A realist review of shared medical appointments: How, for whom, and under what circumstances do they work?

BACKGROUND: Shared medical appointments (SMAs) are doctor-patient visits in which groups of patients are seen by one or more health care providers in a concurrent session. There is a growing interest in understanding the potential benefits of SMAs in various contexts to improve clinical outcomes and reduce healthcare costs. This study builds upon the existing evidence base that suggests SMAs are indeed effective. In this study, we explored how they are effective in terms of the underlying mechanisms of action and under what circumstances. METHODS: Realist review methodology was used to synthesize the literature on SMAs, which included a broad search of 800+ published articles. 71 high quality primary research articles were retained to build a conceptual model of SMAs and 20 of those were selected for an in depth analysis using realist methodology (i.e.,middle-range theories and and context-mechanism-outcome configurations). RESULTS: Nine main mechanisms that serve to explain how SMAs work were theorized from the data immersion process and configured in a series of context-mechanism-outcome configurations (CMOs). These are: (1) Group exposure in SMAs combats isolation, which in turn helps to remove doubts about one's ability to manage illness; (2) Patients learn about disease self-management vicariously by witnessing others' illness experiences; (3) Patients feel inspired by seeing others who are coping well; (4) Group dynamics lead patients and providers to developing more equitable relationships; (5) Providers feel increased appreciation and rapport toward colleagues leading to increased efficiency; (6) Providers learn from the patients how better to meet their patients' needs; (7) Adequate time allotment of the SMA leads patients to feel supported; (8) Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge; and (9) Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust. CONCLUSIONS: Nine overarching mechanisms were configured in CMO configurations and discussed as a set of complementary middle-range programme theories to explain how SMAs work. It is anticipated that this innovative work in theorizing SMAs using realist review methodology will provide policy makers and SMA program planners adequate conceptual grounding to design contextually sensitive SMA programs in a wide variety of settings and advance an SMA research agenda for varied contexts.

Group visits for chronic illness management: implementation challenges and recommendations.

The group visit approach to improve chronic illness self-management appears promising in terms of selected outcomes, but little information is available about best ways to organize and implement group visits. This literature review of 84 articles identified group visit implementation challenges, including lack of a group visit billing code, inadequate administrative support and resources, difficult participant recruitment and retention, and logistical issues such as space and scheduling. Recommendations for future implementation initiatives were also abstracted from the literature. Patients and providers can benefit from well-planned and well-conducted group visits. These benefits include greater patient and provider satisfaction, reduced overall utilization, improved clinical outcomes, and greater provider efficiency and productivity.

Using mobile phones and short message service to deliver self-management interventions for chronic conditions: a meta-review.

BACKGROUND: The worldwide burden of chronic disease is widespread and growing. This shift from acute to chronic care requires rethinking how resources are invested in managing these conditions. One response has been to create programs and interventions that have the goal of helping patients better manage their own conditions. Over time, these self-management interventions and strategies have increasingly relied on various technologies for their implementation, with the newest technology being mobile phones and short message service (SMS). AIM: The objective of this meta-review was to evaluate the current evidence on the use of mobile phones and SMS to deliver self-management interventions for chronic conditions. METHODS: A meta-review was conducted of the 11 systematic reviews (SRs) that were identified and retrieved after an extensive search of electronic databases covering the years 2000-2012. Relevant information was abstracted from each systematic review and a quality assessment carried out using the AMSTAR ("A Measurement Tool to Assess Systematic Reviews") criteria. FINDINGS: The number and types of included studies and total number of subjects varied significantly across the systematic reviews. Mobile phone text messaging was reported to significantly improve adherence to appointments and antiretroviral therapy, short-term smoking quit rates, and selected clinical and behavioral outcomes. AMSTAR scores ranged from 11 to 3, reflecting substantial variation in SR quality. LINKING EVIDENCE TO ACTION: Mobile phones and SMS show promise as a technology to deliver self-management interventions to improve outcomes of chronic care management. However, the quality of future studies and systematic reviews needs to be improved. There also are unresolved issues about the technology itself.

Comparison of three different methods to prevent heat loss in healthy dogs undergoing 90 minutes of general anesthesia.

OBJECTIVE: To compare a towel under, a warm water pad under or a forced warm air blanket over dogs as techniques to reduce heat loss during a standardized anesthetic. STUDY DESIGN: Prospective, randomized, crossover study. ANIMALS: Eight, healthy, mixed breed dogs weighing 16.3-19.6 kg. METHODS: Dogs were anesthetized four times for 90 minutes. Dogs were placed on a steel table (treatment TA), with a cotton towel (treatment TO) or a circulating warm water pad (treatment WP) between the dog and the table, or with, a towel under the dog and covered with a forced warm air blanket (treatment WAB). Rectal temperature (RT) was recorded at 5 minute intervals. Changes in temperature (ΔRT) were calculated as the RT at a given point subtracted from the RT before anesthesia (baseline) and compared over time. RESULTS: After 90 minutes of anesthesia, the ΔRT was 3.42 °C ± 0.29 for TA, 2.78 °C ± 0.43 for TO, 1.98 °C ± 0.29 for WP, and 0.91 °C ± 0.27 for WAB. Significant differences in ΔRT occurred between TA and WAB at 20 minutes (0.94 °C ± 0.42, p = 0.0206), between TO and WAB at 30 minutes (1.16 °C ± 0.62, p = 0.0063), between WP and WAB at 50 minutes (0.96 °C ± 0.98, p = 0.0249), between TA and WP at 35 minutes (1.19 °C ± 0.54, p = 0.0091), between TO and WP at 70 minutes (1.12 °C ± 0.56, p = 0.0248), and between TA and TO at 75 minutes (0.96 °C ± 0.62, p = 0.0313). These differences in ΔRT between each treatment persisted from the times indicated until the end of the anesthesia. CONCLUSION AND CLINICAL RELEVANCE: During anesthesia, forced warm air blankets were superior to other methods tested for limiting heat loss. An efficient heat loss technique should be used for anesthesia longer than 20 minutes duration in medium sized dogs.

Global Health Education Revamped: Implementation of a Cross-Cultural Virtual Elective Through Continuous Improvement Methods.

Introduction: Virtual platforms can increase access to global health (GH) education and cross-cultural communication. The Cleveland-Cusco Connection (CCC) is a virtual GH elective between medical schools in the USA and Peru. This elective was held annually from 2020 to 2023, with monthly virtual sessions held in English and Spanish to facilitate bidirectional learning about healthcare systems, culture, and barriers to care in both nations. Using student surveys throughout the electives, we report the outcomes, barriers, and changes of the CCC over 3 years. Methods: We administered pre- and post-elective surveys to students in the elective in their native languages. We evaluated self-reported non-native language skills, health systems, GH knowledge, and cultural sensitivity. We also surveyed students about course efficacy in achieving learning objectives and areas for improvement. We performed non-parametric statistical analyses to evaluate trends in survey responses. Results: Over three academic years, 92 students participated in CCC. Students from the US had statistically significant increases in their self-reported understanding of the Peruvian healthcare and medical education systems (p = 0.013). US students also saw an increase in cultural sensitivity scores, with statistically significant increases in the knowledge (p = 0.035) and motivation components (p = 0.031). The most frequently reported challenges encountered throughout the course included: competing coursework assignments, scheduling conflicts, and language barriers. Discussion: Cross-cultural virtual electives demonstrate effectiveness in teaching trainees about international healthcare systems and can improve cultural sensitivity. Strategies to improve the elective include reducing workload, improving engagement for partner countries, and teaching bilingually. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01941-6.

The oncology acuity tool: a reliable, valid method for measuring patient acuity for nurse assignment decisions.

BACKGROUND AND PURPOSE: Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments. METHODS: Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events. RESULTS: Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls. CONCLUSIONS: The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

Expanded adult day program as a transition option from hospital to home.

This article describes a pilot program for provision of postacute care (PAC) in an established adult day program. Demographic, clinical, utilization, and satisfaction data were abstracted retrospectively from program records; postdischarge readmission and emergency department visit data were obtained from the electronic health record. Comparative data were obtained from the health records of patients who were offered but declined the adult day program. Between 2005 and 2008, 78 patients requiring PAC were approached by the RN coordinator; 33 selected the adult day program, and 45 selected alternative destinations. The majority of patients had a neurological diagnosis, most commonly stroke. Participants and their family caregivers were highly satisfied with the program. The 30-day readmission rate for adult day program participants was significantly lower than that for nonparticipants. An expanded adult day program may represent a viable Transitional Care Model for selected patients and a feasible alternative to skilled nursing facility and home health care for PAC.

Rating the level, quality, and strength of the research evidence.

Improving patient safety and quality requires more consistent application of best practices based on the strongest scientific evidence available. Although evidence-based practice initiatives are increasingly being implemented in healthcare settings, clinicians may not have had the necessary preparation to accurately determine the overall strength of evidence supporting specific practice change recommendations. A particular issue is lack of clarity in use of the terms level of evidence, quality of evidence, and strength of evidence. This article clarifies the important differences among these terms.

Why do chronic venous leg ulcers not heal?

Chronic venous leg ulcers account for the majority of lower extremity ulcers and represent a serious health and financial burden. Although several clinical practice guidelines and systematic reviews are available to guide treatment decisions, healing rates have not improved over the last decade. This research study illustrates some of the limitations of relying on existing databases to guide wound management as well as the importance of considering patient preferences, staff knowledge and skill, and available resources.

Real-time PCR assays to address genetic diversity among strains of Mycoplasma hyopneumoniae.

Mycoplasma hyopneumoniae is an important cause of pneumonia in pigs around the world, but confirming its presence in (or absence from) pigs can be difficult. Culture for diagnosis is impractical, and seroconversion is often delayed after natural infection, limiting the use of serology. Numerous PCR assays for the detection of M. hyopneumoniae have been developed, targeting several different genes. Recently, genetic diversity among strains of M. hyopneumoniae was demonstrated. The effect of this diversity on the accuracy and sensitivity of the M. hyopneumoniae PCR assays could result in false-negative results in current PCR tests. In this study, a panel of isolates of M. hyopneumoniae, M. flocculare, M. hyorhinis, and M. hyosynoviae were tested with a number of M. hyopneumoniae-specific PCR assays. Some M. hyopneumoniae PCR assays tested did not detect all isolates of M. hyopneumoniae. To increase the efficiency of PCR testing, two new real-time PCR assays that are specific and capable of detecting all of the M. hyopneumoniae isolates used in this study were developed.

Chronic Wounds: Factors Influencing Healing Within 3 Months and Nonhealing After 5-6 Months of Care.

Chronic wounds affect approximately 2.5 million to 4.5 million people in the US and are particularly a problem for the elderly. Nonhealing or slow healing wounds represent a major health burden and drain on resources, contributing to substantial disability, morbidity, and costs. This study was conducted to identify factors that influence the healing of chronic wounds within 3 months of starting treatment, compared to factors influencing nonhealing wounds after 5 or 6 months of treatment. A retrospective review of medical records of subjects with chronic pressure, diabetic, or venous ulcers using a structured data collection form and protocol was conducted at 4 sites located in disperse geographic areas. The sample consisted of 400 subjects with at least 3 months of data. Demographic, case mix, wound characteristics, and treatment characteristics were analyzed. Consistent with the literature, wounds that were larger, deeper, infected, draining larger amounts of exudate, and/or covered with slough or eschar were significantly less likely to heal within 3 months and more likely not to heal after 5-6 months of treatment. Medicaid insurance coverage and being non-white were also associated with poorer healing. A lower percentage of antimicrobial dressings was associated with faster healing, while a lower percentage of moisture-management dressings was associated with nonhealing after 5-6 months. The analysis also showed that inappropriate management of wound exudate and necrotic tissue was associated with poorer healing outcomes. While the influence of insurance coverage and race on healing needs further exploration, healing rates could improve in certain centers through better adherence to evidence-based wound management recommendations.

Assessing the appropriateness of pain medication prescribing practices in nursing homes.

OBJECTIVES: To test a tool for screening the quality of nursing home (NH) pain medication prescribing. DESIGN: Validity and reliability of measurement tool developed for a pre/postintervention with untreated comparison group. SETTING: Six treatment NHs and six comparison NHs in rural and urban Colorado. PARTICIPANTS: NH staff, physicians, and repeated 20% random sample of each home's residents (N = 2,031). INTERVENTION: Nurse and physician education; NH internal pain team to champion better pain management using a pain vital sign, consultations, and rounds. MEASUREMENTS: An expert panel reviewed the Pain Medication Appropriateness Scale (PMAS) for content validity. Research assistants interviewed NH residents, assessed them for pain using standardized instruments, and reviewed their medical records for prescriptions and use of pain and adjuvant medication. Construct validity was assessed by comparing the PMAS of residents in pain with the PMAS of those not in pain and comparing scores in homes in which the intervention was more effective with those in which it was less effective, using the Fisher exact and Student t tests. Interrater and test-retest reliability were measured. RESULTS: The mean total PMAS was 64% of optimal. Fewer than half of residents with predictably recurrent pain were prescribed scheduled pain medication; 23% received at least one high-risk medication. PMAS scores were better for residents not in pain (68% vs 60%, P = .004) and in homes where nurses' knowledge of pain assessment and management improved or stayed the same during the intervention (69% vs 61%, P = .03). CONCLUSION: The PMAS is useful for assessing pain medication prescribing in NHs and elucidates why so many residents have poorly controlled pain.

Nursing home resident barriers to effective pain management: why nursing home residents may not seek pain medication.

OBJECTIVES: Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior. DESIGN: Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication. SETTING: The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings. PARTICIPANTS: A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices. MEASUREMENTS: A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication. RESULTS: More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01). CONCLUSION: Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.

Measuring pain intensity in nursing home residents.

Assessing pain intensity in nursing home residents remains a challenge. As part of a multifaceted intervention study to improve pain practices in nursing homes, quarterly pain assessments were conducted in 12 Colorado nursing homes. Residents who reported pain or discomfort of any kind in the past 24 hours were asked to choose one of three pain intensity scales to quantify their current and highest level of pain intensity. They were also observed for pain behaviors using Feldt's Checklist of Nonverbal Pain Indicators. Residents preferred the Verbal Descriptor Scale almost 2:1 over the 11-point Verbal Numeric Rating Scale and the Faces Pain Scale. Sex and ethnicity were associated with differences in scale preference. More than one-half of residents reporting pain had an observable pain indicator. There was a monotonic relationship between reported pain intensity and number of observed pain indicators. To improve pain assessment and management in nursing homes, residents should be given a choice of pain intensity scales and observed for possible pain behaviors.

Nursing home resident barriers to effective pain management: why nursing home residents may not seek pain medication.

OBJECTIVES: Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior. DESIGN: Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication. SETTING: The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings. PARTICIPANTS: A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices. MEASUREMENTS: A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication. RESULTS: More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01). CONCLUSION: Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.

Predictors of serious fall injury in hospitalized patients.

The purpose of this study was to identify predictors of falls that result in serious injury in hospitalized patients. The study involved secondary data analysis of 1,438 patient falls in a community hospital system between 2008 and 2010. The analysis included demographics, severity of illness, diagnosis-related group (surgical vs. medical), event type (bathroom, bed, chair, transfer, ambulating), risk factors identified by the Hendrich II fall risk assessment prior to the fall (confusion, depression, altered elimination, dizziness, antiepileptic or benzodiazepine medications), and contributing factors identified through an online event reporting system post-fall (incontinence, confusion, history of falls, alteration in mobility, and medication-related). Logistic regression results indicated that the overall model was a good fit and two predictors, age greater than 64 and male gender, were statistically reliable in predicting which patient falls would result in serious injury.

Improving nursing home staff knowledge and attitudes about pain.

PURPOSE: Effective pain management remains a serious problem in the nursing home setting. Barriers to achieving optimal pain practices include staff knowledge deficits, biases, and attitudes that influence assessment and management of the residents' pain. DESIGN AND METHODS: Twelve nursing homes participated in this intervention study: six treatment homes and six control homes, divided evenly between urban and rural locations. Three hundred licensed and unlicensed nursing home staff members completed written knowledge and attitude surveys at baseline, and 378 staff members completed the surveys after intervention implementation. RESULTS: Baseline results revealed notable knowledge deficits in the areas of pharmacology, drug addiction and dependence, side effect management, and nonpharmacologic management-strategy effectiveness. Significant differences were noted by job title (registered nurse/licensed practical nurse/certified nursing assistant). Case studies displayed a knowledge application problem, with nurses often filtering resident pain reports through observed resident behaviors. The intervention led to significant improvement in knowledge scores in some, but not all, the treatment homes. Perceived barriers to effective pain management showed a significant decline across all study nursing homes. IMPLICATIONS: Knowledge deficits related to pain management persist in nursing homes. An interactive multifaceted educational program was only partially successful in improving knowledge across settings and job categories. Attitudes and beliefs appear more difficult to change, whereas environmental and contextual factors appeared to be reducing perceived barriers to effective pain management across all participating nursing homes.

Outcomes research: an interdisciplinary perspective.

Outcomes achieved by healthcare providers are a function of patient clinical and demographic characteristics, baseline health status, delivered treatments and interventions, and setting characteristics. This article describes a prospective, interdisciplinary study of the outcomes of selected surgeries using both generic and condition-specific data collection instruments. The results of several different analyses are discussed, which illustrate the usefulness of such an effort for patients, nurses and physicians, the institution, and the respective disciplines in general.

State of the science: the relationship between nurse staffing and patient outcomes.

Over a decade of research on the relationship between nurse staffing and patient outcomes has demonstrated the important role of nurses in the provision of high-quality, safe care, yet currently, no evidence-based nurse staffing guidelines exist. A systematic review of reviews was conducted to explore reasons why this is the case and recommend directions for future research to improve upon this gap. Authors of the 29 included reviews reported variability in methods and measurement approaches, lack of incorporation of nurse processes and system factors that potentially affect relationships among variables, and overall inconsistencies in results across primary studies. We propose use of an Integrated Framework for a Systems Approach to Nurse Staffing Research to inform the development of applicable conceptual models. Future studies that use a systems approach and focus on establishing causal relationships among variables will potentially strengthen the evidence and advance the science in this area.