Family in Rehabilitation, Empowering Carers for Improved Malnutrition Outcomes: Protocol for the FREER Pilot Study

BACKGROUND

Interventions to improve the nutritional status of older adults and the integration of formal and family care systems are critical research areas to improve the independence and health of aging communities and are particularly relevant in the rehabilitation setting.

OBJECTIVE

The primary outcome aimed to determine if the FREER (Family in Rehabilitation: EmpowERing Carers for improved malnutrition outcomes) intervention in malnourished older adults during and postrehabilitation improve nutritional status, physical function, quality of life, service satisfaction, and hospital and aged care admission rates up to 3 months postdischarge, compared with usual care. Secondary outcomes evaluated include family carer burden, carer services satisfaction, and patient and carer experiences. This pilot study will also assess feasibility and intervention fidelity to inform a larger randomized controlled trial.

METHODS

This protocol is for a mixed-methods two-arm historically-controlled prospective pilot study intervention. The historical control group has 30 participants, and the pilot intervention group aims to recruit 30 patient-carer pairs. The FREER intervention delivers nutrition counseling during rehabilitation, 3 months of postdischarge telehealth follow-up, and provides supportive resources using a novel model of patient-centered and carer-centered nutrition care. The primary outcome is nutritional status measured by the Scored Patient-Generated Subjective Global Assessment Score. Qualitative outcomes such as experiences and perceptions of value will be measured using semistructured interviews followed by thematic analysis. The process evaluation addresses intervention fidelity and feasibility.

RESULTS

Recruitment commenced on July 4, 2018, and is ongoing with eight patient-carer pairs recruited at the time of manuscript submission.

CONCLUSIONS

This research will inform a larger randomized controlled trial, with potential for translation to health service policies and new models of dietetic care to support the optimization of nutritional status across a continuum of nutrition care from rehabilitation to home.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number (ACTRN) 12618000338268; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374608&isReview=true (Archived by WebCite at http://www.webcitation.org/74gtZplU2).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12647.

Patients' Experiences and Perspectives of Telehealth Coaching with a Dietitian to Improve Diet Quality in Chronic Kidney Disease: A Qualitative Interview Study

BACKGROUND

Dietary behavior change interventions for the self-management of chronic kidney disease (CKD) have the potential to slow disease progression and reduce metabolic complications. Telehealth-delivered dietary interventions may assist in the self-management of CKD, although their acceptability by patients is unknown.

OBJECTIVE

This study aims to describe the acceptability and experiences of a telehealth coaching intervention that utilized telephone calls and tailored text messages to improve diet quality in patients with stage 3 to 4 CKD.

DESIGN

Semistructured interview study of adults with CKD.

PARTICIPANTS/SETTING

Adults with stage 3 to 4 CKD (n=21) aged 28 to 78 (mean 62) years, who completed a 12-week telehealth-delivered dietary intervention in Queensland, Australia, were interviewed from March to July 2017.

DATA ANALYSIS

Interviews were transcribed verbatim and analyzed thematically.

RESULTS

Five themes were identified: valuing relationships (receiving tangible and perceptible support, building trust and rapport remotely, motivated by accountability, readily responding to a personalized approach, reassured by health professional expertise); appreciating convenience (integrating easily into lifestyle, talking comfortably in a familiar environment, minimizing travel and wait time burden); empowered with actionable knowledge (comprehending diet-disease mechanisms, practical problem solving for sustainable dietary behavior); increasing diet consciousness (learning from recurrent feedback, prompted by reiteration of messages); making sense of complexity (contextualizing and prioritizing comorbidities, gaining confidence to make dietary decisions, setting and achieving realistic goals).

CONCLUSIONS

Among adults with stage 3 to 4 CKD, individualized telehealth coaching for improving diet quality was convenient for patients, and they felt supported and empowered to navigate recommendations and prioritize dietary behavior changes. Telehealth-delivered dietary interventions appear to be well accepted by patients as a way of providing regular, tailored contact with a health professional to support dietary management in CKD.

Feasibility and acceptability of telehealth coaching to promote healthy eating in chronic kidney disease: a mixed-methods process evaluation

OBJECTIVE

To evaluate the feasibility and acceptability of a personalised telehealth intervention to support dietary self-management in adults with stage 3-4 chronic kidney disease (CKD).

DESIGN

Mixed-methods process evaluation embedded in a randomised controlled trial.

PARTICIPANTS

People with stage 3-4 CKD (estimated glomerular filtration rate [eGFR]15-60 mL/min/1.73 m²).

SETTING

Participants were recruited from three hospitals in Australia and completed the intervention in ambulatory community settings.

INTERVENTION

The intervention group received one telephone call per fortnight and 2-8 tailored text messages for 3 months, and then 4-12 tailored text messages for 3 months without telephone calls. The control group received usual care for 3 months then non-tailored education-only text messages for 3 months.

MAIN OUTCOME MEASURES

Feasibility (recruitment, non-participation and retention rates, intervention fidelity and participant adherence) and acceptability (questionnaire and semistructured interviews).

STATISTICAL ANALYSES PERFORMED

Descriptive statistics and qualitative content analysis.

RESULTS

Overall, 80/230 (35%) eligible patients who were approached consented to participate (mean±SD age 61.5±12.6 years). Retention was 93% and 98% in the intervention and control groups, respectively, and 96% of all planned intervention calls were completed. All participants in the intervention arm identified the tailored text messages as useful in supporting dietary self-management. In the control group, 27 (69%) reported the non-tailored text messages were useful in supporting change. Intervention group participants reported that the telehealth programme delivery methods were practical and able to be integrated into their lifestyle. Participants viewed the intervention as an acceptable, personalised alternative to face-face clinic consultations, and were satisfied with the frequency of contact.

CONCLUSIONS

This telehealth-delivered dietary coaching programme is an acceptable intervention which appears feasible for supporting dietary self-management in stage 3-4 CKD. A larger-scale randomised controlled trial is needed to evaluate the efficacy of the coaching programme on clinical and patient-reported outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12616001212448; Results.

Reporting of Telehealth-Delivered Dietary Intervention Trials in Chronic Disease: Systematic Review

BACKGROUND

Telehealth-delivered dietary interventions are effective for chronic disease management and are an emerging area of clinical practice. However, to apply interventions from the research setting in clinical practice, health professionals need details of each intervention component.

OBJECTIVE

The aim of this study was to evaluate the completeness of intervention reporting in published dietary chronic disease management trials that used telehealth delivery methods.

METHODS

Eligible randomized controlled trial publications were identified through a systematic review. The completeness of reporting of experimental and comparison interventions was assessed by two independent assessors using the Template for Intervention Description and Replication (TIDieR) checklist that consists of 12 items including intervention rationale, materials used, procedures, providers, delivery mode, location, when and how much intervention delivered, intervention tailoring, intervention modifications, and fidelity. Where reporting was incomplete, further information was sought from additional published material and through email correspondence with trial authors.

RESULTS

Within the 37 eligible trials, there were 49 experimental interventions and 37 comparison interventions. One trial reported every TIDieR item for their experimental intervention. No publications reported every item for the comparison intervention. For the experimental interventions, the most commonly reported items were location (96%), mode of delivery (98%), and rationale for the essential intervention elements (96%). Least reported items for experimental interventions were modifications (2%) and intervention material descriptions (39%) and where to access them (20%). Of the 37 authors, 14 responded with further information, and 8 could not be contacted.

CONCLUSIONS

Many details of the experimental and comparison interventions in telehealth-delivered dietary chronic disease management trials are incompletely reported. This prevents accurate interpretation of trial results and implementation of effective interventions in clinical practice.

Releasing resources for reinvestment in health gain

The National Health Services in Wales has adopted a strategic approach based on health gain. Five approaches to meeting this problem are considered (i) eliminating basic inefficiencies; (ii) eliminating unnecessary clinical activity; (iii) doing what is done now but differently; (iv) investing now to save later and (v) withdrawing from a particular area of activity, because it is less important than other competing claims. Each of these is briefly considered with particular reference to the Welsh situation. Three particular lines of advance are identified to achieve the above: creating new sources of information; working more effectively across organisational boundaries; and making the cultural changes to make it all possible.

Objectivity and emancipation in learning disabilities: holism from the perspective of critical realism

The present article provides a critique of holism (as developed in the writings of Heshusius, Iano, and Poplin) from the point of view of critical realism, primarily as the latter standpoint is explicated in the writing of the British philosopher of science Roy Bhaskar. Whereas the holists have been largely correct in their criticisms of the positivism and scientism that have characterized theory and practice in the learning disabilities field, it is argued that they run the risk of promoting a subjectivist standpoint with its own set of limitations.

Intracarotid norepinephrine infusions inhibit ventilation in goats

Plasma norepinephrine (NE) increases from rest to exercise during normoxic exercise, and significantly more during hypoxic exercise in goats. To determine carotid body (CB) mediated effects of increased NE on ventilatory control, we investigated ventilatory responses to intracarotid NE infusions in awake, resting goats. NE was infused (0.5-5.0 micrograms.kg-1 x min-1, 2-3 min) into either a CB intact or contralateral CB-denervated carotid artery in both normoxia and hypoxia (FIO2. = 0.11). PRE-infusion measurements of arterial blood gases, blood pressure and pulmonary ventilation (VI) were compared with values 30-45 sec after beginning NE infusions at 1.0 micrograms.kg-1 x min-1. On the CB-intact side, NE infusions decreased VI by an average of 43% (P < 0.05) and increased PaCO2 4.0 +/- 0.3 mmHg (P < 0.05); ventilatory inhibition preceded an increase in arterial blood pressure. NE infusions on the CB-denervated side had no significant effects on VI or PaCO2, but still increased blood pressure to the same level as infusions on the CB-intact side. In hypoxia, NE infusions on the intact side no longer inhibited VI. NE induced VI inhibition in normoxia was similar in magnitude and time course to dopamine induced VI inhibition. Experiments were repeated following administration the alpha-adrenergic receptor antagonist, phenoxybenzamine (1 mg.kg-1, i.v.) the beta-adrenergic receptor antagonist, propranolol (1 mg.kg-1, i.v.) and the D2-dopamine receptor antagonist, domperidone (1 mg.kg-1, i.v.). Phenoxybenzamine partially blocked NE induced ventilatory depression and domperidone blocked it, but propranolol had no effect. These data indicate that NE inhibits ventilation in goats via effects on carotid chemoreceptors. NE induced inhibition is independent of changes in blood pressure or baroreceptor feedback, and appears to involve both alpha-adrenergic and D2-dopaminergic receptors.

Role of catecholamines and beta-receptors in ventilatory response during hypoxic exercise

The ventilatory response to moderate exercise in hypoxia is potentiated in goats, decreasing PaCO2 more than in normoxic exercise. We investigated the hypothesis that this potentiation results from a ventilatory stimulus provided by increased levels of circulating catecholamines (norepinephrine and/or epinephrine), acting via beta-receptors. Plasma norepinephrine [NE] and epinephrine [E] concentrations, arterial blood gases and ventilation were measured in normoxia and hypoxia (PaO2 = 34-38 Torr) at rest and during moderate exercise (5.6 kph; 5% grade) in seven female goats. PaCO2 decreased from rest to exercise in normoxia (2.9 +/- 0.7 Torr; P less than 0.01), and decreased significantly more from rest during hypoxic exercise (6.4 +/- 0.6 Torr; P less than 0.01). [NE] increased in both normoxic (1.1 +/- 0.4 ng/ml; P less than 0.05) and hypoxic exercise (2.5 +/- 0.5 ng/ml; P less than 0.01); the [NE] increase in hypoxia was significantly greater (P less than 0.01). [E] increased in normoxic (0.3 +/- 0.1 ng/ml; P less than 0.05) but not hypoxic exercise (0.6 +/- 0.5 ng/ml; P greater than 0.2). Experiments were repeated following administration of the beta-adrenergic receptor blocker, propranolol (2 mg/kg, i.v.). After beta-blockade, PaCO2 decreases from rest to exercise in normoxia (3.2 +/- 0.7 Torr; P less than 0.01) and hypoxia (8.1 +/- 0.7 Torr; P less than 0.001) were not significantly different from control. The data indicate that beta-adrenergic receptor stimulation is not necessary for a greater decrease in PaCO2 during hypoxic versus normoxic exercise. The greater rise in [NE] suggests a possible role in ventilatory control during hypoxic exercise, perhaps via alpha-adrenergic receptors. However, recent evidence suggests that NE is inhibitory in goats, and that NE is unlikely to mediate extra ventilatory stimulation during hypoxic exercise.

Ventilatory responses to hyperkalemia and exercise in normoxic and hypoxic goats

The ventilatory response to moderate exercise is potentiated during hypoxia in goats, causing PaCO2 to decrease more from rest to exercise than in normoxia. We investigated the hypothesis that this response is due to the ventilatory stimulus provided by an interaction between exercise induced hyperkalemia and hypoxia. Plasma potassium concentration ([K+]), arterial blood gases and ventilation were measured in normoxia and hypoxia (PaO2 = 34-38 Torr) at rest and during steady-state exercise (5.6 kph; 5% grade) in seven goats. PaCO2 decreased during normoxic exercise (2.9 +/- 0.7 Tor; P less than 0.01), and decreased significantly more during hypoxic exercise (6.4 +/- 0.6 Torr; P less than 0.01). [K+] increased in both normoxic (1.0 +/- 0.1 mEq/L; P less than 0.01) and hypoxic (0.9 +/- 0.2 mEq/L; P less than 0.01) exercise, but these changes were not significantly different from each other. On a different day, resting goats were infused intravenously with 200 mM KCl for 5 min at a rate sufficient to obtain [K+] similar to exercise (8.6-12 ml/min) in normoxia and hypoxia. Hyperkalemia at rest caused similar PaCO2 decreases in normoxia (1.7 +/- 0.7 Torr; P less than 0.05) and hypoxia (1.7 +/- 0.5 Torr; P less than 0.01), but had no statistically significant effect on ventilation in either condition. These data indicate that hyperkalemia, at levels approximating those during moderate exercise, has a mild stimulatory effect on alveolar ventilation; however, hypoxia does not affect this response. We conclude that hyperkalemia does not provide sufficient ventilatory stimulation to account for exercise hyperpnea, nor does hypoxia potentiate the ventilatory stimulation from hyperkalemia at rest.

Visual imagery and self-questioning: strategies to improve comprehension of written material

Two learning strategies, visual imagery and self-questioning, designed to increase reading comprehension, were taught to six learning disabled students using a multiple baseline across strategies design. The visual imagery strategy requires the student to read a passage and to create visual images representative of the content of the passage. The self-questioning strategy teaches the student to form questions about the content of a passage as he or she reads to maintain interest and to enhance recall. Specific instructional procedures were followed that included: (a) testing the student's current level of functioning, (b) describing the strategy, (c) modeling the strategy, (d) verbal rehearsal of strategy steps, (e) practice in reading ability level material, and (f) practice in grade level material.

Consumers, family physicians, allied health workers, and sociomedical problems

Patients and doctors have differing opinions about the role of family physicians. These opinions were sampled by two questionnaires and the results suggest that family physicians have, for example, high expectations of themselves and their psychiatric colleagues whereas patients expect other allied health professionals to play a significant role in providing care.

Patient or consumer? Implications for family physicians

Canada has the opportunity to plan its health care delivery systems. The role of the family doctor is at the least uncertain. But, more important, are present modes of operation and education relevant for the current task? If not, increasing pressures will be brought to bear by governments, locally elected officials and most of all by patients turned consumers of service. This article discusses the role, nationally and internationally, of the family doctor and also that of the patient as consumer. The author makes suggestions for areas of research.