Using Facilitative Coaching to Support Patient Aligned Care Teams.

Despite the challenges of implementing facilitative coaching, the Richard L. Roudebush VAMC staff succeeded in translating primary care medical home theory into process.

Regression from prediabetes to normal glucose regulation is associated with reduction in cardiovascular risk: results from the Diabetes Prevention Program outcomes study.

OBJECTIVE: Restoration of normal glucose regulation (NGR) in people with prediabetes significantly decreases the risk of future diabetes. We sought to examine whether regression to NGR is also associated with a long-term decrease in cardiovascular disease (CVD) risk. RESEARCH DESIGN AND METHODS: The Framingham (2008) score (as an estimate of the global 10-year CVD risk) and individual CVD risk factors were calculated annually for the Diabetes Prevention Program Outcomes Study years 1-10 among those patients who returned to NGR at least once during the Diabetes Prevention Program (DPP) compared with those who remained with prediabetes or those in whom diabetes developed during DPP (N = 2,775). RESULTS: The Framingham scores by glycemic exposure did not differ among the treatment groups; therefore, pooled estimates were stratified by glycemic status and were adjusted for differences in risk factors at DPP baseline and in the treatment arm. During 10 years of follow-up, the mean Framingham 10-year CVD risk scores were highest in the prediabetes group (16.2%), intermediate in the NGR group (15.5%), and 14.4% in people with diabetes (all pairwise comparisons P < 0.05), but scores decreased over time for those people with prediabetes (18.6% in year 1 vs. 15.9% in year 10, P < 0.01). The lower score in the diabetes group versus other groups, a declining score in the prediabetes group, and favorable changes in each individual risk factor in all groups were explained, in part, by higher or increasing medication use for lipids and blood pressure. CONCLUSIONS: Prediabetes represents a high-risk state for CVD. Restoration of NGR and/or medical treatment of CVD risk factors can significantly reduce the estimated CVD risk in people with prediabetes.

Quality of life in MAP.3 (Mammary Prevention 3): a randomized, placebo-controlled trial evaluating exemestane for prevention of breast cancer.

PURPOSE: Exemestane, a steroidal aromatase inhibitor, reduced invasive breast cancer incidence by 65% among 4,560 postmenopausal women randomly assigned to exemestane (25 mg per day) compared with placebo in the National Cancer Institute of Canada (NCIC) Clinical Trials Group MAP.3 (Mammary Prevention 3) trial, but effects on quality of life (QOL) were not fully described. PATIENTS AND METHODS: Menopause-specific and health-related QOL were assessed by using the four Menopause-Specific Quality of Life Questionnaire (MENQOL) domains and the eight Medical Outcomes Study Short Form Health Survey (SF-36) scales at baseline, 6 months, and yearly thereafter. MENQOL questionnaire completion was high (88% to 98%) in both groups at each follow-up visit. Change scores for each MENQOL and SF-36 scale, calculated at each assessment time relative to baseline, were compared by using the Wilcoxon rank-sum test. Clinically important worsened QOL was defined as a MENQOL change score increase of more than 0.5 (of 8) points and an SF-36 change score decrease of more than 5 (of 100) points from baseline. RESULTS: Exemestane had small negative effects on women's self-reported vasomotor symptoms, sexual symptoms, and pain, which occurred mainly in the first 6 months to 2 years after random assignment. However, these changes represented only a small excess number of women being given exemestane with clinically important worsening of QOL at one time or another; specifically, 8% more in the vasomotor domain and 4% more each in the sexual domain and for pain. No other between-group differences were observed. Overall, slightly more women in the exemestane arm (32%) than in the placebo arm (28%) discontinued assigned treatment. CONCLUSION: Exemestane given for prevention has limited negative impact on menopause-specific and health-related QOL in healthy postmenopausal women at risk for breast cancer.

Skin damage associated with intravenous therapy: common problems and strategies for prevention.

Infusion therapy is among the most common health care interventions, with approximately 90% of hospitalized patients receiving vascular access and an estimated 1.3 million home infusion therapies delivered annually. Whereas most individuals complete their therapy uneventfully, others experience alterations in skin integrity, some significant enough to disrupt therapy. There are limited published data on the incidence of skin damage associated with infusion therapy, and the etiology of damage has not been previously described in detail. Wound, ostomy, and continence (WOC) nurses have developed a significant understanding of skin-related problems and effective prevention strategies from over 40 years of experience with ostomy patients--another population in which adhesive wear is a constant and localized, superficial skin damage is common. This article will offer a WOC nursing perspective of skin damage and seek to provide a context for understanding and preventing skin damage in the infusion therapy patient.

Using no-show modeling to improve clinic performance.

'No-shows' or missed appointments result in under-utilized clinic capacity. We develop a logistic regression model using electronic medical records to estimate patients' no-show probabilities and illustrate the use of the estimates in creating clinic schedules that maximize clinic capacity utilization while maintaining small patient waiting times and clinic overtime costs. This study used information on scheduled outpatient appointments collected over a three-year period at a Veterans Affairs medical center. The call-in process for 400 clinic days was simulated and for each day two schedules were created: the traditional method that assigned one patient per appointment slot, and the proposed method that scheduled patients according to their no-show probability to balance patient waiting, overtime and revenue. Combining patient no-show models with advanced scheduling methods would allow more patients to be seen a day while improving clinic efficiency. Clinics should consider the benefits of implementing scheduling software that includes these methods relative to the cost of no-shows.

Incontinence-associated skin damage in nursing home residents: a secondary analysis of a prospective, multicenter study.

More than half of the nursing home population is incontinent of urine or feces, presenting challenges to perineal skin health. To determine the occurrence and severity of skin damage in nursing home residents with incontinence, a secondary analysis of data collected from a multisite, open-label, quasi-experimental study of cost and efficacy of four regimens for preventing incontinence-associated dermatitis in nursing home residents was performed. Sixteen randomly selected nursing homes from across the US were included in the study. Participating nursing home residents were incontinent of urine and/or feces and free of skin damage. Of the 1,918 persons screened, 51% (n = 981) qualified for prospective surveillance. Perineal skin was assessed over a 6-week period; frequency, type, and severity of skin damage were observed. Skin damage developed after a median of 13 (range 6 to 42) days in 45 out of 981 residents (4.6%), of which 3.4% was determined to be incontinence-associated dermatitis. Some residents (14 out of 45, 31%) had incontinence-associated dermatitis of other skin damage in more than one area. This study is one of the first to report the characteristics of incontinence-associated dermatitis in a large sample of nursing home residents. The sample size and random selection of nursing homes impart generalizability to the findings. Incontinence-associated dermatitis is a risk in nursing home residents, especially those with fecal incontinence. These findings suggest that the rate and severity of incontinence-associated dermatitis are low with close monitoring and use of a defined skin care regimen that includes a pH-balanced cleanser and moisture barrier.

An evaluation of two incontinence skin care protocols in a long-term care setting.

Caring for the skin of patients with incontinence is an essential activity in long-term care. A prospective descriptive study to compare the effect of two skin care protocols on skin condition, pain, and caregiver time was conducted. Thirty-two (32) skilled nursing facility residents with incontinence participated in the 3-week study. Patients were randomly assigned to a standard care regimen (soap and water cleansing after each incontinence episode, followed by application of a moisturizing lotion) or study care protocol (no-rinse skin cleanser after each episode and application of a barrier cream with durable properties after the first incontinence episode of each shift). Number and type of incontinence episodes, skin condition, pain, and caregiver time spent were assessed. Skin integrity was maintained in the majority of control (69%) and study group (72%) patients and improvement occurred in 8% of control and 17% of the study group (NS). Study protocol procedures took less time to complete than control procedures (a savings of 79 minutes/patient/day). A positive correlation between pain intensity and level of skin impairment was observed (r = 0.88). The results of this study suggest that at this facility, use of soap, water, and a moisturizer may be less effective and more time-consuming than using a no-rinse cleanser and a durable barrier product.