The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review

Evaluating provider communication in pediatric chronic kidney disease care using a global coding system

OBJECTIVE

Among adolescents and young adults (AYAs) with chronic illness, effective provider communication is essential for patient-centered care during a sensitive developmental period. However, communication in chronic illness care for AYAs is not well studied. Our objectives were to describe the provider communication skills in pediatric chronic kidney disease (CKD) care visits; and determine if communication skills differ by AYA characteristics.

METHODS

We adapted a global consultation rating system for pediatric subspecialty care using audiotaped clinic encounters of 18 pediatric nephrologists with 99 AYAs (age M(SD) = 14.9(2.6)) with CKD stages 1-5 and 96 caregivers. We hypothesized that provider communication skills would differ by AYA characteristics (age, gender, and race).

RESULTS

The strongest provider skills included initiating the session and developing rapport; lowest rated skills were asking patient's perspective and checking understanding. Communication scores did not consistently differ by AYA age or race, but were rated higher with female AYAs in several domains (ps<0.05).

CONCLUSIONS

Pediatric providers generally had adequate or good communication scores with AYAs, but improvement in certain skills, particularly with male AYAs, may further support patient-centered care.

PRACTICE IMPLICATIONS

To achieve consistent, patient-centered communication with AYAs, an observation-based global assessment may identify areas for provider improvement.

The effects of a transitional care program on discharge readiness, transitional care quality, health services utilization and satisfaction among Chinese kidney transplant recipients: A randomized controlled trial

BACKGROUND

Kidney transplantation is the major treatment for end-stage renal disease (ESRD). However, kidney transplant recipients (KTRs) face severe challenges during the transition period from hospital discharge to home, increasing the risk of early hospital readmission (EHR) and affecting patient safety. Nevertheless, knowledge of effective transitional care for KTRs is limited in China.

OBJECTIVE

To evaluate the effectiveness of an innovative transitional care program in improving discharge readiness, transitional care quality, health services utilization and patient satisfaction among KTRs in China.

DESIGN

A prospective randomized controlled trial.

SETTINGS AND PARTICIPANTS

Patients admitted to undergo kidney transplantation were recruited in a general tertiary hospital in Chengdu, China.

METHODS

A total of 220 eligible patients were recruited and randomly assigned to the intervention and control groups. Participants in the intervention group received a transitional care intervention developed by the research team, including a risk assessment for early readmission, health education from admission to predischarge, individualized discharge planning, and a telephone follow-up once per week for one month and WeChat follow-up postdischarge. The control group received routine care of comparable length and follow-up contact. A trained research assistant collected all patients' baseline data on admission (T0), evaluated the discharge readiness (by the Readiness for Hospital Discharge Scale) on the day of discharge (T1), collected data on transitional care quality (by the Care Transition Measure-15) and patients' satisfaction with transitional care services (by a self-developed patient satisfaction scale) on the 30th day postdischarge (T2), and collected data on hospital readmission, unscheduled outpatient department visits, and emergency room visits on the 30th and 90th days (by a self-developed health services utilization record table) (T3) postdischarge. Intervention effects were analyzed using independent samples t-tests, Wilcoxon-Mann-Whitney U tests, Chi-square tests or Fisher's exact test.

RESULTS

Compared with the control group, the intervention group showed significantly better discharge readiness (personal status, P<0.001; knowledge, P = 0.010; coping ability, P<0.001; expected support, P = 0.007; total score, P<0.001), better transitional care quality (importance of preferences, P<0.001; management preparation, P<0.001; critical understanding, P = 0.003; written and understandable care plan, P = 0.012; total score, P<0.001), lower readmission rate at T2 (P = 0.033) and at T3 (P = 0.013), lower emergency room visit rate at T3 (P = 0.014), and better satisfaction with transitional care services (P<0.001).

CONCLUSIONS

This study provides evidence that an innovative transitional care program is effective in promoting KTRs' discharge readiness, transitional care quality, reducing hospital readmission and emergency room visits, and improving their satisfaction with transitional care services.

TRIAL REGISTRATION

Clinical Trials ChiCTR1800014971.

Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 1: Race, History of Incarceration, and Health Literacy

Patients anticipating surgery and anesthesia often need preoperative care to reduce risk and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges is vital to reducing disparities in health and health care.

Factors Affecting Loss to Follow-Up in Children and Adolescents with Chronic Endocrine Conditions

OBJECTIVE

Most children with endocrine diseases require long-term continuity of care. We investigated the prevalence of loss to follow-up (LTFU) in pediatric patients with chronic endocrine diseases and the risk factors associated with LTFU.

METHODS

This observational cohort study included all children with chronic endocrine diseases included in the database of a single academic pediatric care center over a period of 8 years. LTFU was defined as a lack of attendance at clinical visits for over 2 years, for unknown reasons.

RESULTS

LTFU was recorded for 154 of the 1,067 patients included (14%). Median age at diagnosis was 5.8 (0.3-11.8) vs. 1.2 (0.0-6.9) years, and age at last visit was 14.1 (9.7-16.1) vs. 11.7 (6.1-15.8) years, for the LTFU and no-LTFU groups, respectively. In multivariate analysis, the risk of LTFU increased with age at diagnosis (OR 1.18; 95% CI 1.12-1.24) and was higher for patients diagnosed before 2006 (vs. after 2006; OR 4.80; 95% CI 3.00-7.66), with fewer visits in the last 3 years (OR 0.72; 95% CI 0.65-0.80; p < 0.0001) and a lower health insurance classification (OR 1.79; 95% CI 1.10-2.89; p = 0.02). The risk of LTFU was higher for patients with isolated growth hormone deficiency than for those with other endocrine conditions, such as multiple pituitary deficiencies, hypogonadotropic hypogonadism, Turner syndrome, or thyroid, adrenal, or gonadal disorders (OR 5.24; 95% CI 1.13-24.37; p = 0.03).

CONCLUSION

This study provides the first epidemiological data for LTFU in children and adolescents with chronic endocrine diseases. It should facilitate the targeting of interventions to improve adherence to medical care and healthcare organization during the pediatric period.

Teach-back: A systematic review of implementation and impacts

Patients often have difficulty comprehending or recalling information given to them by their healthcare providers. Use of 'teach-back' has been shown to improve patients' knowledge and self-care abilities, however there is little guidance for healthcare services seeking to embed teach-back in their setting. This review aims to synthesize evidence about the translation of teach-back into practice including mode of delivery, use of implementation strategies and effectiveness. We searched Ovid Medline, CINAHL, Embase and The Cochrane Central Register of Controlled Trials for studies reporting the use of teach-back as an educational intervention, published up to July 2019. Two reviewers independently extracted study data and assessed methodologic quality. Implementation strategies were extracted into distinct categories established in the Implementation Expert Recommendations for Implementing Change (ERIC) project. Overall, 20 studies of moderate quality were included in this review (four rated high, nine rated moderate, seven rated weak). Studies were heterogeneous in terms of setting, population and outcomes. In most studies (n = 15), teach-back was delivered as part of a simple and structured educational approach. Implementation strategies were infrequently reported (n = 10 studies). The most used implementation strategies were training and education of stakeholders (n = 8), support for clinicians (n = 6) and use of audits and provider feedback (n = 4). Use of teach-back proved effective in 19 of the 20 studies, ranging from learning-related outcomes (e.g. knowledge recall and retention) to objective health-related outcomes (e.g. hospital re-admissions, quality of life). Teach-back was found to be effective across a wide range of settings, populations and outcome measures. While its mode of delivery is well-defined, strategies to support its translation into practice are not often described. Use of implementation strategies such as training and education of stakeholders and supporting clinicians during implementation may improve the uptake and sustainability of teach-back and achieve positive outcomes.

The Effectiveness of the Good Affordable Food Intervention for Adults with Low Socioeconomic Status and Small Incomes

Good Affordable Food (GAF) is a small-group nutrition education intervention for adults with low socioeconomic status and small incomes. It aims to empower participants to save money on groceries and consume healthier diets. This paper reports the short-term and longer-term effects on behavioural determinants and self-reported behavioural changes. A quasi-experimental control group design was applied with a baseline measurement, a post-test immediately after the intervention, and a follow-up measurement after six months. The study included 237 participants (intervention group: n = 131; control group: n = 106) at baseline, 197 at post-test, and 152 at follow-up. Data were collected by telephone, mostly using closed interview questions. Positive short-term and longer-term effects were found for attitude towards the costs of healthy foods, food label use, and the use of liquid butter or oil to prepare hot meals. Short-term intervention effects related to knowledge towards saving money on groceries, self-efficacy towards healthy eating, portion size awareness, and mindful eating. GAF was effective in changing some determinants and behaviours related to cost and food consumption, however, mostly in the short term. Thereby, it is an example of combining pricing and health information in nutrition education that developers of effective nutrition education for low-income groups can build on.

The Effect of Self-Management Education by the Teach-Back Method on Uncertainty of Patients with Breast Cancer: a Quasi-Experimental Study

The present study aimed to determine the effect of self-management education by the teach-back method on uncertainty of patients with breast cancer. This quasi-experimental study (before and after) investigated 50 patients with breast cancer who referred to Surgery Clinic in Kerman from December 2015 to March 2016. The convenient sampling method was used for participants' selection. Participants were randomly divided into intervention and control groups. The questionnaire was completed before and after training by the teach-back method in both groups. Data were analyzed by SPSS software version 20. The results of the study showed that teach-back training in the intervention group improved self-management compared to the control group and the total score decreased from 106 to 73 (p = 0.01). Even after controlling confounders, such as place of residence and history of cancer education, the differences between the above groups remained statistically significant. Self-management education program by the teach-back method can help reduce uncertainty in patients with breast cancer. Therefore, it is recommended to use this educational method to improve self-management and reduce uncertainty in these patients.

Midwives' self-reported knowledge and skills to assess and promote maternal health literacy: A national cross-sectional survey

BACKGROUND

Little is known about midwives' knowledge and skills to assess and promote maternal health literacy.

AIMS

To test the reliability and validity of a new tool to assess midwives' health literacy knowledge, skills and attitudes.

METHODS

Using a cross-sectional design, midwives were recruited through professional and social media networks. The online survey included demographic and professional questions and a new measure on midwives' health literacy knowledge, skills and attitudes. Convergent validity was assessed using ten items from the Caring Assessment Scale. Perceived barriers to promoting maternal health literacy were sought.

FINDINGS

Three hundred and seven participants completed the survey. A two-factor solution accounted for 41% of variance and resulted in 14 items, including all attitude items, being removed. Cronbach's alpha reliability was acceptable (Skills=.76; Knowledge=.66). Convergent validity was established. Most midwives (77.1%, n=221) reported giving limited attention to formally assessing women's health literacy. Between 30 to 60% of midwives never or only sometimes used specific techniques to promote maternal health literacy. Most (75%, n=201) had not received education about health literacy.

DISCUSSION AND CONCLUSIONS

The new Transforming Maternity Care Collaborative Health Literacy tool was valid and reliable. Few midwives formally assessed or promoted women's health literacy. Midwives require education about maternal health literacy assessment and promotion to ensure women understand information being conveyed. A large national survey of midwives using the new tool is recommended.

A Comparison of the Effects of Teach-Back and Motivational Interviewing on the Adherence to Medical Regimen in Patients with Hypertension

BACKGROUND AND OBJECTIVE

Arterial hypertension is considered a chronic medical problem and also a challenging condition. The present study aimed to compare the effects of motivational interviewing and teach-back on people with hypertension.

MATERIALS AND METHODS

In this clinical trial conducted in Yasuj in 2018 a total of 81 patients with essential hypertension were selected in terms of the inclusion criteria. Then, they were randomly divided into three groups: teach-back (Group 1), motivational interviewing (Group 2), and control (Group 3). Three teach-back sessions were held for the teach-back group, five sessions of motivational interviewing for the motivational interviewing group, and the routine care was provided for the control group. In addition, data were collected by the demographic form and scale of Adherence to Systemic Hypertension Treatment, which were completed by participants of all three groups at baseline and also two months from the intervention. Data were analyzed using SPSS 21 by applying descriptive statistics, one-way ANOVA, chi-squared test, Fisher's exact test, and Bonferroni test.

FINDINGS

Two months from the interventions, in Group 1, the score of adherence to the hypertension treatment regimen significantly increased by 816.38 points compared to the control group, in Group 2 by 1228.9 points compared to the control group, and in Group 2 by 412.6 points compared to Group 1 (p >0.05).

CONCLUSION

Both teach-back and motivational interviewing increased the adherence to the hypertension treatment regimen; however, motivational interviewing was more effective compared to teach-back in boosting adherence to the hypertension treatment regimen.

Participatory implementation research in the field of migrant health: Sustainable changes and ripple effects over time

Objective

This study aimed to explore whether positive impacts were sustained and unanticipated ripple effects had occurred four years after the implementation of interventions to improve cross‐cultural communication in primary care.

Background

Sustaining the implementation of change using complex interventions is challenging. The EU‐funded “RESTORE” study implemented guidelines and training on cross‐cultural communication in five Primary Care sites in Europe, combining implementation theory (Normalisation Process Theory) with participatory methodology (participatory learning and action—PLA). There were positive impacts on knowledge, skills and clinical routines.

Design, setting and participants

Four of the five original sites (England, Ireland, Greece, The Netherlands) were available for this qualitative follow‐up study. The study population (N = 44) was primary healthcare staff and migrants, most of whom had participated in RESTORE.

Intervention; main outcome measures

PLA‐style focus groups and interviews explored routine practice during consultations with migrants. Etic cards based on the effects of RESTORE stimulated the discussion. Deductive framework analysis was performed in each country followed by comparative data analysis and synthesis.

Results

Changes in knowledge, attitudes and behaviour with regard to consultations with migrants were sustained and migrants felt empowered by their participation in RESTORE. There were ongoing concerns about macro level factors, like the political climate and financial policies, negatively affecting migrant healthcare.

Conclusion

There were sustained effects in clinical settings, and additional unanticipated positive ripple effects, due in part, from the participatory approach employed.

Exploring the perspectives on medication self-management among persons with spinal cord injury/dysfunction and providers

RATIONALE

Spinal cord injury/dysfunction (SCI/D) is an exemplar condition with a high prevalence of secondary complications, chronic conditions and use of multiple medications (polypharmacy). Optimizing medication self-management is important for persons with SCI/D to improve outcomes; however, there is a lack of research on how healthcare/service providers and persons with SCI/D experience medication self-management.

OBJECTIVE

To explore attitudes and experiences of medication self-management from the perspectives of persons with SCI/D and providers, and to explore the extent to which the Taxonomy of Everyday Self-management Strategies (TEDSS) framework captured participants' experiences with medication self-management.

METHODS

In-depth, semi-structured interviews were conducted by telephone until data saturation was reached. Interviews were transcribed verbatim and analyzed using constant comparative approaches. The TEDSS framework was adapted and applied deductively.

RESULTS

Fifty-one individuals participated in this study, 32 providers and 19 persons with SCI/D. Disease controlling strategies was the domain discussed in most detail by all participants. In this domain, participants discussed managing medications and treatments, monitoring/managing side effects, and controlling complications. Process strategies (problem-solving, decision-making) and resource strategies (seeking support) were the next most frequently discussed domains. Among all participant groups, there was a lack of detailed discussion of social interactions, health behaviour, and internal strategies. Medication self-management support was not extensively discussed by any group.

CONCLUSION

This study highlighted the complex nature of medication self-management. While persons with SCI/D and providers discussed similar components of the TEDSS framework, providers had minimal reflections on the impact of medication self-management on everyday life. This study identified the need for explicit discussions between providers and persons with SCI/D, involving all components of self-management and self-management support in order to improve medication self-management.

Pain severity and e-cigarette health literacy: the moderating role of sex

Although electronic cigarette (e-cigarette) use has increased among adults in the United States, there is still little knowledge of factors that may influence e-cigarette use or beliefs about use. Prior research suggests that health literacy plays an important role in e-cigarette beliefs, including perceived benefits and risks of e-cigarette use, as well as e-cigarette dependence. Yet, limited work has examined risk factors of poor e-cigarette health literacy. From a biopsychological perspective, sex and pain severity represent two constructs that may impact e-cigarette health literacy. To date, however, no research has investigated differences in e-cigarette health literacy across pain, sex, or their interrelation. Thus, the present study was conducted to evaluate the interactive effect of pain severity and sex on e-cigarette health literacy. Participants included 319 current, adult e-cigarette users (60.5% female, M_age= 36.82 years, SD = 10.62). Findings supported a significant pain by sex interaction, such that pain related to e-cigarette health literacy among women (b = .10, SE = .03, P < .001), but not men (b = .01, SE = .03, P = .60). The present findings suggest that pain may uniquely impact the degree to which women, but not men, seek and understand information on e-cigarettes.

Targeted and tailored pharmacist-led intervention to improve adherence to antihypertensive drugs among patients with type 2 diabetes in Indonesia: study protocol of a cluster randomised controlled trial

INTRODUCTION

Current intervention programme to improve drug adherence are either too complex or expensive for implementation and scale-up in low-middle-income countries. The aim of this study is to assess the process and effects of implementing a low-cost, targeted and tailored pharmacist intervention among patients with type 2 diabetes who are non-adherent to antihypertensive drugs in a real-world primary care Indonesian setting.

METHODS AND ANALYSIS

A cluster randomised controlled trial with a 3-month follow-up will be conducted in 10 community health centres (CHCs) in Indonesia. Type 2 diabetes patients aged 18 years and older who reported non-adherence to antihypertensive drugs according to the Medication Adherence Report Scale (MARS) are eligible to participate. Patients in CHCs randomised to the intervention group will receive a tailored intervention based on their personal adherence barriers. Interventions may include reminders, habit-based strategies, family support, counselling to educate and motivate patients, and strategies to address other drug-related problems. Interventions will be provided at baseline and at a 1-month follow-up. Simple question-based flowcharts and an innovative adherence intervention wheel are provided to support the pharmacy staff. Patients in CHCs randomised to the control group will receive usual care based on the Indonesian guideline. The primary outcome is the between-group difference in medication adherence change from baseline to 3-month follow-up assessed by MARS. Secondary outcomes include changes in patients' blood pressure, their medication beliefs assessed by the Beliefs about Medicines Questionnaire (BMQ)-specific, as well as process characteristics of the intervention programme from a pharmacist and patient perspective.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethical Committee of Universitas Padjadjaran, Indonesia (No. 859/UN6.KEP/EC/2019) and all patients will provide written informed consent prior to participation. The findings of the study will be disseminated through international conferences, one or more peer-reviewed journals and reports to key stakeholders.

TRIAL REGISTRATION NUMBER

NCT04023734.

The Relationship of Disease-Specific Knowledge and Health Literacy With the Uptake of Self-Care Behaviors in CKD

INTRODUCTION

Individuals with chronic kidney disease (CKD) generally have poor participation in self-care. We hypothesized that greater kidney disease knowledge and health literacy would associate with better self-care.

METHODS

We enrolled 401 participants with non-dialysis-dependent CKD from one academic center in this cross-sectional study. Validated surveys were used to assess health literacy level (inadequate vs. adequate; Rapid Estimate of Adult Literacy in Medicine), perceived kidney disease knowledge (Perceived Kidney Disease Knowledge Survey [PiKS]), objective kidney disease knowledge (Kidney Disease Knowledge Survey [KiKS]), and a CKD self-care measure was constructed as the sum of self-reported self-care behaviors using the adapted Summary of Diabetes Self-Care Activities Assessment. The association between health literacy level, PiKS scores, KiKS scores, and the CKD self-care measure was assessed with multivariable adjusted linear regression models.

RESULTS

Participants had a mean age of 57 years and 17.7% had inadequate health literacy. PiKS scores were positively associated with the CKD self-care measure (β = 1.05, 95% confidence interval [CI] 0.50-1.63), and a positive trend was observed for KiKS scores and the CKD self-care measure (β = 0.30, 95% CI: -0.12 to 0.72). Health literacy was not associated with CKD self-care measure.

CONCLUSION

Objective kidney disease knowledge is likely necessary, but not sufficient for self-care and may depend on the level of health literacy. Perceived kidney knowledge may offer a novel target to assess patients at risk for poor self-care, and be used in targeted educational interventions.

The Canadian anaphylaxis action plan for kids: development and validation

OBJECTIVES

We designed a written Canadian Anaphylaxis Action Plan for Kids (Kids' CAP) which incorporates validated pictograms with written instructions. Using a patient-centered approach, we aimed to validate the Kids' CAP and assess its impact on anaphylaxis recognition and treatment, and to determine its' perceived usefulness.

PATIENT INVOLVEMENT

Children and their parents were involved in appraising the design and written contents of the Kids' CAP.

METHODS

The design process consisted of a development phase and clinical validation phase. First, we assessed the readability and understandability of the Kids' CAP using validated instruments. Then, patients (12-17 years of age) and parents of patients (<12 years of age) were given the Kids' CAP during the first consultation with allergy specialists or an Emergency Department visit for anaphylaxis. Subsequently, we conducted a phone interview 2-3 weeks later to assess their comprehension of anaphylaxis management. We also used the Consumer Information Rating Form to measure the participants' perception of the design quality and usefulness of the Kids' CAP.

RESULTS

Of the 230 participants enrolled, 205 (89%) completed the follow-up interview. The written contents of the Kid's CAP were modified to match grade 7 readability level. The total mean score of the Consumer Information Rating Form for comprehensibility was 23.1 (SD 2.4), and 25.1 (SD 2.3) for design quality. The mean comprehension score was 11.3 (SD 1.8) (reference range 0-12), with no significant difference between participants with and without previous experience with anaphylaxis, or high vs. low literacy level.

CONCLUSION

Engaging children and parents in the design and contents of written anaphylaxis action plan is an innovative approach to produce a useful document for the end-users.

PRACTICE IMPLICATIONS

The Kids' CAP is a valid tool that can be used in emergency departments and allergy clinics to improve patient's comprehension of anaphylaxis manifestations and treatment.

Compassionate and Clinical Behavior of Residents in a Simulated Informed Consent Encounter

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Compassionate behavior in clinicians is described as seeking to understand patients’ psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery.

Methods

Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion.

Results

Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial η2 = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not.

Conclusions

In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

Chinese Hospitalized Cardiovascular Patients' Attitudes Towards Self-Management: A Qualitative Study

PURPOSE

This study is aiming to investigate cardiovascular patients' attitudes towards self-management during hospitalization in China.

PATIENTS AND METHODS

Twenty-nine individuals living with cardiovascular disease from one designated Cardiology Department in Hangzhou, China, were recruited through a purposive sampling procedure. A qualitative descriptive methodology was used. Semi-structured interviews were also used to gain attitudes toward self-management. The interviews were audio-recorded, transcribed and analyzed by thematic analysis to develop the results.

RESULTS

Four themes were identified from the qualitative data: (1): Responsibilities of self-management; (2): Reflections on self-management; (3): Acknowledgement of self-management support; (4): Challenges in implementing and adherence to self-management. Additionally, interview data were also given to illustrate these main themes emerging during the analysis. Patients gradually took their responsibilities to manage chronic symptoms. During their self-management process, they did reflections to help correct their regiments through supportive interactions. Health system responsiveness, health disparities, social capital, and cultural setting were the main external factors influencing better self-management implementation and adherence.

CONCLUSION

This study revealed the hospitalized cardiovascular patients' attitudes towards self-management in China. These findings emphasized the importance of patients' responsibility, reflections, and various social support receiving and pointed out specific external factors influencing the health outcomes and their quality of life. This study also proves the guide for the policymakers and health system better instructions to develop individually and culturally tailored advanced self-management interventions and programs.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Predictors of Adherence to Self-Care in Rural Patients With Heart Failure

BACKGROUND

The common reality of not following a recommended course of treatment is a major cause of poor health outcomes in patients with heart failure (HF). The purpose of this study was to identify predictors of adherence to HF self-care recommendations in rural HF patients who received an intervention to promote symptom management and self-care.

METHODS

Data from 349 rural HF patients (42% female, 90% Caucasian) randomized to the intervention arms of the study were used. Adherence was measured using the European Heart Failure Self-Care Scale questionnaire, a brief measure that asks patients to report their adherence to a variety of recommended HF symptom management behaviors (ie, daily weight monitoring, when to call the physician, medications, diet, and exercise). The following predictors were tested: age, gender, marital status, education level, depression score (measured using PHQ-9), anxiety score (measured with the Brief Symptom Inventory), and level of perceived control (measured using Control Attitudes Scale-R). Multivariate linear regression was used to test the model.

RESULTS

The model to predict adherence was significant (P < .0001). Of the covariates tested in the regression model, being a male (P = .009), having less anxiety (P = .018), not being depressed (P = .017), and having higher perceived control (P = .003) were predictors of improved self-care score at 3 months.

CONCLUSION

Adherence is a multifaceted and a challenging behavior based on the assumption that the patient agrees with self-care recommendations. These data suggest interventions designed to promote adherence behaviors should include an assessment of gender, anxiety, depression, and perceived control for optimal outcomes.

Self-management of a musculoskeletal condition for people from harder to reach groups: a qualitative patient interview study

Background: This study recorded the functional health literacy levels of people with musculoskeletal (MSK) conditions from harder to reach groups and explored their experiences in engaging with health care professionals to self-manage their MSK condition.Methods: We recruited participants, identified by key health and social care contacts as likely to have lower health literacy levels, and used semi-structured interviews to collect data. Thematic analysis was used to identify the main key themes arising from the transcribed interviews.Results: Eighteen participants were identified and recruited from harder to reach community populations, 10 were scored as having inadequate functional health literacy on the Short Form Rapid Estimate of Adult Literacy Measure. Three themes were identified in relation to participants' experiences of MSK self-management approaches: engaging with health care services; interpreting the health care providers' message; and facilitating participation in MSK self-management.Conclusions: Our findings indicate that people with a MSK condition, from harder to reach groups, experience multi-morbidity, find health care systems complicated and hear from health care professionals that their MSK condition cannot be cured. People interpreted that a lack of cure meant that nothing could be done to help their MSK pain. Engaging with self-management strategies was not seen as a priority for our participants. Strategies to simplify health communication, more time to process health information and supportive social networks helped our participants to understand and manage their MSK health on a day-to-day basis. Implications for RehabilitationMSK conditions are long term and prevalent in the UK with substantial impact on people's daily life.Currently self-management strategies for MSK conditions are poorly communicated and many patients believe that nothing can be done to help their MSK pain.Good clinician communication that supports self-management is needed so that key messages can be effectively understood and used by patients with a range of literacy skills.Health services need to be even more accessible to help all individuals from a range of backgrounds better self-manage their MSK conditions.

Cardiologists' and patients' views about the informed consent process and their understanding of the anticipated treatment benefits of coronary angioplasty: A survey study

BACKGROUND

Percutaneous coronary intervention is a common revascularisation technique. Serious complications are uncommon, but death is one of them. Seeking informed consent in advance of percutaneous coronary intervention is mandatory. Research shows that percutaneous coronary intervention patients have inaccurate perceptions of risks, benefits and alternative treatments.

AIM

To assess cardiologists' and patients' views about the informed consent process and anticipated treatment benefits.

METHODS

Two cross-sectional, anonymous surveys were distributed in England: an electronic version to a sample of cardiologists and a paper-based version to patients recruited from 10 centres.

RESULTS

A sample of 118 cardiologists and 326 patients completed the surveys. Cardiologists and patients shared similar views on the purpose of informed consent; however, over 40% of patients and over a third of cardiologists agreed with statements that patients do not understand, or remember, the information given to them. Patients placed less value than cardiologists on the consent process and over 60% agreed that patients depended on their doctor to make the decision for them. Patients' and cardiologists' views on the benefits of percutaneous coronary intervention were significantly different; notably, 60% of patients mistakenly believed that percutaneous coronary intervention was curative.

CONCLUSIONS

The percutaneous coronary intervention informed consent process requires improvement to ensure that patients are more involved and accurately understand treatment benefits to make an informed decision. Redesign of the patient pathway is recommended to allow protected time for health professionals to engage in discussions using evidence-based approaches such as 'teach back' and decision support which improve patient comprehension.

Providing effective asthma care at a pediatric patient-centered medical home

BACKGROUND

A recent assessment of the national annual burden of the cost of asthma among school-aged children was nearly $6 million. In a Midwestern county, the incidence of childhood asthma was 15.8%, which was above both state and national levels.

LOCAL PROBLEM

Effective asthma care was not being provided at a rural, pediatric patient-centered medical home due to a lack of standardization. This quality improvement (QI) initiative aimed to increase the mean effective asthma care score to 78% for patients with asthma over the course of 90 days.

METHODS

This right care initiative was implemented using a rapid-cycle Plan-Do-Study-Act methodology. Tests of change in the areas of team engagement, patient engagement, and two process measures were analyzed through chart audits and run charts over four cycles. Likert scale surveys were used to analyze qualitative data.

INTERVENTIONS

Interventions included developing the Asthma Patient Identification Tool, implementing an asthma education protocol with teach-back, creating standardized smart phrases for effective documentation, and initiating asthma care huddles.

RESULTS

The delivery of effective asthma care increased to 84%. The number of patients receiving the asthma education protocol increased to 65%, with 80% of the patients participating in effective teach-back sessions. The mean effective documentation score increased to 92%.

CONCLUSIONS

A standardized approach to asthma care grounded in evidence-based guidelines positively affected the delivery of care. Nurse practitioners are effective team leaders for clinical QI initiatives.

Reassessing health literacy best practices to improve medication adherence among patients with dyslexia

BACKGROUND

Dyslexia is characterized as unexpected and persistent difficulty in reading. In addition to language-based deficits, evidence indicates that people with dyslexia may struggle with tasks related to memory and executive function. This discussion paper explores how these non-linguistic deficits could plausibly affect medication adherence among patients with dyslexia.

DISCUSSION

There is a dearth of original research literature exploring the intersection of dyslexia and health behaviors in the United States. The authors examine selected best practices from the field of health literacy with potential to improve medication adherence among patients with dyslexia and suggest areas for further research on the intersection of dyslexia, health literacy and medication adherence.

CONCLUSION

Dyslexia is a high-prevalence condition. Patients with dyslexia may be more likely to experience challenges when learning and implementing complex, multi-step health behaviors, such as the tasks associated with medication adherence. However, there has been no research to assess the specific needs of patients with dyslexia, or design interventions to meet those needs. Foundational research is necessary to develop a health communications framework that meets the needs of these neurodiverse patients.

Effect of Resistance Exercise Plus Cholecalciferol on Nutritional Status Indicators in Adults With Stage 4 Chronic Kidney Disease

OBJECTIVE

Decreased serum concentrations of 25-hydroxyvitamin D (25(OH)D) affect people with chronic kidney disease (CKD); lower concentrations of 25(OH)D have been associated with decrease in nutritional status indicators. On the other hand, muscle resistance exercise has improved the nutritional status of patients with CKD.The aim of this study was to evaluate the effect of resistance exercise and dietary supplementation with cholecalciferol on nutritional status indicators in adults with stage 4 CKD.

METHODS

Patients with an estimated glomerular filtration rate between 15 and 29 mL/min/1.73 m² in an open-label clinical trial were followed for 12 weeks. The intervention group received exercise resistance training sessions three times per week with oral cholecalciferol supplementation each day. The control group only received standard medical care. The outcomes were anthropometric measurements, handgrip strength, and bioelectrical impedance analysis.

RESULTS

Thirty-nine patients of a median age of 48 (36-52) years had an estimated glomerular filtration rate of 21.8 ± 6.5 mL/min/1.73 m². A total of 57.5% of the patients were women. In 41% of the patients, the etiology of CKD was diabetes. After 12 weeks, in the intervention group, the adherence to the resistance training was 77%, and the adherence to the supplementation with cholecalciferol was 96.2%. Significant improvements in 25(OH)D serum concentrations and in handgrip strength were detected in the intervention group (P < .05). In the control group, a decrease in 25(OH)D serum concentrations and a loss in handgrip strength were observed, although the difference was not statistically significant. Anthropometrics and biochemical and dietary indicators, but not bioelectrical impedance data, exhibited changes.

CONCLUSION

Supplementation with cholecalciferol improves serum concentrations of 25(OH)D and, when combined with resistance exercise, improved muscle function as measured by handgrip strength in a study of patients with CKD not on dialysis.

Teach-Back Experience and Hospitalization Risk Among Patients with Ambulatory Care Sensitive Conditions: a Matched Cohort Study

BACKGROUND

The teach-back method, also known as the "show-me" method, has been endorsed by many medical and health care societies. However, limited investigation has been conducted regarding its association with patient outcomes.

OBJECTIVES

To examine the association between patient teach-back experience and the risk of hospitalizations and length of hospital stay among patients with ambulatory care sensitive conditions (ACSCs).

DESIGN

A matched cohort study.

SETTING

Data from the 2011-2015 Longitudinal Medical Expenditure Panel Survey (panels 16-19).

PARTICIPANTS

Three thousand nine hundred ninety-four US adults aged ≥ 18 years with any of 5 ACSCs (hypertension, type 2 diabetes, heart disease, asthma, and chronic obstructive pulmonary disease [COPD]).

MEASUREMENTS

Hospital admissions (all-cause or ACSC-related) and the length of stay of the first admission were examined by teach-back during interaction with a health provider.

RESULTS

Patients with teach-back experience were less likely to experience hospitalization for an ACSC-related condition (relative risk, 0.85; 95% CI, 0.71 to 0.99) and had a lower risk for a condition-related readmission (hazard ratio, 0.77; 95% CI, 0.60 to 0.99), compared with those without teach-back experience. The median length of hospital stay did not differ between patients with teach-back experience and those without teach-back experience (median 3 days [IQR 1 to 8 days] and median 3 days [IQR 0 to 8 days], respectively; P = 0.84). Subgroup analysis showed that the association of reported teach-back experience on the outcomes was relatively stable among those with hypertension, diabetes, and heart disease, but was not among those with asthma or COPD.

LIMITATION

Teach-back exposure relied on patient self-reported information.

CONCLUSIONS

Our findings suggest that patient teach-back method is associated with reduced risk of hospitalization for those with ACSCs, especially among patients with cardiovascular diseases and type 2 diabetes. Encouraging providers to utilize the teach-back method at every visit has the potential to further reduce hospitalizations for individuals with ACSCs.

A cross-sectional study of health literacy in patients with chronic kidney disease: Associations with demographic and clinical variables

AIM

The aim of this study was to investigate health literacy in patients with chronic kidney disease in a multidimensional perspective.

DESIGN

A descriptive, cross-sectional study.

METHODS

Patients with chronic kidney disease at stages 3-5 were included in the study between February-August 2017 (N = 187). Health literacy was measured by the Health Literacy Questionnaire (HLQ). Multiple linear regression analysis was performed to identify associations between health literacy and demographic and clinical variables. Hierarchical cluster analysis was performed to identify characteristics of groups with high and low health literacy.

RESULTS

Finding and critical appraise health information were the most challenging dimensions of health literacy. Female gender, lower level of education, greater number of prescribed medications and depressive symptoms were associated with lower health literacy. The group identified with lowest health literacy was further characterized by living alone and presence of comorbidity.

Caregiver Voices: Cross-Cultural Input on Improving Access to Autism Services

Decades of research have established that racial ethnic minority, low-income, and/or non-English speaking children with autism spectrum disorder (ASD) are diagnosed later than white children, and their families experience greater difficulty accessing services in the USA. Delayed access to timely diagnosis and early intervention may impact child outcomes and family quality of life. Despite their cognition of these disparities and their significant impact on the lives of those affected, explanations for the barriers experienced by underserved families are elusive, likely due to the complex interaction between structural and family factors. This study used qualitative methods to gather family and provider perspectives of perceived barriers and facilitators to obtaining an ASD diagnosis and accessing ASD-related services for underserved families. Themes from focus groups and interviews with families from three cultural groups (black, Hispanic/Latino, and Korean) and three primary languages (English, Korean, and Spanish) highlight specific barriers related to family, community, and systemic challenges as well as facilitators to accessing care for these populations. Family experiences are expanded upon with viewpoints from the providers who work with them. Recommendations are made for reducing disparities in the existing ASD service system including increasing professional, family, and community education; increasing culturally responsive care; improving provider-family partnerships; and addressing practical challenges to service access.

Clinician-patient communication during the diagnostic workup: The ABIDE project

Introduction

We aimed to describe clinician-patient communication in the diagnostic process of memory clinics, specifically clinician behavior known to facilitate knowledgeable participation of patients during consultations.

Methods

In this multicenter, observational study, we audio-recorded routine diagnostic consultations of 41 clinicians and 136 patients/caregivers at eight memory clinics. Patients/caregivers completed surveys after each audiotaped consultation. We used a study-specific coding scheme to categorize communication behavior.

Results

Clinicians often provided information on (results of) diagnostic testing. They infrequently invited questions and/or checked understanding. Clinician behavior to involve patients in decision-making about diagnostic testing was limited. Of note, patients/caregivers rarely expressed their information or involvement preferences. Yet, approximately, one quarter of them would have liked to receive more information.

Discussion

Involving patients more explicitly by means of shared decision-making could benefit the quality of care provided in memory clinics because it enables clinicians to attune the diagnostic workup to the individual patient's needs.

•

Considering patient preferences in the diagnostic process enables personalized care.

•

Knowledgeable participation in diagnostic consultations is therefore warranted.

•

Clinicians often provided information on diagnostic procedures and test results.

•

Yet, they showed limited behavior to promote patients' understanding.

•

And patients were seldom involved in decision-making about diagnostic testing.

Improving Communication in Breast Cancer Treatment Consultation: Use of a Computer Test of Health Numeracy

Background: Communication of statistics and probability is challenging in the cancer care setting. The objectives of this study are to evaluate a novel approach to cancer communication through the use of a computer assessment of patient health numeracy. Methods: We conducted a pilot study of the Computer Adapted Test of Numeracy Understanding in Medicine Instrument (CAT-NUMi) before the cancer treatment consultation for women with stage 0-3 breast cancer. Patient outcomes included the interpersonal processes of care (IPC) and the decisional conflict scale. We evaluated clinician use of numeric information in the cancer consultation and assessed feasibility outcomes from the clinician and patient perspective. Results: Patient participants (n = 50) had a median (interquartile range) age of 51 years (46-61), 70% were English speaking, and 30% Spanish speaking. Decisional conflict was low with a mean (standard deviation [SD]) decisional conflict score of 17.4 (12.3). The lack of clarity score (range 1-5) on the IPC was low (mean, SD),1.70 (0.71), indicating clear communication. Clinicians more often used percentages in communicating prognosis among those with higher numeracy scores (median, range): high (2, 0-8), medium (1, 0-7), and low (0, 0-8); p = 0.04. The patient experience of taking the CAT-NUMi was rated as very good or excellent by 65%, fair by 33%, and poor by 2% of patients. Conclusion: Screening for health numeracy with a short computer-based test may be a feasible strategy to optimize clear communication in the cancer treatment consultation. Further studies are needed to evaluate this strategy across cancer treatment clinical settings and populations.

Not feeling ready to go home: a qualitative analysis of chronically ill patients' perceptions on care transitions

QUALITY PROBLEM

Unplanned hospital readmissions frequently occur and have profound implications for patients. This study explores chronically ill patients' experiences and perceptions of being discharged to home and then acutely readmitted to the hospital to identify the potential impact on future care transition interventions.

INITIAL ASSESSMENT AND IMPLEMENTATION

Twenty-three semistructured interviews were conducted with chronically ill patients who had an unplanned 30-day hospital readmission at a university teaching hospital in the Netherlands.

CHOICE OF SOLUTION

A constructive grounded theory approach was used for data analysis.

EVALUATION

The core category identified was 'readiness for hospital discharge,' and the categories related to the core category are 'experiencing acute care settings' and 'outlook on the recovery period after hospital discharge.' Patients' readiness for hospital discharge was influenced by the organization of hospital care, patients' involvement in decision-making and preparation for discharge. The experienced difficulties during care transitions might have influenced patients' ability to cope with challenges of recovery and dependency on others.

LESSONS LEARNED

The results demonstrated the importance of assessing patients' readiness for hospital discharge. Health care professionals are recommended to recognize patients and guide them through transitions of care. In addition, employing specifically designated strategies that encourage patient-centered communication and shared decision-making can be vital in improving care transitions and reduce hospital readmissions. We suggest that health care professionals pay attention to the role and capacity of informal caregivers during care transitions and the recovery period after hospital discharge to prevent possible postdischarge problems.

Cluster randomized controlled trial testing the effectiveness of a self-management intervention using the teach-back method for people with heart failure

In this study, we examined the effectiveness of a self-management intervention delivered to people with heart failure in Vietnam. It used teach-back, a cyclical method of teaching content, checking comprehension, and re-teaching to improve understanding. A single-site cluster randomized controlled trial was conducted, and six hospital wards were randomized into two study groups. On the basis of ward allocation, 140 participants received either usual care or the teach-back heart failure self-management intervention plus usual care. The intervention involved, prior to discharge, an individual educational session on heart failure self-care, with understanding reinforced using teach-back, a heart failure booklet, weighing scales, diary, and a follow-up phone call 2 weeks post-discharge. The control group received usual care and the booklet. Outcomes were heart failure knowledge, self-care (maintenance, management and confidence), and all-cause hospitalizations assessed at 1 and 3 months (end-point). Upon completion of the study, the intervention group had significantly greater knowledge and self-care maintenance than the control group. Other outcomes did not differ between the two groups. The teach-back self-management intervention demonstrated promising benefits in promoting self-care for heart failure patients.

Influence of Cognition on Length of Stay and Rehospitalization in Older Veterans Admitted for Post-Acute Care

OBJECTIVES

Evaluate the relative contribution of cognitive test performance to post-acute care (PAC) length of stay (LOS) and rehospitalization while controlling for key demographic, medical, and functional outcomes.

METHODS

Retrospective medical record review of 160 older Veterans, including cognitive test performance (Addenbrooke's Cognitive Examination-Revised [ACE-R]), on admission to a Veterans Administration Hospital Community Living Center (CLC) PAC.

RESULTS

Individuals with impaired scores on the ACE-R had a longer LOS (10 median days longer; U = 2,547.00, p = .028). Of those rehospitalized, 71.4% (n = 20) screened positive for cognitive impairment. Key medical factors explained the largest amount of variance in CLC-PAC LOS (29.8%), followed by admission ADL (activities of daily living) dependency (4.6%) and ACE-R total score (3.30%).

DISCUSSION

Cognitive screening should be considered on PAC admission, with impairment on ACE-R predicting geriatric rehabilitation outcomes such as risk of increased LOS and rehospitalization.

A systematic review and meta-analysis on the effectiveness of education on medication adherence for patients with hypertension, hyperlipidaemia and diabetes

AIM

To evaluate the effectiveness of educational interventions in improving medication adherence among adult patients diagnosed with hypertension, hyperlipidaemia and/or diabetes.

DESIGN

This review was conducted with reference to methods set out in the Cochrane Handbook for Systematic Reviews of Interventions (PROSPERO registration number: CRD42016053402).

DATA SOURCES

A search from seven electronic databases (2003-2016).

REVIEW METHOD

The quality of evidence and strength of the studies was evaluated systematically, followed by an assessment of risks of bias by two reviewers with the Cochrane Collaboration's tool.

RESULTS

Eighteen randomized controlled trials demonstrated a low to moderate quality evidence on the improvements of medication adherence with educational interventions. Participants with type 2 diabetes benefited from education interventions but not those with hypertension. No randomized controlled trials (RCT) was found for participants with hyperlipidaemia. Education that was conducted at home showed better medication adherence than education conducted in clinics. Medication adherence was improved after two to three sessions but no significant differences found after three sessions.

CONCLUSION

Through education, health literacy is improved, thus improving medication adherence.

IMPACT

A plethora of educational interventions have been implemented in the clinical settings, but no reviews have hitherto been conducted on their effectiveness. This review suggested that education improves health literacy which is directly proportionate to optimal disease management including medication adherence. The suggestions proposed in this review may impact the individual in terms of their adherence to medication to tackle exacerbation and relapse of chronic diseases and also proposed suggestions for future implementation of an education intervention.

Effects of mindfulness-based health education practice on health behaviors and quality of life among hypertensive patients

Purpose

The purpose of this paper is to examine the effect of mindfulness practice on health behaviors and quality of life (QOL) among hypertensive patients.

Design/methodology/approach

A quasi-experimental research was designed by before, after and a follow-up phase (i.e. on the 0th, 6th and 12th weeks). Two primary health care units (PCU) were selected as control and experiment groups. Samples included patients 35–59 years old who had been diagnosed with stage I hypertension. Both groups received treatment according to standard hypertension guidelines. The experimental group was added as a drill for the purpose of a mindfulness-based health education (MBHE) practice that would emphasize behavior skills (in diet, exercise and mental function) and instill a feeling of adaptation to everyday life.

Findings

The total mean score of the prevention and promotional hypertension behaviors (PPHB), QOL, perceived in mindfulness (MF) and self-efficacy (SE) in the experiment group showed a significant statistical difference when compared to the control group in the 6th week in PPHB and SE (p<0.001), QOL and MF (p=0.001). Similar results were found in the 12th week in PPHB, QOL, SE (p<0.001) and MF (p=0.023), respectively.

Research limitations/implications

However, finished implementation in experiment group, during the follow-up phase on the 12th week, ten participants in the control group were excluded (Figure 1). It may be no active intervention or as usual in the control group. Thus, the authors controlled missing data using intention-to-treat analysis comparison and the data distribution was successfully tested by a normality plot before the use of statistical data. Based on the results of this study, the following recommendations can be made: patients should practice in mindfulness in lifestyle modification continued for intensive skill practice over the long term in order to promote sustainability in behavior and in QOL.

Practical implications

Mindfulness trainer should drill and faith in the value of mindfulness corporation owner with patients learning all of the times; and for health practitioner, it should add MBHE for patients.

Social implications

Education institution should add mindfulness in educational programs all of graduates.

Originality/value

The mindfulness practice-based health education training should be in counterpart with modern medicine in order to promote sound health behaviors and an improved QOL for stage I hypertensive patients and to forestall cardiovascular and blood-pressure diseases.

Assessing the link between modified 'Teach Back' method and improvement in knowledge of the medical regimen among youth with kidney transplants: The application of digital media

OBJECTIVE

The objective of this study was to facilitate functional health literacy (FHL) with a modified "Teach Back" method. A computer-based program was developed for adolescent and young adult kidney transplant recipients (KTR) to knowledgeably answer questions about their medical condition, medications, and create a simple synopsis of their personal health record with the help of the heath care provider (HCP).

METHODS

In a pre-post quasi-experimental design, 16 patients received the computer intervention in which they navigated questionnaires and brief informational video clips. Knowledge scores were assessed at baseline and 3 months. The binomial sign test was used to evaluate change in knowledge and purpose of medications.

RESULTS

Mean age was 17.3 ± 2.4 years and 94% were non-Caucasian. Seven of 16 patients were academically below grade level. Twelve of 16 patients improved their overall knowledge (P = 0.0002) and purpose of medications (P = 0.0017).

CONCLUSIONS

A Modified "Teach Back" during clinic visits was associated with improvements in FHL.

PRACTICE IMPLICATIONS

This modified 'teach back' program has the potential to improve FHL which could contribute to long-term preservation of kidney transplants.

Integrative hospital treatment in older patients to benchmark and improve outcome and length of stay - the In-HospiTOOL study

BACKGROUND

A comprehensive in-hospital patient management with reasonable and economic resource allocation is arguably the major challenge of health-care systems worldwide, especially in elderly, frail, and polymorbid patients. The need for patient management tools to improve the transition process and allocation of health care resources in routine clinical care particularly for the inpatient setting is obvious. To address these issues, a large prospective trial is warranted.

METHODS

The "Integrative Hospital Treatment in Older patients to benchmark and improve Outcome and Length of stay" (In-HospiTOOL) study is an investigator-initiated, multicenter effectiveness trial to compare the effects of a novel in-hospital management tool on length of hospital stay, readmission rate, quality of care, and other clinical outcomes using a time-series model. The study aims to include approximately 35`000 polymorbid medical patients over an 18-month period, divided in an observation, implementation, and intervention phase. Detailed data on treatment and outcome of polymorbid medical patients during the in-hospital stay and after 30 days will be gathered to investigate differences in resource use, inter-professional collaborations and to establish representative benchmarking data to promote measurement and display of quality of care data across seven Swiss hospitals. The trial will inform whether the "In-HospiTOOL" optimizes inter-professional collaboration and thereby reduces length of hospital stay without harming subjective and objective patient-oriented outcome markers.

DISCUSSION

Many of the current quality-mirroring tools do not reflect the real need and use of resources, especially in polymorbid and elderly patients. In addition, a validated tool for optimization of patient transition and discharge processes is still missing. The proposed multicenter effectiveness trial has potential to improve interprofessional collaboration and optimizes resource allocation from hospital admission to discharge. The results will enable inter-hospital comparison of transition processes and accomplish a benchmarking for inpatient care quality.

Examining Uncertainty in Illness in Parents and Children With Chronic Kidney Disease and Systemic Lupus Erythematosus: A Mediational Model of Internalizing Symptoms and Health-Related Quality of Life

To examine if parent illness uncertainty is indirectly associated with child depression, anxiety, and HRQOL in the CKD/SLE population. Parent-child dyads (N = 31) from outpatient rheumatology and nephrology clinics included children (ages 9-18) diagnosed with CKD (Stage 1, 2, or nephrotic syndrome) or SLE. Parents completed demographic and uncertainty measures and children completed uncertainty, depression, anxiety, and HRQOL measures. This cross-sectional study examined mediational models using the percentile bootstrapping method. Parent uncertainty had an indirect effect on child depression, anxiety, and HRQOL through the mediator, child uncertainty. In other words, parents' illness uncertainty regarding their child's condition correlates to the child's illness uncertainty, which then is associated with the child's mental health and wellbeing. Reverse mediations illustrated that parent uncertainty did not mediate child uncertainty and outcome variables. Results extend previous research by examining parent and child illness uncertainty in understudied conditions (CKD/SLE) and the relationship to outcome variables commonly related to depression (e.g., anxiety and HRQOL). Findings allow health psychologists and medical personnel to understand the impact of uncertainty on the child's wellbeing and HRQOL. Clinical implications, including using specialized interventions to address illness uncertainty, are discussed.

Improving Self-Reported Preoperative Anxiety Through a Preoperative Education Program: A Quality Improvement Project

BACKGROUND

Preoperative education is an important component of preparing patients for surgery. Preoperative anxiety is one of the most important problems for patients, because it causes emotional and psychiatric problems as well as physical problems. Anxiety has been associated with several pathophysiological responses such as hypertension and dysrhythmias, which can increase perioperative morbidity. Estimates suggest that between 11% and 80% of adult presurgical patients experience heightened levels of anxiety.

OBJECTIVE

The purpose of this pilot project was to develop a preoperative education program for thoracic surgery patients and to assess the effectiveness of the program in decreasing patient's self-reported anxiety levels using the validated Patient-Reported Outcomes Measurement Information System (PROMIS) tool.

METHODS

This quality improvement project used a pre- and posttest improvement design to evaluate patient's self-reported anxiety levels at three different timepoints during the preoperative and postoperative period. A total of 15 patients from a thoracic surgery practice participated in the study.

RESULTS

The study showed no statistically significant change in patients' self-reported anxiety levels after completion of the preoperative education program (p = .538). Patients reported improvements in parameters such as expectations, pain, and preparedness.

CONCLUSIONS

Although some studies have found that preoperative patient education decreases anxiety, this study supports others that indicate that anxiety is not affected by or associated with educational preparation prior to thoracic surgery. Though no statistical improvement in anxiety levels was demonstrated in this study, a majority of patients reported improvements in parameters such as expectations, pain, and preparedness.

IMPLICATIONS FOR NURSING

As patient education is largely provided by the nursing profession, this article will help the profession to better understand what is important for patients to know in the preoperative setting. Setting patient expectations has a great impact on the patient's recovery and satisfaction with their surgical experience. As this is a pilot study, the goal is for continued research in the area of decreasing preoperative anxiety and preparing patients for surgery.

After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews

BACKGROUND

After-visit summary (AVS) documents presenting key information from each medical encounter have become standard in the USA due to federal health care reform. Little is known about how they are used or whether they improve patient care.

METHODS

First, we completed a literature review and described the totality of the literature on AVS by article type and major outcome measures. Next, we used reputational sampling from large-scale US studies on primary care to identify and interview nine stakeholders on their perceptions of AVS across high-performing primary care practices. Interviews were transcribed and coded for AVS use in practice, perceptions of the best/worst features and recommendations for improving AVS utility in routine care.

RESULTS

The literature review resulted in 17 studies; patients reported higher perceived value of AVS compared with providers, despite poor recall of specific AVS content and varied post-visit use. In key informant interviews, key informants expressed enthusiasm for the potential of using AVS to reinforce key information with patients, especially if AVS were customizable. Despite this potential, key informants found that AVS included incorrect information and did not feel that patients or their practices were using AVS to enhance care.

CONCLUSIONS

There is a gap between the potential of AVS and how providers and patients are using it in routine care. Suggestions for improved use of AVS include increasing customization, establishing care team responsibilities and workflows and ensuring patients with communication barriers have dedicated support to review AVS during visits.

Shared decision-making about cardiovascular disease medication in older people: a qualitative study of patient experiences in general practice

OBJECTIVES

To explore older people's perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention.

DESIGN, SETTING AND PARTICIPANTS

Semi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol) or had received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis.

RESULTS

Twenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication.

CONCLUSIONS

Results demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general.

Limited Health Literacy Is Associated With Worse Patient-Reported Outcomes in Inflammatory Bowel Disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) face complex health tasks and decisions. Limited health literacy is a risk factor for poor health outcomes, but this has not been examined in IBD. This study aims to assess the role of health literacy for patients with IBD.

METHODS

We prospectively enrolled adults with IBD receiving care from the Section of Gastroenterology at the Boston Medical Center. In-person, standardized questionnaires were administered to measure health literacy with the Newest Vital Sign, self-efficacy with the Medication Use and Self-Efficacy Scale, quality of life with the 10-question Short Inflammatory Bowel Disease Questionnaire, depression with the Patient-Reported Outcomes Measurement System Short Form, and clinical disease activity for patients with Crohn's disease with the Harvey-Bradshaw Index and for patients with ulcerative colitis with the Simple Clinical Colitis Activity Index (SCCAI). The relationships between health literacy and these variables were subsequently examined.

RESULTS

Of 112 patients invited to participate, 99 enrolled and completed the interview. Limited health literacy was identified in 40% (n = 40) of patients. Patients with limited health literacy reported significantly worse overall health (P = 0.03) and more depressive symptoms (P = 0.01). Of the 56 patients with Crohn's disease, those with adequate health literacy were more likely to be in clinical remission (mean Harvey-Bradshaw Index score < 5), compared with those with limited health literacy (odds ratio, 4.15; 95% confidence interval, 1.37 to 13.45; P = 0.01). There was no significant association between health literacy and clinical disease activity (SCCAI) in patients with ulcerative colitis.

CONCLUSIONS

Limited health literacy is associated with lower ratings of subjective health and depression in IBD and more symptoms of active disease in patients with Crohn's disease.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Shared decision making in mild cognitive impairment

Shared decision making (SDM) occurs when patients and clinicians consider patients' values and preferences while discussing medical evidence to inform healthcare decisions. SDM enables patients with mild cognitive impairment (MCI) to express values and preferences when making current healthcare decisions and presents a unique opportunity to inform future decision making in the case of further cognitive decline. However, clinicians often fail to facilitate SDM with patients with MCI. This review describes research pertaining to value solicitation, weighing of the medical evidence, and medical decision making for individuals with MCI, explores the role of caregivers, identifies barriers to and facilitators of SDM in MCI, and suggests strategies to optimize SDM for persons with MCI in neurology clinical practice. Further research is needed to identify more strategies for decision support for individuals affected by cognitive impairment.