Management of chronic hypertension in older men: an exploration of patient goal-setting

Why did this happen to me? Causal attributions of illness and cultural health capital

This study examines how conversations between patients and clinicians about the causes of their health conditions relate to patient engagement in care. Leveraging cultural health capital (CHC) theory, we find that patient-physician discussions of health attributions are one mechanism to build patient understanding and activate engagement. We present a qualitative interpretive analysis of data collected in three phases with adult home health care patients: phone interviews (n = 28), field observations (n = 61), and semi-structured field interviews (n = 38). We find that engaging in discussions of causal health attributions with clinicians enables patients to overcome uncertainty, envision preventive actions, and engage in setting future goals. Such discussions must be supported by acknowledgement of the co-responsibility of individual factors and structural factors such as social determinants of health. These discussions are not easy to navigate but they can potentially help patients transition from a mindset of treating the disease (pathogenic approach) to an awareness of their available capabilities to improve health (salutogenic approach). This study contributes to research on attribution theory and cultural health capital theory by demonstrating how discussing causes for poor health can enable patients resolve doubts and accrue instrumental and symbolic resources that facilitate healing.

Setting Goals to Reduce Cardiovascular Risk: A Retrospective Chart Review of a Pharmacist-Led Initiative in the Workplace

Background: Cardiovascular diseases (CVD) are the second leading cause of death in Canada with many modifiable risk factors. Pharmacists at a Canadian university delivered a novel CVD risk management program, which included goal-setting and medication management. Aim: This study aimed to describe what CVD prevention goals are composed of in a workplace CVD risk reduction program, and how might these goals change over time. Methods: A longitudinal, descriptive qualitative study using a retrospective chart review of clinical care plans for 15 patients enrolled in a CVD prevention program. Data across 6 visits were extracted from charts (n = 5413 words) recorded from May 2019-November 2020 and analyzed using quantitative content analysis and descriptive statistics. Results: Behavioural goals were most popular among patients and were more likely to change over the 12-month follow-up period, compared to health measure goals. Behavioural goals included goals around diet, physical activity (PA), smoking, medication, sleep and alcohol; health measure goals centered on weight measures, blood pressure (BP) and blood lipid levels. The most common behavioural goals set by patients were for diet (n = 11) and PA (n = 9). Over time, goals around PA, medication, alcohol and weight were adapted while others were added (e.g. diet) and some only continued. Patients experienced a number of barriers to their goal(s) which informed how they adapted their goal(s). These included environmental limitations (including COVID-19) and work-related time constraints. Conclusions: This study found CVD goal-setting in the pharmacist-led workplace wellness program was complex and evolved over time, with goals added and/or adapted. More detailed qualitative research could provide further insights into the patient-provider goal-setting experience in workplace CVD prevention.

Turkish Validity and Reliability of the Self-care of Hypertension Inventory (SC-HI) among Older Adults

PURPOSE

To assess the psychometric properties of the Turkish version of the Self-care of Hypertension Inventory (SC-HI) among older adults with hypertension.

DESIGN

This was a methodological study.

METHODS

The study sample enrolled 176 older adults. The study carried out preliminary psychometric analyses.

FINDINGS

Item-level content validity index ranged between 0.87 to 1.0, and the index of content validity was 0.98. The Cronbach's α for the total scale was 0.84.

CONCLUSION

The cross-cultural adaptation of SC-HI has been realized successfully in Turkish.

CLINICAL EVIDENCE

Health care providers may utilize the scale to evaluate "older individuals" hypertension self-care abilities.

Advancements and critical steps for statistical analyses in blood pressure response to resistance training in hypertensive older women: a methodological approach

BACKGROUND

Repeated measures analysis of covariance and three-way analysis of variance with repeated measures are common statistical methods. For a valid interpretation of blood pressure (BP) response to exercise, a variety of additional statistical methods must be implemented. Four additional statistical methods are presented: technical error of measurement (SEM), smallest real difference (SRD), magnitude-based inference and mixed effect modeling technique (MEM). The aim of this perspective article is to demonstrate how to apply already known statistical analyses regarding BP responsiveness in order to improve interpretation and achieve higher reliability for future studies in exercise science.

METHODS

A total of 27 hypertensive older women (aged 68.37 ± 5.55 years) participated in the present study. A whole-body resistance training (RT) program was performed on two nonconsecutive days per week for 10 weeks. BP was monitored during the 10-week RT intervention and after 15 weeks of detraining. First, individuals were classified as high and low responders, then statistical methods to analyze data included the use of SEM, SRD, magnitude-based inference and MEM.

RESULTS

When magnitude-based inference was used to classify responsiveness, most participants displayed a trivial response. Decrements in SBP between 1 and 10 mmHg were not clinically meaningful but fell within the measurement error of the SBP measurements. Baseline SBP and time of training predicted post-SBP response.

CONCLUSION

Changes over time and declines in SBP might not be a SRD and fell in the SEM. Moreover, SBP responsiveness was the result of inappropriate control of covariates such as period of training.

Outcome Goals and Health Care Preferences of Older Adults With Multiple Chronic Conditions

IMPORTANCE

Older adults with multiple chronic conditions (MCCs) vary in their health outcome goals and the health care that they prefer to receive to achieve these goals.

OBJECTIVE

To describe the outcome goals and health care preferences of this population with MCCs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included participants in the Patient Priorities Care study who underwent health priorities identification from February 1, 2017, to August 31, 2018, in a primary care practice. Patients eligible to participate were 65 years or older, English speaking, and had at least 3 chronic conditions; in addition, they used at least 10 medications, saw at least 2 specialists, or had at least 2 emergency department visits or 1 hospitalization during the past year. Of 236 eligible patients, 163 (69%) agreed to participate in this study. Data were analyzed from August 1 to October 31, 2020.

EXPOSURES

Guided by facilitators, participants identified their core values, as many as 3 actionable and realistic outcome goals, health-related barriers to these goals, and as many as 3 helpful and 3 bothersome health care activities.

MAIN OUTCOMES AND MEASURES

Frequencies were ascertained for outcome goals and health care preferences. Preferences included health care activities (medications, health care visits, procedures, diagnostic tests, and self-management) reported as either helpful or bothersome.

RESULTS

Most of the 163 participants were White (158 [96.9%]) and women (109 [66.9%]), with a mean (SD) age of 77.6 (7.6) years. Of 459 goals, the most common encompassed meals and other activities with family and friends (111 [24.2%]), shopping (28 [6.1%]), and exercising (21 [4.6%]). Twenty individuals (12.3%) desired to live independently without specifying necessary activities. Of 312 barriers identified, the most common were pain (128 [41.0%]), fatigue (45 [14.4%]), unsteadiness (42 [13.5%]), and dyspnea (19 [6.1%]). Similar proportions of patients identified at least 1 medication that was helpful (130 [79.8%]) or bothersome (128 [78.5%]). Medications most commonly cited as helpful were pain medications, including nonopiods (36 of 55 users [65.5%]) and opioids (15 of 27 users [55.6%]); sleep medications (27 of 51 users [52.9%]); and respiratory inhalants (19 of 45 [42.2%]). Most often mentioned as bothersome were statins (25 of 97 users [25.8%]) and antidepressants (13 of 40 users [32.5%]). Thirty-two participants (19.6%) reported using too many medications. Health care visits were identified as helpful by 43 participants (26.4%); 15 (9.2%) reported too many visits. Procedures were named helpful by 38 participants (23.3%); 24 (14.7%) cited unwanted procedures. Among 48 participants with diabetes, monitoring of glucose levels was doable for 18 (37.5%) and too bothersome for 9 (18.8%).

CONCLUSIONS AND RELEVANCE

Participants identified realistic and actionable goals while varying in health care activities deemed helpful or bothersome. The goals and health care preferences of more diverse populations must be explored. Previous work suggests that clinicians can use this information in decision-making.

Health-related preferences of older patients with multimorbidity: an evidence map

OBJECTIVES

To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence.

DESIGN

Evidence map (systematic review variant).

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018.

STUDY SELECTION

Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions).

DATA EXTRACTION

Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software.

RESULTS

The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies.

CONCLUSION

Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences.

TRIAL REGISTRATION NUMBER

Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.

Challenges and strategies in patients' health priorities-aligned decision-making for older adults with multiple chronic conditions

OBJECTIVES

While patients' health priorities should inform healthcare, strategies for doing so are lacking for patients with multiple conditions. We describe challenges to, and strategies that support, patients' priorities-aligned decision-making.

DESIGN

Participant observation qualitative study.

SETTING

Primary care and cardiology practices in Connecticut.

PARTICIPANTS

Ten primary care clinicians, five cardiologists, and the Patient Priorities implementation team (four geriatricians, physician expert in clinician training, behavioral medicine expert). The patients discussed were ≥ 66 years with >3 chronic conditions and ≥10 medications or saw ≥ two specialists.

EXPOSURE

Following initial training and experience in providing Patient Priorities Care, the clinicians and Patient Priorities implementation team participated in 21 case-based, group discussions (10 face-to-face;11 telephonic). Using emergent learning (i.e. learning which arises from interactions among the participants), participants discussed challenges, posed solutions, and worked together to determine how to align care options with the health priorities of 35 patients participating in the Patient Priorities Care pilot.

MAIN OUTCOMES

Challenges to, and strategies for, aligning decision-making with patient's health priorities.

RESULTS

Categories of challenges discussed among participants included uncertainty, complexity, and multiplicity of problems and treatments; difficulty switching to patients' priorities as the focus of decision-making; and differing perspectives between patients and clinicians, and among clinicians. Strategies identified to support patient priorities-aligned decision-making included starting with one thing that matters most to each patient; conducting serial trials of starting, stopping, or continuing interventions; focusing on function (i.e. achieving patient's desired activities) rather than eliminating symptoms; basing communications, decision-making, and effectiveness on patients' priorities not solely on diseases; and negotiating shared decisions when there are differences in perspectives.

CONCLUSIONS

The discrete set of challenges encountered and the implementable strategies identified suggest that patient priorities-aligned decision-making in the care of patients with multiple chronic conditions is feasible, albeit complicated. Findings require replication in additional settings and determination of their effect on patient outcomes.

Perspectives of Patients in Identifying Their Values-Based Health Priorities

OBJECTIVES

Patient Health Priorities Identification (PHPI) is a values-based process in which trained facilitators assist older adults with multiple chronic conditions identify their health priorities. The purpose of this study was to evaluate patients' perceptions of PHPI.

DESIGN

Qualitative study using thematic analysis.

SETTING

In-depth semistructured telephone and in-person interviews.

PARTICIPANTS

Twenty-two older adults who participated in the PHPI process.

MEASUREMENTS

Open-ended questions about patient perceptions of the PHPI process, perceived benefits of the process, enablers and barriers to PHPI, and recommendations for process enhancement.

RESULTS

Patient interviews ranged from 9 to 63 minutes (median = 20 min; interquartile range = 15-26). The mean age was 80 years (standard deviation = 7.96), 64% were female, and all patients identified themselves as white. Of the sample, 73% reported no caregiver involvement in their healthcare; 36% lived alone. Most patients felt able to complete the PHPI process with ease. Perceived benefits included increased knowledge and insight into disease processes and treatment options, patient activation, and enhanced communication with family and clinicians. Patients identified several factors that were both enablers and barriers to PHPI including facilitator characteristics, patient demographic and clinical characteristics, social support, relationships between the patient and their primary care provider, and the changing health priorities of the patient. Recommendations for process enhancement included more frequent and flexible facilitator contacts, selection of patients for participation based on specific patient characteristics, clarification of process aims and expectations, involvement of family, written reminders of established health priorities, short duration between facilitation and primary care provider follow-up, and the inclusion of health-related tasks in facilitation visits.

CONCLUSIONS

Patients found the PHPI process valuable in identifying actionable health priorities and healthcare goals leading to enhanced knowledge, activation, and communication regarding their treatment options and preferences. PHPI may be useful for aligning the healthcare that patients receive with their values-based priorities.

Development of a Clinically Feasible Process for Identifying Individual Health Priorities

OBJECTIVES

To develop a values-based, clinically feasible process to help older adults identify health priorities that can guide clinical decision-making.

DESIGN

Prospective development and feasibility study.

SETTING

Primary care practice in Connecticut.

PARTICIPANTS

Older adults with 3 or more conditions or taking 10 or more medications (N=64).

INTERVENTION

The development team of patients, caregivers, and clinicians used a user-centered design framework-ideate → prototype → test →redesign-to develop and refine the value-based patient priorities care process and medical record template with trained clinician facilitators.

MEASUREMENTS

We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions).

RESULTS

We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians.

CONCLUSION

Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.

Hypertension management for community-dwelling older people with diabetes in Nanchang, China: study protocol for a cluster randomized controlled trial

BACKGROUND

Although China has a large number of older people living with diabetes and hypertension, the primary care system is underdeveloped and so management of these conditions in community care settings is suboptimal. Studies have shown that the collaborative care model across care settings that address both pharmacology and nonpharmacology interventions can achieve hypertension control for older people with diabetes. Barriers to implementing and evaluating this model of care are widely recognized in low and middle-income countries including China. This study will therefore test the hypothesis that a hypertension management program built on collaboration between hospitals and community health service centers in China can improve blood pressure control in people aged 60 years and older with diabetes as compared to usual care.

METHODS

A cluster randomized controlled trial will randomly allocate 10 wards from four hospitals in Nanchang to either an intervention group (N = 5) or a usual care group (N = 5). At least 27 participants will be recruited from each ward and the estimated sample size will be 135 patients in each group. The intervention includes individualized self-care education prior to discharge and 6-month follow-up in community health service centers. Health professionals from both hospitals and community health service centers will be resourced to collaborate on the implementation of the postdischarge interventions that reinforce self-care. The primary outcome is systolic blood pressure at 6-month follow-up adjusted for baseline value. Secondary outcomes are self-care knowledge, treatment adherence, HbA1c and lipid levels, quality of life, the incidence of adverse events and the incidence of unplanned hospital readmission at 6-month follow-up adjusted for baseline value. A multilevel mixed-effect linear regression model will be used to compare the changes in health outcomes between the intervention and usual care groups.

DISCUSSION

This study will determine whether collaborative care among health professionals between hospitals and community health service centers will improve hypertension management for older people with diabetes in the study sites. The program, if effective, will have an immediate application to hypertension management in the healthcare system in China.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry, ACTRN12617001352392 . Retrospectively registered on 26 September 2017.

Disentangling self-management goal setting and action planning: A scoping review

INTRODUCTION

The ongoing rise in the numbers of chronically ill people necessitates efforts for effective self-management. Goal setting and action planning are frequently used, as they are thought to support patients in changing their behavior. However, it remains unclear how goal setting and action planning in the context of self-management are defined in the scientific literature. This study aimed to achieve a better understanding of the various definitions used.

METHODS

A scoping review was conducted, searching PubMed, Cinahl, PsychINFO and Cochrane. Inclusion and exclusion criteria were formulated to ensure the focus on goal setting/action planning and self-management. The literature was updated to December 2015; data selection and charting was done by two reviewers. A qualitative content analysis approach was used.

RESULTS

Out of 9115 retrieved articles, 58 met the inclusion criteria. We created an overview of goal setting phases that were applied (preparation, formulation of goals, formulation of action plan, coping planning and follow-up). Although the phases we found are in accordance with commonly known frameworks for goal setting, it was striking that the majority of studies (n = 39, 67%) did not include all phases. We also prepared an overview of components and strategies for each goal setting phase. Interestingly, few strategies were found for the communication between patients and professionals about goals/action plans. Most studies (n = 35, 60%) focused goal setting on one single disease and on a predefined lifestyle behavior; nearly half of the articles (n = 27, 47%) reported a theoretical framework.

DISCUSSION

The results might provide practical support for developers of interventions. Moreover, our results might encourage professionals to become more aware of the phases of the goal setting process and of strategies emphasizing on patient reflection. However, more research might be useful to examine strategies to facilitate communication about goals/action plans. It might also be worthwhile to develop and evaluate goal setting/action planning strategies for people with different and multiple chronic conditions.

Understanding the Medication Adherence Strategies of Older Adults with Hypertension

Many older adults are living with at least one chronic disease and must adhere to prescribed medication to mitigate and control its impact. Hypertension is one chronic disease that affects a significant portion of the world’s population, especially older adults, and is responsible for a high number of annual deaths. It is asymptomatic, meaning that there are no perceptible symptoms and, as such, older adults may struggle with adhering to their prescribed antihypertensive medications. How one internalizes the disease may influence the degree of success in managing the condition. The current study analyzed archival data from a multifaceted prospective memory intervention for older adults with hypertension who were nonadherent to their medication. We coded their responses to self-management interview questions to identify the common themes regarding the knowledge and sense of control the older adults held relevant to managing their illness. Participants’ responses revealed how they internalized hypertension and their medication, as well as the strategies and goals they reportedly used to manage the illness. The association strategy was found to be the most commonly used within participants’ routines. In addition, many participants expressed a general lack of knowledge about the disease or their medication, and their goals regarding hypertension management were general and inexplicit (e.g., “to reduce their blood pressure). This information informs the design of more effective and longer-lasting interventions geared toward significantly improving the medication adherence of older adults diagnosed with hypertension.

Self-care behavior and related factors in older patients with uncontrolled hypertension

BACKGROUND

Effective self-care behavior can help reduce hypertension complications, but the rate of engagement in self-care behavior is relatively low among elderly patients.

OBJECTIVES

To examine levels of self-care and factors affecting self-care among elderly patients with uncontrolled hypertension compared with those with controlled hypertension.

DESIGN

Cross-sectional survey.

METHODS

A total of 255 elderly patients were selected to measure hypertensive patients' self-care behavior and self-efficacy, knowledge of hypertension management, family support, and perceived severity of hypertension as well as their depression levels.

RESULTS

The uncontrolled hypertension group showed lower scores for self-care behavior and self-efficacy than the controlled hypertension group. Only self-efficacy significantly affected self-care behavior in the latter group, whereas self-efficacy, education level, and family support affected self-care behavior in the former group.

CONCLUSIONS

The study results indicated that strategies for uncontrolled hypertension elderly patients should consider patients' educational, family support, and self-efficacy levels in order to improve their self-regulation.

The website-based eaTracker®‘My Goals’ feature: a qualitative evaluation

Objective

In 2011, Dietitians of Canada added ‘My Goals’ to its website-based nutrition/activity tracking program (eaTracker®,http://www.eaTracker.ca/); this feature allows users to choose ‘ready-made’ or ‘write-your-own’ goals and to self-report progress. The purpose of the present study was to document experiences and perceptions of goal setting and My Goals, and report users’ feedback on what is needed in future website-based goal setting/tracking tools.

Design

One-on-one semi-structured interviews were conducted with (i) My Goals users and (ii) dietitians providing a public information support service, EatRight Ontario (ERO).

Setting

My Goals users from Ontario and Alberta, Canada were recruited via an eaTracker website pop-up box; ERO dietitians working in Ontario, Canada were recruited via ERO.

Subjects

My Goals users (n23; age 19–70 years; 91 % female;n5 from Alberta/n18 from Ontario) and ERO dietitians (n5).

Results

Dietitians and users felt goal setting for nutrition (and activity) behaviour change was both a beneficial and a challenging process. Dietitians were concerned about users setting poor-quality goals and users felt it was difficult to stick to their goals. Both users and dietitians were enthusiastic about the My Goals concept, but felt the current feature had limitations that affected use. Dietitians and users provided suggestions to improve My Goals (e.g. more prominent presence of My Goals in eaTracker; assistance with goal setting; automated personalized feedback).

Conclusions

Dietitians and users shared similar perspectives on the My Goals feature and both felt goal use was challenging. Several suggestions were provided to enhance My Goals that are relevant to website-based goal setting/tracking tool design in general.

A retrospective analysis of real-world use of the eaTracker® My Goals website by adults from Ontario and Alberta, Canada

Background

Little is known about use of goal setting and tracking tools within online programs to support nutrition and physical activity behaviour change. In 2011, Dietitians of Canada added “My Goals,” a nutrition and physical activity behaviour goal setting and tracking tool to their free publicly available self-monitoring website (eaTracker® (http://www.eaTracker.ca/)). My Goals allows users to: a) set “ready-made” SMART (Specific, Measurable, Attainable, Realistic, Time-related) goals (choice of n = 87 goals from n = 13 categories) or “write your own” goals, and b) track progress using the “My Goals Tracker.” The purpose of this study was to characterize: a) My Goals user demographics, b) types of goals set, and c) My Goals Tracker use.

Methods

Anonymous data on all goals set using the My Goals feature from December 6/2012-April 28/2014 by users ≥19y from Ontario and Alberta, Canada were obtained. This dataset contained: anonymous self-reported user demographic data, user set goals, and My Goals Tracker use data. Write your own goals were categorized by topic and specificity. Data were summarized using descriptive statistics. Multivariate binary logistic regression was used to determine associations between user demographics and a) goal topic areas and b) My Goals Tracker use.

Results

Overall, n = 16,511 goal statements (75.4 % ready-made; 24.6 % write your own) set by n = 8,067 adult users 19-85y (83.3 % female; mean age 41.1 ± 15.0y, mean BMI 28.8 ± 7.6kg/m²) were included for analysis. Overall, 33.1 % of ready-made goals were from the “Managing your Weight” category. Of write your own goal entries, 42.3 % were solely distal goals (most related to weight management); 38.6 % addressed nutrition behaviour change (16.6 % had unspecific general eating goals); 18.1 % addressed physical activity behaviour change (47.3 % had goals without information on exercise amount and type). Many write your own goals were poor quality (e.g., non-specific (e.g., missing amounts)), and possibly unrealistic (e.g., no sugar). Few goals were tracked (<10 %). Demographic variables had statistically significant relations with goal topic areas and My Goals Tracker use.

Conclusions

eaTracker® users had high interest in goal setting and the My Goals feature, however, self-written goals were often poor quality and goal tracking was rare. Further research is needed to better support users.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3640-6) contains supplementary material, which is available to authorized users.

Health Values and Treatment Goals of Older, Multimorbid Adults Facing Life-Threatening Illness

OBJECTIVES

To identify a taxonomy of health-related values that frame goals of care of older, multimorbid adults who recently faced cancer diagnosis and treatment.

DESIGN

Qualitative analysis of data from a longitudinal cohort study of multimorbid cancer survivors.

SETTING

Cancer registries from regional Department of Veterans Affairs networks in New England and southeast Texas.

PARTICIPANTS

Multimorbid adults who completed interviews 12 months after diagnosis of head and neck, colorectal, gastric, or esophageal cancer and after cancer treatment (N = 146).

MEASUREMENTS

An interdisciplinary team conducted thematic analyses of participants' intuitive responses to two questions: Now that you have had cancer and may face ongoing decisions about medical care in the future, what would you want your family, friends, and doctors to know about you, in terms of what is most important to you in your life? If your cancer were to recur, is there anything you'd want to be sure your loved ones knew about you and your goals of care?

RESULTS

Analysis revealed five distinct health-related values that guide how multimorbid cancer survivors conceptualize specific health care goals and medical decisions: self-sufficiency, life enjoyment, connectedness and legacy, balancing quality and length of life, and engagement in care. Participants typically endorsed more than one value as important.

CONCLUSION

Older multimorbid adults who recently faced life-threatening cancer endorsed a multidimensional taxonomy of health-related values. These health-related values guide how they frame their goals for care and treatment preferences. Eliciting individuals' sense of their values during clinical encounters may improve their experiences with health care and more effectively align treatments with goals of care.

[Conceptual self-management analysis of hypertensive individuals]

This research aimed to analyze the concept of self-management of hypertensive individuals. Theoretical and documentary study based on Walker and Avant's conceptual analysis by means of the Scientific Electronic Library Brazil and the Medical Literature Analysis and Retrieval System Online in the Coordination for Higher Education Personnel Development (CAPES, in Portuguese) and the National Library of Medicine websites. Fourteen (14) articles and one (1) thesis were selected and reviewed in Portuguese and English, in the period January 2007 to September 2012.

BACKGROUND

missing doctor's appointments, non-compliance to blood pressure control treatment to recommendations to proper diet standards and stress. Attributer blood pressure control and disease management Consequences home monitoring of blood pressure with control improvement, accomplishment of disease management, compliance and sharing of the creation process of self-management goals and caring activities by the interdiscplinary team through individualized actions. It was concluded that the self-management concept is a dynamic, active process which requires knowledge, attitude, discipline, determination, commitment self-regulation, empowerment and self-efficiency in order to manage the disease and achieve healthy living.

Factors affecting self-care in elderly patients with hypertension in Korea

The objective of this study was to test nine variables which derived from the model of self-care in chronic illness and previous studies on elderly patients with hypertension. A descriptive research design was employed in this study. Totally, 306 elderly patients diagnosed with hypertension were selected from three public health centres for the study. The stepwise regression analysis was conducted by analysing predictors of self-care in elderly patients with hypertension. Statistical analyses, including correlation analysis, t-test and analysis of variance tests were conducted for seven variables. The results indicated that only four variables were significant, and the model explained 57% of the variance in self-care. Among these predictors, empowerment was the strongest predictor, followed by social support, depression and perceived severity. These findings demonstrate the significance of assessing predictors of self-care behaviour when examining patients' health behaviours and planning intervention strategies.

Goal setting with caregivers of adults in the community: a mixed methods systematic review

PURPOSE

To examine how goal setting is used with caregivers of community residing adults and the effect of goal setting practices in improving the outcomes.

METHODS

A mixed methods systematic review was conducted. The methodological rigour of included studies was critiqued using Cochrane Collaboration's risk of bias assessment tool, Downs and Black checklist and a framework for evaluating qualitative research. Narrative synthesis was created through tabulation and categorisation, visual mapping of the goal setting process, thematic analysis on common goal setting features and critical reflection on the accuracy and robustness of the synthesis.

RESULTS

Seventeen studies were included: 10 randomised trials, 5 other quantitative studies and two descriptive studies which incorporated qualitative methods. The trials demonstrated a relatively low risk of bias in contrast to the other studies that had varied methodological rigour. No studies isolated the effect of the goal setting process on outcomes and therefore the effectiveness of goal setting could not be evaluated. However, through a narrative synthesis six prominent features of collaborative goal setting were identified.

CONCLUSIONS

Despite the fact that goal setting is an important component of client-centred care, and the prominence of client-centred care in healthcare discourse, the review uncovered a surprisingly limited number of studies. Goal setting is an elusive process that is of therapeutic value and warrants further investigation. Implications for Rehabilitation The current body of empirical evidence suggests that there are six prominent features of collaborative goal setting with caregivers. The goals that are most important to caregivers are often different to those that are important to clinicians; it is important that caregivers and clinicians agree on goals to maximise adherence to treatment and goal attainment. The quality of evidence for goal setting with caregivers is limited although some intervention trials illustrate the usefulness of collaborative goal setting in contributing to improved outcomes.

Behavioral health coaching for rural veterans with diabetes and depression: a patient randomized effectiveness implementation trial

BACKGROUND

Depression and diabetes cause significant burden for patients and the healthcare system and, when co-occurring, result in poorer self-care behaviors and worse glycemic control than for either condition alone. However, the clinical management of these comorbid conditions is complicated by a host of patient, provider, and system-level barriers that are especially problematic for patients in rural locations. Patient-centered medical homes provide an opportunity to integrate mental and physical health care to address the multifaceted needs of complex comorbid conditions. Presently, there is a need to not only develop robust clinical interventions for complex medically ill patients but also to find feasible ways to embed these interventions into the frontlines of existing primary care practices.

METHODS/DESIGN

This randomized controlled trial uses a hybrid effectiveness-implementation design to evaluate the Healthy Outcomes through Patient Empowerment (HOPE) intervention, which seeks to simultaneously address diabetes and depression for rural veterans in Southeast Texas. A total of 242 Veterans with uncontrolled diabetes and comorbid symptoms of depression will be recruited and randomized to either the HOPE intervention or to a usual-care arm. Participants will be evaluated on a host of diabetes and depression-related measures at baseline and 6- and 12-month follow-up. The trial has two primary goals: 1) to examine the effectiveness of the intervention on both physical (diabetes) and emotional health (depression) outcomes and 2) to simultaneously pilot test a multifaceted implementation strategy designed to increase fidelity and utilization of the intervention by coaches interfacing within the primary care setting.

DISCUSSION

This ongoing blended effectiveness-implementation design holds the potential to advance the science and practice of caring for complex medically ill patients within the constraints of a busy patient-centered medical home.

TRIAL REGISTRATION

Behavioral Activation Therapy for Rural Veterans with Diabetes and Depression: NCT01572389.

Interaction between functional health literacy, patient activation, and glycemic control

BACKGROUND

Functional health literacy (FHL) and patient activation can impact diabetes control through enhanced diabetes self-management. Less is known about the combined effect of these characteristics on diabetes outcomes. Using brief, validated measures, we examined the interaction between FHL and patient activation in predicting glycosylated hemoglobin (HbA1c) control among a cohort of multimorbid diabetic patients.

METHODS

We administered a survey via mail to 387 diabetic patients with coexisting hypertension and ischemic heart disease who received outpatient care at one regional VA medical center between November 2010 and December 2010. We identified patients with the study conditions using the International Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9-CM) diagnoses codes and Current Procedure Terminology (CPT) procedures codes. Surveys were returned by 195 (50.4%) patients. We determined patient activation levels based on participant responses to the 13-item Patient Activation Measure and FHL levels using the single-item screening question, "How confident are you filling out medical forms by yourself?" We reviewed patient medical records to assess glycemic control. We used multiple logistic regression to examine whether activation and FHL were individually or jointly related to HbA1c control.

RESULTS

Neither patient activation nor FHL was independently related to glycemic control in the unadjusted main effects model; however, the interaction between the two was significantly associated with glycemic control (odds ratio 1.05 [95% confidence interval 1.01-1.09], P=0.02). Controlling for age, illness burden, and number of primary care visits, the combined effect of these measures on glycemic control remained significant (odds ratio 1.05 [95% confidence interval 1.01-1.09], P=0.02).

CONCLUSION

The interaction between FHL and patient activation is associated with HbA1c control beyond the independent effects of these parameters alone. A personalized approach to diabetes management incorporating these characteristics may increase patient-centered care and improve outcomes for patients with diabetes.

Self-Management of Wellness and Illness in an Aging Population

In this chapter, we review the last 10 years of literature on self-management of illnesses (acute/episodic and chronic) and wellness (e.g., health promotion). We focus on health self-management in the context of an aging population, wherein middle-aged adults are more likely to be managing wellness activities and older adults are often managing both maintenance of health and chronic illnesses. The critical issues related to self-management of health are discussed, including those imposed by health care demands and those stemming from individual differences in general abilities (e.g., motor, perception, cognition) and socioemotional characteristics. The dynamic relationship between theory and practice is highlighted. Health care demands reflect the nature of the illness or wellness activity and include managing comorbidities, symptoms, and medications; engaging in health promotion activities (e.g., exercise, diet); the required use of health technologies; the need for health-related information; and coordination of the care network. Individual differences in motor, perceptual, and cognitive abilities, as well as in the severity and complexity of the illness and the consequent demands, also impact how a person self-manages health. Cognitive abilities, such as decision making, knowledge, literacy (i.e., general, health, and e-health literacy), and numeracy are particularly implicated in the process of managing one’s own health and are especially important in the context of an aging population; therefore we give these cognitive abilities special attention in this chapter. Socioemotional characteristics, and attitudes and beliefs about one’s health, impact an individual’s self-management of health as well, impacting his or her motivation and goal-setting behaviors. Moreover, we discuss literature on interventions that have been used to improve self-management of health, and we examine the potential for technology. We conclude with guidelines for technology design and instruction, and discuss emerging themes.

Consumers' various and surprising responses to direct-to-consumer advertisements in magazine print

Direct-to-consumer advertising (DTCA) is ubiquitous in media outlets, but little is known about the ways in which consumers' values, needs, beliefs, and biases influence the perceived meaning and value of DTCA. This article aims to identify the taxonomy of readership categories that reflect the complexity of how health care consumers interact with DTCA, with particular focus on individuals' perceptions of print DTCA in popular magazines. Respondent-driven sampling was used to recruit 18 male and female magazine readers and 18 male and female prescription medication users aged 18-71 years. Semi-structured, in-depth interviews with consumers about their attentiveness, motivations, perceived value, and behavioral responses to DTCA were conducted. The analyses were guided by principles of grounded theory analysis; four categories that vary in consumers' attentiveness, motivations, perceived value, and behavioral responses to DTCA were identified. Two categories - the lay physician and the informed shopper - see value in information from DTCA and are likely to seek medical care based on the information. One category - the voyeur - reads DTCA, but is not likely to approach a clinician regarding advertised information. The fourth category - the evader - ignores DTCA and is not likely to approach a clinician with DTCA information. Responses to DTCA vary considerably among consumers, and physicians should view patients' understanding and response to DTCA within the context of their health-related needs. Patients' comments related to DTCA may be used as an opportunity to engage and understand patients' perspectives about illness and medication use. Clinicians may use information about these categories to facilitate shared understanding and improve communication within the doctor-patient relationship.

The effect of a designated tool on person-centred goal identification and service planning among older people receiving homecare in New Zealand

This study sought to determine the ability of a designated tool developed to identify client-directed goals in a sample of older people referred for homecare. A retrospective pre/post-intervention design was used and a total of 360 older people in an urban centre in New Zealand were included in the analysis. All clients receiving services at the time of data collection (July 2007) who were referred for service provision between July 2003 and the implementation in January 2007 of a restorative model of homecare were included in the analysis. The restorative model of homecare included a designated goal-facilitation tool [Towards Achieving Realistic Goal in Elders Tool (TARGET)]. Prior to the use of TARGET, participants had a goal recorded for their home-care episode in 31 cases (8.6%), whereas following the implementation of TARGET, goals were recorded in 339 cases (94.2%). At a quarterly review, eight clients (2.2%) achieved their goal prior to TARGET, whereas 172 clients (47.8%) fully achieved their goal when TARGET was utilised. Within the sample, multinomial logistic regression showed that the use of TARGET significantly improved goal attainment. Furthermore, moderate-to-severe cognitive impairment significantly reduced the successful attainment of goals. The study highlighted the importance of a designated tool for facilitating older people to set goals that are then used in developing support plans to structure services to assist them in the home. The need for alternative strategies for goal setting for people with significant cognitive impairment was highlighted. This study, in attempting to determine the effect of a goal-facilitation tool as a driver for quality improvement in homecare, had an observational comparative design, this being the most pragmatic option to assess the feasibility of TARGET prior to further work being undertaken. The results do show that in this sample of older people receiving homecare, the use of TARGET led to a greater proportion of goal identification, higher rates of goal attainment and a more diverse range of categories of goals than traditional non-structured methods of goal setting.

Transitioning from active treatment: colorectal cancer survivors' health promotion goals

OBJECTIVE

The purpose of this study is to describe the post-treatment goals of colorectal cancer (CRC) survivors. We sought to determine whether goals were a salient concept during the period immediately following treatment, and whether a goal-setting intervention might be feasible and acceptable to these patients.

METHOD

Semi-structured qualitative interviews were administered to a convenience sample of 41 CRC patients who were 0-24 months post-treatment. Topics discussed included expectations and goals for future health, cancer prevention awareness, health-promoting behavior-change goals, and post-treatment cancer issues. Content analysis was used to explore emergent themes.

RESULTS

Overall, participants' health-related goals were: being healthy, getting back to normal, and not having a cancer recurrence. Most of the CRC survivors reported being proactive with their health by maintaining healthy behaviors or making healthy behavior changes, or had goals to change their behavior. All respondents had plans to maintain follow-up care and regular screening appointments. Some patients were managing treatment side effects or non-cancer issues that limited their functional abilities. Many respondents were satisfied with the care they received, and felt it was now their responsibility to do their part in taking care of themselves.

SIGNIFICANCE OF RESULTS

CRC survivors talk about goals, and many of them are either making or have an interest in making health behavior changes. Self-management support could be an appropriate strategy to assist patients with achieving their health goals post-treatment. Patients may need help addressing lingering treatment side effects or non-cancer issues. Healthcare providers should consider assessing patients' goals to help patients resolve post-treatment issues and promote healthy behaviors.

Patient-physician role relationships and patient activation among individuals with chronic illness

OBJECTIVE

To examine whether chronically ill patients' perceptions of their role relationships with their physicians are associated with levels of patient activation.

DATA SOURCES

Random digit dial survey of 8,140 chronically ill patients and the Area Resource File.

STUDY DESIGN

Cross-sectional, multivariate analysis of the relationship between dimensions of patient-physician role relationships and level of patient activation. The study controlled for variables related to patient demographics, socioeconomic status, health status, and market and family context.

PRINCIPAL FINDINGS

Higher perceived quality of interpersonal exchange with physicians, greater fairness in the treatment process, and more out-of-office contact with physicians were associated with higher levels of patient activation. Treatment goal setting was not significantly associated with patient activation.

CONCLUSION

Patient-physician relationships are an important factor in patients taking a more active role in their health and health care. Efforts to increase activation that focus only on individual patients ignore the important fact that the nature of roles and relationships between provider and patient can shape the behaviors and attitudes of patients in ways that support or discourage patient activation.

Goal setting as a health behavior change strategy in overweight and obese adults: a systematic literature review examining intervention components

OBJECTIVE

This paper describes goal setting components used for behavior change specific to diet and physical activity in community-based interventions targeting overweight and obese adults.

METHODS

A systematic literature review was conducted. Studies were evaluated using the S.T.A.R.T. (Specificity, Timing, Acquisition, Rewards and feedback, and Tools) criteria which were developed for the purposes of this paper in order to elucidate which intervention features elicit optimal health behavior outcomes.

RESULTS

Eighteen studies were included. Based on the S.T.A.R.T. criteria, it was determined that developing specific goals that are in close proximity, involve the participant in acquisition, and incorporate regular feedback, are common features in this context.

CONCLUSION

Goal setting can be useful for effecting health behavior changes in this population. However, as different intervention components were often implemented concurrently (e.g., education sessions, self-monitoring records), it was not possible to ascertain which were responsible for positive changes independently.

PRACTICE IMPLICATIONS

Goal setting shows promise as a tool that can be incorporated into weight reduction programs by health care professionals and researchers. Studies are warranted to identify the specific mechanisms through which individuals with overweight or obesity can apply the S.T.A.R.T. criteria with respect to goal setting for the purposes of weight loss.

Strategies for the management of intermittent allergic rhinitis: an Australian study

OBJECTIVE

Allergic rhinitis is increasing globally despite treatment focussed on pharmacotherapy. This study aimed to (i) examine the range and proportion of symptoms and triggers experienced by patients with intermittent allergic rhinitis (IAR); (ii) conduct a qualitative analysis of strategies devised to control symptoms and triggers; and (iii) measure medication adherence.

METHODS

A qualitative and observational study of data drawn from a randomized controlled trial on patients with IAR. Strategies collaboratively devised by participants and pharmacist staff to minimize symptoms and triggers were analysed thematically. In the 10-day observational study, the participants recorded all symptoms and triggers of IAR along with use of medications and these were analysed descriptively.

RESULTS

Number of 124 participants recorded 620 symptoms and identified 357 triggers of IAR. To minimize these, 579 strategies were devised in consultation with pharmacy staff. The frequency and type of strategy varied according to whether the goals were aimed at controlling symptoms or triggers. Adherence to a course of antihistamines over the 10-day trial was self-reported by participants with 36% indicating full adherence.

CONCLUSION

A large number and range of symptoms and triggers were identified, and individualized strategies were devised to minimize symptoms and triggers. Medication adherence was poor.

PRACTICE IMPLICATIONS

  Patients with IAR can be assisted to identify their symptoms and triggers and develop relevant strategies to manage these. This approach has the potential to facilitate patient self-management of a chronic and incapacitating condition.

Advancing the Prevention and Control of Hypertension

Hypertension is on a worrisome public health trajectory. This review discusses some key contributing dynamics as well as considerations for progress toward the prevention and control of hypertension and its comorbidities.

Integrating diabetes self-management with the health goals of older adults: a qualitative exploration

OBJECTIVE

This study investigates the life and health goals of older adults with diabetes, and explores the factors that influence their diabetes self-management.

METHODS

Qualitative in-depth interviews were conducted with 24 older adults with diabetes and other morbid conditions and/or their caregivers, when appropriate.

RESULTS

Participants' provided a consistent set of responses when describing life and health goals. Participants described goals for longevity, better physical functioning, spending time with family, or maintaining independence. Diabetes discordant conditions, but not diabetes, were seen as barriers to life goals for participants with functional impairments. Functionally independent participants described additional health goals that related to diabetes self-management as diabetes was seen often a barrier to life goals. Caregivers, co-morbid conditions, denial and retirement were among the factors that influenced initiation of diabetes self-management.

CONCLUSION

Participants endorsed health goals and diabetes self-management practices that they believed would help them accomplish their life goals. Functional capabilities and social support were key factors in the relationship between diabetes self-management and their broader goals.

PRACTICE IMPLICATIONS

When planning diabetes treatments, clinicians, patients and caregivers should discuss the relationship between diabetes self-management and health and life goals as well as the affects of functional limitations and caregiver support.

Physician counseling for hypertension: what do doctors really do?

OBJECTIVE

To describe patient counseling by physicians on hypertension and lifestyle and assess its impact on participants' satisfaction.

METHODS

An analysis was conducted of transcripts of audio-recorded outpatient visits, augmented with patient and physician surveys. Participants were 30 primary care physicians, 11 cardiologists, and 120 hypertensive patients. Each transcript was coded into categories descriptive of physicians' counseling behaviors. Patients and physicians completed pre- and post-visit questionnaires; patients also completed a survey 2 weeks after their visit.

RESULTS

Most physicians assessed patient medication adherence, but counseling on hypertension and lifestyle was limited. Receipt of lifestyle counseling had a positive, short-lived impact on patient satisfaction. Physicians reported greater satisfaction with visits characterized by more lifestyle counseling. Amount of counseling provided was unrelated to the presence of cardiovascular comorbidities. Provision of counseling was not associated with physicians' perceptions of visit burden. Lifestyle counseling was associated with longer visits.

CONCLUSION

Hypertensive patients received relatively little information about hypertension and beneficial lifestyle changes.

PRACTICE IMPLICATIONS

Office visits provide an important opportunity for physicians to reinforce key hypertension-related educational messages. Physicians could do more to underscore the importance of medication adherence and healthy living to their patients with hypertension.