to inform synthesis, replication, and refinement.

Multidisciplinary approach to the diagnosis and management of patients with peripheral arterial disease

PubMed Central

Walker, Craig M; Bunch, Frank T; Cavros, Nick G; Dippel, Eric J

2015-01-01

Peripheral arterial disease (PAD) is frequently diagnosed after permanent damage has occurred, resulting in a high rate of morbidity, amputation, and loss of life. Early and ongoing diagnosis and treatment is required for this progressive disease. Lifestyle modifications can prevent or delay disease progression and improve symptoms. Limb-sparing endovascular interventions can restore circulation based on appropriate diagnostic testing to pinpoint vascular targets, and intervention must occur as early as possible to ensure optimal clinical outcomes. An algorithm for the diagnosis and management of PAD was developed to enable a collaborative approach between the family practice and primary care physician or internist and various specialists that may include a diabetologist, endocrinologist, smoking cessation expert, hypertension and lipid specialist, endovascular interventionalist, vascular surgeon, orthopedist, neurologist, nurse practitioner, podiatrist, wound healing expert, and/or others. A multidisciplinary team working together has the greatest chance of providing optimal care for the patient with PAD and ensuring ongoing surveillance of the patient’s overall health, ultimately resulting in better quality of life and increased longevity for patients with PAD. PMID:26203234

Achieving Good Outcomes for Asthma Living (GOAL): mixed methods feasibility and pilot cluster randomised controlled trial of a practical intervention for eliciting, setting and achieving goals for adults with asthma.

PubMed

Hoskins, Gaylor; Williams, Brian; Abhyankar, Purva; Donnan, Peter; Duncan, Edward; Pinnock, Hilary; van der Pol, Marjon; Rauchhaus, Petra; Taylor, Anne; Sheikh, Aziz

2016-12-08

Despite being a core component of self-management, goal setting is rarely used in routine care. We piloted a primary care, nurse-led intervention called Achieving Good Outcomes for Asthma Living (GOAL) for adults with asthma. Patients were invited to identify and prioritise their goals in preparation for discussing and negotiating an action/coping plan with the nurse at a routine asthma review. The 18-month mixed methods feasibility cluster pilot trial stratified and then randomised practices to deliver usual care (UC) or a goal-setting intervention (GOAL). Practice asthma nurses and adult patients with active asthma were invited to participate. The primary outcome was asthma-specific quality of life. Semi-structured interviews with a purposive patient sample (n = 14) and 10 participating nurses explored GOAL perception. The constructs of normalisation process theory (NPT) were used to analyse and interpret data. Ten practices participated (five in each arm), exceeding our target of eight. However, only 48 patients (target 80) were recruited (18 in GOAL practices). At 6 months post-intervention, the difference in mean asthma-related quality of life (mAQLQ) between intervention and control was 0.1 (GOAL 6.20: SD 0.76 (CI 5.76-6.65) versus UC 6.1: SD 0.81 (CI 5.63-6.57)), less than the minimal clinically important difference (MCID) of 0.5. However, change from baseline was stronger in the intervention group: at 6 months the change in the emotions sub-score was 0.8 for intervention versus 0.2 for control. Costs were higher in the intervention group by £22.17. Routine review with goal setting was considered more holistic, enhancing rapport and enabling patients to become active rather than passive participants in healthcare. However, time was a major barrier for nurses, who admitted to screening out patient goals they believed were unrelated to asthma. The difference in AQLQ score from baseline is larger in the intervention arm than the control, indicating the intervention may have impact if appropriately strengthened. The GOAL intervention changed the review dynamic and was well received by patients, but necessitated additional time, which was problematic in the confines of the traditional nurse appointment. Modification to recruitment methods and further development of the intervention are needed before proceeding to a definitive cluster randomised controlled trial. ISRCTN18912042 . Registered on 26 June 2012.

The loss of reason in patient decision aid research: do checklists damage the quality of informed choice interventions?

PubMed

Bekker, Hilary L

2010-03-01

To discuss whether using the International Patient Decision Aids Standards (IPDAS) Collaboration checklist as a gold standard to judge interventions' quality is premature and potentially detrimental to the validity of resources designed to help patients make treatment choices. Conceptual review integrating the science behind individuals' decision making with the demands of designing complex, healthcare interventions. Patient decision aids are promoted as interventions to help professionals engage in shared and/or patient-centred care. The IPDAS domains were informed by experts' opinions of best practice. Decision scientists study how individuals make decisions, what biases their choices and how best to support decisions. There is debate from decision scientists about which component parts are the active ingredients that help people make decisions. Interventions to help patients make choices have different purposes, component parts and outcomes to those facilitating professional-patient communications. The IPDAS checklist will change to respond to new evidence from the decision sciences. Adhering uncritically to the IPDAS checklist may reduce service variation but is not sufficient to ensure interventions enable good patient decision making. Developers must be encouraged to reason about the IPDAS checklist to identify those component parts that do (not) meet their intervention's purpose. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

Challenges of using quality improvement methods in nursing homes that "need improvement".

PubMed

Rantz, Marilyn J; Zwygart-Stauffacher, Mary; Flesner, Marcia; Hicks, Lanis; Mehr, David; Russell, Teresa; Minner, Donna

2012-10-01

Qualitatively describe the adoption of strategies and challenges experienced by intervention facilities participating in a study targeted to improve quality of care in nursing homes "in need of improvement". To describe how staff use federal quality indicator/quality measure (QI/QM) scores and reports, quality improvement methods and activities, and how staff supported and sustained the changes recommended by their quality improvement teams. A randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes in facilities in "need of improvement". Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality-improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making. A qualitative analysis revealed a subgroup of homes likely to continue quality improvement activities and readiness indicators of homes likely to improve: (1) a leadership team (nursing home administrator, director of nurses) interested in learning how to use their federal QI/QM reports as a foundation for improving resident care and outcomes; (2) one of the leaders to be a "change champion" and make sure that current QI/QM reports are consistently printed and shared monthly with each nursing unit; (3) leaders willing to involve all staff in the facility in educational activities to learn about the QI/QM process and the reports that show how their facility compares with others in the state and nation; (4) leaders willing to plan and continuously educate new staff about the MDS and federal QI/QM reports and how to do quality improvement activities; (5) leaders willing to continuously involve all staff in quality improvement committee and team activities so they "own" the process and are responsible for change. Results of this qualitative analysis can help allocate expert nurse time to facilities that are actually ready to improve. Wide-spread adoption of this intervention is feasible and could be enabled by nursing home medical directors in collaborative practice with advanced practice nurses. Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Effects of communication training with the MAAS-Global-D instrument on the antibiotic prescribing for respiratory infections in primary care: study protocol of a randomised controlled trial.

PubMed

Hammersen, Friederike; Goetz, Katja; Soennichsen, Andreas; Emcke, Timo; Steinhaeuser, Jost

2016-04-02

Primary care physicians account for the majority of antibiotic prescribing in ambulatory care in Germany. Respiratory diseases are, regardless of effectiveness, often treated with antibiotics. Research has found this use without indication to be caused largely by communication problems (e.g. expectations on the patient's part or false assumptions about them by the physician). The present randomised controlled trial (RCT) study evaluates whether communication training for primary care physicians can reduce the antibiotic prescribing rate for respiratory tract infections. The study consists of three groups: group A will receive communication training; group B will be given the same, plus additional, access to an evidence-based point-of-care tool; and group C will function as the control group. The primary endpoint is the difference between intervention and control groups regarding the antibiotic prescribing rate before and after the intervention assessed through routine data. The communication skills are captured with the help of the communication instrument MAAS-Global-D, as well as individual videos of physician-patient consultations recorded by the primary care physicians. These skills will also be regarded with respect to the antibiotic prescribing rate. A process evaluation using qualitative as well as quantitative methods should provide information about barriers and enablers to implementing the communication training. The trial contributes to an insight into the effectiveness of the different components to reduce antibiotic prescribing, which will also be supported by an extensive evaluation. Communication training could be an effective method of reducing antibiotic prescribing in primary care. DRKS00009566 DATE REGISTRATION: 5 November 2015.

Rapid assessment of infrastructure of primary health care facilities - a relevant instrument for health care systems management.

PubMed

Scholz, Stefan; Ngoli, Baltazar; Flessa, Steffen

2015-05-01

Health care infrastructure constitutes a major component of the structural quality of a health system. Infrastructural deficiencies of health services are reported in literature and research. A number of instruments exist for the assessment of infrastructure. However, no easy-to-use instruments to assess health facility infrastructure in developing countries are available. Present tools are not applicable for a rapid assessment by health facility staff. Therefore, health information systems lack data on facility infrastructure. A rapid assessment tool for the infrastructure of primary health care facilities was developed by the authors and pilot-tested in Tanzania. The tool measures the quality of all infrastructural components comprehensively and with high standardization. Ratings use a 2-1-0 scheme which is frequently used in Tanzanian health care services. Infrastructural indicators and indices are obtained from the assessment and serve for reporting and tracing of interventions. The tool was pilot-tested in Tanga Region (Tanzania). The pilot test covered seven primary care facilities in the range between dispensary and district hospital. The assessment encompassed the facilities as entities as well as 42 facility buildings and 80 pieces of technical medical equipment. A full assessment of facility infrastructure was undertaken by health care professionals while the rapid assessment was performed by facility staff. Serious infrastructural deficiencies were revealed. The rapid assessment tool proved a reliable instrument of routine data collection by health facility staff. The authors recommend integrating the rapid assessment tool in the health information systems of developing countries. Health authorities in a decentralized health system are thus enabled to detect infrastructural deficiencies and trace the effects of interventions. The tool can lay the data foundation for district facility infrastructure management.

A knowledge synthesis of culturally- and spiritually-sensitive end-of-life care: findings from a scoping review.

PubMed

Fang, Mei Lan; Sixsmith, Judith; Sinclair, Shane; Horst, Glen

2016-05-18

Multiple factors influence the end-of-life (EoL) care and experience of poor quality services by culturally- and spiritually-diverse groups. Access to EoL services e.g. health and social supports at home or in hospices is difficult for ethnic minorities compared to white European groups. A tool is required to empower patients and families to access culturally-safe care. This review was undertaken by the Canadian Virtual Hospice as a foundation for this tool. To explore attitudes, behaviours and patterns to utilization of EoL care by culturally and spiritually diverse groups and identify gaps in EoL care practice and delivery methods, a scoping review and thematic analysis of article content was conducted. Fourteen electronic databases and websites were searched between June-August 2014 to identify English-language peer-reviewed publications and grey literature (including reports and other online resources) published between 2004-2014. The search identified barriers and enablers at the systems, community and personal/family levels. Primary barriers include: cultural differences between healthcare providers; persons approaching EoL and family members; under-utilization of culturally-sensitive models designed to improve EoL care; language barriers; lack of awareness of cultural and religious diversity issues; exclusion of families in the decision-making process; personal racial and religious discrimination; and lack of culturally-tailored EoL information to facilitate decision-making. This review highlights that most research has focused on decision-making. There were fewer studies exploring different cultural and spiritual experiences at the EoL and interventions to improve EoL care. Interventions evaluated were largely educational in nature rather than service oriented.

Using logic models to enhance the methodological quality of primary health-care interventions: guidance from an intervention to promote nutrition care by general practitioners and practice nurses.

PubMed

Ball, Lauren; Ball, Dianne; Leveritt, Michael; Ray, Sumantra; Collins, Clare; Patterson, Elizabeth; Ambrosini, Gina; Lee, Patricia; Chaboyer, Wendy

2017-04-01

The methodological designs underpinning many primary health-care interventions are not rigorous. Logic models can be used to support intervention planning, implementation and evaluation in the primary health-care setting. Logic models provide a systematic and visual way of facilitating shared understanding of the rationale for the intervention, the planned activities, expected outcomes, evaluation strategy and required resources. This article provides guidance for primary health-care practitioners and researchers on the use of logic models for enhancing methodological rigour of interventions. The article outlines the recommended steps in developing a logic model using the 'NutriCare' intervention as an example. The 'NutriCare' intervention is based in the Australian primary health-care setting and promotes nutrition care by general practitioners and practice nurses. The recommended approach involves canvassing the views of all stakeholders who have valuable and informed opinions about the planned project. The following four targeted, iterative steps are recommended: (1) confirm situation, intervention aim and target population; (2) document expected outcomes and outputs of the intervention; (3) identify and describe assumptions, external factors and inputs; and (4) confirm intervention components. Over a period of 2 months, three primary health-care researchers and one health-services consultant led the collaborative development of the 'NutriCare' logic model. Primary health-care practitioners and researchers are encouraged to develop a logic model when planning interventions to maximise the methodological rigour of studies, confirm that data required to answer the question are captured and ensure that the intervention meets the project goals.

The impact of mHealth interventions on health systems: a systematic review protocol.

PubMed

Fortuin, Jill; Salie, Faatiema; Abdullahi, Leila H; Douglas, Tania S

2016-11-25

Mobile health (mHealth) has been described as a health enabling tool that impacts positively on the health system in terms of improved access, quality and cost of health care. The proposed systematic review will examine the impact of mHealth on health systems by assessing access, quality and cost of health care as indicators. The systematic review will include literature from various sources including published and unpublished/grey literature. The databases to be searched include: PubMed, Cochrane Library, Google Scholar, NHS Health Technology Assessment Database and Web of Science. The reference lists of studies will be screened and conference proceedings searched for additional eligible reports. Literature to be included will have mHealth as the primary intervention. Two authors will independently screen the search output, select studies and extract data; discrepancies will be resolved by consensus and discussion with the assistance of the third author. The systematic review will inform policy makers, investors, health professionals, technologists and engineers about the impact of mHealth in strengthening the health system. In particular, it will focus on three metrics to determine whether mHealth strengthens the health system, namely quality of, access to and cost of health care services. Systematic review registration: PROSPERO CRD42015026070.

Cultural Leverage: Interventions Using Culture to Narrow Racial Disparities in Health Care

PubMed Central

Fisher, Thomas L.; Burnet, Deborah L.; Huang, Elbert S.; Chin, Marshall H.; Cagney, Kathleen A.

2008-01-01

The authors reviewed interventions using cultural leverage to narrow racial disparities in health care. Thirty-eight interventions of three types were identified: interventions that modified the health behaviors of individual patients of color, that increased the access of communities of color to the existing health care system, and that modified the health care system to better serve patients of color and their communities. Individual-level interventions typically tapped community members’ expertise to shape programs. Access interventions largely involved screening programs, incorporating patient navigators and lay educators. Health care interventions focused on the roles of nurses, counselors, and community health workers to deliver culturally tailored health information. These interventions increased patients’ knowledge for self-care, decreased barriers to access, and improved providers’ cultural competence. The delivery of processes of care or intermediate health outcomes was significantly improved in 23 interventions. Interventions using cultural leverage show tremendous promise in reducing health disparities, but more research is needed to understand their health effects in combination with other interventions. PMID:17881628

Cell Phone Intervention to Improve Adherence

PubMed Central

Marciel, Kristen K.; Saiman, Lisa; Quittell, Lynne M.; Dawkins, Kevin; Quittner, Alexandra L.

2010-01-01

Summary Background Treatment regimens for patients with cystic fibrosis (CF) are time-consuming and complex, resulting in consistently low adherence rates. To date, few studies have evaluated innovative technologies to improve adherence in this population. Current infection control guidelines for patients with CF seek to minimize patient-to-patient transmission of potential pathogens. Thus, interventions must avoid face-to-face contact and be delivered individually, limiting opportunities for peer support. This study aimed to develop and assess a web-enabled cell phone, CFFONE™, designed to provide CF information and social support to improve adherence in adolescents with CF. Methods The acceptability, feasibility, and utility of CFFONE™ were evaluated with health care professionals (n = 17) adolescents with CF aged 11–18 years old (n = 12), adults with CF aged 21–36 years old (n = 6), parents of adolescents with CF (n = 12), and technology experts (n = 8). Adolescents also tested a prototype of CFFONE™ (n = 9). Qualitative and quantitative data were collected. Results Focus group data with health care = professionals indicated a need for this intervention, and indicated that CFFONE™ would be likely to improve knowledge and social support, and somewhat likely to improve adherence. Adolescent, adults, and parents all rated CFFONE™ as likely to improve adherence. Technology experts rated the prototype design and format as appropriate. Conclusions The current study provided some support from key stakeholders for this intervention to improve adherence in adolescents with CF. Next steps include a multi-center trial of the efficacy and safety of CFFONE™. PMID:20054860

[Leadership and vision in the improvement of universal health care coverage in low-income countries].

PubMed

Meda, Ziemlé Clément; Konate, Lassina; Ouedraogo, Hyacinthe; Sanou, Moussa; Hercot, David; Sombie, Issiaka

2011-01-01

In Burkina Faso, as in most developing countries, the operational level of the health system is made up of Health Districts (HDs), the activities of which are typically coordinated by the District Team (DT). Assessing the the core functions of DTs, as described by WHO, shows two important weaknesses. Firstly, instructions from "above" are often implemented rather passively: DTs tend not to display much leadership. Secondly, the current organisation, based on input financing and centralised planning, does not sufficiently promote either the vision or research functions of DTs. In this article, we report our experience in the Orodora HD in Burkina Faso, where the DT's leadership and vision proved to be essential ingredients for effective health action in the district. Our description of six interventions implemented between 2004 and 2008 shows how DT leadership and vision have improved outputs at the HD level. Until 2004, the district applied static health planning. The health system was insufficiently financed and performed poorly. Faced with this situation, the DT decided to set up several priority interventions based on health care access criteria and patient concerns, while respecting and contextualizing national norms and objectives. Six interventions were then implemented. The first was ensure that quality blood (meeting transfusion security norms) was available at the District Hospital (DH), by picking blood up from the regional blood transfusion center weekly. This speeded up care at the DH, reduced the number of cases referred to the regional hospital for transfusion, and reduced neonatal and maternal mortality. The second intervention sought to improve the skills of health workers in managing emergency cases and to improve relationships with the referral hospital through the reintroduction of counter-referral procedures. This led to a decrease in unnecessary referrals and also reduced the mortality rates of serious cases. The third intervention, by implementing a decentralized approach to tuberculosis detection, succeeded in improving access to care and enabled us to quantify the rate of tuberculosis-HIV co-infection in the HD. The fourth intervention improved financial access to emergency obstetric care by providing essential drugs and consumables for emergency obstetric surgery free of charge. The fifth intervention boosted the motivation of health workers by an annual 'competition of excellence', organised for workers and teams in the HD. Finally, our sixth intervention was the introduction of a "culture" of evaluation and transparency, by means of a local health journal, used to interact with stakeholders both at the local level and in the health sector more broadly. We also present our experiences regularly during national health science symposia. Although the DT operates with limited resources, it has over time managed to improve care and services in the HD, through its dynamic management and strategic planning. It has reduced inpatient mortality and improved access to care, particularly for vulnerable groups, in line with the Primary Health Care and Bamako Initiative principles. This case study would have benefited from a stronger methodology. However, it shows that in a context of limited resources it is still possible to strengthen the local health system by improving management practices. To progress towards universal health coverage, all core functions of a DT are worth implementing, including leadership and vision. National and international health strategies should thus include a plan to provide for and train local health system managers who can provide both leadership and strategic vision.

Mindfulness in Motion (MIM): An Onsite Mindfulness Based Intervention (MBI) for Chronically High Stress Work Environments to Increase Resiliency and Work Engagement.

PubMed

Klatt, Maryanna; Steinberg, Beth; Duchemin, Anne-Marie

2015-07-01

A pragmatic mindfulness intervention to benefit personnel working in chronically high-stress environments, delivered onsite during the workday, is timely and valuable to employee and employer alike. Mindfulness in Motion (MIM) is a Mindfulness Based Intervention (MBI) offered as a modified, less time intensive method (compared to Mindfulness-Based Stress Reduction), delivered onsite, during work, and intends to enable busy working adults to experience the benefits of mindfulness. It teaches mindful awareness principles, rehearses mindfulness as a group, emphasizes the use of gentle yoga stretches, and utilizes relaxing music in the background of both the group sessions and individual mindfulness practice. MIM is delivered in a group format, for 1 hr/week/8 weeks. CDs and a DVD are provided to facilitate individual practice. The yoga movement is emphasized in the protocol to facilitate a quieting of the mind. The music is included for participants to associate the relaxed state experienced in the group session with their individual practice. To determine the intervention feasibility/efficacy we conducted a randomized wait-list control group in Intensive Care Units (ICUs). ICUs represent a high-stress work environment where personnel experience chronic exposure to catastrophic situations as they care for seriously injured/ill patients. Despite high levels of work-related stress, few interventions have been developed and delivered onsite for such environments. The intervention is delivered on site in the ICU, during work hours, with participants receiving time release to attend sessions. The intervention is well received with 97% retention rate. Work engagement and resiliency increase significantly in the intervention group, compared to the wait-list control group, while participant respiration rates decrease significantly pre-post in 6/8 of the weekly sessions. Participants value institutional support, relaxing music, and the instructor as pivotal to program success. This provides evidence that MIM is feasible, well accepted, and can be effectively implemented in a chronically high-stress work environment.

Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA-International (NANDA-I) and Nursing Interventions Classification (NIC).

PubMed

Rabelo-Silva, Eneida Rejane; Dantas Cavalcanti, Ana Carla; Ramos Goulart Caldas, Maria Cristina; Lucena, Amália de Fátima; Almeida, Miriam de Abreu; Linch, Graciele Fernanda da Costa; da Silva, Marcos Barragan; Müller-Staub, Maria

2017-02-01

To assess the quality of the advanced nursing process in nursing documentation in two hospitals. Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike. Cross-sectional study. A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA-International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0-58 points. Nursing records were dated 2012-2013 for Centre 1 and 2010-2011 for Centre 2. Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the 'Nursing Diagnoses as Process' dimension, whereas in the 'Nursing Diagnoses as Product', 'Nursing Interventions' and 'Nursing Outcomes' dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the 'Nursing Interventions' domain in Centre 1 and the 'Nursing Diagnoses as Process' and 'Nursing Diagnoses as Product' domains in Centre 2. The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies. Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies. © 2016 John Wiley & Sons Ltd.

Mindfulness in Motion (MIM): An Onsite Mindfulness Based Intervention (MBI) for Chronically High Stress Work Environments to Increase Resiliency and Work Engagement

PubMed Central

Klatt, Maryanna; Steinberg, Beth; Duchemin, Anne-Marie

2015-01-01

A pragmatic mindfulness intervention to benefit personnel working in chronically high-stress environments, delivered onsite during the workday, is timely and valuable to employee and employer alike. Mindfulness in Motion (MIM) is a Mindfulness Based Intervention (MBI) offered as a modified, less time intensive method (compared to Mindfulness-Based Stress Reduction), delivered onsite, during work, and intends to enable busy working adults to experience the benefits of mindfulness. It teaches mindful awareness principles, rehearses mindfulness as a group, emphasizes the use of gentle yoga stretches, and utilizes relaxing music in the background of both the group sessions and individual mindfulness practice. MIM is delivered in a group format, for 1 hr/week/8 weeks. CDs and a DVD are provided to facilitate individual practice. The yoga movement is emphasized in the protocol to facilitate a quieting of the mind. The music is included for participants to associate the relaxed state experienced in the group session with their individual practice. To determine the intervention feasibility/efficacy we conducted a randomized wait-list control group in Intensive Care Units (ICUs). ICUs represent a high-stress work environment where personnel experience chronic exposure to catastrophic situations as they care for seriously injured/ill patients. Despite high levels of work-related stress, few interventions have been developed and delivered onsite for such environments. The intervention is delivered on site in the ICU, during work hours, with participants receiving time release to attend sessions. The intervention is well received with 97% retention rate. Work engagement and resiliency increase significantly in the intervention group, compared to the wait-list control group, while participant respiration rates decrease significantly pre-post in 6/8 of the weekly sessions. Participants value institutional support, relaxing music, and the instructor as pivotal to program success. This provides evidence that MIM is feasible, well accepted, and can be effectively implemented in a chronically high-stress work environment. PMID:26168365

Interventions and approaches to integrating HIV and mental health services: a systematic review

PubMed Central

Chuah, Fiona Leh Hoon; Haldane, Victoria Elizabeth; Cervero-Liceras, Francisco; Ong, Suan Ee; Sigfrid, Louise A; Murphy, Georgina; Watt, Nicola; Balabanova, Dina; Hogarth, Sue; Maimaris, Will; Otero, Laura; Buse, Kent; McKee, Martin; Piot, Peter; Perel, Pablo; Legido-Quigley, Helena

2017-01-01

Abstract Background The frequency in which HIV and AIDS and mental health problems co-exist, and the complex bi-directional relationship between them, highlights the need for effective care models combining services for HIV and mental health. Here, we present a systematic review that synthesizes the literature on interventions and approaches integrating these services. Methods This review was part of a larger systematic review on integration of services for HIV and non-communicable diseases. Eligible studies included those that described or evaluated an intervention or approach aimed at integrating HIV and mental health care. We searched multiple databases from inception until October 2015, independently screened articles identified for inclusion, conducted data extraction, and assessed evaluative papers for risk of bias. Results Forty-five articles were eligible for this review. We identified three models of integration at the meso and micro levels: single-facility integration, multi-facility integration, and integrated care coordinated by a non-physician case manager. Single-site integration enhances multidisciplinary coordination and reduces access barriers for patients. However, the practicality and cost-effectiveness of providing a full continuum of specialized care on-site for patients with complex needs is arguable. Integration based on a collaborative network of specialized agencies may serve those with multiple co-morbidities but fragmented and poorly coordinated care can pose barriers. Integrated care coordinated by a single case manager can enable continuity of care for patients but requires appropriate training and support for case managers. Involving patients as key actors in facilitating integration within their own treatment plan is a promising approach. Conclusion This review identified much diversity in integration models combining HIV and mental health services, which are shown to have potential in yielding positive patient and service delivery outcomes when implemented within appropriate contexts. Our review revealed a lack of research in low- and middle- income countries, and was limited to most studies being descriptive. Overall, studies that seek to evaluate and compare integration models in terms of long-term outcomes and cost-effectiveness are needed, particularly at the health system level and in regions with high HIV and AIDS burden. PMID:29106512

Support and assessment for fall emergency referrals (SAFER 2) research protocol: cluster randomised trial of the clinical and cost effectiveness of new protocols for emergency ambulance paramedics to assess and refer to appropriate community-based care

PubMed Central

Snooks, Helen; Anthony, Rebecca; Chatters, Robin; Cheung, Wai-Yee; Dale, Jeremy; Donohoe, Rachael; Gaze, Sarah; Halter, Mary; Koniotou, Marina; Logan, Phillippa; Lyons, Ronan; Mason, Suzanne; Nicholl, Jon; Phillips, Ceri; Phillips, Judith; Russell, Ian; Siriwardena, A Niroshan; Wani, Mushtaq; Watkins, Alan; Whitfield, Richard; Wilson, Lynsey

2012-01-01

Introduction Emergency calls to ambulance services are frequent for older people who have fallen, but ambulance crews often leave patients at the scene without ongoing care. Evidence shows that when left at home with no further support older people often experience subsequent falls which result in injury and emergency-department attendances. SAFER 2 is an evaluation of a new clinical protocol which allows paramedics to assess and refer older people who have fallen, and do not need hospital care, to community-based falls services. In this protocol paper, we report methods and progress during trial implementation. SAFER 2 is recruiting patients through three ambulance services. A successful trial will provide robust evidence about the value of this new model of care, and enable ambulance services to use resources efficiently. Design Pragmatic cluster randomised trial. Methods and analysis We randomly allocated 25 participating ambulance stations (clusters) in three services to intervention or control group. Intervention paramedics received training and clinical protocols for assessing and referring older people who have fallen to community-based falls services when appropriate, while control paramedics deliver care as usual. Patients are eligible for the trial if they are aged 65 or over; resident in a participating falls service catchment area; and attended by a trial paramedic following an emergency call coded as a fall without priority symptoms. The principal outcome is the rate of further emergency contacts (or death), for any cause and for falls. Secondary outcomes include further falls, health-related quality of life, ‘fear of falling’, patient satisfaction reported by participants through postal questionnaires at 1 and 6 months, and quality and pathways of care at the index incident. We shall compare National Health Service (NHS) and patient/carer costs between intervention and control groups and estimate quality-adjusted life years (QALYs) gained from the intervention and thus incremental cost per QALY. We shall estimate wider system effects on key-performance indicators. We shall interview 60 intervention patients, and conduct focus groups with contributing NHS staff to explore their experiences of the assessment and referral service. We shall analyse quantitative trial data by ‘treatment allocated’; and qualitative data using content analysis. Ethics and dissemination The Research Ethics Committee for Wales gave ethical approval and each participating centre gave NHS Research and Development approval. We shall disseminate study findings through peer-reviewed publications and conference presentations. Trial Registration: ISRCTN 60481756 PMID:23148348

Improving postpartum care delivery and uptake by implementing context-specific interventions in four countries in Africa: a realist evaluation of the Missed Opportunities in Maternal and Infant Health (MOMI) project

PubMed Central

Djellouli, Nehla; Mann, Sue; Nambiar, Bejoy; Meireles, Paula; Miranda, Diana; Barros, Henrique; Bocoum, Fadima Y; Yaméogo, W Maurice E; Yaméogo, Clarisse; Belemkoabga, Sylvie; Tougri, Halima; Coulibaly, Abou; Kouanda, Seni; Mochache, Vernon; Mwakusema, Omar K; Irungu, Eunice; Gichangi, Peter; Dembo, Zione; Kadzakumanja, Angela; Makwenda, Charles Vidonji; Timóteo, Judite; Cossa, Misete G; de Melo, Malica; Griffin, Sally; Osman, Nafissa B; Foia, Severiano; Ogbe, Emilomo; Duysburgh, Els

2017-01-01

Postpartum care (PPC) has remained relatively neglected in many interventions designed to improve maternal and neonatal health in sub-Saharan Africa. The Missed Opportunities in Maternal and Infant Health project developed and implemented a context-specific package of health system strengthening and demand generation in four African countries, aiming to improve access and quality of PPC. A realist evaluation was conducted to enable nuanced understanding of the influence of different contextual factors on both the implementation and impacts of the interventions. Mixed methods were used to collect data and test hypothesised context–mechanism–outcome configurations: 16 case studies (including interviews, observations, monitoring data on key healthcare processes and outcomes), monitoring data for all study health facilities and communities, document analysis and participatory evaluation workshops. After evaluation in individual countries, a cross-country analysis was conducted that led to the development of four middle-range theories. Community health workers (CHWs) were key assets in shifting demand for PPC by ‘bridging’ communities and facilities. Because they were chosen from the community they served, they gained trust from the community and an intrinsic sense of responsibility. Furthermore, if a critical mass of women seek postpartum healthcare as a result of the CHWs bridging function, a ‘buzz’ for change is created, leading eventually to the acceptability and perceived value of attending for PPC that outweighs the costs of attending the health facility. On the supply side, rigid vertical hierarchies and defined roles for health facility workers (HFWs) impede integration of maternal and infant health services. Additionally, HFWs fear being judged negatively which overrides the self-efficacy that could potentially be gained from PPC training. Instead the main driver of HFWs’ motivation to provide comprehensive PPC is dependent on accountability systems for delivering PPC created by other programmes. The realist evaluation offers insights into some of the contextual factors that can be pivotal in enabling the community-level and service-level interventions to be effective. PMID:29225949

Patients’ Perspective on Participation in Care With or Without the Support of a Smartphone App During Radiotherapy for Prostate Cancer: Qualitative Study

PubMed Central

2017-01-01

Background Patients with prostate cancer are often cared for as outpatients during radiotherapy, which can be an aggravating circumstance for patient participation. There is a need to evaluate whether an interactive smartphone app could enable participation in care, specifically during treatment for prostate cancer. The interactive app (Interaktor) used in this study is developed in codesign with patients and health care professionals; it includes daily reports of symptoms, a risk assessment model, evidence-based self-care advice, along with the provision of immediate access to clinicians. Objective The aim of this study was to explore how patients with prostate cancer perceived their participation with or without the support of the smartphone app during radiotherapy. Methods A total of 28 prostate cancer patients receiving adjuvant radiotherapy were interviewed about their perceived participation in their own care. All the patients interviewed in this study participated in an intervention study where the control group received standard care that comprised having access to a contact nurse to turn to with any concerns during their treatment. In addition to standard care, the patients in the intervention group received the app downloaded in a smartphone. The patients’ age ranged between 57 and 77 years; 17 patients used the smartphone app. The interviews were analyzed with directed qualitative content analysis. Results The four dimensions of patient participation, which include mutual participation, fight for participation, requirement for participation, and participation in getting basic needs satisfied, were confirmed as valid perspectives in the interviews with the patients with prostate cancer, irrespective of whether they used the smartphone app. However, the patients who had used the smartphone app described it as a facilitating factor, especially for mutual participation. Conclusions Using innovative ways to communicate with patients, such as an interactive app for symptom management with contact with health care in real time, can successfully help achieve increased patient participation in care. PMID:28747294

Interventions to Improve Hand Hygiene Compliance in the ICU: A Systematic Review.

PubMed

Lydon, Sinéad; Power, Michael; McSharry, Jennifer; Byrne, Molly; Madden, Caoimhe; Squires, Janet Elaine; O'Connor, Paul

2017-11-01

To synthesize the literature describing interventions to improve hand hygiene in ICUs, to evaluate the quality of the extant research, and to outline the type, and efficacy, of interventions described. Systematic searches were conducted in November 2016 using five electronic databases: Medline, CINAHL, PsycInfo, Embase, and Web of Science. Additionally, the reference lists of included studies and existing review papers were screened. English language, peer-reviewed studies that evaluated an intervention to improve hand hygiene in an adult ICU setting, and reported hand hygiene compliance rates collected via observation, were included. Data were extracted on the setting, participant characteristics, experimental design, hand hygiene measurement, intervention characteristics, and outcomes. Interventional components were categorized using the Behavior Change Wheel. Methodological quality was examined using the Downs and Black Checklist. Thirty-eight studies were included. The methodological quality of studies was poor, with studies scoring a mean of 8.6 of 24 (SD= 2.7). Over 90% of studies implemented a bundled intervention. The most frequently employed interventional strategies were education (78.9%), enablement (71.1%), training (68.4%), environmental restructuring (65.8%), and persuasion (65.8%). Intervention outcomes were variable, with a mean relative percentage change of 94.7% (SD= 195.7; range, 4.3-1155.4%) from pre to post intervention. This review demonstrates that best practice for improving hand hygiene in ICUs remains unestablished. Future research employing rigorous experimental designs, careful statistical analysis, and clearly described interventions is important.

Percutaneous Coronary and Structural Interventions in Women. A Position Statement from the EAPCI Women Committee.

PubMed

Chieffo, Alaide; Buchanan, Gill Louise; Mehilli, Julinda; Capodanno, Davide; Kunadian, Vijay; Petronio, Anna Sonia; Mikhail, Ghada W; Capranzano, Piera; Gonzal, Nieves; Karam, Nicole; Manzo-Silberman, Stéphane; Schüpke, Stefanie; Byrne, Robert A; Capretti, Giuliana; Appelman, Yolande; Morice, Marie-Claude; Presbitero, Patrizia; Radu, Maria; Mauri, Josepa

2018-05-22

Several expert documents on sex-based differences in interventional outcomes are now available, however this is the first position paper from the EAPCI Women Committee discussing the potential influence of sex in the percutaneous treatment of coronary and structural heart disease. Despite the misconception that coronary artery disease is a 'man's disease', contemporary data shows a growing incidence in women. However, women are under-represented in randomised coronary clinical trials (~25%). The generalisation of such studies is therefore problematic in decision-making for females undergoing coronary intervention. Differences in pathophysiology between sexes exist, highlighting the need for greater awareness amongst healthcare professionals to enable best evidence-based therapies for women as well as for men. Reassuringly, women represent half of the population included in transcatheter aortic valve implantation clinical trials and may actually benefit more. Growing evidence is also emerging for other interventional atrial procedures which may well be advantageous to women. Awareness of sex disparities is increasing, and we must all work collaboratively within our profession to ensure we provide effective care for all patients with heart disease. The EAPCI Women Committee aim to highlight such issues through this position paper and through visibility within the interventional community.

A randomised controlled trial of a lengthened and multi-disciplinary consultation model in a socially deprived community: a study protocol.

PubMed

Whitford, David L; Chan, Wai-Sun

2007-06-28

There has been little development of the general practice consultation over the years, and many aspects of the present consultation do not serve communities with multiple health and social problems well. Many of the problems presenting to general practitioners in socio-economically disadvantaged areas are not amenable to a purely medical solution, and would particularly benefit from a multidisciplinary approach. Socio-economic deprivation is also associated with those very factors (more psychosocial problems, greater need for health promotion, more chronic diseases, more need for patient enablement) that longer consultations have been shown to address. This paper describes our study protocol, which aims to evaluate whether a lengthened multidisciplinary primary care team consultation with families in a socially deprived area can improve the psychological health of mothers in the families. In a randomised controlled trial, families with a history of social problems, substance misuse or depression are randomly allocated to an intervention or control group. The study is based in three general practices in a highly deprived area of North Dublin. Primary health care teams will be trained in conducting a multidisciplinary lengthened consultation. Families in the intervention group will participate in the new style multidisciplinary consultation. Outcomes of families receiving the intervention will be compared to the control group who will receive only usual general practitioner care. The primary outcome is the psychological health of mothers of the families and secondary outcomes include general health status, quality of life measures and health service usage. The main aim of this study is to evaluate the effectiveness of a lengthened multidisciplinary team consultation in primary care. The embedded nature of this study in general practices in a highly deprived area ensures generalisability to other deprived communities, but more particularly it promises relevance to primary care. Current Controlled Trials ISRCTN70578736.

Infection in conflict wounded

PubMed Central

Eardley, W. G. P.; Brown, K. V.; Bonner, T. J.; Green, A. D.; Clasper, J. C.

2011-01-01

Although mechanisms of modern military wounding may be distinct from those of ancient conflicts, the infectious sequelae of ballistic trauma and the evolving microbial flora of war wounds remain a considerable burden on both the injured combatant and their deployed medical systems. Battlefield surgeons of ancient times favoured suppuration in war wounding and as such Galenic encouragement of pus formation would hinder progress in wound care for centuries. Napoleonic surgeons eventually abandoned this mantra, embracing radical surgical intervention, primarily by amputation, to prevent infection. Later, microscopy enabled identification of microorganisms and characterization of wound flora. Concurrent advances in sanitation and evacuation enabled improved outcomes and establishment of modern military medical systems. Advances in medical doctrine and technology afford those injured in current conflicts with increasing survivability through rapid evacuation, sophisticated resuscitation and timely surgical intervention. Infectious complications in those that do survive, however, are a major concern. Addressing antibiotic use, nosocomial transmission and infectious sequelae are a current clinical management and research priority and will remain so in an era characterized by a massive burden of combat extremity injury. This paper provides a review of infection in combat wounding from a historical setting through to the modern evidence base. PMID:21149356

Launching nurse-initiated HIV rapid testing in Veterans Affairs primary care: a comprehensive overview of a self-sustaining implementation.

PubMed

Knapp, H; Anaya, H D; Feld, J E; Hoang, T; Goetz, M B

2011-12-01

Our objectives were to use foundational pilot findings to guide the implementation of an HIV rapid testing (RT) intervention at one Veterans Affairs outpatient clinic and to evaluate the success and sustainability of this intervention over the course of one year. Policy modifications were drafted and adopted to enable nurses to order, administer, interpret and document HIV RTs. Staff enrolled in a two-part training sessions designed to teach pre- and post-test counselling techniques and the mechanics of administering, interpreting and coding test results in the patients' medical records. They were subsequently evaluated on their efforts at: (1) increasing HIV RT, (2) sustaining this effort one year post-launch. Enabling nurses to carry out HIV RT resulted in a significant increase in not only HIV RT, but also HIV testing rates overall at this facility, measured over the first year of this implementation. Our findings indicate that targeted strategies, aimed at increasing HIV RT rates, worked to increase testing rates overall, and also, that our initial testing strategies were independently sustainable, which is in contrast to findings in the literature on implementation science.

Development of a Behavior Change Intervention to Improve Sexual Health Service Use Among University Undergraduate Students: Mixed Methods Study Protocol.

PubMed

Cassidy, Christine; Steenbeek, Audrey; Langille, Donald; Martin-Misener, Ruth; Curran, Janet

2017-11-02

University students are at risk for acquiring sexually transmitted infections and suffering other negative health outcomes. Sexual health services offer preventive and treatment interventions that aim to reduce these infections and associated health consequences. However, university students often delay or avoid seeking sexual health services. An in-depth understanding of the factors that influence student use of sexual health services is needed to underpin effective sexual health interventions. In this study, we aim to design a behavior change intervention to address university undergraduate students' use of sexual health services at two universities in Nova Scotia, Canada. This mixed methods study consists of three phases that follow a systematic approach to intervention design outlined in the Behaviour Change Wheel. In Phase 1, we examine patterns of sexual health service use among university students in Nova Scotia, Canada, using an existing dataset. In Phase 2, we identify the perceived barriers and enablers to students' use of sexual health services. This will include focus groups with university undergraduate students, health care providers, and university administrators using a semistructured guide, informed by the Capability, Opportunity, Motivation-Behaviour Model and Theoretical Domains Framework. In Phase 3, we identify behavior change techniques and intervention components to develop a theory-based intervention to improve students' use of sexual health services. This study will be completed in March 2018. Results from each phase and the finalized intervention design will be reported in 2018. Previous intervention research to improve university students' use of sexual health services lacks a theoretical assessment of barriers. This study will employ a mixed methods research design to examine university students' use of sexual health service and apply behavior change theory to design a theory- and evidence-based sexual health service intervention. Our approach will provide a comprehensive foundation to co-design a theory-based intervention with service users, health care providers, and administrators to improve sexual health service use among university students and ultimately improve their overall health and well-being. ©Christine Cassidy, Audrey Steenbeek, Donald Langille, Ruth Martin-Misener, Janet Curran. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 02.11.2017.

Implementation and evaluation of a follow-up programme after intensive care treatment: A practice development project.

PubMed

van Mol, Margo; Ista, Erwin; van Dijk, Monique

2018-05-02

This study aimed to measure the effects of a newly developed follow-up programme on intensive care unit patient quality of care, as perceived by their relatives, and the appropriateness of the programme according to nurses. This before and after implementation study was conducted in a level III intensive care unit for adult patients and related follow-up wards and included 135 intensive care nurses and 105 general ward nurses. The implemented programme included a personalised poster, a revised discharge protocol and follow-up visits on the ward. Eligible relatives of patients who had remained in the intensive care for a minimum of 48 hours were included. Total quality of care and communication were assessed by relatives as high according to the Quality Monitor. Most intensive care nurses evaluated the usefulness of the discharge protocol as positive (71.8% partly/totally agreed) and in accordance with the patients' needs (82.1% partly/totally agreed). Communication and general support as perceived by patients' relatives improved; however, no influence on the total quality of care of the revised discharge protocol was shown. Nurses considered the programme as useful. The intervention might enable nurses to better respond to the instrumental and affective needs of patients and their relatives. Copyright © 2018 Elsevier Ltd. All rights reserved.

Exposure to a patient-centered, Web-based intervention for managing cancer symptom and quality of life issues: impact on symptom distress.

PubMed

Berry, Donna L; Blonquist, Traci M; Patel, Rupa A; Halpenny, Barbara; McReynolds, Justin

2015-06-03

Effective eHealth interventions can benefit a large number of patients with content intended to support self-care and management of both chronic and acute conditions. Even though usage statistics are easily logged in most eHealth interventions, usage or exposure has rarely been reported in trials, let alone studied in relationship to effectiveness. The intent of the study was to evaluate use of a fully automated, Web-based program, the Electronic Self Report Assessment-Cancer (ESRA-C), and how delivery and total use of the intervention may have affected cancer symptom distress. Patients at two cancer centers used ESRA-C to self-report symptom and quality of life (SxQOL) issues during therapy. Participants were randomized to ESRA-C assessment only (control) or the ESRA-C intervention delivered via the Internet to patients' homes or to a tablet at the clinic. The intervention enabled participants to self-monitor SxQOL and receive self-care education and customized coaching on how to report concerns to clinicians. Overall and voluntary intervention use were defined as having ≥2 exposures, and one non-prompted exposure to the intervention, respectively. Factors associated with intervention use were explored with Fisher's exact test. Propensity score matching was used to select a sample of control participants similar to intervention participants who used the intervention. Analysis of covariance (ANCOVA) was used to compare change in Symptom Distress Scale (SDS-15) scores from pre-treatment to end-of-study by groups in the matched sample. Radiation oncology participants used the intervention, overall and voluntarily, more than medical oncology and transplant participants. Participants who were working and had more than a high school education voluntarily used the intervention more. The SDS-15 score was reduced by an estimated 1.53 points (P=.01) in the intervention group users compared to the matched control group. The intended effects of a Web-based, patient-centered intervention on cancer symptom distress were modified by intervention use frequency. Clinical and personal demographics influenced voluntary use. Clinicaltrials.gov NCT00852852; http://clinicaltrials.gov/ct2/show/NCT00852852 (Archived by WebCite at http://www.webcitation.org/6YwAfwWl7).

The @RISK Study: Risk communication for patients with type 2 diabetes: design of a randomised controlled trial.

PubMed

Welschen, Laura M C; Bot, Sandra D M; Dekker, Jacqueline M; Timmermans, Daniëlle R M; van der Weijden, Trudy; Nijpels, Giel

2010-08-05

Patients with type 2 diabetes mellitus (T2DM) have an increased risk to develop severe diabetes related complications, especially cardiovascular disease (CVD). The risk to develop CVD can be estimated by means of risk formulas. However, patients have difficulties to understand the outcomes of these formulas. As a result, they may not recognize the importance of changing lifestyle and taking medication in time. Therefore, it is important to develop risk communication methods, that will improve the patients' understanding of risks associated with having diabetes, which enables them to make informed choices about their diabetes care.The aim of this study is to investigate the effects of an intervention focussed on the communication of the absolute 10-year risk to develop CVD on risk perception, attitude and intention to change lifestyle behaviour in patients with T2DM. The conceptual framework of the intervention is based on the Theory of Planned Behaviour and the Self-regulation Theory. A randomised controlled trial will be performed in the Diabetes Care System West-Friesland (DCS), a managed care system. Newly referred T2DM patients of the DCS, younger than 75 years will be eligible for the study. The intervention group will be exposed to risk communication on CVD, on top of standard managed care of the DCS. This intervention consists of a simple explanation on the causes and consequences of CVD, and possibilities for prevention. The probabilities of CVD in 10 year will be explained in natural frequencies and visualised by a population diagram. The control group will receive standard managed care. The primary outcome is appropriateness of risk perception. Secondary outcomes are attitude and intention to change lifestyle behaviour and illness perception. Differences between baseline and follow-up (2 and 12 weeks) between groups will be analysed according to the intention-to-treat principle. The study was powered on 120 patients in each group. This innovative risk communication method based on two behavioural theories might improve patient's appropriateness of risk perception and attitude concerning lifestyle change. With a better understanding of their CVD risk, patients will be able to make informed choices concerning diabetes care. The trial is registered as NTR1556 in the Dutch Trial Register.

Effects of interprofessional education for medical and nursing students: enablers, barriers and expectations for optimizing future interprofessional collaboration - a qualitative study.

PubMed

Homeyer, Sabine; Hoffmann, Wolfgang; Hingst, Peter; Oppermann, Roman F; Dreier-Wolfgramm, Adina

2018-01-01

To ensure high quality patient care an effective interprofessional collaboration between healthcare professionals is required. Interprofessional education (IPE) has a positive impact on team work in daily health care practice. Nevertheless, there are various challenges for sustainable implementation of IPE. To identify enablers and barriers of IPE for medical and nursing students as well as to specify impacts of IPE for both professions, the 'Cooperative academical regional evidence-based Nursing Study in Mecklenburg-Western Pomerania' (Care-N Study M-V) was conducted. The aim is to explore, how IPE has to be designed and implemented in medical and nursing training programs to optimize students' impact for IPC. A qualitative study was conducted using the Delphi method and included 25 experts. Experts were selected by following inclusion criteria: (a) ability to answer every research question, one question particularly competent, (b) interdisciplinarity, (c) sustainability and (d) status. They were purposely sampled. Recruitment was based on existing collaborations and a web based search. The experts find more enablers than barriers for IPE between medical and nursing students. Four primary arguments for IPE were mentioned: (1) development and promotion of interprofessional thinking and acting, (2) acquirement of shared knowledge, (3) promotion of beneficial information and knowledge exchange, and (4) promotion of mutual understanding. Major barriers of IPE are the coordination and harmonization of the curricula of the two professions. With respect to the effects of IPE for IPC, experts mentioned possible improvements on (a) patient level and (b) professional level. Experts expect an improved patient-centered care based on better mutual understanding and coordinated cooperation in interprofessional health care teams. To sustainably implement IPE for medical and nursing students, IPE needs endorsement by both, medical and nursing faculties. In conclusion, IPE promotes interprofessional cooperation between the medical and the nursing profession. Skills in interprofessional communication and roles understanding will be primary preconditions to improve collaborative patient-centered care. The impact of IPE for patients and caregivers as well as for both professions now needs to be more specifically analysed in prospective intervention studies.

Quasi-experimental evaluation of a multifaceted intervention to improve quality of end-of-life care and quality of dying for patients with advanced dementia in long-term care institutions.

PubMed

Verreault, René; Arcand, Marcel; Misson, Lucie; Durand, Pierre J; Kroger, Edeltraut; Aubin, Michèle; Savoie, Maryse; Hadjistavropoulos, Thomas; Kaasalainen, Sharon; Bédard, Annick; Grégoire, Annie; Carmichael, Pierre-Hughes

2018-03-01

Improvement in the quality of end-of-life care for advanced dementia is increasingly recognized as a priority in palliative care. To evaluate the impact of a multidimensional intervention to improve quality of care and quality of dying in advanced dementia in long-term care facilities. Quasi-experimental study with the intervention taking place in two long-term care facilities versus usual care in two others over a 1-year period. The intervention had five components: (1) training program to physicians and nursing staff, (2) clinical monitoring of pain using an observational pain scale, (3) implementation of a regular mouth care routine, (4) early and systematic communication with families about end-of-life care issues with provision of an information booklet, and (5) involvement of a nurse facilitator to implement and monitor the intervention. Quality of care was assessed with the Family Perception of Care Scale. The Symptom Management for End-of-Life Care in Dementia and the Comfort Assessment in Dying scales were used to assess the quality of dying. A total of 193 residents with advanced dementia and their close family members were included (97 in the intervention group and 96 in the usual care group). The Family Perception of Care score was significantly higher in the intervention group than in the usual care group (157.3 vs 149.1; p = 0.04). The Comfort Assessment and Symptom Management scores were also significantly higher in the intervention group. Our multidimensional intervention in long-term care facilities for patients with terminal dementia resulted in improved quality of care and quality of dying when compared to usual care.

Strengthening Moral Courage Among Nurse Leaders.

PubMed

Edmonson, Cole

2015-02-17

Moral distress among practicing nurses is frequently discussed in the nursing literature, along with well-developed recommendations for increasing moral courage in practicing nurses. Implementing these recommendations depends on nurse leaders being morally fit to lead and to create an environment in which moral courage actions can emerge. The literature is lacking pertaining to nurse leaders' preparation to lead in a morally courageous and transformational manner in our current corporate environments and hierarchies of healthcare. In this article, the author reviews the literature addressing moral distress and moral courage among direct care nurses; describes the development of an intervention to strengthen the moral courage of nurse leaders; reports a study that involved implementing this intervention; presents the findings of this study; evaluates the effectiveness of the intervention; and discusses the findings in terms of lessons learned and future directions. He concludes with a call for healthcare leaders to demonstrate moral courage and create environments that promote morally courageous acts that enable nurses to remain centered on the patients, families, and communities we serve.

Screening, brief intervention, and referral to treatment for military spouses experiencing alcohol and substance use disorders: a literature review.

PubMed

Ahmadi, Halima; Green, Scott L

2011-06-01

This paper provides an overview of alcohol and substance use issues in military spouses, and explore how the screening, brief intervention, and referral to treatment (SBIRT) model may enable health care providers to identify individuals at risk for developing substance use related disorders. The information presented is based on a broad literature scan relating to the characteristics of the military lifestyle, health infrastructure, screening and intervention processes, and the uses of SBIRT in military and civilian settings. Current literature suggests that military spouses, and families, tend to be at different points in their life course than civilian families of similar ages. Marrying earlier and having children sooner coupled with military lifestyle stressors place them at increased risk for developing adverse coping mechanisms, particularly during deployment. SBIRT has been recognized as an effective method among civilian patients although there is limited research on the efficacy of SBIRT for military spouses at risk of or experiencing substance use problems.

Organization of surveillance in GI practice.

PubMed

Senore, Carlo; Bellisario, Cristina; Hassan, Cesare

2016-12-01

Several reports documented an inefficient utilisation of available resources, as well as a suboptimal compliance with surveillance recommendations. Although, evidence suggests that organisational issues can influence the quality of care delivered, surveillance protocols are usually based on non-organized approaches. We conducted a literature search (publication date: 01/2000-06/2016) on PubMed and Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Cochrane Central Register of Controlled Trials for guidelines, or consensus statements, for surveys of practice, reporting information about patients, or providers attitudes and behaviours, for intervention studies to enhance compliance with guidelines. Related articles were also scrutinised. Based on the clinical relevance and burden on endoscopy services this review was focused on surveillance for Barrett's oesophagus, IBD and post-polypectomy surveillance of colonic adenomas. Existing guidelines are generally recognising structure and process requirements influencing delivery of surveillance interventions, while less attention had been devoted to transitions and interfaces in the care process. Available evidence from practice surveys is suggesting the need to design organizational strategies aimed to enable patients to attend and providers to deliver timely and appropriate care. Well designed studies assessing the effectiveness of specific interventions in this setting are however lacking. Indirect evidence from screening settings would suggest that the implementation of automated standardized recall systems, utilisation of clinical registries, removing financial barriers, could improve appropriateness of use and compliance with recommendations. Lack of sound evidence regarding utility and methodology of surveillance can contribute to explain the observed variability in providers and patients attitudes and in compliance with the recommended surveillance. Copyright © 2016 Elsevier Ltd. All rights reserved.

Social workers' perceptions of barriers to interpersonal therapy implementation for treating postpartum depression in a primary care setting in Israel.

PubMed

Bina, Rena; Barak, Adi; Posmontier, Barbara; Glasser, Saralee; Cinamon, Tali

2018-01-01

Research on evidence-based practice (EBP) implementation in social work often neglects to include evaluation of application barriers. This qualitative study examined social workers' perspectives of provider- and organisational-related barriers to implementing a brief eight-session interpersonal therapy (IPT) intervention, a time-limited EBP that addresses reducing depressive symptoms and improving interpersonal functioning. Implementation took place in a primary care setting in Israel and was aimed at treating women who have postpartum depression (PPD) symptoms. Using purposeful sampling, 25 primary care licensed social workers were interviewed between IPT training and implementation regarding their perceived barriers to implementing IPT in practice. Data analysis was facilitated using a phenomenological approach, which entails identifying the shared themes and shared experiences of research participants regarding barriers to implementing IPT. Three themes emerged from the analysis of interviews: Perceived lack of flexibility of IPT intervention in comparison with more familiar methods social workers previously applied, specifically regarding the number of sessions and therapeutic topics included in the IPT protocol; insecurity and hesitance to gain experience with a new method of intervention; and organisational barriers, including difficulties with referrals, the perception of HMOs as health facilities not suitable for therapy, and time constraints. Addressing perceived barriers of social workers toward implementing EBPs, such as IPT for postpartum depression, during the training phase is crucial for enabling appropriate implementation. Future training should include examining practitioners' attitudes toward implementation of EBPs, as part of standardised training protocols. © 2017 John Wiley & Sons Ltd.

Innovations in non-communicable diseases management in ASEAN: a case series.

PubMed

Lim, Jeremy; Chan, Melissa M H; Alsagoff, Fatimah Z; Ha, Duc

2014-01-01

Non-communicable diseases (NCDs) are reaching epidemic proportions worldwide and present an unprecedented challenge to economic and social development globally. In Southeast Asia, the challenges are exacerbated by vastly differing levels of health systems development and funding availability. In addressing the burden of NCDs, ASEAN nations need to fundamentally re-examine how health care services are structured and delivered and discover new models as undiscerning application of models from other geographies with different cultures and resources will be problematic. We sought to examine cases of innovation and identify critical success factors in NCD management in ASEAN. A qualitative design, focusing on in-depth interviews and site visits to explore the meanings and perceptions of participants regarding innovations in NCD against the backdrop of the overall context of delivering health care within the country's context was adopted. In total 12 case studies in six ASEAN countries were analysed. Primary interventions accounted for five of the total cases, whereas secondary interventions comprised four, and tertiary interventions three. Five core themes contributing to successful innovation for NCD management were identified. They include: 1) encourage better outcomes through leadership and support, 2) strengthen inter-disciplinary partnership, 3) community ownership is key, 4) recognise the needs of the people and what appeals to them, and 5) raise awareness through capacity building and increasing health literacy. Innovation is vital in enabling ASEAN nations to successfully address the growing crisis of NCDs. More of the same or wholesale transfers of developed world models will be ineffective and lead to financially unsustainable programmes or programmes lacking appropriate human capital. The case studies have demonstrated the transformative impact of innovation and identified key factors in successful implementation. Beyond pilot success, the bigger challenge is scaling up. Medical technologies are crucial but insufficient; passionate and engaged leaders and communities enabled by enlightened policy makers and funding agencies matter more.

Innovations in non-communicable diseases management in ASEAN: a case series

PubMed Central

Lim, Jeremy; Chan, Melissa M. H.; Alsagoff, Fatimah Z.; Ha, Duc

2014-01-01

Background Non-communicable diseases (NCDs) are reaching epidemic proportions worldwide and present an unprecedented challenge to economic and social development globally. In Southeast Asia, the challenges are exacerbated by vastly differing levels of health systems development and funding availability. In addressing the burden of NCDs, ASEAN nations need to fundamentally re-examine how health care services are structured and delivered and discover new models as undiscerning application of models from other geographies with different cultures and resources will be problematic. Objective We sought to examine cases of innovation and identify critical success factors in NCD management in ASEAN. Design A qualitative design, focusing on in-depth interviews and site visits to explore the meanings and perceptions of participants regarding innovations in NCD against the backdrop of the overall context of delivering health care within the country's context was adopted. Results In total 12 case studies in six ASEAN countries were analysed. Primary interventions accounted for five of the total cases, whereas secondary interventions comprised four, and tertiary interventions three. Five core themes contributing to successful innovation for NCD management were identified. They include: 1) encourage better outcomes through leadership and support, 2) strengthen inter-disciplinary partnership, 3) community ownership is key, 4) recognise the needs of the people and what appeals to them, and 5) raise awareness through capacity building and increasing health literacy. Conclusions Innovation is vital in enabling ASEAN nations to successfully address the growing crisis of NCDs. More of the same or wholesale transfers of developed world models will be ineffective and lead to financially unsustainable programmes or programmes lacking appropriate human capital. The case studies have demonstrated the transformative impact of innovation and identified key factors in successful implementation. Beyond pilot success, the bigger challenge is scaling up. Medical technologies are crucial but insufficient; passionate and engaged leaders and communities enabled by enlightened policy makers and funding agencies matter more. PMID:25249061

How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden

PubMed Central

2012-01-01

Background There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department. Methods We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses. Results Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration. Conclusions Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure). PMID:22296919

How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden.

PubMed

Mazzocato, Pamela; Holden, Richard J; Brommels, Mats; Aronsson, Håkan; Bäckman, Ulrika; Elg, Mattias; Thor, Johan

2012-02-01

There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department. We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses. Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration. Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure).

Quality of antenatal and childbirth care in rural health facilities in Burkina Faso, Ghana and Tanzania: an intervention study.

PubMed

Duysburgh, Els; Temmerman, Marleen; Yé, Maurice; Williams, Afua; Massawe, Siriel; Williams, John; Mpembeni, Rose; Loukanova, Svetla; Haefeli, Walter E; Blank, Antje

2016-01-01

To assess the impact of an intervention consisting of a computer-assisted clinical decision support system and performance-based incentives, aiming at improving quality of antenatal and childbirth care. Intervention study in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania. In each country, six intervention and six non-intervention PHC facilities, located in one intervention and one non-intervention rural districts, were selected. Quality was assessed in each facility by health facility surveys, direct observation of antenatal and childbirth care, exit interviews, and reviews of patient records and maternal and child health registers. Findings of pre- and post-intervention and of intervention and non-intervention health facility quality assessments were analysed and assessed for significant (P < 0.05) quality of care differences. Post-intervention quality scores do not show a clear difference to pre-intervention scores and scores at non-intervention facilities. Only a few variables had a statistically significant better post-intervention quality score and when this is the case this is mostly observed in only one study-arm, being pre-/post-intervention or intervention/non-intervention. Post-intervention care shows similar deficiencies in quality of antenatal and childbirth care and in detection, prevention, and management of obstetric complications as at baseline and non-intervention study facilities. Our intervention study did not show a significant improvement in quality of care during the study period. However, the use of new technology seems acceptable and feasible in rural PHC facilities in resource-constrained settings, creating the opportunity to use this technology to improve quality of care. © 2015 John Wiley & Sons Ltd.

Enabling factors for specialist outreach in western KwaZulu-Natal

PubMed Central

2018-01-01

Background There exists a major disparity in access to specialist care between patients in urban and rural areas. Specialists are a scarce resource and are concentrated in urban areas. Specialist outreach attempts to fill the gap in service provision for patients situated remotely. While there is international evidence that multifaceted specialist outreach has achieved varying levels of success, factors that influence the effectiveness of outreach have not yet been fully elucidated in South Africa. Aim This study attempts to uncover some of the factors that enable good multifaceted specialist outreach. Setting The study was conducted in hospitals in western KwaZulu-Natal province. This health area is served by a tertiary hospital and 20 peripheral hospitals; three of these are regional level and the majority are district level hospitals. Specialist outreach emanates from the tertiary hospital. Methods Specialists providing outreach services from the tertiary hospital and medical officers at seven receiving hospitals were interviewed to explore perceptions regarding factors that might enable successful specialist outreach. Framework analysis on the transcribed interviews was carried out using NVivo version 11. Results A major positive finding concerns the relationships formed between outreach specialists and doctors at the recipient hospitals. The management of the programme with respect to structure, dependability, data management, transport provision, communication technology and public health systems was also seen as beneficial in specialist outreach. Conclusion Specialist outreach plays an essential role in providing equality in health care. To enable effectiveness, it is important to make full use of the multifaceted nature of this intervention. PMID:29781691

Assessing the success of the WomanKind program: an integrated model of 24-hour health care response to domestic violence.

PubMed

Short, Lynn M; Hadley, Susan M; Bates, Bonnie

2002-01-01

The WomanKind program, a non-profit health care based program for for victims of domestic/intimate partner violence (IPV), seeks to enable and motivate health care providers to identify victims of such violence and refer them to WomanKind's in-house services. An evaluation designed to assess client referral to WomanKind services and the impact of health care provider training was carried out. Data were collected at three intervals over a 2-year period at 3 intervention and 2 comparison hospitals located in Minneapolis, MN. The focus of data collection efforts was to assess the providers' knowledge, attitudes, beliefs, and behaviors (KABB) concerning identification and referral of victims of IPV. Hospital staff and volunteer advocate training programs also were evaluated. Chart reviews were conducted and client referrals assessed. Providers at WomanKind hospitals demonstrated significantly higher knowledge, attitudes, beliefs and behaviors than those at comparison hospitals throughout the study. During the data collection period, 1719 IPV victims were identified and referred to the WomanKind program, while only 27 IPV victims were referred to trained social workers at the comparison hospitals. Chart reviews indicated that emergency staff at the intervention sites provide documentation of IPV in patient records twice as frequently as emergency staff at the comparison sites. This research underscores the efficacy of a well-structured, multidisciplinary effort to deliver services to IPV victims. The results demonstrate that specialized training and on-site client services create a significant positive impact on the KABB of health care providers.

Information technology for the treatment of diabetes: improving outcomes and controlling costs.

PubMed

Wyne, Kathleen

2008-03-01

Diabetes in particular presents an ideal opportunity for the incorporation of information technology (IT) in the provision of care. The disease is highly prevalent in managed care populations, is frequently associated with comorbid conditions, and requires multiple medications in its management. Furthermore, effective diabetes care involves the monitoring of several measures of disease control, such as hemoglobin A1c (A1c) and lipid levels, by several different levels of providers, such as physicians, nurse practitioners, physician assistants, pharmacists, and dieticians. All of these factors combined make diabetes an opportune disease state for a case study of the implementation of health information technology (HIT) in managed care. To review practical applications of HIT for improving the delivery of care in diabetes management. Between 1990 and 2002, the incidence of type 2 diabetes increased by 61% in the United States. The total costs associated with diabetes have been increasing since the late 1970s as well, with a more dramatic rise over the last 10 years. In fact, the total cost of diabetes in the United States will approach $200 billion per year by the year 2020. In order to improve diabetes management efforts nation wide, the goal of glucose lowering therapy has been recommended to lower the hemoglobin A1c (A1c) to < 7% and keep it below that level long term. Other measures beyond A1c levels have also been identified as being important components to effective diabetes management and incorporated into national treatment recommendations, providing an ideal opportunity for the incorporation of HIT interventions. These interventions have been aimed at 3 different groups of stakeholders in managed care: payers, providers, and patients. While uncontrolled diabetes remains a major concern in managed care from both a health and a cost perspective, implementation of information technology enabled diabetes management (ITDM) has demonstrated significant potential for improving processes of care, preventing the development of diabetic complications, and generating cost savings. ITDM improves the synthesis of information, the delivery of knowledge, and the efficiency of communication, allowing for coordination of care across delivery teams. Of the existing technologies targeting providers, patients, and payers, provider centered interventions, such as diabetes registries currently show the most potential for benefit in improving outcomes and reducing costs.

An exploratory study to examine intentions to adopt an evidence-based HIV linkage-to-care intervention among state health department AIDS directors in the United States

PubMed Central

2012-01-01

Background Widespread dissemination and implementation of evidence-based human immunodeficiency virus (HIV) linkage-to-care (LTC) interventions is essential for improving HIV-positive patients' health outcomes and reducing transmission to uninfected others. To date, however, little work has focused on identifying factors associated with intentions to adopt LTC interventions among policy makers, including city, state, and territory health department AIDS directors who play a critical role in deciding whether an intervention is endorsed, distributed, and/or funded throughout their region. Methods Between December 2010 and February 2011, we administered an online questionnaire with state, territory, and city health department AIDS directors throughout the United States to identify factors associated with intentions to adopt an LTC intervention. Guided by pertinent theoretical frameworks, including the Diffusion of Innovations and the "push-pull" capacity model, we assessed participants' attitudes towards the intervention, perceived organizational and contextual demand and support for the intervention, likelihood of adoption given endorsement from stakeholder groups (e.g., academic researchers, federal agencies, activist organizations), and likelihood of enabling future dissemination efforts by recommending the intervention to other health departments and community-based organizations. Results Forty-four participants (67% of the eligible sample) completed the online questionnaire. Approximately one-third (34.9%) reported that they intended to adopt the LTC intervention for use in their city, state, or territory in the future. Consistent with prior, related work, these participants were classified as LTC intervention "adopters" and were compared to "nonadopters" for data analysis. Overall, adopters reported more positive attitudes and greater perceived demand and support for the intervention than did nonadopters. Further, participants varied with their intention to adopt the LTC intervention in the future depending on endorsement from different key stakeholder groups. Most participants indicated that they would support the dissemination of the intervention by recommending it to other health departments and community-based organizations. Conclusions Findings from this exploratory study provide initial insight into factors associated with public health policy makers' intentions to adopt an LTC intervention. Implications for future research in this area, as well as potential policy-related strategies for enhancing the adoption of LTC interventions, are discussed. PMID:22471965

Ethical issues of prison nursing: A qualitative study in Northern Italy.

PubMed

Sasso, Loredana; Delogu, Barbara; Carrozzino, Roberto; Aleo, Giuseppe; Bagnasco, Annamaria

2018-05-01

Prisons are contexts where nurses are required to have specific skills to ensure that, in a setting designed for the expiation of crime, prisoners receive the same type of care as anyone else. But this is not always the case, giving rise to ethical issues. 'How do correctional nurses describe their working experience in prisons? What issues emerged?' This is a qualitative descriptive study. Following purposive sampling, we conducted five focus groups. Thematic analysis was used to analyse the data. Participants and research context: Our sample included 31 correctional nurses in seven prisons in Northern Italy. Ethical considerations: The scientific merit of this study was recognized by the Academic Board of the University of Genoa. Approval to conduct the study was obtained from the Liguria Regional Government that funded this study and from the Local Health Authority that was the prison nurses' employer. Formal consent was obtained from all the nurses who volunteered to participate in this study. Five themes emerged from the focus groups: (1) prisoners' healthcare needs, (2) negotiation between custody and care, (3) satisfaction of working in prisons, (4) obstacles to quality care and (5) safety. 'Manipulation' was a transversal theme that emerged from all the focus groups. The problems generated by the clash between prison security and nursing care priorities did not enable nurses to practice autonomously and provide the best possible to care prisoners, giving rise to ethical issues and moral distress. This in turn causes high nursing turnover rates that negatively impact continuum of care. In Italy, correctional nurses urgently require specific education interventions with the participation of all those who work in prisons. Interventions based on the post-modern concept of restorative nursing could offer prison nurses the opportunity to both resolve ethical issues and reduce moral distress.

Integrated Care and Connected Health Approaches Leveraging Personalised Health through Big Data Analytics.

PubMed

Maglaveras, Nicos; Kilintzis, Vassilis; Koutkias, Vassilis; Chouvarda, Ioanna

2016-01-01

Integrated care and connected health are two fast evolving concepts that have the potential to leverage personalised health. From the one side, the restructuring of care models and implementation of new systems and integrated care programs providing coaching and advanced intervention possibilities, enable medical decision support and personalized healthcare services. From the other side, the connected health ecosystem builds the means to follow and support citizens via personal health systems in their everyday activities and, thus, give rise to an unprecedented wealth of data. These approaches are leading to the deluge of complex data, as well as in new types of interactions with and among users of the healthcare ecosystem. The main challenges refer to the data layer, the information layer, and the output of information processing and analytics. In all the above mentioned layers, the primary concern is the quality both in data and information, thus, increasing the need for filtering mechanisms. Especially in the data layer, the big biodata management and analytics ecosystem is evolving, telemonitoring is a step forward for data quality leverage, with numerous challenges still left to address, partly due to the large number of micro-nano sensors and technologies available today, as well as the heterogeneity in the users' background and data sources. This leads to new R&D pathways as it concerns biomedical information processing and management, as well as to the design of new intelligent decision support systems (DSS) and interventions for patients. In this paper, we illustrate these issues through exemplar research targeting chronic patients, illustrating the current status and trends in PHS within the integrated care and connected care world.

Protocol investigating the clinical outcomes and cost-effectiveness of cognitive–behavioural therapy delivered remotely for unscheduled care users with health anxiety: randomised controlled trial

PubMed Central

Patel, Shireen; Malins, Sam; Guo, Boliang; James, Marilyn; Kai, Joe; Kaylor-Hughes, Catherine; Rowley, Emma; Simpson, Jayne; Smart, David; Stubley, Michelle; Tyrer, Helen

2016-01-01

Background Health anxiety and medically unexplained symptoms cost the National Health Service (NHS) an estimated £3 billion per year in unnecessary costs with little evidence of patient benefit. Effective treatment is rarely taken up due to issues such as stigma or previous negative experiences with mental health services. An approach to overcome this might be to offer remotely delivered psychological therapy, which can be just as effective as face-to-face therapy and may be more accessible and suitable. Aims To investigate the clinical outcomes and cost-effectiveness of remotely delivered cognitive–behavioural therapy (CBT) to people with high health anxiety repeatedly accessing unscheduled care (trial registration: NCT02298036). Method A multicentre randomised controlled trial (RCT) will be undertaken in primary and secondary care providers of unscheduled care across the East Midlands. One hundred and forty-four eligible participants will be equally randomised to receive either remote CBT (6–12 sessions) or treatment as usual (TAU). Two doctoral research studies will investigate the barriers and facilitators to delivering the intervention and the factors contributing to the optimisation of therapeutic outcome. Results This trial will be the first to test the clinical outcomes and cost-effectiveness of remotely delivered CBT for the treatment of high health anxiety. Conclusions The findings will enable an understanding as to how this intervention might fit into a wider care pathway to enhance patient experience of care. Declaration of interest None. Copyright and usage © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-commercial, No Derivatives (CC BY-NC-ND) licence. PMID:27703758

eHealth as the Next-Generation Perinatal Care: An Overview of the Literature.

PubMed

van den Heuvel, Josephus Fm; Groenhof, T Katrien; Veerbeek, Jan Hw; van Solinge, Wouter W; Lely, A Titia; Franx, Arie; Bekker, Mireille N

2018-06-05

Unrestricted by time and place, electronic health (eHealth) provides solutions for patient empowerment and value-based health care. Women in the reproductive age are particularly frequent users of internet, social media, and smartphone apps. Therefore, the pregnant patient seems to be a prime candidate for eHealth-supported health care with telemedicine for fetal and maternal conditions. This study aims to review the current literature on eHealth developments in pregnancy to assess this new generation of perinatal care. We conducted a systematic literature search of studies on eHealth technology in perinatal care in PubMed and EMBASE in June 2017. Studies reporting the use of eHealth during prenatal, perinatal, and postnatal care were included. Given the heterogeneity in study methods, used technologies, and outcome measurements, results were analyzed and presented in a narrative overview of the literature. The literature search provided 71 studies of interest. These studies were categorized in 6 domains: information and eHealth use, lifestyle (gestational weight gain, exercise, and smoking cessation), gestational diabetes, mental health, low- and middle-income countries, and telemonitoring and teleconsulting. Most studies in gestational diabetes and mental health show that eHealth applications are good alternatives to standard practice. Examples are interactive blood glucose management with remote care using smartphones, telephone screening for postnatal depression, and Web-based cognitive behavioral therapy. Apps and exercise programs show a direction toward less gestational weight gain, increase in step count, and increase in smoking abstinence. Multiple studies describe novel systems to enable home fetal monitoring with cardiotocography and uterine activity. However, only few studies assess outcomes in terms of fetal monitoring safety and efficacy in high-risk pregnancy. Patients and clinicians report good overall satisfaction with new strategies that enable the shift from hospital-centered to patient-centered care. This review showed that eHealth interventions have a very broad, multilevel field of application focused on perinatal care in all its aspects. Most of the reviewed 71 articles were published after 2013, suggesting this novel type of care is an important topic of clinical and scientific relevance. Despite the promising preliminary results as presented, we accentuate the need for evidence for health outcomes, patient satisfaction, and the impact on costs of the possibilities of eHealth interventions in perinatal care. In general, the combination of increased patient empowerment and home pregnancy care could lead to more satisfaction and efficiency. Despite the challenges of privacy, liability, and costs, eHealth is very likely to disperse globally in the next decade, and it has the potential to deliver a revolution in perinatal care. ©Josephus FM van den Heuvel, T Katrien Groenhof, Jan HW Veerbeek, Wouter W van Solinge, A Titia Lely, Arie Franx, Mireille N Bekker. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 05.06.2018.

Thematic Analysis: How do patient diaries affect survivors' psychological recovery?

PubMed

Teece, Angela; Baker, John

2017-08-01

This review aims to use thematic analysis to explore and synthesise evidence of the actual or potential reported effects of diaries on the psychological rehabilitation and recovery of discharged critical care patients. Evidence suggests that whilst admission to critical care may save patient lives, the psychological aftermath can damage a patient's recovery and these needs must be met. Patient diaries are one potential intervention to aid patients understand their critical illness and fill memory gaps caused by sedation, thus reducing psychological distress post-discharge. Prospective patient diaries are increasing in popularity amongst critical care units in the United Kingdom, however there is little evidence base to support their use or understand their effects. A literature review using systematic methods was undertaken of studies relating to the effects of diaries on discharged patients. Thematic analysis enabled the generation and synthesis of themes. Three themes arose from the generated codes: 1) Reclaiming ownership of lost time. 2) Emphasising personhood. 3) Fear and frustration. The diary intervention was shown to have a largely positive impact on survivors' psychological rehabilitation. However, caution should be exercised as recipients could find the contents painful and emotional. Diaries should be embedded within a robust critical care follow-up plan. This review suggests that diaries have the potential to form one aspect of rehabilitation and make a positive impact on patients' recovery. More research is indicated to fully evaluate the effects of diaries on their recipients. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Examining clinical supervision as a mechanism for changes in practice: a research protocol.

PubMed

Dilworth, Sophie; Higgins, Isabel; Parker, Vicki; Kelly, Brian; Turner, Jane

2014-02-01

This paper describes the research protocol for a study exploring if and how clinical supervision facilitates change in practice relating to psychosocial aspects of care for Health Professionals, who have been trained to deliver a psychosocial intervention to adults with cancer. There is a recognized need to implement care that is in line with clinical practice guidelines for the psychosocial care of adults with cancer. Clinical supervision is recommended as a means to support Health Professionals in providing the recommended psychosocial care. A qualitative design embedded within an experimental, stepped wedge randomized control trial. The study will use discourse analysis to analyse audio-recorded data collected in clinical supervision sessions that are being delivered as one element of a large randomized control trial. The sessions will be attended primarily by nurses, but including physiotherapists, radiation therapists, occupational therapists. The Health Professionals are participants in a randomized control trial designed to reduce anxiety and depression of distressed adults with cancer. The sessions will be facilitated by psychiatrists experienced in psycho-oncology and the provision of clinical supervision. The proposed research is designed specifically to facilitate exploration of the mechanisms by which clinical supervision enables Health Professionals to deliver a brief, tailored psychosocial intervention in the context of their everyday practice. This is the first study to use discourse analysis embedded within an experimental randomized control trial to explore the mechanisms of change generated within clinical supervision by analysing the discourse within the clinical supervision sessions. © 2013 John Wiley & Sons Ltd.

Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury.

PubMed

Newgard, C D; Hedges, J R; Stone, J V; Lenfesty, B; Diggs, B; Arthur, M; Mullins, R J

2005-12-01

To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care. We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18-65 years with a serious head injury (AIS > or =3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based "high therapeutic intensity" measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule. 504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation. This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.

Using Complexity Theory to Guide Medical School Evaluations.

PubMed

Jorm, Christine; Roberts, Chris

2018-03-01

Contemporary medical school evaluations are narrow in focus and often do not consider the wider systems implications of the relationship between learning and teaching, research, clinical care, and community engagement. The result is graduates who lack the necessary knowledge and skills for the modern health care system and an educational system that is limited in its ability to learn and change.To address this issue, the authors apply complexity theory to medical school evaluation, using four key factors-nesting, diversity, self-organization, and emergent outcomes. To help medical educators apply this evaluation approach in their own settings, the authors offer two tools-a modified program logic model and sensemaking. In sensemaking, they use the organic metaphor of the medical school as a neuron situated within a complex neural network to enable medical educators to reframe the way they think about program evaluation. The authors then offer practical guidance for applying this model, including describing the example of addressing graduates' engagement in the health care system. The authors consider the input of teachers, the role of culture and curriculum, and the clinical care system in this example.Medical school evaluation is reframed as an improvement science for complex social interventions (medical school is such an intervention) in this model. With complexity theory's focus on emergent outcomes, evaluation takes on a new focus, reimagining medical students as reaching their future potential as change agents, who transform health systems and the lives of patients.

[Social factors associated with use of prenatal care in Ecuador].

PubMed

Sánchez-Gómez, Amaya; Cevallos, William; Grijalva, Mario J; Silva-Ayçaguer, Luis C; Tamayo, Susana; Jacobson, Jerry O; Costales, Jaime A; Jiménez-Garcia, Rodrigo; Hernández-Barrera, Valentín; Serruya, Suzanne; Riera, Celia

2016-11-01

Prenatal care is a pillar of public health, enabling access to interventions including prevention of mother-to-child transmission of HIV and congenital syphilis. This paper describes social factors related to use of prenatal care in Ecuador. In 2011 and 2012, participant clinical history and interview information was analyzed from a national probability sample of 5 998 women presenting for delivery or miscarriage services in 15 healthcare facilities in Ecuador, to estimate prevalence of HIV, syphilis, and Chagas disease, and prenatal care coverage. The study found that 94.1% of women had attended at least one prenatal visit, but that attendance at no less than four visits was 73.1%. Furthermore, lower educational level, greater number of pregnancies, occupation in the agriculture or livestock sector, and membership in ethnic indigenous, Afro-Ecuadorian, or other minority groups were factors associated with lack of use (no prenatal visits) or insufficient use of prenatal care (fewer than four visits or first visit at >20 weeks gestation) in Ecuador. These results point to persistence of marked inequalities in access to and use of prenatal health services attributable to socioeconomic factors and to the need to strengthen strategies to address them, to reach the goal of universal prenatal care coverage.

National infection prevention and control programmes: Endorsing quality of care.

PubMed

Stempliuk, Valeska; Ramon-Pardo, Pilar; Holder, Reynaldo

2014-01-01

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.

Revisiting Primary Care's Critical Role in Achieving Health Equity: Pisacano Scholars' Reflections from Starfield Summit II.

PubMed

Park, Brian; Coutinho, Anastasia J; Doohan, Noemi; Jimenez, Jonathan; Martin, Sara; Romano, Max; Wohler, Diana; DeVoe, Jennifer

2018-01-01

The second Starfield Summit was held in Portland, Oregon, in April 2017. The Summit addressed the role of primary care in advancing health equity by focusing on 4 key domains: social determinants of health in primary care, vulnerable populations, economics and policy, and social accountability. Invited participants represented an interdisciplinary group of primary care clinicians, researchers, educators, policymakers, community leaders, and trainees. The Pisacano Leadership Foundation was one of the Summit sponsors and held its annual leadership symposium in conjunction with the Summit, enabling several Pisacano Scholars to attend the Summit. After the Summit, a small group of current and former Pisacano Scholars formed a writing group to highlight key themes and implications for action discussed at the Summit. The Summit resonated as a call to action for primary care to move beyond identifying existing health inequities and toward the development of interventions that advance health equity, through education, research, and enhanced community partnerships. In doing so, the Summit aimed to build on the foundational work of Dr. Starfield, challenging us to explore the significant role of primary care in truly achieving health equity. © Copyright 2018 by the American Board of Family Medicine.

Perceived Enablers and Barriers Related to Sustainability of School-Wide Positive Behavioral Interventions and Supports

ERIC Educational Resources Information Center

Pinkelman, Sarah E.; McIntosh, Kent; Rasplica, Caitlin K.; Berg, Tricia; Strickland-Cohen, M. Kathleen

2015-01-01

The purpose of this study was to identify the most important perceived enablers and barriers regarding sustainability of school-wide positive behavioral interventions and supports. School personnel representing 860 schools implementing or preparing to implement school-wide positive behavioral interventions and supports completed an open-ended…

Using conversation analytic methods to assess fidelity to a talk-based healthcare intervention for frequently attending patients.

PubMed

Barnes, Rebecca K; Jepson, Marcus; Thomas, Clare; Jackson, Sue; Metcalfe, Chris; Kessler, David; Cramer, Helen

2018-06-01

The study aim was to assess implementation fidelity (i.e., adherence) to a talk-based primary care intervention using Conversation Analytic (CA) methods. The context was a UK feasibility trial where General Practitioners (GPs) were trained to use "BATHE" (Background,Affect,Trouble,Handling,Empathy) - a technique to screen for psychosocial issues during consultations - with frequently attending patients. 35 GPs received BATHE training between July-October 2015. 15 GPs across six practices self-selected to record a sample of their consultations with study patients at three and six months. 31 consultations were recorded. 21/26 patients in four intervention practices gave permission for analysis. The recordings were transcribed and initially coded for the presence or absence of the five BATHE components. CA methods were applied to assess delivery, focusing on position and composition of each component, and patients' responses. Initial coding showed most of the BATHE components to be present in most contacts. However the CA analysis revealed unplanned deviations in position and adaptations in composition. Frequently the intervention was initiated too early in the consultation, and the BATHE questions misunderstood by patients as pertaining to their presenting problems rather than the psychosocial context for their problems. Often these deviations resulted in reducing theoretical fidelity of the intervention as a whole. A CA approach enabled a dynamic assessment of the delivery and receipt of BATHE in situ revealing common pitfalls in delivery and provided valuable examples of more and less efficacious implementations. During the trial this evidence was used in top-up trainings to address problems in delivery and to improve GP engagement. Using CA methods enabled a more accurate assessment of implementation fidelity, a fuller description of the intervention itself, and enhanced resources for future training. When positioned appropriately, BATHE can be a useful tool for eliciting information about the wider context of the medical visit. Copyright © 2018 Elsevier Ltd. All rights reserved.

Predictors of the utilization of oral health services by children of low-income families in the United States: beliefs, cost, or provider?

PubMed

Kim, Young Ok Rhee; Telleen, Sharon

2004-12-01

This study examined the predictive factors enabling access to children's oral health care at the level of financial barriers, beliefs, and the provider. In-depth interviews were conducted with 320 immigrant mothers of low-income families regarding their use of oral health services for children aged four to eight years old. Access to oral health care was measured with frequency of planned dental visits, continuity of care, and age at first visit to dentist. The mother took her child to the dentist at a younger age if she received referrals to a dentist from pediatrician. Regular dental visits were significantly related to household income, provider availability on weekends, and insurance coverage. The extended clinic hours in the evenings, and the belief in the importance of the child's regular dentist visits increased the likelihood of continuing care. The mothers perceiving a cost burden for the child's dental care were also less likely to return to the dentist. The available care delivery system, coordinated medical care, and health beliefs were among important predictors of the health service use. The study findings suggest need for culturally competent dental health interventions to enhance access to oral health care among particularly vulnerable populations such as low-income children in Korean communities.

[Evaluations by hospital-ward physicians of patient care management quality for patients hospitalized after an emergency department admission].

PubMed

Bartiaux, M; Mols, P

2017-01-01

patient management in the acute and sub-acute setting of an Emergency Department is challenging. An assessment of the quality of provided care enables an evaluation of failings. It contributes to the identification of areas for improvement. to obtain an analysis, by hospital-ward physicians, of adult patient care management quality, as well as of the correctness of diagnosis made during emergency admissions. To evaluate the consequences of inadequate patient care management on morbidity, mortality and cost and duration of hospitalization. prospective data analysis obtained between the 1/12/2009 and the 21/12/2009 from physicians using a questionnaire on adult-patient emergency admissions and subsequent hospitalization. questionnaires were completed for 332 patients. Inadequate management of patient care were reported for 73/332 (22 %) cases. Incorrect diagnoses were reported for 20/332 (6 %) cases. 35 cases of inadequate care management (10.5 % overall) were associated with morbidity (34 cases) or mortality (1 case), including 4 cases (1.2 % ) that required emergency intensive-care or surgical interventions. this quality study analyzed the percentage of patient management cases and incorrect diagnoses in the emergency department. The data for serious outcome and wrong diagnosis are comparable with current literature. To improve performance, we consider the process for establishing a diagnosis and therapeutic care.

Improving medication management in multimorbidity: development of the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel.

PubMed

Sinnott, Carol; Mercer, Stewart W; Payne, Rupert A; Duerden, Martin; Bradley, Colin P; Byrne, Molly

2015-09-24

Multimorbidity, the presence of two or more chronic conditions, affects over 60 % of patients in primary care. Due to its association with polypharmacy, the development of interventions to optimise medication management in patients with multimorbidity is a priority. The Behaviour Change Wheel is a new approach for applying behavioural theory to intervention development. Here, we describe how we have used results from a review of previous research, original research of our own and the Behaviour Change Wheel to develop an intervention to improve medication management in multimorbidity by general practitioners (GPs), within the overarching UK Medical Research Council guidance on complex interventions. Following the steps of the Behaviour Change Wheel, we sought behaviours associated with medication management in multimorbidity by conducting a systematic review and qualitative study with GPs. From the modifiable GP behaviours identified, we selected one and conducted a focused behavioural analysis to explain why GPs were or were not engaging in this behaviour. We used the behavioural analysis to determine the intervention functions, behavioural change techniques and implementation plan most likely to effect behavioural change. We identified numerous modifiable GP behaviours in the systematic review and qualitative study, from which active medication review (rather than passive maintaining the status quo) was chosen as the target behaviour. Behavioural analysis revealed GPs' capabilities, opportunities and motivations relating to active medication review. We combined the three intervention functions deemed most likely to effect behavioural change (enablement, environmental restructuring and incentivisation) to form the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention. MY COMRADE primarily involves the technique of social support: two GPs review the medications prescribed to a complex multimorbid patient together. Four other behavioural change techniques are incorporated: restructuring the social environment, prompts/cues, action planning and self-incentives. This study is the first to use the Behaviour Change Wheel to develop an intervention targeting multimorbidity and confirms the usability and usefulness of the approach in a complex area of clinical care. The systematic development of the MY COMRADE intervention will facilitate a thorough evaluation of its effectiveness in the next phase of this work.

Service evaluation of the implementation of a digitally-enabled care pathway for the recognition and management of acute kidney injury.

PubMed

Connell, Alistair; Montgomery, Hugh; Morris, Stephen; Nightingale, Claire; Stanley, Sarah; Emerson, Mary; Jones, Gareth; Sadeghi-Alavijeh, Omid; Merrick, Charles; King, Dominic; Karthikesalingam, Alan; Hughes, Cian; Ledsam, Joseph; Back, Trevor; Rees, Geraint; Raine, Rosalind; Laing, Christopher

2017-01-01

Acute Kidney Injury (AKI), an abrupt deterioration in kidney function, is defined by changes in urine output or serum creatinine. AKI is common (affecting up to 20% of acute hospital admissions in the United Kingdom), associated with significant morbidity and mortality, and expensive (excess costs to the National Health Service in England alone may exceed £1 billion per year). NHS England has mandated the implementation of an automated algorithm to detect AKI based on changes in serum creatinine, and to alert clinicians. It is uncertain, however, whether 'alerting' alone improves care quality. We have thus developed a digitally-enabled care pathway as a clinical service to inpatients in the Royal Free Hospital (RFH), a large London hospital. This pathway incorporates a mobile software application - the "Streams-AKI" app, developed by DeepMind Health - that applies the NHS AKI algorithm to routinely collected serum creatinine data in hospital inpatients. Streams-AKI alerts clinicians to potential AKI cases, furnishing them with a trend view of kidney function alongside other relevant data, in real-time, on a mobile device. A clinical response team comprising nephrologists and critical care nurses responds to these AKI alerts by reviewing individual patients and administering interventions according to existing clinical practice guidelines. We propose a mixed methods service evaluation of the implementation of this care pathway. This evaluation will assess how the care pathway meets the health and care needs of service users (RFH inpatients), in terms of clinical outcome, processes of care, and NHS costs. It will also seek to assess acceptance of the pathway by members of the response team and wider hospital community. All analyses will be undertaken by the service evaluation team from UCL (Department of Applied Health Research) and St George's, University of London (Population Health Research Institute).

Barriers and Enablers of Kangaroo Mother Care Practice: A Systematic Review

PubMed Central

Seidman, Gabriel; Unnikrishnan, Shalini; Kenny, Emma; Myslinski, Scott; Cairns-Smith, Sarah; Mulligan, Brian; Engmann, Cyril

2015-01-01

Kangaroo mother care (KMC) is an evidence-based approach to reducing mortality and morbidity in preterm infants. Although KMC is a key intervention package in newborn health initiatives, there is limited systematic information available on the barriers to KMC practice that mothers and other stakeholders face while practicing KMC. This systematic review sought to identify the most frequently reported barriers to KMC practice for mothers, fathers, and health practitioners, as well as the most frequently reported enablers to practice for mothers. We searched nine electronic databases and relevant reference lists for publications reporting barriers or enablers to KMC practice. We identified 1,264 unique publications, of which 103 were included based on pre-specified criteria. Publications were scanned for all barriers / enablers. Each publication was also categorized based on its approach to identification of barriers / enablers, and more weight was assigned to publications which had systematically sought to understand factors influencing KMC practice. Four of the top five ranked barriers to KMC practice for mothers were resource-related: “Issues with the facility environment / resources,” “negative impressions of staff attitudes or interactions with staff,” “lack of help with KMC practice or other obligations,” and “low awareness of KMC / infant health.” Considering only publications from low- and middle-income countries, “pain / fatigue” was ranked higher than when considering all publications. Top enablers to practice were included “mother-infant attachment” and “support from family, friends, and other mentors.” Our findings suggest that mother can understand and enjoy KMC, and it has benefits for mothers, infants, and families. However, continuous KMC may be physically and emotionally difficult, and often requires support from family members, health practitioners, or other mothers. These findings can serve as a starting point for researchers and program implementers looking to improve KMC programs. PMID:25993306

Community Priorities for Healthy Eating in Older Adults.

PubMed

Jiang, Qianzhi; Cohen, Nancy L; Marra, Melissa Ventura; Woolf, Kathleen; Gilbride, Judith; Francis, Sarah L

2017-01-01

Community planners such as policymakers and health care and nutrition service providers can create an "age-friendly" environment to support healthy eating in older residents by addressing the highest priorities that enable older adults to improve their dietary intake through different food-related community settings. To identify and prioritize these factors that facilitate behavioral change (enablers) and behavioral settings important for older adult nutrition based on the social ecological model, nutrition and aging professionals (n = 30) from two rural (West Virginia, Iowa) and two urban (Massachusetts, New York) city/county regions (communities) participated in an online or live focus group discussion and completed an analytic hierarchy process survey online. Overall, the most important perceived enablers were accessibility and cost, followed by transportation and social support, but their relative importance varied by community. Participants from all communities considered congregate meal sites and food banks among the most important behavioral settings. Participants from most communities considered food stores to be important and also highlighted other settings unique to the area, such as senior housing, neighborhood, and farmers' markets. By targeting interventions to address the most notable enablers and behavioral settings specific to their community, planning groups can enhance their older residents' ability to achieve optimal nutritional health.

Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned.

PubMed

Slusher, Tina M; Kiragu, Andrew W; Day, Louise T; Bjorklund, Ashley R; Shirk, Arianna; Johannsen, Colleen; Hagen, Scott A

2018-01-01

Pediatric critical care is an important component of reducing morbidity and mortality globally. Currently, pediatric critical care in low middle-income countries (LMICs) remains in its infancy in most hospitals. The majority of hospitals lack designated intensive care units, healthcare staff trained to care for critically ill children, adequate numbers of staff, and rapid access to necessary medications, supplies and equipment. In addition, most LMICs lack pediatric critical care training programs for healthcare providers or certification procedures to accredit healthcare providers working in their pediatric intensive care units (PICU) and high dependency areas. PICU can improve the quality of pediatric care in general and, if properly organized, can effectively treat the severe complications of high burden diseases, such as diarrhea, severe malaria, and respiratory distress using low-cost interventions. Setting up a PICU in a LMIC setting requires planning, specific resources, and most importantly investment in the nursing and permanent medical staff. A thoughtful approach to developing pediatric critical care services in LMICs starts with fundamental building blocks: training healthcare professionals in skills and knowledge, selecting resource appropriate effective equipment, and having supportive leadership to provide an enabling environment for appropriate care. If these fundamentals can be built on in a sustainable manner, an appropriate critical care service will be established with the potential to significantly decrease pediatric morbidity and mortality in the context of public health goals as we reach toward the sustainable development goals.

The effects of non-attendance information therapy on the control of glycosylated hemoglobin (HbA1C) in type 2 diabetic patients.

PubMed

Yarahmadi, Azam; Zare-Farashbandi, Firoozeh; Kachuei, Ali; Nouri, Rasoul; Hassanzadeh, Akbar

2014-01-01

Patient education plays an important role in the control of diabetes. Nonattendance education, enabling elimination of limitations caused by time and space and facilitating the relationship between patient and care liaison is an effective, simple, and cheap method. The aim of this study is determination of the effects of nonattendance information therapy on the control of glycosylated hemoglobin (HbA1C) in type 2 diabetic patients in Isfahan. The present study was an interventional semi experimental study with pretest and post-test and control groups. Statistical population were type 2 diabetics patients of the Isfahan Endocrine and Metabolism Research Center, of whom 64 people were randomly selected and divided into intervention and control groups. First, the preliminary data were collected using the HbA1c test in patients. Then, the intervention group received training package and Short Message Service (SMS) for eight weeks. After one-month incubation period, HbA1c was again determined in both groups. Data were analyzed using t-test, paired t-test and Mann-Whitney U and Chi-square tests. Results showed that diabetes patients' HbA1c in the intervention group was significantly lower after the intervention through training packages and SMS service compared to before the intervention (P < 0.001). Comparison of the two groups showed that there was a significant difference in the HbA1C between the intervention and control groups (P = 0.048). Follow-up of education of patients with type 2 diabetes through training packages and SMS services had significant effects on the control of the patients' HbA1C. Also due to the low cost and high effectiveness of this method, it is recommended to health-care providers and treatment groups. This study also showed that having medical librarians along with treatment group can have a positive effect on the type 2 diabetic patients' health.

Clinic-based nutrition and lifestyle counseling for Hispanic women delivered by community health workers: design of the California WISEWOMAN study.

PubMed

Farrell, Maureen A; Hayashi, Toshi; Loo, Ryan K; Rocha, David A; Sanders, Charlene; Hernandez, Marianne; Will, Julie C

2009-05-01

The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program in California, named Heart of the Family, implements and evaluates the effectiveness of lifestyle interventions to improve nutrition and physical activity while reducing cardiovascular disease (CVD) risk factors among low-income, uninsured or underinsured Hispanic women aged 40-64 who participate in the Cancer Detection Programs: Every Woman Counts (CDP:EWP). This paper reports the study design and baseline findings of the California WISEWOMAN program. Heart of the Family, a within-site randomized controlled study at four community health centers in Los Angeles and San Diego, featured a unique set of strategies meeting the state population in implementing a California WISEWOMAN program. The program exclusively targeted Hispanic women who are at risk of developing CVD, provided lifestyle intervention using a validated intervention material in Spanish and English to motivate behavioral changes, and used bilingual (English and Spanish) community health workers (CHWs) to provide individually based face-to-face counseling. Women meeting enrollment criteria were randomly assigned either to an enhanced intervention group (EIG), who received lifestyle intervention, or usual care group (UCG), who received the usual care for elevated blood pressure or cholesterol. A total of 1093 women enrolled between January 2006 and August 2006. Demographic and baseline CVD risk profiles are similar in both groups. Some notable characteristics of the California participants are lower smoking rate (5%), higher average body mass index (BMI) (31.9), and a significantly higher percentage with less than high school education (70%). With its unique study design and large number of enrolls, Heart of the Family will enable future public health efforts to better meet the health needs of Hispanic women by addressing education levels, economic considerations, and cultural and linguistic needs.

The feasibility of community level interventions for pre-eclampsia in South Asia and Sub-Saharan Africa: a mixed-methods design.

PubMed

Khowaja, Asif Raza; Qureshi, Rahat Najam; Sawchuck, Diane; Oladapo, Olufemi T; Adetoro, Olalekan O; Orenuga, Elizabeth A; Bellad, Mrutyunjaya; Mallapur, Ashalata; Charantimath, Umesh; Sevene, Esperança; Munguambe, Khátia; Boene, Helena Edith; Vidler, Marianne; Bhutta, Zulfiqar A; von Dadelszen, Peter

2016-06-08

Globally, pre-eclampsia and eclampsia are major contributors to maternal and perinatal mortality; of which the vast majority of deaths occur in less developed countries. In addition, a disproportionate number of morbidities and mortalities occur due to delayed access to health services. The Community Level Interventions for Pre-eclampsia (CLIP) Trial aims to task-shift to community health workers the identification and emergency management of pre-eclampsia and eclampsia to improve access and timely care. Literature revealed paucity of published feasibility assessments prior to initiating large-scale community-based interventions. Arguably, well-conducted feasibility studies can provide valuable information about the potential success of clinical trials prior to implementation. Failure to fully understand the study context risks the effective implementation of the intervention and limits the likelihood of post-trial scale-up. Therefore, it was imperative to conduct community-level feasibility assessments for a trial of this magnitude. A mixed methods design guided by normalization process theory was used for this study in Nigeria, Mozambique, Pakistan, and India to explore enabling and impeding factors for the CLIP Trial implementation. Qualitative data were collected through participant observation, document review, focus group discussion and in-depth interviews with diverse groups of community members, key informants at community level, healthcare providers, and policy makers. Quantitative data were collected through health facility assessments, self-administered community health worker surveys, and household demographic and health surveillance. Refer to CLIP Trial feasibility publications in the current and/or forthcoming supplement. Feasibility assessments for community level interventions, particularly those involving task-shifting across diverse regions, require an appropriate theoretical framework and careful selection of research methods. The use of qualitative and quantitative methods increased the data richness to better understand the community contexts. NCT01911494.

Paving the way for a gold standard of care for infertility treatment: improving outcomes through standardization of laboratory procedures.

PubMed

Schoolcraft, William; Meseguer, Marcos

2017-10-01

Infertility affects over 70 million couples globally. Access to, and interest in, assisted reproductive technologies is growing worldwide, with more couples seeking medical intervention to conceive, in particular by IVF. Despite numerous advances in IVF techniques since its first success in 1978, almost half of the patients treated remain childless. The multifactorial nature of IVF treatment means that success is dependent on many variables. Therefore, it is important to examine how each variable can be optimized to achieve the best possible outcomes for patients. The current approach to IVF is fragmented, with various protocols in use. A systematic approach to establishing optimum best practices may improve IVF success and live birth rates. Our vision of the future is that technological advancements in the laboratory setting are standardized and universally adopted to enable a gold standard of care. Implementation of best practices for laboratory procedures will enable clinicians to generate high-quality gametes, and to produce and identify gametes and embryos of maximum viability and implantation potential, which should contribute to improving take-home healthy baby rates. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Observations of Group Care Worker-Child Interaction in Residential Youth Care: Pedagogical Interventions and Child Behavior

ERIC Educational Resources Information Center

Bastiaanssen, Inge L. W.; Delsing, Marc J. M. H.; Geijsen, Luuk; Kroes, Gert; Veerman, Jan W.; Engels, Rutger C. M. E.

2014-01-01

Background: The work of group care workers in residential youth care is often described as professional parenting. Pedagogical interventions of group care workers influence the quality of care for looked-after children. Objective: The aim of the current study was to observe the pedagogical interventions of group care workers within residential…

Physician attitude toward depression care interventions: Implications for implementation of quality improvement initiatives

PubMed Central

Henke, Rachel Mosher; Chou, Ann F; Chanin, Johann C; Zides, Amanda B; Scholle, Sarah Hudson

2008-01-01

Background Few individuals with depression treated in the primary care setting receive care consistent with clinical treatment guidelines. Interventions based on the chronic care model (CCM) have been promoted to address barriers and improve the quality of care. A current understanding of barriers to depression care and an awareness of whether physicians believe interventions effectively address those barriers is needed to enhance the success of future implementation. Methods We conducted semi-structured interviews with 23 primary care physicians across the US regarding their experience treating patients with depression, barriers to care, and commonly promoted CCM-based interventions. Themes were identified from interview transcripts using a grounded theory approach. Results Six barriers emerged from the interviews: difficulty diagnosing depression, patient resistance, fragmented mental health system, insurance coverage, lack of expertise, and competing demands and other responsibilities as a primary care provider. A number of interventions were seen as helpful in addressing these barriers – including care managers, mental health integration, and education – while others received mixed reviews. Mental health consultation models received the least endorsement. Two systems-related barriers, the fragmented mental health system and insurance coverage limitations, appeared incompletely addressed by the interventions. Conclusion CCM-based interventions, which include care managers, mental health integration, and patient education, are most likely to be implemented successfully because they effectively address several important barriers to care and are endorsed by physicians. Practices considering the adoption of interventions that received less support should educate physicians about the benefit of the interventions and attend to physician concerns prior to implementation. A focus on interventions that address systems-related barriers is needed to overcome all barriers to care. PMID:18826646

The Performance of mHealth in Cancer Supportive Care: A Research Agenda

PubMed Central

2015-01-01

Background Since the advent of smartphones, mHealth has risen to the attention of the health care system as something that could radically change the way health care has been viewed, managed, and delivered to date. This is particularly relevant for cancer, as one of the leading causes of death worldwide, and for cancer supportive care, since patients and caregivers have key roles in managing side effects. Given adequate knowledge, they are able to expect appropriate assessments and interventions. In this scenario, mHealth has great potential for linking patients, caregivers, and health care professionals; for enabling early detection and intervention; for lowering costs; and achieving better quality of life. Given its great potential, it is important to evaluate the performance of mHealth. This can be considered from several perspectives, of which organizational performance is particularly relevant, since mHealth may increase the productivity of health care providers and as a result even the productivity of health care systems. Objective This paper aims to review studies on the evaluation of the performance of mHealth, with particular focus on cancer care and cancer supportive care processes, concentrating on its contribution to organizational performance, as well as identifying some indications for a further research agenda. Methods We carried out a review of literature, aimed at identifying studies related to the performance of mHealth in general or focusing on cancer care and cancer supportive care. Results Our analysis revealed that studies are almost always based on a single dimension of performance. Any evaluations of the performance of mHealth are based on very different methods and measures, with a prevailing focus on issues linked to efficiency. This fails to consider the real contribution that mHealth can offer for improving the performance of health care providers, health care systems, and the quality of life in general. Conclusions Further research should start by stating and explaining what is meant by the evaluation of mHealth’s performance and then conduct more in-depth analysis in order to create shared frameworks to specifically identify the different dimensions of mHealth’s performance. PMID:25720295

The performance of mHealth in cancer supportive care: a research agenda.

PubMed

Nasi, Greta; Cucciniello, Maria; Guerrazzi, Claudia

2015-02-13

Since the advent of smartphones, mHealth has risen to the attention of the health care system as something that could radically change the way health care has been viewed, managed, and delivered to date. This is particularly relevant for cancer, as one of the leading causes of death worldwide, and for cancer supportive care, since patients and caregivers have key roles in managing side effects. Given adequate knowledge, they are able to expect appropriate assessments and interventions. In this scenario, mHealth has great potential for linking patients, caregivers, and health care professionals; for enabling early detection and intervention; for lowering costs; and achieving better quality of life. Given its great potential, it is important to evaluate the performance of mHealth. This can be considered from several perspectives, of which organizational performance is particularly relevant, since mHealth may increase the productivity of health care providers and as a result even the productivity of health care systems. This paper aims to review studies on the evaluation of the performance of mHealth, with particular focus on cancer care and cancer supportive care processes, concentrating on its contribution to organizational performance, as well as identifying some indications for a further research agenda. We carried out a review of literature, aimed at identifying studies related to the performance of mHealth in general or focusing on cancer care and cancer supportive care. Our analysis revealed that studies are almost always based on a single dimension of performance. Any evaluations of the performance of mHealth are based on very different methods and measures, with a prevailing focus on issues linked to efficiency. This fails to consider the real contribution that mHealth can offer for improving the performance of health care providers, health care systems, and the quality of life in general. Further research should start by stating and explaining what is meant by the evaluation of mHealth's performance and then conduct more in-depth analysis in order to create shared frameworks to specifically identify the different dimensions of mHealth's performance.

Type 2 diabetes–related foot care knowledge and foot self-care practice interventions in the United States: a systematic review of the literature

PubMed Central

Bonner, Timethia; Foster, Margaret; Spears-Lanoix, Erica

2016-01-01

Introduction The purpose of this systematic literature review is to review published studies on foot care knowledge and foot care practice interventions as part of diabetic foot care self-management interventions. Methods Medline, CINAHL, CENTRAL, and Cochrane Central Register of Controlled Trials databases were searched. References from the included studies were reviewed to identify any missing studies that could be included. Only foot care knowledge and foot care practice intervention studies that focused on the person living with type 2 diabetes were included in this review. Author, study design, sample, intervention, and results were extracted. Results Thirty studies met the inclusion criteria and were classified according to randomized controlled trial (n=9), survey design (n=13), cohort studies (n=4), cross-sectional studies (n=2), qualitative studies (n=2), and case series (n=1). Improving lower extremity complications associated with type 2 diabetes can be done through effective foot care interventions that include foot care knowledge and foot care practices. Conclusion Preventing these complications, understanding the risk factors, and having the ability to manage complications outside of the clinical encounter is an important part of a diabetes foot self-care management program. Interventions and research studies that aim to reduce lower extremity complications are still lacking. Further research is needed to test foot care interventions across multiple populations and geographic locations. PMID:26899439

Type 2 diabetes-related foot care knowledge and foot self-care practice interventions in the United States: a systematic review of the literature.

PubMed

Bonner, Timethia; Foster, Margaret; Spears-Lanoix, Erica

2016-01-01

The purpose of this systematic literature review is to review published studies on foot care knowledge and foot care practice interventions as part of diabetic foot care self-management interventions. Medline, CINAHL, CENTRAL, and Cochrane Central Register of Controlled Trials databases were searched. References from the included studies were reviewed to identify any missing studies that could be included. Only foot care knowledge and foot care practice intervention studies that focused on the person living with type 2 diabetes were included in this review. Author, study design, sample, intervention, and results were extracted. Thirty studies met the inclusion criteria and were classified according to randomized controlled trial (n=9), survey design (n=13), cohort studies (n=4), cross-sectional studies (n=2), qualitative studies (n=2), and case series (n=1). Improving lower extremity complications associated with type 2 diabetes can be done through effective foot care interventions that include foot care knowledge and foot care practices. Preventing these complications, understanding the risk factors, and having the ability to manage complications outside of the clinical encounter is an important part of a diabetes foot self-care management program. Interventions and research studies that aim to reduce lower extremity complications are still lacking. Further research is needed to test foot care interventions across multiple populations and geographic locations.

Microrandomized trials: An experimental design for developing just-in-time adaptive interventions.

PubMed

Klasnja, Predrag; Hekler, Eric B; Shiffman, Saul; Boruvka, Audrey; Almirall, Daniel; Tewari, Ambuj; Murphy, Susan A

2015-12-01

This article presents an experimental design, the microrandomized trial, developed to support optimization of just-in-time adaptive interventions (JITAIs). JITAIs are mHealth technologies that aim to deliver the right intervention components at the right times and locations to optimally support individuals' health behaviors. Microrandomized trials offer a way to optimize such interventions by enabling modeling of causal effects and time-varying effect moderation for individual intervention components within a JITAI. The article describes the microrandomized trial design, enumerates research questions that this experimental design can help answer, and provides an overview of the data analyses that can be used to assess the causal effects of studied intervention components and investigate time-varying moderation of those effects. Microrandomized trials enable causal modeling of proximal effects of the randomized intervention components and assessment of time-varying moderation of those effects. Microrandomized trials can help researchers understand whether their interventions are having intended effects, when and for whom they are effective, and what factors moderate the interventions' effects, enabling creation of more effective JITAIs. (PsycINFO Database Record (c) 2015 APA, all rights reserved).

Impact of specialist palliative care on coping with Parkinson's disease: patients and carers.

PubMed

Badger, Nathan J; Frizelle, Dorothy; Adams, Debi; Johnson, Miriam J

2018-06-01

UK guidelines recommend palliative care access for people with Parkinson's disease; however, this remains sporadic, and it is unknown whether specialist palliative care helps patients and carers cope with this distressing condition. This study aimed to explore whether, and how, access to specialist palliative care services affected patients' and carers' coping with Parkinson's disease. Semistructured interviews were conducted, audio-recorded and verbatim transcribed. Data were analysed using interpretative phenomenological analysis. Participants were patients with advanced idiopathic Parkinson's disease (n=3), and carers of people with Parkinson's disease (n=5, however, one diagnosis was reviewed) receiving care from an integrated specialist palliative care and Parkinson's disease service in North East England. Access to specialist palliative care helped participants cope with some aspects of advanced Parkinson's disease. Three superordinate themes were developed:' managing uncertainty', 'impacts on the self' and 'specialist palliative care maintaining a positive outlook'. Specialist palliative care helped patients and carers cope with advanced Parkinson's disease. Specialist palliative care is a complex intervention that acknowledges the complex and holistic nature of Parkinson's disease, enabling health in some domains despite continued presence of pathology. These exploratory findings support the utility of this approach for people living with Parkinson's disease. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

The Responsive Leadership Intervention: Improving leadership and individualized care in long-term care.

PubMed

Caspar, Sienna; Le, Anne; McGilton, Katherine S

The Responsive Leadership Intervention (RLI) is a multi-faceted intervention. We evaluated the influence of the RLI on i) responsive leadership practices by team leaders; ii) health care aides' (HCAs) self-determination; iii) HCAs' perceived ability to provide individualized care. A quasi-experimental repeated measures non-equivalent control group design was used to assess participant outcomes in four long-term care facilities (two control, two intervention) across four time periods. Change from baseline to 1-month post-intervention was greater in the intervention group than control group for Individualized Care (IC) (p = 0.001), but not for Self Determination (p = 0.26). Perceived levels of responsive leadership was greater following the intervention among participants with baseline measures that were less than the median (p = 0.007), but not if greater. At 3-months post-intervention, the intervention group retained 32% of the difference from control in IC, and 49% of the difference from control in responsive leadership; at 6-months post-intervention, 35% and 28%, respectively. The RLI is a feasible method for improving responsive leadership practices and individualized care. Copyright © 2017 Elsevier Inc. All rights reserved.

Nudging socially isolated people towards well-being with the ‘Happiness Route’: design of a randomized controlled trial for the evaluation of a happiness-based intervention

PubMed Central

2013-01-01

Background The Happiness Route is an innovative intervention that uses a happiness-based approach for people with an accumulation of risk factors for low well-being: socially isolated people with health impairments and a low socioeconomic status. The goal of this intervention is to improve well-being by engaging participants in intrinsically motivated activities with methods from positive psychology. We hypothesize that the primary outcome measure, emotional, social and psychological well-being of participants of the Happiness Route, will increase in comparison to the traditional and commonly-used problem-based approach. Secondary outcome measures are health-related quality of life, psychosocial functioning and health care consumption. Methods and design Participants will be socially isolated people with health problems and a low socioeconomic status. Participants will be recruited in ten Dutch communities and candidates will be signed up by intermediaries, professionals from the health and social sector. Randomly assigned, half of the participants will follow the Happiness Route and half of the participants will follow the active, problem-focused control group ‘Customized Care’. In total, 256 participants will be included. In both conditions, participants will receive counseling sessions from trained counselors. In the control group, participants will talk about their problems and the care they get and counselors help to optimize their care. In the Happiness Route, the counselor ask questions such as “How do you want to live your life?”. The intervention helps people to find their ‘passion’, i.e., a positive goal-engaged and intrinsically motivated activity. It enables them to follow their passion through by a once-only personal happiness budget (maximal €500). We use well-validated and reliable questionnaires to measure primary and secondary outcome measures at baseline, directly after the intervention and at a nine-month follow-up. Discussion Shortcomings of earlier intervention studies in positive psychology will be tackled with this study, such as having a target group who is especially vulnerable for low well-being. The practice-based setting is especially interesting, as it can give valuable insights in how positive psychology interventions work in practice, but can also give rise to several challenges. Trial registration Dutch Trial Register, trial registration number TC=3377NTR. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3377. PMID:24053566

Enhancing Shared Decision Making Through Carefully Designed Interventions That Target Patient And Provider Behavior.

PubMed

Tai-Seale, Ming; Elwyn, Glyn; Wilson, Caroline J; Stults, Cheryl; Dillon, Ellis C; Li, Martina; Chuang, Judith; Meehan, Amy; Frosch, Dominick L

2016-04-01

Patient-provider communication and shared decision making are essential for primary care delivery and are vital contributors to patient experience and health outcomes. To alleviate communication shortfalls, we designed a novel, multidimensional intervention aimed at nudging both patients and primary care providers to communicate more openly. The intervention was tested against an existing intervention, which focused mainly on changing patients' behaviors, in four primary care clinics involving 26 primary care providers and 300 patients. Study results suggest that compared to usual care, both the novel and existing interventions were associated with better patient reports of how well primary care providers engaged them in shared decision making. Future research should build on the work in this pilot to rigorously examine the comparative effectiveness and scalability of these interventions to improve shared decision making at the point of care. Project HOPE—The People-to-People Health Foundation, Inc.

Risks to health care workers from nano-enabled medical products.

PubMed

Murashov, Vladimir; Howard, John

2015-01-01

Nanotechnology is rapidly expanding into the health care industry. However, occupational safety and health risks of nano-enabled medical products have not been thoroughly assessed. This manuscript highlights occupational risk mitigation practices for nano-enabled medical products throughout their life cycle for all major workplace settings including (1) medical research laboratories, (2) pharmaceutical manufacturing facilities, (3) clinical dispensing pharmacies, (4) health care delivery facilities, (5) home health care, (6) health care support, and (7) medical waste management. It further identifies critical research needs for ensuring worker protection in the health care industry.

Enhancing the capacity and effectiveness of community health volunteers to improve maternal, newborn and child health: Experience from Kenya.

PubMed

Avery, Lisa S; Du Plessis, Elsabé; Shaw, Souradet Y; Sankaran, Deepa; Njoroge, Peter; Kayima, Ruth; Makau, Naomi; Munga, James; Kadzo, Maureen; Blanchard, James; Crockett, Maryanne

2017-11-09

To determine whether a simple monitoring and tracking tool, Mwanzo Mwema Monitoring and Tracking Tool (MMATT), would enable community health volunteers (CHVs) in Kenya to 1) plan their workloads and activities, 2) identify the women, newborns and children most in need of accessing critical maternal, newborn and child health (MNCH) interventions and 3) improve key MNCH indicators. A mixed methods approach was used. Household surveys at baseline (n = 912) and endline (n = 1143) collected data on key MNCH indicators in the four subcounties of Taita Taveta County, Kenya. Eight focus group discussions were held with 40 CHVs to ascertain their perspectives on using the tool. Qualitative findings revealed that the CHVs found the MMATT to be useful in planning their activities and prioritizing beneficiaries requiring more support to access MNCH services. They also identified potential barriers to care at both the community and health system levels. At endline, previously pregnant women were more likely to have received four or more antenatal care visits, facility delivery, postnatal care within two weeks of delivery and a complete package of care than baseline respondents. Among women with children under 24 months, those at endline were more likely to report early breastfeeding and exclusive breastfeeding for the first six months. These results remained after adjustment for age, subcounty, gravida, mother's education and asset index. Our results demonstrate that simple tools enable CHVs to identify disparities in service delivery and health outcomes, and to identify barriers to MNCH care. Tools that enhance CHVs' ability to plan and prioritize the women and children most in need increase CHVs' potential impact.

Protocol for a cluster randomised controlled trial on information technology-enabled nutrition intervention among urban adults in Chandigarh (India): SMART eating trial

PubMed Central

Kaur, Jasvir; Kaur, Manmeet; Webster, Jacqui; Kumar, Rajesh

2018-01-01

ABSTRACT Nutrition is an important determinant of health. At present, nutrition programs in India mainly emphasize improving maternal and child nutrition. Adult nutrition has not received due attention, though diseases like hypertension and diabetes are largely preventable through changes in dietary and physical activity behaviour. Little is known about the best approaches to improve dietary behaviours, especially the role of modern information technology (IT) in health education. We describe the protocol of the SMART Eating (Small, Measurable and Achievable dietary changes by Reducing fat, sugar and salt consumption and Trying different fruits and vegetables) health promotion intervention. A Cluster Randomised Controlled Trial will evaluate the effect of an IT-enabled intervention on nutrition behaviour among urban adults of Chandigarh, India. Formative research using a qualitative exploratory approach was undertaken to inform the intervention. The IT-enabled intervention programme includes website development, Short Message Service (SMS), e-mail reminders and interactive help by mobile and landline phones. The IT-enabled intervention will be compared to the traditional nutrition education program of distributing pamphlets in the control group. The primary outcome will be the percentage of study participants meeting the dietary intake guidelines of the National Institute of Nutrition, Hyderabad, India and the change in intake of fat, sugar, salt, fruit and vegetables after the intervention. The difference in differences method will be used to determine the net change in dietary intakes resulting from the interventions. Measurements will be made at baseline and at 6 months post-intervention, using a food frequency questionnaire. The formative research led to the development of a comprehensive intervention, focusing on five dietary components and using multi-channel communication approach including the use of IT to target urban North Indians from diverse socio-economic backgrounds. The Cluster Randomised Controlled Trial design is suitable for evaluating the effectiveness of this IT-enabled intervention for dietary behaviour change. PMID:29370744

Challenges in defining 'palliative care' for the purposes of clinical trials.

PubMed

Bausewein, Claudia; Higginson, Irene J

2012-12-01

Palliative care has become part of mainstream medicine with increasing evidence about the effectiveness of specialist palliative care (SPC) on patient and family outcomes. Comparison of studies testing SPC interventions is challenging as types of interventions and reporting of components of the intervention vary. In consequence, study results are difficult to interpret. There is a continuous lack of clarity in palliative care definitions. For clinical trials, multidisciplinary care, supportive care documentation, symptom assessment and symptom management are suggested as key domains. In recent studies testing palliative care as an intervention SPC physicians and palliative care nurses were core members of multiprofessional teams, but integration of other team members varied. Management of symptoms and psychosocial issues were central to SPC with various other areas described. Services were delivered by hospital and community support teams, in palliative care units, outpatient clinics and hospital. Cost information was only provided by a few studies. Due to the lack of an agreed definition of palliative care and heterogeneity in reporting of components of an SPC intervention comparison of studies remains challenging. Key aspects of palliative care interventions are incurable disease, multidisciplinary approach, focus on symptom management including standardized assessment, psychosocial and family support, and (advance) care planning. Detailed information about all aspects of the intervention should be provided.

Family intervention for schizophrenia

PubMed Central

Pharoah, Fiona; Mari, Jair; Rathbone, John; Wong, Winson

2014-01-01

Background People with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of emotions. Forms of psychosocial intervention, designed to reduce these levels of expressed emotions within families, are now widely used. Objectives To estimate the effects of family psychosocial interventions in community settings for people with schizophrenia or schizophrenia-like conditions compared with standard care. Search strategy We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register (September 2008). Selection criteria We selected randomised or quasi-randomised studies focusing primarily on families of people with schizophrenia or schizoaffective disorder that compared community-orientated family-based psychosocial intervention with standard care. Data collection and analysis We independently extracted data and calculated fixed-effect relative risk (RR), the 95% confidence intervals (CI) for binary data, and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD). Main results This 2009-10 update adds 21 additional studies, with a total of 53 randomised controlled trials included. Family intervention may decrease the frequency of relapse (n = 2981, 32 RCTs, RR 0.55 CI 0.5 to 0.6, NNT 7 CI 6 to 8), although some small but negative studies might not have been identified by the search. Family intervention may also reduce hospital admission (n = 481, 8 RCTs, RR 0.78 CI 0.6 to 1.0, NNT 8 CI 6 to 13) and encourage compliance with medication (n = 695, 10 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 6 CI 5 to 9) but it does not obviously affect the tendency of individuals/families to leave care (n = 733, 10 RCTs, RR 0.74 CI 0.5 to 1.0). Family intervention also seems to improve general social impairment and the levels of expressed emotion within the family. We did not find data to suggest that family intervention either prevents or promotes suicide. Authors’ conclusions Family intervention may reduce the number of relapse events and hospitalisations and would therefore be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects of these trials may be overestimated due to the poor methodological quality. Further data from trials that describe the methods of randomisation, test the blindness of the study evaluators, and implement the CONSORT guidelines would enable greater confidence in these findings. PMID:21154340

The Australian e-Health Research Centre: enabling the health care information and communication technology revolution.

PubMed

Hansen, David P; Gurney, Phil; Morgan, Gary; Barraclough, Bruce

2011-02-21

The CSIRO (Commonwealth Scientific and Industrial Research Organisation) and the Queensland Government have jointly established the Australian e-Health Research Centre (AEHRC) with the aim of developing innovative information and communication technologies (ICT) for a sustainable health care system. The AEHRC, as part of the CSIRO ICT Centre, has access to new technologies in information processing, wireless and networking technologies, and autonomous systems. The AEHRC's 50 researchers, software engineers and PhD students, in partnership with the CSIRO and clinicians, are developing and applying new technologies for improving patients' experience, building a more rewarding workplace for the health workforce, and improving the efficiency of delivering health care. The capabilities of the AEHRC fall into four broad areas: smart methods for using medical data; advanced medical imaging technologies; new models for clinical and health care interventions; and tools for medical skills development. Since its founding in 2004, new technology from the AEHRC has been adopted within Queensland (eg, a mobile phone-based cardiac rehabilitation program), around Australia (eg, medical imaging technologies) and internationally (eg, our clinical terminology tools).

[Improving the provision of nesting and positioning for premature infants by nurses in neonatal intensive care units].

PubMed

Chen, Chiao-Min; Lin, Kai-Hui; Su, Hsiu-Ya; Lin, Mei-Hsiang; Hsu, Chu-Ling

2014-04-01

Nesting and positioning is a common nursing skill used in the developmental care of premature infants. This skill maintains premature infants in a comfortable position, facilitates the monitoring of stable vital signs, and enables spontaneous motor activity for normal neuromuscular and skeletal joint function. This project was designed to improve nursing staff cognition and skills regarding nesting and positioning for premature infants in the NICU. Strategies used in this project were: develop an infant position assessment tool; record a demonstration video about nesting and positioning skills to provide learning efficacy among the nursing staff; and modify an education program for new nurses. After implementation, nurse cognition regarding premature infant nesting and positioning increased from 58.3% to 92.3%. The rate of correct technique use similarly rose from 63.3% to 91.4%. This is a valid intervention for improving the correctness of nesting and positioning in nursing care. This project standardized education in terms of nesting and positioning practice goals and enhanced quality care for premature infants.

Study protocol: identifying and delivering point-of-care information to improve care coordination.

PubMed

Hysong, Sylvia J; Che, Xinxuan; Weaver, Sallie J; Petersen, Laura A

2015-10-19

The need for deliberately coordinated care is noted by many national-level organizations. The Department of Veterans Affairs (VA) recently transitioned primary care clinics nationwide into Patient Aligned Care Teams (PACTs) to provide more accessible, coordinated, comprehensive, and patient-centered care. To better serve this purpose, PACTs must be able to successfully sequence and route interdependent tasks to appropriate team members while also maintaining collective situational awareness (coordination). Although conceptual frameworks of care coordination exist, few explicitly articulate core behavioral markers of coordination or the related information needs of team members attempting to synchronize complex care processes across time for a shared patient population. Given this gap, we partnered with a group of frontline primary care personnel at ambulatory care sites to identify the specific information needs of PACT members that will enable them to coordinate their efforts to provide effective, coordinated care. The study has three objectives: (1) development of measurable, prioritized point-of-care criteria for effective PACT coordination; (2) identifying the specific information needed at the point of care to optimize coordination; and (3) assessing the effect of adopting the aforementioned coordination standards on PACT clinicians' coordination behaviors. The study consists of three phases. In phase 1, we will employ the Productivity Measurement and Enhancement System (ProMES), a structured approach to performance measure creation from industrial/organizational psychology, to develop coordination measures with a design team of 6-10 primary care personnel; in phase 2, we will conduct focus groups with the phase 1 design team to identify point-of-care information needs. Phase 3 is a two-arm field experiment (n PACT = 28/arm); intervention arm PACTs will receive monthly feedback reports using the measures developed in phase 1 and attend brief monthly feedback sessions. Control arm PACTs will receive no intervention. PACTs will be followed prospectively for up to 1 year. This project combines both action research and implementation science methods to address important gaps in the existing care coordination literature using a partnership-based research design. It will provide an evidence-based framework for care coordination by employing a structured methodology for a systematic approach to care coordination in PACT settings and identifying the information needs that produce the most successful coordination of care. ISRCTN15412521.

Sharing is caring: The potential of the sharing economy to support aging in place.

PubMed

Miller, Julie; Ward, Carley; Lee, Chaiwoo; D'Ambrosio, Lisa; Coughlin, Joseph

2018-01-24

This article explores innovative applications of sharing economy services that have the potential to support a population aging in place, especially the "oldest old," aged 85 and older, and their caregivers. A mixed-methods study conducted by the MIT AgeLab examined perceptions of and experiences with sharing economy services, ultimately finding opportunities and barriers to use. Thus, although sharing economy services have potential to support aging in place, to do so successfully will require reconstructing how older adults, family caregivers, aging service professionals, gerontology educators, and gerontology students conceptualize and deliver care to an aging population. We suggest examples for gerontology educators to integrate into their classrooms to further cultivate an appreciation among students of multiple approaches to intervention, including those that leverage sharing economy and technology-enabled platforms to support older adults and their caregivers.

Make her a virgin again: when medical disputes about minors are cultural clashes.

PubMed

Kopelman, Loretta M

2014-02-01

Recalcitrant disputes among health care providers and patients or their families may signal deep cultural differences about what interventions are needed or about clinicians's professional duties. These issues arose in relation to a mother's request for hymenoplasty or revirgination for her minor daughter to enable an overseas, forced marriage and protect her from an honor killing. The American College of Obstetrics and Gynecology committee recommends against members performing a hymenoplasty or other female genital cosmetic surgeries due to a lack of data concerning their safety and efficacy. A key issue in such cases is how to determine what is in the minor's best interest and the scope of health care moral or professional's duties. The Best Interests Standard can serve as a powerful moral tool for resolving cross-cultural disputes and identifying needed policy.

Pilot Trial of a Licensed Practical Nurse Intervention for Hypertension and Depression

PubMed Central

Bogner, Hillary R.; de Vries, Heather F.; Kaye, Elise M.; Morales, Knashawn H.

2014-01-01

BACKGROUND AND OBJECTIVES Depression is a risk factor for hypertension, and risk of depression is increased substantially in patients with hypertension. Our objective was to examine whether an intervention carried out by Licensed Practical Nurses (LPNs) integrating depression treatment into care for hypertension improved blood pressure control and depressive symptoms. METHODS In all, 60 patients ages 41 to 92 years with hypertension and depressive symptoms at a large primary care practice in Philadelphia were randomly assigned to an integrated care intervention carried out by LPNs (n=30) or usual care (n=30). Intervention and control groups did not differ statistically on baseline measures. Outcomes assessed at baseline and 12 weeks included standard laboratory procedures to measure blood pressure control and the Patient Health Questionnaire (PHQ-9) to assess depression. RESULTS Patients in the integrated care intervention had lower diastolic blood pressure (intervention 74.2 mmHg versus usual care 82.0 mmHg) and fewer depressive symptoms (PHQ-9 mean scores, intervention 2.4 versus usual care 7.1) compared with patients in the usual care group at 12 weeks after adjustment for baseline values. Patients in the integrated care intervention also had lower systolic blood pressure (intervention 130.0 mmHg versus usual care 140.6 mmHg) compared with patients in the usual care group at 12 weeks although the results approached but did not reach conventional levels of statistical significance. CONCLUSION Training existing primary care practice office staff will facilitate implementation in real world practices with limited resources and competing demands. PMID:23681683

Basic nursing care: retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting.

PubMed

Juvé-Udina, Maria-Eulàlia; Pérez, Esperanza Zuriguel; Padrés, Núria Fabrellas; Samartino, Maribel Gonzalez; García, Marta Romero; Creus, Mònica Castellà; Batllori, Núria Vila; Calvo, Cristina Matud

2014-01-01

This study aimed to evaluate the frequency of psychosocial aspects of basic nursing care, as e-charted by nurses, when using an interface terminology. An observational, multicentre study was conducted in acute wards. The main outcome measure was the frequency of use of the psychosocial interventions in the electronic nursing care plans, analysed over a 12 month retrospective review. Overall, 150,494 electronic care plans were studied. Most of the intervention concepts from the interface terminology were used by registered nurses to illustrate the psychosocial aspects of fundamentals of care in the electronic care plans. The results presented help to demonstrate that the interventions of this interface terminology may be useful to inform psychosocial aspects of basic and advanced nursing care. The identification of psychosocial elements of basic nursing care in the nursing documentation may lead to obtain a deeper understanding of those caring interventions nurses consider essential to represent nurse-patient interactions. The frequency of psychosocial interventions may contribute to delineate basic and advanced nursing care. © 2013 Sigma Theta Tau International.

Scotland's Knowledge Network: translating knowledge into action to improve quality of care.

PubMed

Wales, A; Graham, S; Rooney, K; Crawford, A

2012-11-01

The Knowledge Network (www.knowledge.scot.nhs.uk) is Scotland's online knowledge service for health and social care. It is designed to support practitioners to apply knowledge in frontline delivery of care, helping to translate knowledge into better health-care outcomes through safe, effective, person-centred care. The Knowledge Network helps to combine the worlds of evidence-based practice and quality improvement by providing access to knowledge about the effectiveness of clinical interventions ('know-what') and knowledge about how to implement this knowledge to support individual patients in working health-care environments ('know-how'). An 'evidence and guidance' search enables clinicians to quickly access quality-assured evidence and best practice, while point of care and mobile solutions provide knowledge in actionable formats to embed in clinical workflow. This research-based knowledge is complemented by social networking services and improvement tools which support the capture and exchange of knowledge from experience, facilitating practice change and systems improvement. In these cases, the Knowledge Network supports key components of the knowledge-to-action cycle--acquiring, creating, sharing and disseminating knowledge to improve performance and innovate. It provides a vehicle for implementing the recommendations of the national Knowledge into Action review, which outlines a new national approach to embedding knowledge in frontline practice and systems improvement.