Patient self-management: a key to effectiveness and efficiency in care of chronic disease

Mental health and relational self-management experiences of patients with type 2 diabetes and stage 3 chronic kidney disease

Self-management (SM) behaviors reduce disease burden from advancing diabetic kidney disease. From a parent study about patients' transition experience to SM, this study report presents coping resources that support SM and barriers from two focus group interviews (n = 6). Ethnographic analysis identified two patterns: (a) mental health self-management characterized by coping, and (b) relational self-management characterized by social support. Practice implications include focused assessment of perceived social support and social network, dating advisement, and workplace management. Future study considerations include inquiry about diabetes and dating relationships and workplace resources for SM support.

Management of Chronic Diseases in Sub-Saharan Africa: Cross-Fertilisation between HIV/AIDS and Diabetes Care

There is growing attention for chronic diseases in sub-Saharan Africa (SSA) and for bridges between the management of HIV/AIDS and other (noncommunicable) chronic diseases. This becomes more urgent with increasing numbers of people living with both HIV/AIDS and other chronic conditions. This paper discusses the commonalities between chronic diseases by reviewing models of care, focusing on the two most dominant ones, diabetes mellitus type 2 (DM2) and HIV/AIDS. We argue that in order to cope with care for HIV patients and diabetes patients, health systems in SSA need to adopt new strategies taking into account essential elements of chronic disease care. We developed a “chronic dimension framework,” which analyses the “disease dimension,” the “health provider dimension,” the patient or “person dimension,” and the “environment dimension” of chronic diseases. Applying this framework to HIV/AIDS and DM2 shows that it is useful to think about management of both in tandem, comparing care delivery platforms and self-management strategies. A literature review on care delivery models for diabetes and HIV/AIDS in SSA revealed potential elements for cross-fertilisation: rapid scale-up approaches through the public health approach by simplification and decentralisation; community involvement, peer support, and self-management strategies; and strengthening health services.

Factish relations: Affective bodies in diabetes treatment

Chronic diseases pose a major challenge to contemporary western healthcare systems, and consequently there are numerous initiatives designed to meet these challenges. Patient empowerment is considered to be extremely important in chronic disease management. But what does it mean to become an ‘active patient’, managing a condition? This article argues that people are always active in shaping their agency and the agency of numerous others, and that we need to attend to these processes of configuration in order to better understand and conceptualize the problem of chronic disease management. This article analyses the daily practices of people with Type 2 Diabetes, with the use of what is described as the ‘sociology of attachment’ in the field of science and technology studies. The implications of seeing and analysing chronic conditions in this manner are that determinist understandings of chronic conditions are challenged. Accordingly, an experimental and constructive attitude towards the production and assembling of the chronically ill body is enabled. Such an attitude holds that relations with multiple other bodies and entities, such as technologies, the disease, medication and so on continuously and relentlessly affect how the condition unfolds and consequently, the room for interventional strategies and transformation of the chronically ill body is enlarged.

Improving neuro-oncological patients care: basic and practical concepts for nurse specialist in neuro-rehabilitation

Background

Neuro-oncological population well expresses the complexity of neurological disability due to the multiple neurological deficits that affect these patients. Moreover, due to the therapeutical opportunities survival times for patients with brain tumor have increased and more of these patients require rehabilitation care. The figure of nurse in the interdisciplinary specialty of neurorehabilitation is not clearly defined, even if their role in this setting is recognized as being critical and is expanding.

The purpose of the study is to identify the standard competencies for neurorehabilitation nurses that could be taught by means of a specialization course.

Methods

A literature review was conducted with preference given to works published between January 2000 and December 2008 in English. The search strategy identified 523 non-duplicated references of which 271 titles were considered relevant. After reviewing the abstracts, 147 papers were selected and made available to a group of healthcare professionals who were requested to classify them in few conceptual main areas defining the relative topics.

Results

The following five main areas were identified: clinical aspects of nursing; nursing techniques; nursing methodology; relational and organisational models; legal aspects of nursing. The relative topics were included within each area. As educational method a structured course based on lectures and practical sessions was designed. Also multi-choices questions were developed in order to evaluate the participants’ level of knowledge, while a semi-structured interview was prepared to investigate students’ satisfaction.

Conclusions

Literature shows that the development of rehabilitation depends on the improvement of scientific and practical knowledge of health care professionals. This structured training course could be incorporated into undergraduate nursing education programmes and also be inserted into continuing education programmes for graduate nurses. Developing expertise in neuro-rehabilitation for nurses, will be critical to improve overall care and care management of patients with highly complex disabilities as patients affected by brain tumors. The next step will be to start discussing, at the level of scientific societies linked to the field of neurorehabilitation and oncology, the development of a specialisation course in neurorehabilitation nursing.

A comparison of epilepsy self-management needs: provider and patient perspectives

A consistent and serious empirical issue in the epilepsy self-management literature involves dropout and attrition in intervention studies. One explanation for this issue revolves around "top-down" intervention designs (i.e., interventions generated by epilepsy clinicians and researchers) and the potential for disparity with patient interests, capabilities, and perceived needs. The purpose of this study was to extend the work of Fraser et al. (2011) [19] by comparing perceptions regarding self-management problems, topics, and program design, between two subgroups of adult patients with epilepsy (n=165) and epilepsy clinicians (n=20). Results indicate differences in problem severity ratings, program emphasis (i.e., goal-setting, coping, education), and program leadership between clinicians and each patient subgroup to varying degrees. These findings highlight some of the differences in opinion between patients and clinicians and emphasize the need for patient-involved planning with regard to self-management programs. Implications and explanations are offered as points for consideration in self-management program development.

Filling the Gaps in a Fragmented Health Care System: Development of the Health and Welfare Information Portal (ZWIP)

BACKGROUND

Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated.

OBJECTIVE

To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR).

METHODS

We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups.

RESULTS

We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program.

CONCLUSIONS

This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved.

A randomized trial of a web-based intervention to improve migraine self-management and coping

OBJECTIVE

To test the clinical efficacy of a web-based intervention designed to increase patient self-efficacy to perform headache self-management activities and symptom management strategies, and reduce migraine-related psychological distress.

BACKGROUND

In spite of their demonstrated efficacy, behavioral interventions are used infrequently as an adjunct in medical treatment of migraine. Little clinical attention is paid to the behavioral factors that can help manage migraine more effectively and improve the quality of care and quality of life. Access to evidenced-based, tailored, behavioral treatment is limited for many people with migraine.

DESIGN

The study is a parallel group design with 2 conditions: (1) an experimental group exposed to the web intervention; and (2) a no-treatment control group that was not exposed to the intervention. Assessments for both groups were conducted at baseline (T1), 1-month (T2), 3-months (T3), and 6-months (T4).

RESULTS

Compared with controls, participants in the experimental group reported significantly: increased headache self-efficacy, increased use of relaxation, increased use of social support, decreased pain catastrophizing, decreased depression, and decreased stress. The hypothesis that the intervention would reduce pain could not be tested.

CONCLUSIONS

Demonstrated increases in self-efficacy to perform headache self-management, increased use of positive symptom management strategies, and reported decreased migraine-related depression and stress suggest that the intervention may be a useful behavioral adjunct to a comprehensive medical approach to managing migraine.

Improving care and wellness in bipolar disorder: origins, evolution and future directions of a collaborative knowledge exchange network

The Collaborative RESearch team to study psychosocial factors in bipolar disorder (CREST.BD) is a multidisciplinary, cross-sectoral network dedicated to both fundamental research and knowledge exchange on bipolar disorder (BD). The core mission of the network is to advance the science and understanding of psychological and social issues associated with BD, improve the care and wellness of people living with BD, and strengthen services and supports for these individuals. CREST.BD bridges traditional and newer research approaches, particularly embracing community-based participatory research (CBPR) methods. Membership of CREST is broad, including academic researchers, people with BD, their family members and supports, and a variety of health care providers. Here, we describe the origins, evolution, approach to planning and evaluation and future vision for our network within the landscape of CBPR and integrated knowledge translation (KT), and explore the keys and challenges to success we have encountered working within this framework.

Patients with acute exacerbation of chronic obstructive pulmonary disease feel safe when treated at home: a qualitative study

BACKGROUND

The design of new interventions to improve health care for patients with chronic obstructive pulmonary disease (COPD) requires knowledge about what patients with an acute exacerbation experience as important and useful. The objective of the study was to explore patients' experiences of an early discharge hospital at home (HaH) treatment programme for exacerbations in COPD.

METHODS

Six exacerbated COPD patients that were randomised to receiving HaH care and three patients randomised to receiving traditional hospital care were interviewed in semi-structured in-depth interviews. Four spouses were present during the respective patients' interviews. The interviews were audio-taped, transcribed and analysed by a four-step method for systematic text condensing.

RESULTS

Despite limited assistance from the health care service, the patients and their spouses experienced the HaH treatment as safe. They expressed that information that was adapted to specific situations in their daily lives and given in a familiar environment had positive impact on their self-management of COPD.

CONCLUSION

The results contribute to increased knowledge and awareness about what the patients experienced as important aspects of a HaH treatment programme. How adapted input from health services can make patients with exacerbation of COPD feel safe and better able to manage their disease, is important knowledge for developing new and effective health services for patients with chronic disease.

Patients' understanding of pelvic floor disorders: what women want to know

OBJECTIVE

To assess the effect of initial visit with a specialist on disease understanding in women with pelvic floor disorders.

METHODS

Women with referrals or chief complaints suggestive of urinary incontinence or pelvic organ prolapse were recruited from an academic urology clinic. The patients completed a Test of Functional Health Literacy in Adults and scripted interview sessions before and after a physician encounter. Physician's treatment plans were standardized based on diagnosis and were explained using models. Interview transcripts were analyzed using qualitative grounded theory methodology.

RESULTS

Twenty women with pelvic floor disorders (urinary incontinence or pelvic organ prolapse) were recruited and enrolled in this pilot study. The mean age was 60.5 years (range, 31-87 years) and most of the women were white, with a college degree or beyond. Test of Functional Health Literacy in Adults scores indicated adequate to high levels of health literacy. Preliminary themes before and after the physician encounter were extracted from interviews, and 2 main concepts emerged. First, after the initial physician's visit, knowledge of their diagnosis and the ability to treat their symptoms relieved the patients' concerns related to misunderstandings of the severity of their disease, Second, the patients tended to focus on treatment and had difficulty grasping certain diagnostic terms. This resulted in good understanding of treatment plans despite an inconsistent understanding of diagnosis.

CONCLUSION

Our findings demonstrated a significant effect of the initial physician's visit on the patients' understanding of their pelvic floor disorder. Despite the variation in diagnostic recall after the physician encounter, the patients had a good understanding of treatment plans. This served to increase perceived control and adequately relieve patients' fears.

The effects of Hartcoach, a life style intervention provided by telephone on the reduction of coronary risk factors: a randomised trial

Background

Cardiovascular disease (CVD) is the leading cause of death worldwide. Secondary prevention is essential, but participation rates for cardiac rehabilitation are low. Furthermore, current programmes do not accomplish that patients with CVD change their lifestyle in a way that their individual risk factors for recurrent events decrease, therefore more effective interventions are needed. In this study, the effectiveness of the Hartcoach-programme, a telephonic secondary prevention program focussing on self management, is studied.

Methods/design

A multicenter, randomised parallel-group study is being conducted. Participants are 400 patients with acute myocardial infarction (STEMI, NSTEMI,) and patients with chronic or unstable angina pectoris (IAP). Patients are recruited through the participating hospitals and randomly assigned to the experimental group (Hartcoach-programme plus usual care) or the control group (usual care).

The Hartcoach-programme consists of a period of six months during which the coach contacts the patient every four to six weeks by telephone. Coaches train patients to take responsibility for the achievement and maintenance of the defined target levels for their particular individual modifiable risk factors. Target levels and treatment goals are agreed by the nurse and patient together. Data collection is blinded and occurs at baseline and after 26 weeks (post-intervention). Primary outcome is change in cardiovascular risk factors (cholesterol, body mass index, waist circumference, blood pressure, physical activity and diet). Secondary outcomes include chances in glucose, HbA1c, medication adherence, self-management and quality of life.

Discussion

This study evaluates the effects of the Hartcoach-programme on the reduction of individual risk factors of patients with CVDs. Patients who are not invited to follow a hospital based rehabilitation programme or patients who are unable to adhere to such a programme, may be reached by this home based Hartcoach-programme. If positive results are found, the implementation of the Hartcoach-programme will be extended, having implications for the management of many people with CVD.

Trial registration

NTR2388

Supporting chronic disease self-management: translating policies and principles into clinical practice

To support self-management, health professionals need to adopt a client-centred approach and learn to deliver evidence-based behaviour change interventions. This paper reports on the evaluation of 1- and 2-day training programs developed to improve health professionals' capacity to support chronic disease self-management (CDSM). The 321 participants attended one of eighteen supporting CDSM courses held in urban and rural settings. Participants included nurses, allied health professionals, Aboriginal health workers and general practitioners. Data were collected at three time points: before participation; immediately after the training; and, for a sub-sample of 37 participants, 2 months after the training. Results revealed a significant and sustained increase in CDSM self-efficacy following training regardless of participants' gender, age or qualifications. A thematic analysis of the responses concerning intended practice revealed four main areas of intended practice change, namely: use behavioural strategies; improve communication with clients; adopt a client-centred approach; and improve goal setting. The number of practice changes at 2 months reported by a sub-sample of participants ranged from 1 to 20 with a mean of 14 (s.d.=4). The three most common areas of practice change point to the adoption by health professionals of a collaborative approach with chronic disease patients. Lack of staff trained in CDSM was seen as a major barrier to practice change, with lack of support and finance also named as barriers to practice change. Participants identified that increased training, support and awareness of the principles of supporting CDSM would help to overcome barriers to practice change. These results indicate a readiness among health professionals to adopt a more collaborative approach given the skills and the tools to put this approach into practice.

Exploring the impact of language services on utilization and clinical outcomes for diabetics

Background

Significant health disparities exist between limited English proficient and English-proficient patients. Little is known about the impact of language services on chronic disease outcomes such as for diabetes.

Methods/Principal Findings

To determine whether the amount and type of language services received during primary care visits had an impact on diabetes-related outcomes (hospitalization, emergency room utilization, glycemic control) in limited English proficient patients, a retrospective cohort design was utilized. Hospital and medical record data was examined for 1425 limited English proficient patients in the Cambridge Health Alliance diabetes registry. We categorized patients receiving usual care into 7 groups based on the amount and combination of language services (language concordant providers, formal interpretation and nothing) received at primary care visits during a 9 month period. Bivariate analyses and multiple logistic regression were used to determine relationships between language service categories and outcomes in the subsequent 6 months. Thirty-one percent of patients (445) had no documentation of interpreter use or seeing a language concordant provider in any visits. Patients who received 100% of their primary care visits with language concordant providers were least likely to have diabetes-related emergency department visits compared to other groups (p<0001) in the following 6 months. Patients with higher numbers of co-morbidities were more likely to receive formal interpretation.

Conclusions/Significance

Language concordant providers may help reduce health care utilization for limited English proficient patients with diabetes. However, given the lack of such providers in sufficient numbers to meet patients' communication needs, strategies are needed to both increase their numbers and ensure that the highest risk patients receive the most appropriate language services. In addition, systems serving diverse populations must clarify why some limited English proficient patients do not receive language services at some or all of their visits and whether this has an impact on quality of care.

Attitudes and dilemmas of caregivers supporting people with intellectual disabilities who have diabetes

OBJECTIVE

To explore how professional caregivers in communal living arrangements support people with a mild or moderate intellectual disability (ID) who have diabetes.

METHODS

A qualitative study, 13 caregivers participated in semi-structured interviews.

RESULTS

Professional caregiver support in diabetes care is almost solely directed towards administering medication and controlling food intake. Caregivers want to provide person-centered care but are hindered by a conflict between protecting a client's health and at the same time respecting autonomy. None of the caregivers had received training in supporting self-management; their knowledge about diabetes is limited. The few that engaged their client in self-management stressed the importance of a positive and collaborative approach.

CONCLUSION

This study provides a first insight into the challenges that professional caregivers experience when a client with ID has diabetes. More education for caregivers seems needed. Self-management support is likely to benefit from consensus among caregivers about what comprises person-centered care and self-management in people with ID who have a chronic disease.

PRACTICE IMPLICATIONS

Increasing caregivers' awareness of the importance of supporting self-management in people with ID and a chronic disease is essential. Discussing practice examples in the light of existing knowledge about developing autonomy will contribute to their awareness.

An online approach to providing chronic illness self-management information

The purpose of this article was to describe an online approach to providing chronic illness self-management information to rural women with chronic illness. To self-manage chronic illness, individuals require information about their conditions. For those in rural areas who have limited access to health services, computer-based interventions are a means of providing this information. Participants were randomly assigned either to an 11-week computer intervention in which they completed nine online self-study health teaching units related to self-management, or to a control group. The health teaching units were positively rated as being helpful in managing their chronic illnesses, with scores ranging from 4.09 to 4.84 on a six-point scale. Perceptions of computer skills increased significantly for the intervention group, with no increase in the control group. Computer-based programs can be an effective approach to providing health information to rural women with chronic conditions that will assist them in their self-management efforts.

Effects of a Web-based intervention for adults with chronic conditions on patient activation: online randomized controlled trial

BACKGROUND

With almost one-half of Americans projected to have at least one chronic condition before 2020, a vital role of the health care system is to develop informed, engaged individuals who are effective self-managers of their health. Self-management interventions (SMIs) delivered face-to-face or by telephone (traditional SMIs) are associated with improved self-management knowledge, skills, and self-efficacy, which are expressed by the composite construct of patient activation, a predictor of health outcomes. Web-based interventions to support self-management across the spectrum of chronic diseases have the potential to reach a broader population of patients for extended periods than do traditional SMIs. However, evidence of the effectiveness of Web-based interventions on patient activation is sparse. High-quality studies featuring controlled comparisons of patients with different chronic conditions are needed to explore the interaction of Web-based interventions and patient activation.

OBJECTIVE

To explore the effect of a Web-based intervention on the patient activation levels of patients with chronic health conditions, measured as attitudes toward knowledge, skills, and confidence in self-managing health.

METHODS

For this 12-week study, prospective participants were selected from the patient panel of a regional health care system in the United States. The 201 eligible participants were randomly assigned to two groups. Intervention group participants had access to MyHealth Online, a patient portal featuring interactive health applications accessible via the Internet. Control participants had access to a health education website featuring various topics. Patient activation was assessed pre- and posttest using the 13-item patient activation measure. Parametric statistical models (t test, analysis of variance, analysis of covariance) were applied to draw inferences.

RESULTS

The Web-based intervention demonstrated a positive and significant effect on the patient activation levels of participants in the intervention group. A significant difference in posttest patient activation scores was found between the two groups (F(1,123) = 4.438, P = .04, r = .196). Patients starting at the most advanced development of patient activation (stage 4) in the intervention group did not demonstrate significant change compared with participants beginning at earlier stages.

CONCLUSIONS

To our knowledge, this is the first study to measure change in patient activation when a Web-based intervention is used by patients living with different chronic conditions. Results suggest that Web-based interventions increase patient activation and have the potential to enhance the self-management capabilities of the growing population of chronically ill people. Activated patients are more likely to adhere to recommended health care practices, which in turn leads to improved health outcomes. Designing Web-based interventions to target a specific stage of patient activation may optimize their effectiveness. For Web-based interventions to reach their potential as a key component of chronic disease management, evidence is needed that this technology produces benefits for a sustained period among a diverse population.

Closing the gap: eliminating health care disparities among Latinos with diabetes using health information technology tools and patient navigators

Latinos have higher rates of diabetes and diabetes-related complications compared to non-Latinos. Clinical diabetes self-management tools that rely on innovative health information technology (HIT) may not be widely used by Latinos, particularly those that have low literacy or numeracy, low income, and/or limited English proficiency. Prior work has shown that tailored diabetes self-management educational interventions are feasible and effective in improving diabetes knowledge and physiological measures among Latinos, especially those interventions that utilize tailored coaching and navigator programs. In this article, we discuss the role of HIT for diabetes management in Latinos and describe a novel "eNavigator" role that we are developing to increase HIT adoption and thereby reduce health care disparities.

Moving towards effective chronic illness management: asthma as an exemplar

The United States health care system is at a pivotal point in its ability to manage chronic illness. The demands and philosophical differences between the management of acute and chronic illnesses suggest the need for different strategies for effective and efficient management of chronic illness. The purpose of this article is to discuss the Chronic Care Model and the collaborative approach to managing chronic illnesses. Asthma, as an exemplar, will be used to illustrate the need for the development of new models of collaborative care for the treatment of chronic illnesses.

Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: experiences from the Ann Arbor Patient-Aligned Care Team Laboratory

While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient-peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.

‘Oh dear, should I really be saying that on here?’: Issues of identity and authority in an online diabetes community

We explore peer-to-peer discussions which took place in a UK-based diabetes ‘Virtual Clinic’ online community. In particular, we seek to understand the rhetorical nature and content of exchanges over a period of six months from the community’s inception. Data were captured weekly and analysis based on thematic discourse analysis. Two key issues emerged regarding how the community shaped the nature of the discussion forum. First, the identity of the forum was established, and boundaries drawn about what was, and was not, acceptable. Second, participants sought to present themselves as reliable and authoritative sources of information. Internet discussion communities are shaped in important ways early on by the community of users, including how the character and focus of discussion is formed, and how both information and users can be constructed as authoritative and reliable.

Do physicians understand Type 2 diabetes patients' perceptions of seriousness; the emotional impact and needs for care improvement? A cross-national survey

OBJECTIVE

To explore across countries the extent to which physicians understand Type 2 diabetes patients' perceptions of seriousness, worries about complications, emotional distress, and needs for care improvement.

METHODS

Cross-sectional data were collected in a multinational survey (SHARED). Type 2 diabetes patients (n=1609), general practitioners (n=818) and diabetes specialists (n=697) from eight countries were included. Data were gathered online and via telephone interviews. Responses from patients and professionals were compared using descriptive statistics and multilevel analyses.

RESULTS

Patients generally perceived diabetes as a serious condition and reported moderate distress. Physicians tended to underestimate patients' perceived seriousness, while overestimating their level of distress. Physicians had difficulty estimating which diabetes complications concerned patients most, and what they needed to feel more confident about their diabetes. Patients did not wish for more consultation time, but rather active involvement, information and easy access to their physician.

CONCLUSION

Results of this large survey highlight the importance of patient involvement and shared decision making.

PRACTICE IMPLICATIONS

Further improvement of patient-provider communication as a basis for shared responsibilities and achieving optimal treatment outcomes is needed. With the growing numbers of diabetes patients worldwide, task delegation should be considered, in the framework of a multidisciplinary diabetes care model.

Care challenges for informal caregivers of chronically ill lung patients: Results from a questionnaire survey

Aims: The article aims to answer who the informal caregivers of patients with chronic obstructive pulmonary disease (COPD) are, what kind of help they provide, and how they experience providing help to the patient. Method: Data from a questionnaire survey to next of kin of COPD patients carried through in Norway in December 2009 and January 2010 is explored. Result: About 70% of the patients have one or more informal caregivers, and a majority of the caregivers is the patient’s spouse, most often a wife. The help provided is, to a large extent, practical help like housework, garden work, and shopping. Another important support is to accompany the patient to health care. About 45% of the caregivers are part of the work force. Rather few of the respondents experience the caregiving as so demanding that they have chosen to work part-time or quit working. The most demanding part of being an informal caregiver is an overall worrying for the patient. Conclusions: Paid sick leaves for caregivers that are employed, and hospital-at-home programmes that provide education and surveillance to the patient and his/her family through different phases of the illness, are policy means that both can help the informal caregivers to manage daily life and reduce the pressure on the formal healthcare and long-term care services in the future.

The growing caseload of chronic life-long conditions calls for a move towards full self-management in low-income countries

Background

The growing caseload caused by patients with chronic life-long conditions leads to increased needs for health care providers and rising costs of health services, resulting in a heavy burden on health systems, populations and individuals. The professionalised health care for chronic patients common in high income countries is very labour-intensive and expensive. Moreover, the outcomes are often poor. In low-income countries, the scarce resources and the lack of quality and continuity of health care result in high health care expenditure and very poor health outcomes. The current proposals to improve care for chronic patients in low-income countries are still very much provider-centred.

The aim of this paper is to show that present provider-centred models of chronic care are not adequate and to propose 'full self-management' as an alternative for low-income countries, facilitated by expert patient networks and smart phone technology.

Discussion

People with chronic life-long conditions need to 'rebalance' their life in order to combine the needs related to their chronic condition with other elements of their life. They have a crucial role in the management of their condition and the opportunity to gain knowledge and expertise in their condition and its management. Therefore, people with chronic life-long conditions should be empowered so that they become the centre of management of their condition. In full self-management, patients become the hub of management of their own care and take full responsibility for their condition, supported by peers, professionals and information and communication tools.

We will elaborate on two current trends that can enhance the capacity for self-management and coping: the emergence of peer support and expert-patient networks and the development and distribution of smart phone technology both drastically expand the possibilities for full self-management.

Conclusion

Present provider-centred models of care for people with chronic life-long conditions are not adequate and we propose 'full self-management' as an alternative for low-income countries, supported by expert networks and smart phone technology.

Goal Setting Education and Counseling Practices of Diabetes Educators

Purpose

The purpose of this study was to identify goal setting education practices used by diabetes educators working with type 2 diabetes patients.

Methods

Data were collected by a mail questionnaire with 179 diabetes educators purposively selected from the 2008 American Association of Diabetes Educators membership listing.

Results

Many diabetes educators (52%) reported that more than 75% of their patients set goals for diabetes control. Independent factor patterns for the frequency of information collected from the patient for the first diabetes education session showed that educators either focused on patients’ self-management practices (exercise and dietary practices, knowledge, and social impacts of diabetes) or issues with learning about self-management, such as understanding the patient’s learning style and motivation for managing diabetes. Factor patterns overall showed diverse approaches to working with patients, including strategies used with patients struggling with dietary goals and the importance of tasks to complete during the first patient session.

Conclusion

Although most educators reported practices that were largely patient centered as promoted by the American Diabetes Association (ADA) and models of chronic disease management, patterns of practice suggest that diabetes educators vary considerably in how they apply education practices, especially with dietary self-management education.

Patient self-management and pharmacist-led patient self-management in Hong Kong: a focus group study from different healthcare professionals' perspectives

Background

Patient self-management is a key approach to manage non-communicable diseases. A pharmacist-led approach in patient self-management means collaborative care between pharmacists and patients. However, the development of both patient self-management and role of pharmacists is limited in Hong Kong. The objectives of this study are to understand the perspectives of physicians, pharmacists, traditional Chinese medicine (TCM) practitioners, and dispensers on self-management of patients with chronic conditions, in addition to exploring the possibilities of developing pharmacist-led patient self-management in Hong Kong.

Methods

Participants were invited through the University as well as professional networks. Fifty-one participants comprised of physicians, pharmacists, TCM practitioners and dispensers participated in homogenous focus group discussions. Perspectives in patient self-management and pharmacist-led patient self-management were discussed. The discussions were audio recorded, transcribed and analysed accordingly.

Results

The majority of the participants were in support of patients with stable chronic diseases engaging in self-management. Medication compliance, monitoring of disease parameters and complications, lifestyle modification and identifying situations to seek help from health professionals were generally agreed to be covered in patient self-management. All pharmacists believed that they had extended roles in addition to drug management but the other three professionals believed that pharmacists were drug experts only and could only play an assisting role. Physicians, TCM practitioners, and dispensers were concerned that pharmacist-led patient self-management could be hindered, due to unfamiliarity with the pharmacy profession, the perception of insufficient training in disease management, and lack of trust of patients.

Conclusions

An effective chronic disease management model should involve patients in stable condition to participate in self-management in order to prevent health deterioration and to save healthcare costs. The role of pharmacists should not be limited to drugs and should be extended in the primary healthcare system. Pharmacist-led patient self-management could be developed gradually with the support of government by enhancing pharmacists' responsibilities in health services and developing public-private partnership with community pharmacists. Developing facilitating measures to enhance the implementation of the pharmacist-led approach should also be considered, such as allowing pharmacists to access electronic health records, as well as deregulation of more prescription-only medicines to pharmacy-only medicines.

Case management in oncology rehabilitation (CAMON): the effect of case management on the quality of life in patients with cancer after one year of ambulant rehabilitation. a study protocol for a randomized controlled clinical trial in oncology rehabilitation

Background

Cancer diseases and their therapies have negative effects on the quality of life. The aim of this study is to assess the effectiveness of case management in a sample of oncological outpatients with the intent of rehabilitation after cancer treatment. Case management wants to support the complex information needs of the patients in addition to the segmented structure of the health care system. Emphasis is put on support for self-management in order to enhance health - conscious behaviour, learning to deal with the burden of the illness and providing the opportunity for regular contacts with care providers. We present a study protocol to investigate the efficacy of a case management in patients following oncology rehabilitation after cancer treatment.

Methods

The trial is a multicentre, two-arm randomised controlled study. Patients are randomised parallel in either 'usual care' plus case management or 'usual care' alone. Patients with all types of cancer can be included in the study, if they have completed the therapy with chemo- and/or radiotherapy/surgery with curative intention and are expected to have a survival time >1 year. To determine the health-related quality of life the general questionnaire FACT G is used. The direct correlation between self-management and perceived self-efficacy is measured with the Jerusalem & Schwarzer questionnaire. Patients satisfaction with the care received is measured using the Patient Assessment of Chronic Illness Care 5 As (PACIC-5A). Data are collected at the beginning of the trial and after 3, 6 and 12 months. The power analysis revealed a sample size of 102 patients. The recruitment of the centres began in 2009. The inclusion of patients began in May 2010.

Discussion

Case management has proved to be effective regarding quality of life of patients with chronic diseases. When it comes to oncology, case management is mainly used in cancer treatment, but it is not yet common in the rehabilitation of cancer patients. Case management in oncology rehabilitation is not well-established in Switzerland. A major challenge of the study will therefore probably be the recruitment of the patients due to the physicians' and patients' scarcely existing awareness of this issue.

Trial registration

ISRCTN41474586

Women's experience with severe overactive bladder symptoms and treatment: insight revealed from patient focus groups

AIMS

Research has focused on treatment of overactive bladder (OAB) symptoms in women with the goal of cure. The objective of this study was to assess women's perceptions of their OAB symptoms, treatment experience, and outcomes by conducting patient focus groups.

METHODS

Women seen in our academic center female urology referral clinics were identified by ICD-9 codes for OAB symptoms and recruited to participate in one of five focus groups, totaling 33 patients. Non-clinician moderators conducted the focus group sessions incorporating topics related to patients' perceptions of OAB symptoms, treatments, and outcomes. Data analysis was performed using grounded theory methodology.

RESULTS

Qualitative analysis yielded several preliminary themes: impact of OAB on quality of life, strategies to control wetness, medications and side effects, and triggers. The majority of focus group participants reported only a partial response to medication and other physician-recommended treatments for OAB. Therefore, they developed self-reliant personalized strategies to improve their quality of life. These strategies included fluid restriction, preventive toileting, and, most importantly, the use of incontinence pads.

CONCLUSIONS

The majority of the women who participated in the focus groups reported only a partial response to medical and other treatments for OAB. As a result, they developed personalized self-management strategies to improve their quality of life. Although most studies addressing the treatment of OAB aim at curing the condition, such a strategy may be unrealistic. Applying a chronic care model that uses a patient-centered symptom-management approach to OAB may optimize patient outcomes and improve quality of life.

Care of self - care by other - care of other: the meaning of self-care from research, practice, policy and industry perspectives

BACKGROUND

Currently, no single definition of self-care is broadly accepted in the literature. Definitions vary as to (i) who engages in self-care behaviour; (ii) what motivates self-care behaviours; and (iii) the extent to which healthcare professionals are involved. Perspectives of self-care differ between healthcare professionals and the general public, and between healthcare professionals in different disciplines and different roles. As different professions view self-care within their own domain of practice, we are left with a multitude of explanations and descriptions. This variety of conceptualisations does impact and complicate research on self-care. As part of a larger enquiry focused on the clarification of this complex concept, this study provides a content analysis of documented definitions of self-care, and a summary of the evolution of the definition of self-care over time.

OBJECTIVES

To examine the diversity of definitions of self-care from the perspectives of research, practice, policy and industry, and to identify themes or trends in the evolution of the definition of self-care over time.

SEARCH STRATEGY

The search strategy was designed in consultation with a library scientist to find both published and unpublished papers. A three-step search strategy was used to locate the literature. The databases searched included CINAHL, Medline, EMBASE, PsycINFO, AMED, Cochrane Library, Scirus and Mednar.

DATA COLLECTION AND ANALYSIS

The definition of self-care was extracted from each paper included in the study. Using an inductive process, a content analysis was performed identifying common terms and phrases from the definitions. The definitions were then divided into four decades, 1970s, 1980s, 1990s and 2000s, and the evolution of the definition of self-care was examined.

RESULTS AND CONCLUSIONS

In this study we sought to clarify the concept of self-care by examining in detail the definition of self-care. Content analysis of 139 definitions identified seven components of the definition and a range of terms that were applicable to each component. Evolution of the definition over time showed a more expansive definition by the end of the 2000s. Current and evolving definitions of self-care would benefit by being comprehensive and encompassing as many facets of the concept as possible.

IMPLICATIONS FOR PRACTICE

Healthcare professionals assess, guide, instruct and support individuals as they initiate or engage in self-care. Using a comprehensive definition of self-care would provide an anchor linking each discipline as they interact not only with the individual but also among themselves.

IMPLICATIONS FOR RESEARCH

The concept of self-care is a many-layered one. Identifying the components in the definition of the term delineates the different areas for potential research in this area. When planning a research project, the definition of the key concept guides the research and shapes the approach to the investigation. For researchers in this area, this study illustrates the wealth and diversity of the definitions of self-care.

Information and communication technologies for better patient self-management and self-efficacy

Achieving benefits from the introduction of ICTs as part of processes aimed at building sustainable self-efficacy and self-management is very difficult, not least because of a desire to avoid simply replacing patient dependency on health professionals with dependency on technology. Chronic illnesses require ongoing attention that differs from traditional, encounter-based care for acute illnesses. Patients with chronic illnesses such as asthma, cardiovascular disease, depression, diabetes, heart failure and migraine headaches play a central role in managing the broad array of factors that contribute to their health. Individuals with diabetes, for example, provide close to 95% of their own care. Self-efficacy is enhanced when patients succeed in solving patient-identified problems. Patients with chronic conditions make day-to-day decisions about - self-manage - their illnesses. The paper highlights that in deploying ICTs, it is important to ensure that solutions implemented are based on a detailed understanding of users, their needs and complex interactions with health professionals, the health system and their wider environment.

Managing epilepsy well: self-management needs assessment

Epilepsy self-management interventions have been investigated with respect to health care needs, medical adherence, depression, anxiety, employment, and sleep problems. Studies have been limited in terms of representative samples and inconsistent or restricted findings. The direct needs assessment of patients with epilepsy as a basis for program design has not been well used as an approach to improving program participation and outcomes. This study investigated the perceived medical and psychosocial problems of adults with epilepsy, as well as their preferences for self-management program design and delivery format. Results indicated a more psychosocially challenged subgroup of individuals with significant depressive and cognitive complaints. A self-management program that involves face-to-face individual or group meetings led by an epilepsy professional and trained peer leader for 60 minutes weekly was preferred. Six to eight sessions focused on diverse education sessions (e.g., managing disability and medical care, socializing on a budget, and leading a healthy lifestyle) and emotional coping strategies delivered on weeknights or Saturday afternoons were most highly endorsed. Emotional self-management and cognitive compensatory strategies require special emphasis given the challenges of a large subgroup.

Risk stratification for benign prostatic hyperplasia (BPH) treatment

• Benign prostatic hyperplasia (BPH) is a common cause of bothersome lower urinary tract symptoms. In the past, the aim of drug treatment was to relieve symptoms until surgery became necessary, predominantly using an α-blocker or a 5α-reductase inhibitor (5ARI) as monotherapy. • Together with improving knowledge about the pathogenesis of BPH, there is now strong evidence from large randomized trials that risk stratification and appropriate treatment with combined α-blocker/5ARI therapy can significantly reduce the risk of disease progression and avoid long-term complications such as acute urinary retention and surgery. • BPH will increasingly be managed in primary care in the future and, if new management strategies based on this evidence are to be implemented cost effectively, there is a need to introduce shared care between the primary and secondary care sectors to optimise use of resources and expertise.

Outcomes of follow-up visits to chronic nonmalignant pain patients

Follow-up visits by clinical nurse specialists are beneficial for patients with various chronic conditions. It is unknown whether patients with chronic nonmalignant pain can achieve similar benefit. The aim of this study was to assess outcomes of follow-up visits by clinical nurse specialists to chronic nonmalignant pain patients regarding health-related quality of life (HRQoL), pain, opioid treatment, quality of sleep, and depression. A total of 102 patients were enrolled in a prospective randomized controlled trial during a 2-year period after discharge from multidisciplinary pain treatment and randomized to intervention or control group. Intervention group patients (n = 52) received home visits every fourth month for 2 years. The findings showed that HRQoL improved generally more in the intervention group. Statistically significant improvements were observed for physical function and bodily pain. Whereas the intervention group maintained the pain level on a visual analog scale, the control group reported more pain. During the observation period, the control group increased dosage of opioids whereas the intervention group maintained stable dosage. No significant effect on quality of life was found. Nurses identified signs of depression in 80% of their patients scoring depression on the simultaneous depression questionnaire, and thereby could refer patients to early treatment. Follow-up visits by clinical nurse specialists appeared to offer positive benefits to patients with chronic nonmalignant pain after discharge from multidisciplinary pain treatment. The intervention improved physical functioning, reduced bodily pain and pain intensity and prevented opioid dosage increase. Most episodes of depression were identified and referred to relevant treatment.

Use of physical therapy services among middle-aged and older adults with multiple sclerosis

BACKGROUND

There is limited understanding of the utilization of and perceived need for physical therapy services among middle-aged and older adults with multiple sclerosis (MS). The resulting knowledge gap compromises efforts for physical therapy service planning for this population.

OBJECTIVE

The purpose of this study was to examine the use of and need for physical therapy services in a sample of adults with MS living in the Midwestern United States.

DESIGN

This was a cross-sectional, descriptive study.

METHODS

Data from telephone interviews with 1,065 people with MS, aged 45 to 90 years, were used for the study. A multinomial regression model was used to determine factors associated with use of physical therapy services (never, within the past year, more than a year ago). Logistic regression analysis examined factors associated with unmet needs for these services.

RESULTS

Thirty-six percent of the sample reported never using physical therapy services, 33% reported using physical therapy services within the past year, and 31% reported using physical therapy services more than a year prior to the interview. Factors associated with recent use of physical therapy services included living in an urban or suburban community, deteriorating MS status, experiencing problems with spasticity (ie, hypertonicity), having difficulty moving inside the house, being hospitalized in the past 6 months, and seeing a family physician. These same factors were associated with unmet needs. Limitations Physical therapy service use was self-reported. Data were collected in 5 Midwestern states from people 45 years of age or older, which may limit generalizability.

CONCLUSIONS

Factors associated with use of and need for physical therapy services reflect issues of access (geographical, referrals), MS status, and mobility difficulties.

Acute exacerbations of COPD: recommendations for integrated care

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are significant events that come with high costs for patients and for society. Initial management of exacerbations consists of pharmacotherapy and a reassessment of pre-existing management and self-management strategies. Currently, care for AECOPDs is often suboptimal. Integrated care consisting of self-management support, delivery system design, decision support and clinical information systems will probably improve the quality of healthcare delivery for patients with AECOPDs. In this review, we summarize current knowledge related to the epidemiology and management of AECOPDs, identify shortcomings in current clinical practice and give recommendations for innovative, integrated and optimized care for these patients.

Osteoporosis knowledge among individuals with recent fragility fracture

BACKGROUND

To evaluate osteoporosis knowledge among patients with fractures and to evaluate factors associated with osteoporosis knowledge.

METHODS

Patients with fragility fractures participated in a telephone interview. Participants were asked what they thought osteoporosis was. Unadjusted odds ratios (OR, 95% CI) were calculated to identify factors associated with a correct definition. Predictors identified in univariate analysis were entered into multivariable logistic regression models. A subset also completed the Facts on Osteoporosis Quiz.

RESULTS

One hundred twenty-seven patients (82% women) participated in the study, with mean (SD) age being 67.5 (12.7) years. Ninety-five (75%) respondents gave correct osteoporosis definitions. The odds of an individual providing a correct definition of osteoporosis were higher for those who reported a diagnosis of osteoporosis or those who reported higher education levels, but the odds decreased with increasing age. A total of 49 (39%) respondents completed the Facts on Osteoporosis Quiz; the average score was 13.6 (3.8) of 21. Areas that respondents scored poorly on were related to key risk factors.

CONCLUSION

Many patients with fractures are unaware of important risk factors. Education initiatives aimed at improving osteoporosis knowledge should be directed at individuals at high risk of fracture. Nurses and other allied healthcare providers working in fracture clinics, acute care, and rehabilitation settings are in an ideal position to communicate information about osteoporosis and fracture risk to individuals with a recent fragility fracture.

Efficacy of therapeutic patient education in chronic diseases and obesity

OBJECTIVE

To evaluate the clinical, methodological and reporting aspects of systematic reviews and meta-analyses in order to determine the efficacy of therapeutic patient education (TPE).

METHODS

A thorough search of the medical and nursing literature recorded in MedLine database from 1999 to August 2009 was conducted using the keywords: patient education, efficacy, diabetes, asthma, COPD, hypertension, cardiology, obesity, rheumatology, and oncology.

RESULTS

Thirty five relevant meta-analyses were identified and initially selected for critical analyses (598 studies concerning approximately 61,000 patients). The detailed description of the educative intervention was present in 4% of articles whereas in 23% the interventions were briefly described. In the majority of studies, the educative interventions were only named (49%) or totally absent (24%). The majority of studies reported improvement of patient outcomes due to the TPE (64%), 30% of studies reported no effect of TPE and 6% of the analysed reviews and meta-analyses reported worsening of measured outcomes.

CONCLUSION

Patient education could improve patient outcomes. The high benefit from TPE was shown by articles with detailed description of educational intervention as well as by those who report multidimensional and multidisciplinary educational intervention.

PRACTICE IMPLICATIONS

The impact of therapeutic patient education on health outcomes is 50-80%.

Patient self-management by telehealth using the Bosch model of care

A telehealth system that can transmit vital signs data, and also empowers patients to maintain their autonomy and learn how to manage their disease better, can improve patients' quality of life. Such a system can form part of a high-quality and efficient health-care service. The Bosch telehealth system, which focuses on self-management, has been used by thousands of patients with long-term conditions in the USA and Europe. The efficiency of the programmes, as well as their positive effects on quality of life and compliance, have been proven for a number of chronic conditions, as well as for patients with multiple co-morbidities.

Integrating wellness, recovery, and self-management for mental health consumers

Three distinct, yet interrelated, terms-wellness, recovery, and self-management-have received increasing attention in the research, consumer, and provider communities. This article traces the origins of these terms, seeking to understand how they apply, individually and in conjunction with one another to mental health consumers. Each shares a common perspective that is health-centered rather than disease-centered and that emphasizes the role of consumers as opposed to professional providers as the central determinants of health and well-being. Developing approaches combining elements of each construct may hold promise for improving the overall health and well-being of persons with serious mental disorders.

Barriers to effective self-management in cardiac patients: the patient's experience

OBJECTIVE

This paper identifies common obstacles impeding effective self-management among patients with heart disease and explores how for disadvantaged patients access barriers interfere with typical management challenges to undermine patients' efforts to care for their illnesses.

METHODS

We convened 33 focus group discussions with heart patients in 10 U.S. communities. Using content analysis, we identified and grouped the most common barriers that emerged in focus group discussions.

RESULTS

We identified nine major themes reflecting issues related to patients' ability to care for and manage their heart conditions. We grouped the themes into three domains of interest: (1) barriers that interfere with getting necessary services, (2) barriers that impede the monitoring and management of a heart condition on a daily basis, and (3) supports that enable self-management and improve care.

CONCLUSION

For disadvantaged populations, typical problems associated with self-management of a heart condition are aggravated by substantial obstacles to accessing care.

PRACTICE IMPLICATIONS

Ensuring disadvantaged patients with chronic heart conditions are linked to formal systems of care, such as cardiac rehabilitation programs, could better develop patients' self-management skills, reduce barriers to receiving care and improve the overall health outcomes of these patients.