Low-value health care, de-implementation, and implications for nursing research: A discussion paper.

Globally, the nursing profession constitutes the largest proportion of the health workforce; however, it is challenged by widespread workforce shortages relative to need. Strategies to promote recruitment of the nursing workforce are well-established, with a lesser focus on strategies to alleviate the burden on the existing workforce. This burden may be exacerbated by the impact of low-value health care, characterised as health care that provides little or no benefit for patients, or has the potential to cause harm. Low-value health care is a global problem, a major contributor to the waste of healthcare resources, and a key focus of health system reform. Evidence of variation in low-value health care has been identified across countries and system levels. Research on low-value health care has largely focused on the medical profession, with a paucity of research examining either low-value health care or the de-implementation of low-value health care from a nursing perspective. The objective of this paper is to provide a scholarly discussion of the literature around low-value health care and de-implementation, with the purpose of identifying implications for nursing research. With increasing pressures on the global nursing workforce, research identifying low-value health care and developing approaches to de-implement this care, is crucial.

Predictors of effective therapeutic relationships between pharmacists and patients with type 2 diabetes: Comparison between Arabic-speaking and Caucasian English-speaking patients.

BACKGROUND: The benefits of pharmacist-led interventions in achieving desired patient outcomes have been well established. Effective patient-pharmacist relationships are required to provide high-quality pharmacy care. Limited information is available about how Arabic-speaking migrants with diabetes, in Australia, perceive patient-pharmacist relationship and how these perspectives differ from the mainstream society (represented by Caucasian English-speaking people). OBJECTIVE: To examine and compare the patient-pharmacist relationship, medication underuse and adherence levels among Arabic-speaking and Caucasian English-speaking patients with type 2 diabetes. METHODS: A 98-item survey incorporating several previously-validated measurements was completed by Arabic-speaking migrants (ASMs) and Caucasian English-speaking patients (ESPs) with type 2 diabetes. Participants were recruited from various healthcare settings in the Melbourne metropolitan area and rural Victoria, Australia. This survey-based, cross-sectional study was designed to explore patients' perceptions of the patient-pharmacist relationship. A descriptive analysis of responses was undertaken, and binary logistic regression was used to explore patient-pharmacist relationships. RESULTS: A total of 701 participants were recruited; 392 ASMs and 309 ESPs. Of ASMs, 88.3% were non-adherent to their prescribed medication, compared with 45.1% of ESPs. The degree of relationship with community pharmacists differed significantly between ASMs and ESPs. Compared with ASMs, significantly more ESPs reported that they have thought about consulting a pharmacist when they had health problems (P = 0.002). Compared with ESPs, significantly fewer ASMs reported always following pharmacist recommendations (32% versus 61.9% respectively). CONCLUSIONS: Arabic-speaking migrants had less-effective relationships with community pharmacists when having their prescriptions filled. Community pharmacists' expertise appeared to be underused. These minimal relationships represent missed opportunities to improve health outcomes.

Time to question diabetes self-management support for Arabic-speaking migrants: exploring a new model of care.

AIM: The objective of this study was to explore a new model for diabetes self-management support in Arabic-speaking migrants. METHODS: Two qualitative methods were used: face-to-face semi-structured individual interviews and focus groups. Interviews were audio-taped, transcribed verbatim and coded thematically. Arabic-speaking migrants with Type 2 diabetes were recruited from several primary, secondary and tertiary healthcare settings in metropolitan Melbourne, Australia. These settings were purposefully selected to obtain a diverse group of participants. Data collection continued until saturation was reached. This is the first study that involved members of Arabic-speaking communities in Australia in a formal process of consumer and public involvement to inform research design and recruitment in order to provide evidence for a new model of diabetes self-management for Arabic-speaking migrants. RESULTS: No self-management support was offered to Arabic-speaking migrants beyond the initial diagnosis period. Significant knowledge gaps and skills deficits in all self-management domains were evident. The provision of tailored self-management support was considered crucial. When asked about preferred structure and delivery modalities, a strong preference was reported for face-to-face storytelling interactions over telephone- or internet-based interventions. Gender-specific group education and self-management support sessions delivered by Arabic-speaking diabetes health professionals, lay peers or social workers trained in diabetes self-management were highly regarded. CONCLUSIONS: A patient and public involvement approach allows genuine engagement with Arabic-speaking migrants with diabetes. There is urgent need for a new model for self-management support among Arabic-speaking migrants. Findings yielded new recommendations for diabetes health professionals working with these migrant communities to support behaviour change.

Barriers and enablers to healthcare access and use among Arabic-speaking and Caucasian English-speaking patients with type 2 diabetes mellitus: a qualitative comparative study.

OBJECTIVE: The objective of this study was to explore the decision-making processes and associated barriers and enablers that determine access and use of healthcare services in Arabic-speaking and English-speaking Caucasian patients with diabetes in Australia. STUDY SETTING AND DESIGN: Face-to-face semistructured individual interviews and group interviews were conducted at various healthcare settings-diabetes outpatient clinics in 2 tertiary referral hospitals, 6 primary care practices and 10 community centres in Melbourne, Australia. PARTICIPANTS: A total of 100 participants with type 2 diabetes mellitus were recruited into 2 groups: 60 Arabic-speaking and 40 English-speaking Caucasian. DATA COLLECTION: Interviews were audio-taped, translated into English when necessary, transcribed and coded thematically. Sociodemographic and clinical information was gathered using a self-completed questionnaire and medical records. PRINCIPAL FINDINGS: Only Arabic-speaking migrants intentionally delayed access to healthcare services when obvious signs of diabetes were experienced, missing opportunities to detect diabetes at an early stage. Four major barriers and enablers to healthcare access and use were identified: influence of significant other(s), unique sociocultural and religious beliefs, experiences with healthcare providers and lack of knowledge about healthcare services. Compared with Arabic-speaking migrants, English-speaking participants had no reluctance to access and use medical services when signs of ill-health appeared; their treatment-seeking behaviours were straightforward. CONCLUSIONS: Arabic-speaking migrants appear to intentionally delay access to medical services even when symptomatic. Four barriers to health services access have been identified. Tailored interventions must be developed for Arabic-speaking migrants to improve access to available health services, facilitate timely diagnosis of diabetes and ultimately to improve glycaemic control.

A multifaceted pharmacist intervention to improve antihypertensive adherence: a cluster-randomized, controlled trial (HAPPy trial).

WHAT IS KNOWN AND OBJECTIVES: About half of all patients taking antihypertensives discontinue treatment by 12 months. There is potential for substantial health gains at both individual and population levels through improved treatment adherence. The objective was to evaluate a community pharmacist intervention to improve adherence with antihypertensive medicines with a view to improving blood pressure (BP) control. DESIGN: prospective, non-blinded, cluster-randomized, controlled trial. PARTICIPANTS: adults with primary hypertension who obtained antihypertensives in the previous 6 months. Patients with poor refill adherence were preferentially identified with the help of a purpose-built software application. INTERVENTION: package comprising BP monitor; training on BP self-monitoring; motivational interviewing; medication use review; prescription refill reminders. FOLLOW-UP: six months. PRIMARY OUTCOME: change in proportion self-reporting medication adherence. Secondary outcome: BP changes. RESULTS: Participants (n = 395; intervention - 207; control - 188) had a mean age of 66.7 years; 51.1% were males. The proportion of adherent participants increased in both groups but was not significantly different between groups [57·2% to 63·6% (control) vs. 60·0% to 73·5% (intervention), P = 0·23]. The mean reduction in systolic BP was significantly greater in the intervention group (10·0 mmHg vs. 4·6 mmHg; P = 0·05). The proportion of patients who were non-adherent at baseline and adherent at 6 months was 22·6% (95%CI 5·1-40·0%) higher in the intervention group (61·8% vs. 39·2%, P = 0·007). Among participants with baseline BP above target, reduction of systolic BP was significantly greater in the intervention group [by 7·2 mmHg (95%CI 1·6-12·8 mmHg); (P = 0·01)]. Among participants non-adherent at baseline and above target BP, the proportion reporting adherence at 6 months was significantly greater in the intervention group [56·8% vs. 35·9%, P = 0·039). WHAT IS NEW AND CONCLUSION: This community pharmacist intervention resulted in improved adherence to antihypertensive medication and reduced systolic BP.

Prevalence, detection and drug treatment of hypertension in a rural Australian population: the Greater Green Triangle risk factor study 2004-2006.

BACKGROUND: Hypertension is an important risk factor for cardiovascular disease; however, limited findings are available on its detection and management in rural Australia. AIM: To assess the prevalence, awareness and treatment of hypertension in a rural South-East Australian population. METHODS: Three cross-sectional surveys in Limestone Coast, Corangamite Shire and Wimmera regions during 2004-2006 using a random population sample (n = 3320, participation rate 49%) aged 25-74 years. Blood pressure was measured by trained nurses. Information on history of hypertension and medication was obtained by questionnaires. Hypertension was defined as systolic blood pressure >or=140 mmHg and/or diastolic blood pressure >or=90 mmHg and/or on antihypertensive drug treatment. RESULTS: Overall, one-third of participants had hypertension; of these, two-thirds, 54% (95% confidence interval (CI) 47-60) of men and 71% (95% CI 65-77) of women, were aware of their condition. Half of the participants with hypertension were treated and nearly half of these were controlled. Both treatment and control were more common in women (60%, 95% CI 54-67 and 55%, 95% CI 47-64) compared with men (42%, 95% CI 36-49 and 35%, 95% CI 26-44). Monotherapy was used by 55% (95% CI 48-61) of treated hypertensives. Angiotensin-converting enzyme inhibitors were the most frequently used class of antihypertensive drugs in men, whereas angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists and diuretics were all widely used among women. CONCLUSION: This study emphasizes suboptimal detection and treatment of hypertension, especially in men, in rural Australia.