Care Settings (care + setting)

Distribution by Scientific Domains
Distribution within Medical Sciences

Kinds of Care Settings

  • acute care setting
  • ambulatory care setting
  • critical care setting
  • different health care setting
  • emergency care setting
  • health care setting
  • intensive care setting
  • long-term care setting
  • medical care setting
  • primary care setting
  • secondary care setting
  • social care setting
  • tertiary care setting

  • Selected Abstracts


    Jennifer Watson
    ABSTRACT: This project emerged from the concerns of health care professionals at a large acute care hospital in the Northern Territory of Australia. The aim of the project was to develop educational resources through information and experiences provided by Aboriginal and Torres Strait Islander women and health care professionals. The objectives are to optimise collaboration and participation by Indigenous and Torres Strait Islander women in sharing their maternity experiences about the birthing of their baby either in hospital, or out of hospital before arrival. Stage one of a three stage project is reported here. In stage one a modified Delphi method was used to interview ten purposefully chosen professional Indigenous women with insight into the research process and changing social arrangements. Stage two involved the development of an interview schedule and face-to-face interviews. Stage three includes the development of a questionnaire to be answered by health care professionals. Discussion of the background to the study, reviewed literature and issues identified from interviews with the professional Indigenous women regarding best methods and appropriate data collection processes is presented. Research described here explores issues of concern for Indigenous women from the Northern Territory around their child birthing experiences in an acute care setting. [source]


    Jennifer Watson
    ABSTRACT: This is the report of stage two of a three-stage project. The aim of the project is to develop educational resources through information and experiences provided by Aboriginal and Torres Strait Islander women and health care professionals. The objectives were to optimise collaboration and participation by Indigenous and Torres Strait Islander women in sharing their maternity experiences about the birthing of their babies either in hospital, or out of hospital before arrival. The descriptive research of stage two explores issues that existed for twelve Indigenous women during and after their birthing experiences in an acute care setting. The results will inform patient and professional educational programs and policy in order to enhance the experiences for Indigenous women admitted to the acute care setting before or following birth. The results show broad variation in responses related to antenatal care, preparation for hospital and for birth, coming into town, accommodation, family support, experiences while in hospital, relationship with hospital staff and being away from home. Miscommunication and lack of cultural and spiritual understanding by health care professionals generally is a constant theme. The need for preparation of Indigenous women generally, prior to admission to an acute care setting, is confirmed. [source]


    Nadia Chaves
    No abstract is available for this article. [source]

    Migraine Education Improves Quality of Life in a Primary Care Setting

    HEADACHE, Issue 4 2010
    Timothy R. Smith MD
    (Headache 2010;50:600-612) Objective., The objective of this study was to evaluate the effectiveness of the Mercy Migraine Management Program (MMMP), an educational program for physicians and patients. The primary outcome was change in headache days from baseline at 3, 6, and 12 months. Secondary outcomes were changes in migraine-related disability and quality of life, worry about headaches, self-efficacy for managing migraines, emergency room (ER) visits for headache, and satisfaction with headache care. Background., Despite progress in the understanding of the pathophysiology of migraine and development of effective therapeutic agents, many practitioners and patients continue to lack the knowledge and skills to effectively manage migraine. Educational efforts have been helpful in improving the quality of care and quality of life for migraine sufferers. However, little work has been performed to evaluate these changes over a longer period of time. Also, there is a paucity of published research evaluating the influence of education about migraine management on cognitive and emotional factors (for example, self-efficacy for managing headaches, worry about headaches). Methods., In this open-label, prospective study, 284 individuals with migraine (92% female, mean age = 41.6) participated in the MMMP, an educational and skills-based program. Of the 284 who participated in the program, 228 (80%) provided data about their headache frequency, headache-related disability (as measured by the Headache Impact Test-6 (HIT-6), migraine-specific quality of life (MSQ), worry about headaches, self-efficacy for managing headaches, ER visits for headaches, and satisfaction with care at 4 time points over 12 months (baseline, 3 months, 6 months, 12 months). Results., Overall, 46% (106) of subjects reported a 50% or greater reduction in headache frequency. Over 12 months, patients reported fewer headaches and improvement on the HIT-6 and MSQ (all P < .001). The improvement in headache impact and quality of life was greater among those who had more worry about their headaches at baseline. There were also significant improvements in "worry about headaches,""self-efficacy for managing headaches," and "satisfaction with headache care." Conclusion., The findings demonstrate that patients participating in the MMMP reported improvements in their headache frequency as well as the cognitive and emotional aspects of headache management. This program was especially helpful among those with high amounts of worry about their headaches at the beginning of the program. The findings from this study are impetus for further research that will more clearly evaluate the effects of education and skill development on headache characteristics and the emotional and cognitive factors that influence headache. [source]

    Determining Critical Incident Nursing Interventions for the Critical Care Setting: A Pilot Study

    Elizabeth Wong CRNA
    PURPOSE., The purpose of this research survey was to determine which Adult Critical Care Core Nursing Interventions (ACCCNIs) in the Nursing Interventions Classification constitutes a critical incident nursing intervention (CINI). A CINI is defined as any indirect or direct care registered nurse (RN)-initiated treatment performed in response to a life-threatening nursing diagnosis. METHODS., A list of ACCCNIs were sent to 50 critical care RNs in two survey rounds. Responses >80% for each ACCCNI was determined to be a CINI. FINDINGS., Forty-one ACCCNIs were determined to be CINIs. CONCLUSIONS., It is recommended that CINIs be included as a separate Nursing Intervention Classification category to reflect current nursing practice. IMPLICATIONS FOR NURSING PRACTICE., CINIs can enhance RN competency, education, and vigilance, thereby preventing or decreasing the number of deaths that occur from critical incidents. [source]

    Nursing-Sensitive Outcome Reliability Testing in a Tertiary Care Setting

    Julia G. Behrenbeck MS
    purpose., To describe nursing outcomes classification (NOC) that are most relevant for, specialty acute care nursing practice, and to assess the adequacy of measures. methods., Data were collected on 434 patients during the 14-month data collection period at a tertiary care center: cardiac surgery intensive care (n = 76), cardiac transplant unit (n = 153), and medical unit (n = 205). findings., Thirty-six NOC outcomes were used 10 or more times during the study. Of those, 16 had an inter-rater reliability of 75% or higher. conclusions., NOC outcomes show promise for accurately documenting the effectiveness of nursing interventions. Further study is needed to develop meaningful analysis of the documented NOC outcomes and efficiently integrate NOC into electronic documentation systems. practice implications., Increased familiarity with NOC allowed nursing staff to determine which outcomes comprise core nursing-sensitive outcomes for their clinical setting. [source]

    Nursing-Sensitive Outcome Implementation and Reliability Testing in a Tertiary Care Setting

    Julia G. Behrenbeck
    PURPOSE To describe the NOC outcomes most relevant for specialty nursing practice and in selected field sites representing the continuum of care; to assess the adequacy of measures (reliability, validity, sensitivity, specificity, practicality); and to describe the linkages among nursing diagnoses, interventions, and outcomes in clinical decision making. METHODS Data were collected on 434 patients during the 12-month data collection period at a tertiary care center: cardiac surgery intensive care (n= 76), cardiac transplant unit (n= 153), and medical unit (n= 205). Medical diagnoses of patients on the two cardiac units were related to cardiac disease. Medical diagnoses of patients on the medical unit were extremely varied (ranging from e.g., gout to pneumonia). Data were collected on 65 separate outcome labels for a total of 633 ratings. FINDINGS In the cardiac transplant ICU, data were collected on 42 outcomes: 30 had an average interrater reliability of ,85%, and 16 had an absolute agreement interrater reliability of ,85%. In the cardiac surgery ICU, data were collected on 30 outcomes: 25 had an average interrater reliabilty of ,85%, 6 had an absolute agreement interrater of ,85%. In the medical unit, data were collected on 45 outcomes: 41 had an average interrater reliability of ,85%, 14 had an absolute agreement interrater reliability of ,85%. Four outcomes have been implemented into the documentation system for all patients: Tissue Integrity: Skin and Mucous Membranes, Mobility Level, Knowledge: Disease Process, and Coping. CONCLUSIONS Overall, nursing staff were very positive about having the opportunity to participate in nursing research. Staff were able to think about the relative status of their patient and how nursing care contributes to the patient's recovery. They appreciated the opportunity to discuss this with a colleague during the interrater exercise. Increased familiarity with NOC allows staff members to determine which outcomes comprise core nursing-sensitive outcomes for their clinical setting. [source]

    Development and Validation of Quality Indicators for Dementia Diagnosis and Management in a Primary Care Setting

    Marieke Perry MD
    OBJECTIVES: To construct a set of quality indicators (QIs) for dementia diagnosis and management in a primary care setting. DESIGN: RAND modified Delphi method, including a postal survey, a stakeholders consensus meeting, a scientific expert consensus meeting, and a demonstration project. SETTING: Primary care. PARTICIPANTS: General practitioners (GPs), primary care nurses (PCNs), and informal caregivers (ICs) in postal survey and stakeholders consensus meeting. Eight national dementia experts in scientific consensus meeting. Thirteen GPs in the demonstration project. MEASUREMENTS: Mean face validity and feasibility scores. Compliance rates using GPs' electronic medical record data. RESULTS: The initial set consisted of 31 QIs. Most indicators showed moderate or good face validity and feasibility scores. Consensus panels reduced the preliminary set used in the demonstration project to 24 QIs. The overall compliance to the QIs was 45.3%. Discriminative validity of the set was good; significant differences in adherence were found between GPs with high and low levels of patients aged 65 and older in their practice, with and without PCNs, and with positive and negative attitudes toward dementia (all P<.05). Based on the demonstration project, one QI was excluded. The final set consisted of 23 QIs; 15 QIs contained innovative quality criteria on collaboration between GPs and PCNs, referral criteria, and assessment of caregivers' needs. CONCLUSION: This new set of dementia QIs is feasible, reliable, and valid and can be used to improve primary dementia care. Because of the innovative quality criteria, the set is complementary to the existing dementia QIs. [source]

    Will Psychiatry Survive in the Long-Term Care Setting?

    Richard J. Goldberg MD
    No abstract is available for this article. [source]

    Computerized Physician Order Entry with Clinical Decision Support in the Long-Term Care Setting: Insights from the Baycrest Centre for Geriatric Care

    Paula A. Rochon MD
    Although computerized physician order entry (CPOE) has been successfully implemented in many acute care hospitals, few descriptions of its use in the long-term care (LTC) setting are available. This report describes the experiences of one LTC facility in developing and implementing a CPOE system with clinical decision support (CDS). Even when a facility has the necessary resources and "institutional will," many challenges are associated with the implementation of this application. The system was designed to meet the needs of healthcare providers in the LTC setting, in particular by informing prescribing decisions, reducing the frequency of prescribing and monitoring errors, and reducing adverse drug event rates. Based on experience adopting this technology early, 10 insights are offered that it is hoped will assist others who are considering the implementation of CPOE systems with CDS in the LTC setting. [source]

    Preventing Pediatric Obesity: Assessment and Management in the Primary Care Setting

    FAANP, Lorna Schumann PhD
    Purpose To review the literature on and discuss the role of the primary care provider in assessing and managing overweight children before they become obese. Data Sources Selected research, national guidelines and recommendations, and the professional experience of the authors. Conclusions The focus of primary care involves early detectionand family interventions that are designed for lifestyle modifications, specifically for improved nutrition and an increase in regular physical activity, to achieve optimal child health. Early identification and management of children who exceed a healthy weight for height, gender, and age will prevent the increasing incidence of pediatric obesity. Early prevention and management of pediatric overweight and obesity will also decrease the potential for associated medical and psychosocial problems. Implications For Practice Pediatric obesity has risen dramatically in the United States during the last two decades; it is a significant child health problem that is preventable and largely under-diagnosed and under-treated. It is essential to discuss prevention of obesity with parents at every well-child visit; treatment should be initiated when patterns of weight gain exceed established percentiles for increasing height for age and gender. [source]

    Skin Cancer Prevention in the Primary Care Setting: Assessment Using a Standardized Patient

    M.P.H., Robin L. Hornung M.D.
    A secondary goal was to test the feasibility of this technique as a measure of actual physician behaviors in the outpatient setting. We used a convenience sample of 15 primary care physicians. The standardized patient was an 18-year-old woman with skin phototype I. She presented to physicians as needing a general physical examination for a summer lifeguard job at a beach. She stated a family history of skin cancer. Physician performances were rated using a standard checklist completed by the standardized patient following each visit. We found that none of the physicians asked questions specifically related to skin phototype or sun exposure habits such as childhood sunburns. Only 13% asked about mole changes. For counseling, 67% of physicians recommended sunscreen use; only 7% discussed sunscreen types or procedures for effective use. Only 13% counseled other skin protective behaviors. No significant differences by physician gender were found in these areas; however, female physicians counseled more global health behaviors than male physicians (p , 0.01). Our pilot data suggest that little skin cancer primary prevention counseling is performed for high-risk patients. The standardized patient technique worked well in obtaining outcome data for physicians' preventive practices. [source]

    Hope as an Outcome Variable Among Youths in a Residential Care Setting

    Rodney McNeal PhD
    This study investigated changes in hope among 155 youths (ages 10 to 17 years) placed in a residential treatment facility over a 6,month period. The child and adolescent participants met criteria for a range of emotional and behavioral disorders and received interventions hypothesized to improve hopeful thinking. Hope scores significantly improved over 6 months of treatment. The positive changes in hope were not moderated by ethnicity or sex. For Agency hope scores (i.e., willpower), those with higher levels of psychopathology at admission demonstrated significantly more improvement in agency thinking over the course of 6 months. [source]

    Tolerability of High Doses of Lercanidipine versus High Doses of Other Dihydropyridines in Daily Clinical Practice: The TOLERANCE Study

    Vivencio Barrios
    The TOLERANCE study was aimed to compare the tolerability of high doses of lercanidipine (20 mg) with that of other frequently used dihydropyridines (amlodipine 10 mg/nifedipine GITS 60 mg) in the treatment of essential hypertension in daily clinical practice. It was an observational, transversal, multicentre study performed in a Primary Care Setting. A total of 650 evaluable patients with essential hypertension and age , 18 years were included. They had been treated with high doses of lercanidipine (n= 446) or amlodipine/nifedipine GITS (n= 204) during at least 1 month and previously with low doses (10 mg, 5 mg, and 30 mg, respectively) of the same drugs. The main objective was to compare the rates of vasodilation-related adverse events between both groups. Rates of signs and symptoms related to vasodilation were significantly higher (P < 0.001) in the amlodipine/nifedipine GITS group (76.8%, CI 95%[70.7; 82.9]) than in lercanidipine group (60.8%, [56.1;65.5]). Blood pressure control (< 140/90 mmHg or <130/80 for diabetics) and type of concomitant antihypertensive medications were similar in both groups. Treatment compliance was good (around 93%) and fairly comparable in both groups. Most adverse events with lercanidipine were mild (74.5% vs. 64% in amlodipine/nifedipine GITS group, P= 0.035) whereas severe adverse event rates did not differ significantly between groups (2.8% vs. 3.6%). In conclusion, treatment with lercanidipine at high doses is associated with a lower rate of adverse events related to vasodilation compared to high doses of amlodipine or nifedipine GITS in clinical practice. [source]

    The Costs of Childhood Epilepsy in Italy: Comparative Findings from Three Health Care Settings

    EPILEPSIA, Issue 5 2001
    R. Guerrini
    Summary: ,Purpose: To determine the direct costs of epilepsy in a child neurology referral population, stratified by disease, duration, and severity, comparing three different health care settings [i.e., teaching or clinical research (CR) hospitals, general hospitals, and outpatient services]. Methods: Patients were accepted if they had confirmed epilepsy and were resident in the center catchment area. Eligible subjects were grouped in the following categories: (a) newly diagnosed patients; (b) patients with epilepsy in remission; (c) patients with active non,drug-resistant epilepsy; and (d) those with drug-resistant epilepsy. Over a 12-month period, data regarding the consuming of all resources (i.e., consultations, tests, hospital admissions, drugs), were collected for each patient. Using the Italian National Health Service tariffs, the unit cost of each resource was calculated and indicated in Euros, the European currency. Results: A total of 189 patients was enrolled by two teaching-CR hospitals, two general hospitals, and two outpatient services. The patients were evenly distributed across the four categories of epilepsy. The mean annual cost per person with epilepsy was 1,767 Euros. Drug-resistant epilepsy was the most expensive category (3,268 Euros) followed by newly diagnosed epilepsy (1,907 Euros), active non,drug-resistant epilepsy (1,112 Euros), and epilepsy in remission (844 Euros). Costs were generally highest in teaching-CR hospitals and lowest in outpatient services. Hospital services were the major cost in all epilepsy groups, followed by drugs. Conclusions: The cost of epilepsy in children and adolescents in Italy tends to vary significantly depending on the severity and duration of the disease Hospitals services and drugs are the major sources of costs. The setting of health care plays a significant role in the variation of the costs, even for patients in the same category of epilepsy. [source]

    Books and Materials Reviews

    FAMILY RELATIONS, Issue 4 2001
    Article first published online: 19 FEB 200
    Baumeister, R. F. (Ed.). (1999). The Self in Social Psychology. Carter, B., & McGoldrick, M. (1999). The Expanded Family Life Cycle: Individual, Family, and Social Perspectives. Dwyer, D. (2000). Interpersonal Relationships. Knauer, S. (2000). No Ordinary Life: Parenting the Sexually Abused Child and Adolescent. McNair-Blatt, S. (2000). A Guidebook for Raising Foster Children. Stafford-Upshaw, F., & Myers-Walls, J. A. (1999). Learning Centers in Child Care Settings. Seymour, S. C. (1999). Women, Family and Child Care in India: A World in Transition. Berger, R. (1998). Stepfamilies: A Multi-Dimensional Perspective. [source]

    Evidence-Based Recommendations for the Assessment and Management of Sleep Disorders in Older Persons

    AGSF, Harrison G. Bloom MD
    Sleep-related disorders are most prevalent in the older adult population. A high prevalence of medical and psychosocial comorbidities and the frequent use of multiple medications, rather than aging per se, are major reasons for this. A major concern, often underappreciated and underaddressed by clinicians, is the strong bidirectional relationship between sleep disorders and serious medical problems in older adults. Hypertension, depression, cardiovascular disease, and cerebrovascular disease are examples of diseases that are more likely to develop in individuals with sleep disorders. Conversely, individuals with any of these diseases are at a higher risk of developing sleep disorders. The goals of this article are to help guide clinicians in their general understanding of sleep problems in older persons, examine specific sleep disorders that occur in older persons, and suggest evidence- and expert-based recommendations for the assessment and treatment of sleep disorders in older persons. No such recommendations are available to help clinicians in their daily patient care practices. The four sections in the beginning of the article are titled, Background and Significance, General Review of Sleep, Recommendations Development, and General Approach to Detecting Sleep Disorders in an Ambulatory Setting. These are followed by overviews of specific sleep disorders: Insomnia, Sleep Apnea, Restless Legs Syndrome, Circadian Rhythm Sleep Disorders, Parasomnias, Hypersomnias, and Sleep Disorders in Long-Term Care Settings. Evidence- and expert-based recommendations, developed by a group of sleep and clinical experts, are presented after each sleep disorder. [source]

    End-of-Life Care in Assisted Living and Related Residential Care Settings: Comparison with Nursing Homes

    Philip D. Sloane MD
    Objectives: To define the current state of end-of-life care in residential care/assisted living (RC/AL) facilities and nursing homes (NHs) and to compare these two types of care settings. Design: Interviews of staff and family informants about deaths that occurred during a longitudinal study. Setting: Fifty-five RC/AL facilities and 26 NHs in Florida, Maryland, New Jersey, and North Carolina. Participants: Two hundred twenty-four staff and family informants that best knew the 73 RC/AL residents and 72 NH residents who died in or within 3 days after discharge from a study facility. Measurements: Telephone interviews conducted with the facility staff member who knew the decedent best and the family member who was most involved in care during the last month of life of the decedent. Data were collected on circumstances of death, perceptions of dying process, cause of death, care during the last month of life, mood, discomfort, and family satisfaction. Results: Most decedents died in the facility where they had resided, and more than half of the subjects were alone when they died. Greater proportions of staff and family in the NHs knew that the resident's death was only days or weeks away. Both RC/AL and NH residents experienced few highly negative moods, and even on their most uncom-fortable day, the overall discomfort was low for residents in both facility types. Summary ratings of family satisfaction were significantly higher for the RC/AL (32.1) than the NH (41.2) group (P=.016). Conclusion: These data suggest that end-of-life care in RC/AL settings appears similar in process and outcomes to that provided in NHs. Thus, aging and dying-in-place can effectively occur in RC/AL. [source]

    Nurses' Perceptions of Safety Culture in Long-Term Care Settings

    Laura M. Wagner RN
    Abstract Purpose: To describe perceptions of workplace safety culture among nurses employed in long-term care (LTC) settings. Design: A cross-sectional survey. Respondents were licensed nurses (N=550) with membership in gerontological nursing professional organizations in the United States (n=296), Canada (n=251), and other (n=3). Methods: An anonymous, self-administered, mail-in questionnaire, which included the Hospital Survey on Patient Safety Culture as well as questions about individual and institutional characteristics. The survey included key aspects of safety culture, such as work setting, supervisor support, communication about errors, and frequency of events reported. Findings: Nurse-managers reported significantly more positive safety culture perceptions compared with licensed staff nurses. Additionally, licensed nurses employed in government-run facilities had significantly less positive safety culture perceptions compared with those working in nonprofit organizations. Conclusions: Interventions designed to improve safety culture in LTC settings should be focused on the concerns of licensed staff nurses and the improvement of communication between these nurses and their managers. Clinical Relevance: Enhancing safety culture in long-term care settings may facilitate improvements in resident safety. Assessment of workplace safety culture is the first step in identifying barriers that nurses face to provide safe resident care. [source]

    Nutrition and Physical Activity Interventions to Reduce Cardiovascular Disease Risk in Health Care Settings: A Quantitative Review with a Focus on Women

    NUTRITION REVIEWS, Issue 7 2001
    Sara Wilcox Ph.D.
    The authors conducted a quantitative literature review of the impact of 32 diet and physical activity (PA) interventions delivered in health care settings on cardiovascular disease risk factors. Intervention effects were relatively modest but statistically significant for PA, body mass index or weight, dietary fat, blood pressure, and total and low-density lipoprotein serum cholesterol. Intervention effects were generally larger for samples with a mean age >50 years and for studies with <6 months follow-up. Type of comparison group, type of intervention, and use of a behavior theory did not have a consistent impact on intervention effects. Few studies focused on persons of color, although the results from these studies are promising. [source]

    SBIRT in Emergency Care Settings: Are We Ready to Take it to Scale?

    Edward Bernstein MD
    Abstract This article summarizes a panel discussion on "SBIRT in the emergency care setting: are we ready to take it to scale?" Dr. Edward Bernstein commented on the historical developments of emergency department (ED) screening, brief intervention (BI), and referral to treatment (SBIRT) research, practice, and knowledge translation. Dr. Jack Stein addressed SBIRT grant program progress to date, the reimbursement stream, SBIRT lessons learned, and unanswered questions. Dr. Richard Saitz reviewed the limitations of the evidence for alcohol and drug ED screening and BI and cautioned on the danger of proceeding to practice and broad dissemination without evidenced based on randomized controlled trials with sufficient sample size and clinically important outcomes. [source]

    Conceptual Models of Health Behavior: Research in the Emergency Care Settings

    Edwin D. Boudreaux PhD
    Abstract This article provides recommendations for incorporating conceptual models of health behavior change into research conducted in emergency care settings. The authors drafted a set of preliminary recommendations, which were reviewed and discussed by a panel of experienced investigators attending the 2009 Academic Emergency Medicine consensus conference. The original recommendations were expanded and refined based on their input. This article reports the final recommendations. Three recommendations were made: 1) research conducted in emergency care settings that focuses on health behaviors should be grounded in formal conceptual models, 2) investigators should clearly operationalize their outcomes of interest, and 3) expected relations between theoretical constructs and outcomes should be made explicit prior to initiating a study. A priori hypothesis generation grounded in conceptual models of health behavior, followed by empirical validation of these hypotheses, is needed to improve preventive and public health,related interventions in emergency care settings. [source]

    The usage of a simplified self-titration dosing guideline (303 Algorithm) for insulin detemir in patients with type 2 diabetes , results of the randomized, controlled PREDICTIVE‘ 303 study

    L. Meneghini
    The Predictable Results and Experience in Diabetes through Intensification and Control to Target: An International Variability Evaluation 303 (PREDICTIVE‘ 303) Study (n = 5604) evaluated the effectiveness of insulin detemir, a long-acting basal insulin analogue, using a simplified patient self-adjusted dosing algorithm (303 Algorithm group) compared with standard-of-care physician-driven adjustments (Standard-of-care group) in a predominantly primary care setting, over a period of 6 months. Insulin detemir was to be started once-daily as add-on therapy to any other glucose-lowering regimens or as a replacement of prestudy basal insulin in patients with type 2 diabetes. Investigator sites rather than individual patients were randomized to either the 303 Algorithm group or the Standard-of-care group. Patients from the 303 Algorithm group sites were instructed to adjust their insulin detemir dose every 3 days based on the mean of three ,adjusted' fasting plasma glucose (aFPG) values (capillary blood glucose calibrated to equivalent plasma glucose values) using a simple algorithm: mean aFPG < 80 mg/dl (<4.4 mmol/l), reduce dose by 3 U; aFPG between 80 and 110 mg/dl (4.4,6.1 mmol/l), no change; and aFPG > 110 mg/dl (>1.1 mmol/l), increase dose by 3 U. The insulin detemir dose for patients in the Standard-of-care group was adjusted by the investigator according to the standard of care. Mean A1C decreased from 8.5% at baseline to 7.9% at 26 weeks for the 303 Algorithm group and from 8.5 to 8.0% for the Standard-of-care group (p = 0.0106 for difference in A1C reduction between the two groups). Mean FPG values decreased from 175 mg/dl (9.7 mmol/l) at baseline to 141 mg/dl (7.8 mmol/l) for the 303 Algorithm group and decreased from 174 mg/dl (9.7 mmol/l) to 152 mg/dl (8.4 mmol/l) for the Standard-of-care group (p < 0.0001 for difference in FPG reduction between the two groups). Mean body weight remained the same at 26 weeks in both groups (change from baseline 0.1 and ,0.2 kg for the 303 Algorithm group and the Standard-of-care group respectively). At 26 weeks, 91% of the patients in the 303 Algorithm group and 85% of the patients in the Standard-of-care group remained on once-daily insulin detemir administration. The rates of overall hypoglycaemia (events/patient/year) decreased significantly from baseline in both groups [from 9.05 to 6.44 for the 303 Algorithm group (p = 0.0039) and from 9.53 to 4.95 for the Standard-of-care group (p < 0.0001)]. Major hypoglycaemic events were rare in both groups (0.26 events/patient/year for the 303 Algorithm group and 0.20 events/patient/year for the Standard-of-care group; p = 0.2395). In conclusion, patients in the 303 Algorithm group achieved comparable glycaemic control with higher rate of hypoglycaemia as compared with patients in the Standard-of-care group, possibly because of more aggressive insulin dose adjustments. The vast majority of the patients in both groups were effectively treated with once-daily insulin detemir therapy. The use of insulin detemir in this predominantly primary care setting achieved significant improvements in glycaemic control with minimal risk of hypoglycaemia and no weight gain. [source]

    The Audit Commission review of diabetes services in England and Wales, 1998,2001

    B. Fitzsimons
    Abstract Aims of the Audit Commission The Audit Commission has a statutory duty to promote the best use of public money. It does this through value for money studies, such as that reported in Testing Times[1]. This work has been followed with a review of innovative practice in commissioning. These initiatives aim to support the implementation of the diabetes national service framework. The Audit Commission also appoints external auditors to NHS organizations who assess probity and value for money in the NHS; the latter by applying national studies locally and by carrying out local studies. Methods Research for Testing Times consisted of structured visits to nine acute trusts, a telephone survey of 26 health authorities and a postal survey of 1400 people with diabetes and 250 general practitioners. Local audits used a subset of the original research tools. Case studies were identified through a cascade approach to contacts established during Testing Times and through self-nomination. Results Rising numbers of people with diabetes are placing increasing pressure on hospital services. Some health authorities and primary care organizations have reviewed patterns of service provision in the light of the increasing demands. These reviews show wide variations in patterns of routine care. In addition, there is a widespread lack of data on the delivery of structured care to people with diabetes. People with diabetes report delays in gaining access to services, and insufficient time with staff. There are insufficient arrangements in place for providing information and learning opportunities to support self-management. Conclusion As the number of people with diabetes continues to rise, the potential for providing more care in a primary care setting needs to be explored. This will enable specialist services to focus more effectively on those with the most complex needs. [source]

    Ethnic differences in drinking outcomes following a brief alcohol intervention in the trauma care setting

    ADDICTION, Issue 1 2010
    Craig A. Field
    ABSTRACT Background Evidence suggests that brief interventions in the trauma care setting reduce drinking, subsequent injury and driving under the influence (DUI) arrest. However, evidence on the effectiveness of these interventions in ethnic minority groups is lacking. The current study evaluates the efficacy of brief intervention among whites, blacks and Hispanics in the United States. Methods We conducted a two-group parallel randomized trial comparing brief motivational intervention (BMI) and treatment as usual with assessment (TAU+) to evaluate treatment differences in drinking patterns by ethnicity. Patients were recruited from a level 1 urban trauma center over a 2-year period. The study included 1493 trauma patients, including 668 whites, 288 blacks and 537 Hispanics. Hierarchical linear modeling was used to evaluate ethnic differences in drinking outcomes including volume per week, maximum amount consumed in 1 day, percentage days abstinent and percentage days heavy drinking at 6- and 12-month follow-up. Analyses controlled for age, gender, employment status, marital status, prior alcohol treatment, type of injury and injury severity. Special emphasis was given to potential ethnic differences by testing the interaction between ethnicity and BMI. Results At 6- and 12-month follow-up, BMI significantly reduced maximum amount consumed in 1 day (P < 0.001; P < 0.001, respectively) and percentage days heavy drinking (P < 0.05; P < 0.05, respectively) among Hispanics. Hispanics in the BMI group also reduced average volume per week at 12-month follow-up (,2 = 6.8, df = 1, P < 0.01). In addition, Hispanics in TAU+ reduced maximum amount consumed at 6- and 12-month follow-up (P < 0.001; P < 0.001) and volume per week at 12-month follow-up (P < 0.001). Whites and blacks in both BMI and TAU+ reduced volume per week and percentage days heavy drinking at 12-month follow-up (P < 0.001; P < 0.01, respectively) and decreased maximum amount at 6- (P < 0.001) and 12-month follow-up (P < 0.001). All three ethnic groups In both BMI and TAU+ reduced volume per week at 6-month follow-up (P < 0.001) and percentage days abstinent at 6- (P < 0.001) and 12-month follow-up (P < 0.001). Conclusions All three ethnic groups evidenced reductions in drinking at 6- and 12-month follow-up independent of treatment assignment. Among Hispanics, BMI reduced alcohol intake significantly as measured by average volume per week, percentage days heavy drinking and maximum amount consumed in 1 day. [source]

    Determinants of successful chronic hepatitis C case finding among patients receiving opioid maintenance treatment in a primary care setting

    ADDICTION, Issue 12 2009
    Oliver Senn
    ABSTRACT Aims Injection drug users are at high risk for chronic hepatitis C virus infection (CHC). Opioid maintenance treatment (OMT) offers a unique opportunity to screen for CHC. This study proposed the hypothesis that a general practitioner (GP) with special interest in addiction medicine can achieve CHC screening rates comparable to specialized centres and aimed to investigate determinants for a successful CHC case finding in a primary care setting. Design and participants Retrospective medical record analysis of 387 patients who received opioid maintenance therapy between 1 January 2002 and 31 May 2008 in a general practice in Zurich, Switzerland. Measurements Successful CHC assessment was defined as performance of hepatitis C virus (HCV) serology with consecutive polymerase chain reaction-based RNA and genotype recordings. The association between screening success and patient characteristics was assessed using multiple logistic regression. Findings Median (interquartile range) age and duration of OMT of the 387 (268 males) patients was 38.5 (33.6,44.5) years and 34 (11.3,68.0) months, respectively. Fourteen patients (3.6%) denied HCV testing and informed consent about screening was missing in 13 patients (3.4%). In 327 of 360 patients (90.8%) with informed consent a successful CHC assessment has been performed. Screening for HCV antibodies was positive in 136 cases (41.6%) and in 86 of them (63.2%) a CHC was present. The duration of OMT was an independent determinant of a successful CHC assessment. Conclusions In addicted patients a high CHC assessment rate in a primary care setting in Switzerland is feasible and opioid substitution provides an optimal framework. [source]

    Exploring cancer patients' perspectives of CAM within a primary care setting

    A J Kilroy

    Rationale, design and methods of the OSCAR study: observational study on cognitive function and systolic blood pressure reduction in hypertensive patients

    Atul Pathak
    Abstract Data from several recent clinical trials have suggested a beneficial effect of antihypertensive medications on preservation of cognitive function. Eprosartan, an angiotensin type-1 receptor antagonist (ARA) with dual action on both pre- and postsynaptic angiotensin type 1 receptors, may be effective in the control of SBP and the prevention of cognitive decline. The OSCAR (Observational Study on Cognitive function And SBP Reduction) study is an international longitudinal observational study with a duration of 6 months intended to examine the impact of the ARA eprosartan on cognitive function (assessed using the Mini-Mental State Examination [MMSE]) and control of systolic blood pressure (SBP) in a large international population of hypertensive patients managed in a standard primary care setting. A total of 100 000 hypertensive patients, aged ,50 years and with SBP of >140 mmHg will be recruited by more than 20 000 primary care physicians in 27 countries. These patients will receive eprosartan 600 mg once a day for 6 months. The MMSE, a globally validated cognitive screening test, will be performed at baseline, and after 6 months of treatment. After the first month of monotherapy, eprosartan treatment may, at the absolute discretion of individual investigators, be supplemented with other antihypertensive medications for the remainder of the study. The primary outcome indices are the mean relative change in MMSE score and the absolute change from baseline in SBP in the study population as a whole and in subsets of patients according to various factors among them: ethnicity, comorbidities (i.e. target organ damage, diabetes), baseline cognitive level and baseline blood pressure level. The secondary objectives are to identify factors influencing SBP and MMSE changes. The OSCAR trial is the first international observational study focusing on MMSE in a wide international cohort of hypertensive patients. The results are expected in 2007. [source]

    An overview of the data presented at the International Society on Thrombosis and Haemostasis Congress, where results were reported of three major clinical trials on prevention, management and prophylaxis in patients at risk of venous thromboembolism in the hospital care setting.

    FUTURE PRESCRIBER, Issue 3 2007
    Rhonda Siddall

    Factors enabling home death of the elderly in an institution specializing in home medical care: Analysis of apprehension of the bereaved family

    Akiko Akiyama
    Aim: To determine the factors enabling home death despite caregiver apprehension about home medical care. Methods: This study was an anonymous mailed survey of bereaved family members (the caregiver) of patients who died in a home medical care setting provided by an institution specializing in home medical care in Japan (home death rate, ,80%). We analyzed the relationships between caregiver apprehension about home medical care, overall satisfaction with home medical care and the place of death. Results: Higher caregiver apprehension about home medical care and lower overall satisfaction with home medical care were significantly associated with dying in a hospital. In addition, the home death group with apprehension about home medical care significantly rated higher overall satisfaction with home medical care than the hospital death group. Meanwhile, there was no difference in the overall satisfaction with home medical care between those with or without apprehension about home medical care in the home death group. Factors influencing overall satisfaction with home medical care in the home death group with apprehension about home medical care were: (i) being free from pain or symptoms (partial regression coefficient: 0.83); and (ii) fulfilled medical care service system (partial regression coefficient: 0.40). Conclusion: These results suggest that caregiver satisfaction with home medical care is an essential factor to enable home death of the patient despite the caregiver apprehension about home medical care. [source]