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Karthikeyan A, Lee CN, Myneni J, Harthan S, Bragg K, Bentley S, Dubois V, Bhan A. Three-year outcomes of an optometrist-led virtual clinic for new glaucoma referrals. Ophthalmic Physiol Opt 2023. [PMID: 36930523 DOI: 10.1111/opo.13124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/19/2023] [Accepted: 02/28/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION The purpose of this study was to describe and evaluate the outcomes of an optometrist-led virtual glaucoma clinic (VGC). METHODS New patients referred to the glaucoma service who were consultant triaged as 'low risk' were assessed virtually by specialist-trained optometrists in the VGC and either discharged or monitored for a period of 3 years. Ten percent of virtual case notes were audited by a glaucoma consultant to verify quality and generate learning objectives. Retrospective case-note review and analysis of all patients seen in the virtual clinic between 2014 and 2016 was undertaken to determine 3-year outcomes. RESULTS A total of 1710 new patients were seen in the clinic between 1 January 2014 and 31 December 2016. Of these, 1033 (60.4%) patients required no outpatient input in 3 years of follow-up. Additionally, 320 (18.7%) were discharged at the first visit, and the proportion of glaucoma suspect and ocular hypertension patients who converted to glaucoma was 12.1% and 5.8%, respectively. At 3 years, 95 patients had died, 159 were lost to follow-up, 576 were discharged and 371 were diagnosed with glaucoma at baseline or during the 3-year follow-up. The cumulative discharge proportion from the service at the end of 3 years was 82.6%. No patients required emergency eye treatment or sight-impairment registration, and of the 12 referred back to the clinic on discharge, only five required ongoing monitoring. CONCLUSION This optometrist-led VGC combined two aspects of novel service delivery to reduce the burden of glaucoma monitoring in outpatient departments and consolidate consultant contact to patients requiring more intervention. This model will be of value in units establishing virtual services and looking to expand the role of allied health professionals.
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Affiliation(s)
| | - Chan Ning Lee
- Ophthalmology Department, Liverpool University Foundation Trust, Liverpool, UK
| | - Jaya Myneni
- Ophthalmology Department, Liverpool University Foundation Trust, Liverpool, UK
| | - Stephen Harthan
- Ophthalmology Department, Liverpool University Foundation Trust, Liverpool, UK
| | - Kris Bragg
- Ophthalmology Department, Liverpool University Foundation Trust, Liverpool, UK
| | - Sarah Bentley
- Ophthalmology Department, Liverpool University Foundation Trust, Liverpool, UK
| | - Vincent Dubois
- Ophthalmology Department, Liverpool University Foundation Trust, Liverpool, UK
| | - Anna Bhan
- Ophthalmology Department, Liverpool University Foundation Trust, Liverpool, UK
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2
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Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the Time Needed to Provide Adult Primary Care. J Gen Intern Med 2023; 38:147-155. [PMID: 35776372 PMCID: PMC9848034 DOI: 10.1007/s11606-022-07707-x] [Citation(s) in RCA: 97] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 06/16/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care. OBJECTIVE To quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model. DESIGN Simulation study applying preventive and chronic disease care guidelines to hypothetical patient panels. PARTICIPANTS Hypothetical panels of 2500 patients, representative of the adult US population based on the 2017-2018 National Health and Nutrition Examination Survey. MAIN MEASURES The mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care. KEY RESULTS PCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management). CONCLUSIONS PCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.
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Affiliation(s)
- Justin Porter
- Department of Medicine, University of Chicago, Chicago, IL, USA.
| | - Cynthia Boyd
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - M Reza Skandari
- Imperial College Business School, Centre for Health Economics & Policy Innovation, Imperial College London, London, UK
| | - Neda Laiteerapong
- Departments of Medicine & Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
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Matsuyama T, Machida K, Hamu A, Takagi K, Momi H, Higashimoto I, Inoue H. Effects of instructional materials on the proper techniques of inhaler device use. Respir Investig 2022; 60:633-639. [PMID: 35659856 DOI: 10.1016/j.resinv.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/08/2022] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inhaled medication is the cornerstone of pharmacological treatment for asthma. Poor inhaler techniques are associated with poor asthma control and an increased risk of exacerbations. Leaflets and videos are provided by several pharmaceutical companies to explain the proper techniques to patients. We investigated the effects of instructional materials (leaflet and video) on the patient's inhaler techniques. METHODS The subjects were 67 medical students at Kagoshima University. They all were provided with two types of inhalation devices: a dry powder inhaler (DPI) and a pressurized metered-dose inhaler (pMDI). The students were assigned to three groups: (1) leaflet, (2) video, and (3) combination (leaflet + video). Pulmonologists observed and assessed the students' use of the devices by using a validated checklist. The percentage of subjects who avoided critical errors was also assessed. Critical errors were errors that affected drug delivery to the lungs substantially. RESULTS The percentage of overall competence and the number of steps that were mastered out of the 11 steps were higher in the combination group than those in the other two groups. However, only 40% in the combination group were able to successfully execute every critical step. The percentage of subjects who avoided critical errors was also higher in the combination group than in the other groups. CONCLUSIONS A single form of instructional materials (leaflet or video) was insufficient for acquiring proper inhaler techniques. The combination of two learning materials may help patients with asthma acquire proper inhaler techniques and subsequently, improve their asthma control.
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Affiliation(s)
- Takahiro Matsuyama
- Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima 890-8520, Japan
| | - Kentaro Machida
- Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima 890-8520, Japan
| | - Asako Hamu
- Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima 890-8520, Japan
| | - Koichi Takagi
- Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima 890-8520, Japan
| | - Hiroaki Momi
- Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima 890-8520, Japan
| | - Ikkou Higashimoto
- Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima 890-8520, Japan
| | - Hiromasa Inoue
- Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima 890-8520, Japan.
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Dilles T, Heczkova J, Tziaferi S, Helgesen AK, Grøndahl VA, Van Rompaey B, Sino CG, Jordan S. Nurses and Pharmaceutical Care: Interprofessional, Evidence-Based Working to Improve Patient Care and Outcomes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:5973. [PMID: 34199519 PMCID: PMC8199654 DOI: 10.3390/ijerph18115973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/28/2021] [Accepted: 05/29/2021] [Indexed: 12/13/2022]
Abstract
Pharmaceutical care necessitates significant efforts from patients, informal caregivers, the interprofessional team of health care professionals and health care system administrators. Collaboration, mutual respect and agreement amongst all stakeholders regarding responsibilities throughout the complex process of pharmaceutical care is needed before patients can take full advantage of modern medicine. Based on the literature and policy documents, in this position paper, we reflect on opportunities for integrated evidence-based pharmaceutical care to improve care quality and patient outcomes from a nursing perspective. Despite the consensus that interprofessional collaboration is essential, in clinical practice, research, education and policy-making challenges are often not addressed interprofessionally. This paper concludes with specific advises to move towards the implementation of more interprofessional, evidence-based pharmaceutical care.
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Affiliation(s)
- Tinne Dilles
- Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Department of Nursing and Midwifery Science, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium;
| | - Jana Heczkova
- First Faculty of Medicine, Institute of Nursing Theory and Practice, Charles University, 11000 Prague, Czech Republic;
| | - Styliani Tziaferi
- Laboratory of Integrated Health Care, Department of Nursing, University of Peloponnese, 22100 Tripolis, Greece;
| | - Ann Karin Helgesen
- Faculty of Health and Welfare, Østfold University College, 1757 Halden, Norway; (A.K.H.); (V.A.G.)
| | | | - Bart Van Rompaey
- Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Department of Nursing and Midwifery Science, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium;
| | - Carolien G. Sino
- Research Group Care for the Chronically Ill, University of Applied Sciences Utrecht, 3584 CH Utrecht, The Netherlands;
| | - Sue Jordan
- Department of Nursing, Swansea University, Swansea SA2 8PP, Wales, UK;
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Substitution of nurses for physicians in the hospital setting for patient, process of care, and economic outcomes. Cochrane Database Syst Rev 2020; 2020:CD013616. [PMCID: PMC7390487 DOI: 10.1002/14651858.cd013616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: The main objective of the review is to examine the impact of substituting nurses for doctors in the hospital setting (hospital inpatient units and outpatient clinics) on patient outcomes, process of care outcomes, and economic outcomes. The secondary objectives of this review are to assess whether the effects of nurse‐doctor substitution differ according to healthcare setting (low‐ and middle‐income countries versus high‐income countries), patient disease, patient type (inpatients versus outpatients), and mode of nursing practice (unsupervised versus delegated/under medical supervision).
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General medical services by non-medical health professionals: a systematic quantitative review of economic evaluations in primary care. Br J Gen Pract 2020; 69:e304-e313. [PMID: 31015223 DOI: 10.3399/bjgp19x702425] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/12/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Previous systematic reviews have found that nurses and pharmacists can provide equivalent, or higher, quality of care for some tasks performed by GPs in primary care. There is a lack of economic evidence for this substitution. AIM To explore the costs and outcomes of role substitution between GPs and nurses, pharmacists, and allied health professionals in primary care. DESIGN AND SETTING A systematic review of economic evaluations exploring role substitution of allied health professionals in primary care was conducted. Role substitution was defined as 'the substitution of work that was previously completed by a GP in the past and is now completed by a nurse or allied health professional'. METHOD The following databases were searched: Ovid MEDLINE, CINAHL, Cochrane Library, National Institute for Health and Care Excellence (NICE), and the Centre for Reviews and Dissemination. The review followed guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS Six economic evaluations were identified. There was some limited evidence that nurse-led care for common minor health problems was cost-effective compared with GP care, and that nurse-led interventions for chronic fatigue syndrome and pharmacy-led services for the medicines management of coronary heart disease and chronic pain were not. In South Korea, community health practitioners delivered primary care services for half the cost of physicians. The review did not identify studies for other allied health professionals such as physiotherapists and occupational therapists. CONCLUSION There is limited economic evidence for role substitution in primary care; more economic evaluations are needed.
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Bousema S, Verwoerd AJ, Goossens LM, Bohnen AM, Bindels PJE, Elshout G. Protocolled practice nurse-led care for children with asthma in primary care: protocol for a cluster randomised trial. BMJ Open 2019; 9:e022922. [PMID: 31562140 PMCID: PMC6773314 DOI: 10.1136/bmjopen-2018-022922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/23/2019] [Accepted: 09/06/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In children with asthma, daily symptoms and exacerbations have a significant impact on the quality of life of both children and parents. More effective use of asthma medication and, consequently, better asthma control is advocated, since both overtreatment and undertreatment are reported in primary care. Trials in adults suggest that asthma control is better when patients receive a regular medical review. Therefore, protocolled care by the general practitioner may also lead to better asthma control in children. However, such protocolled care by the general practitioner may be time consuming and less feasible. Therefore, this study aims to determine whether protocolled practice nurse-led asthma care for children in primary care provides more effective asthma control than usual care. METHODS AND ANALYSIS The study will be a cluster-randomised open-label trial with an 18-month follow-up. Practice nurses will be the units of randomisation and children with asthma the units of analysis. It is planned to include 180 children aged 6-12 years. Primary outcome will be average asthma control during the 18-month follow-up measured by the Childhood Asthma Control Test (C-ACT). Secondary outcomes include C-ACT scores at t=3, t=6, t=12 and t=18 months; the frequency and severity of exacerbations; cost-effectiveness; quality of life; satisfaction with delivered care; forced expiratory volume in 1 s and forced expiratory flow at 75% and the association of high symptoms scores at baseline and baseline characteristics. Besides, we will conduct identical measurements in a non-randomised sample of children. ETHICS AND DISSEMINATION This will be the first trial to evaluate the effectiveness of protocolled practice nurse-led care for children with asthma in primary care. The results may lead to improvements in asthma care for children and can be directly implemented in revisions of asthma guidelines.The study protocol was approved by the Medical Research Ethics Committee of the Erasmus Medical Centre in Rotterdam. TRIAL REGISTRATION NTR6847.
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Affiliation(s)
- Sara Bousema
- General Practice, Erasmus MC, Rotterdam, The Netherlands
| | | | - Lucas M Goossens
- Health Technology, Erasmus School of Health Policy and Management, Rotterdam, The Netherlands
| | | | | | - Gijs Elshout
- General Practice, Erasmus MC, Rotterdam, The Netherlands
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Schuers M, Chapron A, Guihard H, Bouchez T, Darmon D. Impact of non-drug therapies on asthma control: A systematic review of the literature. Eur J Gen Pract 2019; 25:65-76. [PMID: 30849253 PMCID: PMC6493294 DOI: 10.1080/13814788.2019.1574742] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 11/29/2018] [Accepted: 01/21/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Despite growing access to effective therapies, asthma control still needs improvement. Many non-drug factors, such as allergens, air pollutants and stress also affect asthma control and patient quality of life, but an overview of the effectiveness of non-drug interventions on asthma control was lacking. OBJECTIVES To identify non-drug interventions likely to improve asthma control. METHODS A systematic review of the available literature in Medline and the Cochrane Library was conducted in March 2017, without any time limit. Initial searching identified 884 potentially relevant clinical trial reports, literature reviews and meta-analyses, which were screened for inclusion using criteria of quality, relevance, and reporting outcomes based on asthma control. RESULTS Eighty-two publications met the inclusion criteria. In general, the quality of the studies was low. Patient education programmes (22 studies) significantly improved asthma control. Multifaceted interventions (10 studies), which combined patient education programmes with decreasing exposure to indoor allergens and pollutants, significantly improved asthma control based on clinically relevant outcomes. Renovating homes to reduce exposure to allergens and indoor pollutants improved control (two studies). Air filtration systems (five studies) were effective, especially in children exposed to second-hand smoke. Most measures attempting to reduce exposure to dust mites were ineffective (five studies). Dietary interventions (eight studies) were ineffective. Promoting physical activity (five studies) tended to yield positive results, but the results did not attain significance. CONCLUSION Twenty-six interventions were effective in asthma control. Simultaneously combining several action plans, each focusing on different aspects of asthma management, seems most likely to be effective.
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Affiliation(s)
| | - Anthony Chapron
- Department of General Medicine, Rennes University, Rennes, France
| | - Hugo Guihard
- Department of General Medicine, Rouen University, Rouen, France
| | | | - David Darmon
- Department of General Medicine, Nice University, Nice, France
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Seret J, Gooset F, Durieux V, Lecocq D, Pirson M. What Means A Quality Professional-Patient Relationship From The Asthmatic Patients' Perspective? A Narrative Review Of Their Needs And Expectations. Patient Prefer Adherence 2019; 13:1951-1960. [PMID: 31814711 PMCID: PMC6851714 DOI: 10.2147/ppa.s213545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/25/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Poor treatment adherence among asthmatic patients currently remains a public health challenge. One of the most quoted determinants is the quality of the professional-patient relationship although it has clearly not been fully described. PURPOSE This study aims at deeply exploring asthmatic patients' needs and expectations about the accompaniment proposed by their healthcare professionals. METHODS A rigorous narrative review was performed. RESULTS According to patients, what they expect from professionals can be split into eight themes: getting exhaustive information, relying on an available healthcare professional, being more involved into life with one's asthma, being accompanied by a multidisciplinary team, being respected in one's uniqueness, being cared through a humanist approach, feeling the professional is skilled and Other needs. DISCUSSION AND CONCLUSION Asthmatic patients' needs have little evolved in 20 years illustrating that if they are met, that would positively affect the way patients want to be followed by healthcare professionals and so, that would increase their treatment adherence. Several recommendations such as setting up a doctor - asthma nurse practitioner binomial or studying a concrete care pathway may help in fulfilling these needs. Finally, this research opens the way to other studies since similar results have been found in populations suffering from other chronic diseases than asthma.
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Affiliation(s)
- Jehan Seret
- Health Economics, Hospital Management and Nursing Research Department, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
- Correspondence: Jehan Seret Centre de recherche en économie de la santé, gestion des institutions de soins et sciences infirmières, École de Santé Publique, ULB, Route de Lennik, 808, 1070, BruxellesCP 592, Belgium Email
| | - Fabienne Gooset
- Health Economics, Hospital Management and Nursing Research Department, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Valérie Durieux
- Health Sciences Library Department, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Dan Lecocq
- Health Economics, Hospital Management and Nursing Research Department, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Magali Pirson
- Health Economics, Hospital Management and Nursing Research Department, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
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Villa-Roel C, Ospina M, Majumdar SR, Couperthwaite S, Rawe E, Nikel T, Rowe BH. Engaging patients and primary care providers in the design of novel opinion leader based interventions for acute asthma in the emergency department: a mixed methods study. BMC Health Serv Res 2018; 18:789. [PMID: 30340482 PMCID: PMC6194690 DOI: 10.1186/s12913-018-3587-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 10/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multifaceted interventions driven by the needs of patients and providers can help move evidence into practice more rapidly. This study engaged both patients and primary care providers (PCPs) to help design novel opinion leader (OL)-based interventions for patients with acute asthma seen in emergency departments (EDs). METHODS A mixed methods design was employed. In phase I, we invited convenience samples of patients with asthma presenting to the ED and PCPs to participate in a survey. Perceptions with respect to: a) an ideal OL-profile for asthma guidance; and b) content, style and delivery methods of OL-based interventions in acute asthma directed from the ED were collected. In phase II, we conducted focus groups to further explore preferences and expectations for such interventions with attention to barriers and facilitators for implementation. RESULTS Overall, 54 patients completed the survey; 39% preferred receiving guidance from a respirologist, 44% during their ED visit and 56% through individual discussions. In addition, 55% expressed interest in having PCP follow-up within a week of ED discharge. A respirologist was identified as the ideal OL-profile by 59% of the 39 responding PCPs. All expressed interest in receiving notification of their patients' ED presentation, most within a week and including diagnosis and ED/post ED-treatment. Personalized, guideline-based, recommendations were considered to be the ideal content by the majority; 39% requested this guidance through a pamphlet faxed to their offices. In the focus groups, patients and PCPs recognized the importance of health professional liaisons in transitions in care; patient anxiety and PCP time constraints were identified as potential barriers for ED-educational information uptake and proper post-ED follow-up, respectively. CONCLUSIONS Engaging patients and PCPs yielded actionable information to tailor OL-based multifaceted interventions for acute asthma in the ED. We identified potential facilitators for the implementation of such interventions (e.g., patient interaction with alternative health care professionals who could facilitate transitions in asthma care between the ED and the primary care setting), and for the provision of post discharge self-management education (e.g., consideration of the first week of ED discharge as a practical time frame for this intervention). Prioritization of identified barriers (e.g., lack of PCP involvement) could be addressed by the identification of potential early adopters in practice environments (e.g., clinicians with special interest in asthma).
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Affiliation(s)
- Cristina Villa-Roel
- Department of Emergency Medicine, University of Alberta, 7-30 University Terrace, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada.
| | - Maria Ospina
- Department of Obstetrics & Gynecology, University of Alberta, 7-30 University Terrace, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada.,School of Public Health, University of Alberta, 7-30 University Terrace, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Sumit R Majumdar
- Departments of Medicine, University of Alberta, 7-30 University Terrace, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Stephanie Couperthwaite
- Department of Emergency Medicine, University of Alberta, 7-30 University Terrace, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Erin Rawe
- Department of Emergency Medicine, University of Alberta, 7-30 University Terrace, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Taylor Nikel
- Department of Emergency Medicine, University of Alberta, 7-30 University Terrace, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, 7-30 University Terrace, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada.,School of Public Health, University of Alberta, 7-30 University Terrace, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada
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A systematic review of the effectiveness of clinical nurse specialist interventions in
patients with chronic obstructive pulmonary disease (COPD). FRONTIERS OF NURSING 2018. [DOI: 10.2478/fon-2018-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective
This review aimed to examine the effectiveness of clinical nurse specialist (CNS) interventions in patients with chronic obstructive pulmonary disease (COPD). COPD significantly affects people’s health worldwide. With the development in nursing, CNSs are playing increasingly important roles in different departments. However, the studies on the effectiveness of CNSs in COPD are not as well organized as the studies on the effectiveness of CNSs in bronchiectasis and asthma. Therefore, this review aims to find some updated evidence on the CNS interventions for patients with COPD and on whether these interventions are effective.
Methods
A narrative analysis of the data was performed for the eligible studies. Four databases were chosen: CINAHL, MEDLINE, British Nursing Index, and Cochrane Library. Other websites such as the National Institute for Health and Clinical Excellence, National Health Service Evidence, Association of Respiratory Nurse Specialists, and National Association of Clinical Nurse Specialist were searched as well. Two reviewers performed study identification independently, and all the retrieved articles were stored using the EndNote X7 software. The risk of bias in the included studies was assessed using the Cochrane Collaboration’s risk of bias tool.
Results
A total of nine studies were included in this review. There were five current interventions by CNSs for patients with COPD. These interventions were home nursing support, CNS’s supported discharge, multidisciplinary cooperation programs, nurse-led care programs, and self-care management education. The effectiveness of these five interventions was evaluated individually. There is low- to moderate-quality evidence indicating that home nursing support interventions may have a positive effect on mortality and quality of life. No significant difference in quality of life has been found between the CNS-supported discharge intervention and the usual service. The multidisciplinary cooperation program probably had a positive effect on quality of life in patients with COPD. Both nurse-led care and self-care management education intervention had a positive effect on mortality of patients with COPD.
Conclusions
The findings of this review provide updated evidence on the effectiveness of CNS interventions for patients with COPD. Although nine trials were included and five types of interventions were identified, there is still lack of high-quality evidence.
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Slack CL, Hayward K, Markham AW. The Calgary COPD & Asthma Program: The role of the respiratory therapy profession in primary care. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2018; 54:18. [PMID: 31164787 PMCID: PMC6516137 DOI: 10.29390/cjrt-2018-018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Respiratory therapy is a profession with the depth and breadth required to care for clients by "evaluating, treating, and maintaining cardiopulmonary (heart and lung) function" [1]. Registered Respiratory Therapists (RRTs) work in a variety of settings from critical and acute care to primary and home care. After a brief overview of the models and competencies that underpin the work of the Calgary COPD & Asthma Program, the article provides a description of the program and discuss how RRT Certified Respiratory Educators provide services within the program. These services include health promotion through self-management education rooted in the Chronic Care Model [2] and supported by the National Alliance of Respiratory Therapy Regulatory Bodies' National Competency Framework for the Profession of Respiratory Therapy [3]. The authors hope the success of this program will encourage others to embrace the role of the RRT in a primary health care setting.
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Affiliation(s)
- Cindy L Slack
- Calgary COPD & Asthma Program, Alberta Health Services, Calgary, AB, Canada
| | - Kathy Hayward
- Calgary COPD & Asthma Program, Alberta Health Services, Calgary, AB, Canada
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Ciapponi A, Lewin S, Herrera CA, Opiyo N, Pantoja T, Paulsen E, Rada G, Wiysonge CS, Bastías G, Dudley L, Flottorp S, Gagnon M, Garcia Marti S, Glenton C, Okwundu CI, Peñaloza B, Suleman F, Oxman AD. Delivery arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD011083. [PMID: 28901005 PMCID: PMC5621087 DOI: 10.1002/14651858.cd011083.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services. OBJECTIVES To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review. METHODS We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries. MAIN RESULTS We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions. AUTHORS' CONCLUSIONS A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.
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Affiliation(s)
- Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Simon Lewin
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Cristian A Herrera
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Tomas Pantoja
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | | | - Gabriel Rada
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Internal Medicine and Evidence‐Based Healthcare Program, Faculty of MedicineLira 44, Decanato Primer pisoSantiagoChile
| | - Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Gabriel Bastías
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
| | - Lilian Dudley
- Stellenbosch UniversityDivision of Community Health, Faculty of Medicine and Health SciencesFransie Van Zyl DriveTygerbergCape TownSouth Africa7505
| | - Signe Flottorp
- Norwegian Institute of Public HealthDepartment for Evidence SynthesisPO Box 4404 NydalenOsloNorway0403
| | - Marie‐Pierre Gagnon
- CHU de Québec ‐ Université Laval Research CentrePopulation Health and Optimal Health Practices Research Unit10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Sebastian Garcia Marti
- Institute for Clinical Effectiveness and Health PolicyBuenos AiresCapital FederalArgentinaC1056ABH
| | - Claire Glenton
- Norwegian Institute of Public HealthGlobal Health UnitPO Box 7004 St Olavs plassOsloNorwayN‐0130
| | - Charles I Okwundu
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Blanca Peñaloza
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Fatima Suleman
- University of KwaZulu‐NatalDiscipline of Pharmaceutical Sciences, School of Health SciencesPrivate Bag X54001DurbanKZNSouth Africa4000
| | - Andrew D Oxman
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
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de Thurah A, Esbensen BA, Roelsgaard IK, Frandsen TF, Primdahl J. Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis. RMD Open 2017; 3:e000481. [PMID: 28879053 PMCID: PMC5574437 DOI: 10.1136/rmdopen-2017-000481] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/28/2017] [Accepted: 07/04/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To compare the efficacy of embedded nurse-led versus conventional physician-led follow-up on disease activity in patients with rheumatoid arthritis (RA). METHODS In a systematic literature search, we identified randomised controlled trials (RCTs) reporting on the efficacy of nurse-led follow-up on disease control in patients with RA compared with physician-led follow-up. Primary outcome was disease activity indicated by Disease Activity Score (DAS)-28. Secondary outcomes were: patient satisfaction, physical disability, fatigue, self-efficacy and quality of life. Outcomes were assessed after 1-year and 2 year follow-ups. RESULTS Seven studies representing five RCTs, including a total of 723 participants, were included. All but one study included stable patients in low disease activity or remission at baseline. No difference in DAS-28 was found after 1 year (mean difference (MD) -0.07 (95% CI -0.23 to 0.09)). After 2 years, a statistically significant difference was seen in favour of nurse-led follow-up (MD -0.28 (95% CI -0.53 to -0.04)). However, the difference did not reach a clinically relevant level. No difference was found in patient satisfaction after 1 year (standard mean difference (SMD) -0.17 (95 % CI -1.0 to 0.67), whereas a statistical significant difference in favour of nurse-led follow-up was seen after 2 years (SMD: 0.6 (95% CI -0.00 to 1.20)). CONCLUSION After 1 year no difference in disease activity, indicated by DAS-28, were found between embedded nurse-led follow-up compared with conventional physician-led follow-up, in RA patients with low disease activity or remission.
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Affiliation(s)
- Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bente Appel Esbensen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ida Kristiane Roelsgaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
| | - Tove Faber Frandsen
- Department of Design and Communication, University of Southern Denmark, Kolding, Denmark
| | - Jette Primdahl
- King Christian X's Hospital for Rheumatic Diseases, Graasten, Denmark.,Hospital of Southern Jutland, Aabenraa, Denmark.,Institute for Regional Health Research, University of Southern Denmark, Odense, Denmark
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Chauhan BF, Jeyaraman MM, Mann AS, Lys J, Skidmore B, Sibley KM, Abou-Setta AM, Zarychanski R. Behavior change interventions and policies influencing primary healthcare professionals' practice-an overview of reviews. Implement Sci 2017; 12:3. [PMID: 28057024 PMCID: PMC5216570 DOI: 10.1186/s13012-016-0538-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/13/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers. METHODS Study design: overview of reviews. DATA SOURCE MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015). STUDY SELECTION two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language. DATA EXTRACTION AND SYNTHESIS two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors' conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.). RESULTS Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change. CONCLUSIONS Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.
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Affiliation(s)
- Bhupendrasinh F Chauhan
- College of Pharmacy, University of Manitoba, Winnipeg, Canada.
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada.
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada.
| | - Maya M Jeyaraman
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | | | - Justin Lys
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | | | - Kathryn M Sibley
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ahmed M Abou-Setta
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ryan Zarychanski
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Haematology and Medical Oncology, CancerCare Manitoba, Winnipeg, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Inherent Tensions Between Population Aging and Health Care Systems: What Might the Canadian Health Care System Look Like in Twenty Years? JOURNAL OF POPULATION AGEING 2015. [DOI: 10.1007/s12062-015-9123-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rust G, Zhang S, Holloway K, Tyler-Hill Y. Timing of emergency department visits for childhood asthma after initial inhaled corticosteroid use. Popul Health Manag 2014; 18:54-60. [PMID: 25046059 DOI: 10.1089/pop.2013.0126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Inhaled corticosteroids can prevent acute exacerbations and emergency visits when used as part of a chronic care plan for long-term control of asthma, but low patient adherence and inadequate provider prescribing (clinical inertia) can limit these benefits. State Medicaid programs are a major source of insurance coverage for low-income children, paying for medications and preventive care, as well as bearing the cost of adverse outcomes for common chronic conditions in childhood, such as asthma. This study measured the incidence and timing of emergency department (ED) visits in the first 90 days after an initial inhaled corticosteroid prescription (ICS-Rx) among 43,156 Medicaid-enrolled children with a diagnosis of asthma in 14 southern states in 2007. One in 5 children (19.6%) with asthma had at least 1 ED visit in the first 90 days after initial ICS-Rx; 10% of these visits occurred within the first 48 hours, and 25% occurred within the first week. Continued ICS-Rx use was associated with lower risk of an ED visit. There were no racial differences in the ED visit rates. Initial ICS-Rx for Medicaid-enrolled children is a warning flag for short-term risk of asthma-related ED visits, whereas continued ICS-Rx use is protective for at least 90 days. Primary care follow-up may be needed within the first 2 days after initial ICS-Rx to prevent adverse outcomes. Medicaid programs could use claims data for surveillance of adherence to guideline-concordant therapy and for sentinel events marking windows of a higher risk for ED visits. Population Health Management 2015;18:54-60.
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Affiliation(s)
- George Rust
- 1 National Center for Primary Care, Morehouse School of Medicine , Atlanta, Georgia
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Appleby C, Camacho-Bejarano R. [Challenges and opportunities: contributions of the Advanced Practice Nurse in the chronicity. Learning from experiences]. ENFERMERIA CLINICA 2014; 24:90-8. [PMID: 24468497 DOI: 10.1016/j.enfcli.2013.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 11/26/2022]
Abstract
Undoubtedly, our society is facing new economic, political, demographic, social and cultural challenges that require healthcare services able to meet the growing health needs of the population, especially in dealing with chronic conditions. In this new context, some countries such as the United Kingdom have made a firm commitment to develop new models for chronic patients care based on the introduction of new figures of Advanced Practice Nurses, which includes 4 cornerstones of professional practice: advanced clinical skills, clinical management, teaching and research. The implementation of this new figures implies a redefinition of professional competencies and has its own accreditation system and a specific catalogue of services adapted to the population requirements, in order to provide chronic care support from Primary Care settings. This trajectory allows us analysing the process of design and implementation of these new models and the organizational structure where it is integrated. In Spain, there are already experiences in some regions such as Andalucia and the Basque Country, focused on the creation of new advanced nursing roles. At present, it is necessary to consider suitable strategic proposals for the complete development of these models and to achieve the best results in terms of overall health and quality of life of patients with chronic conditions, improving the quality of services and cost-effectiveness through a greater cohesion and performance of healthcare teams towards the sustainability of healthcare services and patient satisfaction.
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Affiliation(s)
- Christine Appleby
- Parkway Medical Centre, Atención Primaria, Middlesbrough Primary Care Trust, National Health Service, Reino Unido
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Nicholson A, Coldwell CH, Lewis SR, Smith AF. Nurse-led versus doctor-led preoperative assessment for elective surgical patients requiring regional or general anaesthesia. Cochrane Database Syst Rev 2013; 2014:CD010160. [PMID: 24218062 PMCID: PMC10981790 DOI: 10.1002/14651858.cd010160.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The organization of elective surgical services has changed in recent years, with increasing use of day surgery, reduced hospital stay and preoperative assessment (POA) performed in an outpatient clinic rather than by a doctor in a hospital ward after admission. Nurse specialists often lead these clinic-based POA services and have responsibility for assessing a patient's fitness for anaesthesia and surgery and organizing any necessary investigations or referrals. These changes offer many potential benefits for patients, but it is important to demonstrate that standards of patient care are maintained as nurses take on these responsibilities. OBJECTIVES We wished to examine whether a nurse-led service rather than a doctor-led service affects the quality and outcome of preoperative assessment (POA) for elective surgical participants of all ages requiring regional or general anaesthesia. We considered the evidence that POA led by nurses is equivalent to that led by doctors for the following outcomes: cancellation of the operation for clinical reasons; cancellation of the operation by the participant; participant satisfaction with the POA; gain in participant knowledge or information; perioperative complications within 28 days of surgery, including mortality; and costs of POA. We planned to investigate whether there are differences in quality and outcome depending on the age of the participant, the training of staff or the type of surgery or anaesthesia provided. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and two trial registers on 13 February 2013, and performed reference checking and citation searching to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) of participants (adults or children) scheduled for elective surgery requiring general, spinal or epidural anaesthesia that compared POA, including assessment of physical status and anaesthetic risk, undertaken or led by nursing staff with that undertaken or led by doctors. This assessment could have taken place in any setting, such as on a ward or in a clinic. We included studies in which the comparison assessment had taken place in a different setting. Because of the variation in service provision, we included two separate comparison groups: specialist doctors, such as anaesthetists; and non-specialist doctors, such as interns. DATA COLLECTION AND ANALYSIS We used standard methodological approaches as expected by The Cochrane Collaboration, including independent review of titles, data extraction and risk of bias assessment by two review authors. MAIN RESULTS We identified two eligible studies, both comparing nurse-led POA with POA led by non-specialist doctors, with a total of 2469 participants. One study was randomized and the other quasi-randomized. Blinding of staff and participants to allocation was not possible. In both studies, all participants were additionally assessed by a specialist doctor (anaesthetist in training), who acted as the reference standard. In neither study did participants proceed from assessment by nurse or junior doctor to surgery. Neither study reported on cancellations of surgery, gain in participant information or knowledge or perioperative complications. Reported outcomes focused on the accuracy of the assessment. One study undertook qualitative assessment of participant satisfaction with the two forms of POA in a small number of non-randomly selected participants (42 participant interviews), and both groups of participants expressed high levels of satisfaction with the care received. This study also examined economic modelling of costs of the POA as performed by the nurse and by the non-specialist doctor based on the completeness of the assessment as noted in the study and found no difference in cost. AUTHORS' CONCLUSIONS Currently, no evidence is available from RCTs to allow assessment of whether nurse-led POA leads to an increase or a decrease in cancellations or perioperative complications or in knowledge or satisfaction among surgical participants. One study, which was set in the UK, reported equivalent costs from economic models. Nurse-led POA is now widespread, and it is not clear whether future RCTs of this POA strategy are feasible. A diagnostic test accuracy review may provide useful information.
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Affiliation(s)
- Amanda Nicholson
- Faculty of Health and Medicine, Furness Building, Lancaster University, Lancaster, UK, LA1 4YG
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