Redefining avoidable and inappropriate admissions.

OBJECTIVES: Focusing on policy discourse in the United Kingdom, we examine the chain of causation that is characteristic of the ways in which the concepts of avoidability and inappropriateness are defined and used in these contexts. With a particular focus on diabetes complications, we aim to elucidate the way in which avoidable admission to hospital is conceptualised, measured, and applied to policy development and implementation and build a more inclusive model of identification as a basis for further research in this area. STUDY DESIGN: Discourse analysis was used in combination with a scoping review. METHODS: We searched the online databases of the UK Houses of Parliament Hansard, Official reports of the Northern Ireland Assembly and transcripts of the Scottish Parliament in October 2021. We also conducted an electronic search in October 2021 on MEDLINE, PubMed, Google Scholar, EMBASE, CINAHL and The Cochrane Library to review the available literature. In addition, an analysis of policies in place in Scotland, England and Northern Ireland relating to urgent diabetes care was conducted. RESULTS: 'Avoidable' and 'inappropriate' hospital admissions are categories used in health policy and practice internationally as ways of identifying targets for interventions intending to reduce the burden of care. Diabetes mellitus is a chronic condition that is often seen as a costly and avoidable use of health care services and so is a frequent target of such policies. Avoidable admission is interpreted as having a very long chain of causation. The assumption is that people requiring unscheduled hospital admission could have taken steps to prevent the onset of diabetes, or associated complications, arising in the first place. Definitions focus on primary and secondary prevention and largely place responsibility on the individual and their behaviour rather than on structural or social factors. Inadequate or inappropriate care prehospital or in the emergency department is seldom considered as a potential cause of avoidable admissions. Procedural definitions of avoidable admission are proposed whereby health care professionals and people living with diabetes collaborate to identify avoidable admissions in clinical audit rather than using statistical rates of avoidable admission within isolation in policy development and implementation. CONCLUSIONS: Avoidability and inappropriateness are characteristics of cases in which conduct of the individual or attendant health care professionals was a proximate cause of hospital admission, and but for such conduct, admission could have been avoided. This process of definition seeks to provide a basis for contextualised and considered evaluation of where there are problems in care and where there are reasonable opportunities for prevention.

Factors influencing hospital conveyance following ambulance attendance for people with diabetes: A retrospective observational study.

AIM: To assess variables contributing to hospital conveyance for people with diabetes and the interactions between them. A secondary aim was to generate hypotheses for further research into interventions that might reduce avoidable hospital admissions. METHODS: A national retrospective data set including 30 999 diabetes-related callouts from the Scottish Ambulance Service was utilized covering a 5-year period between 2013 and 2017. The relationship between diabetes-related hospital conveyance and seven potential risk factors was analysed. Independent variables included: age, gender, deprivation, paramedic attendance, treatment at the scene, first blood glucose measurement and day of the week. RESULTS: In Scotland, hyperglycaemia was associated with a higher number of people being conveyed to hospital than hypoglycaemia (49.8% with high blood glucose vs. 39.3% with low glucose, P ≤ 0.0001). Treatment provided in pre-hospital care was associated with reduced conveyance rates (47.3% vs. 58.2% where treatment was not administered, P ≤ 0.0001). Paramedic attendance was also associated with reduced conveyance to hospital (51.4% vs. 59.5% where paramedic was not present, P ≤ 0.0001). Paramedic attendance in hyperglycaemic cases was associated with significantly reduced odds of conveyance (odds ratio 0.52, P ≤ 0.001). CONCLUSIONS: A higher rate of conveyance associated with hyperglycaemic cases indicates a need for more resources, education and training in this area. Higher conveyance rates were also associated with no paramedic being present and no treatment being administered. This suggests that paramedic attendance may be crucial in reducing avoidable admissions. Developing and validating protocols for pre-hospital services and treatment may help to reduce hospital conveyance rates.

Exploring organizational support for the provision of structured self-management education for people with Type 2 diabetes: findings from a qualitative study.

AIM: To explore the organizational context in which Type 2 diabetes structured group education is provided. METHODS: Four Clinical Commissioning Groups in England providing Type 2 diabetes structured self-management education participated in a qualitative study exploring the context for provision of that education. Using UK National Diabetes Audit returns, two Clinical Commissioning Groups were selected that had non-attendance rates of ≤25%, and two that had non-attendance rates of ≥50%. Between May 2016 and August 2017, 20 interviews were conducted with Clinical Commissioning Group staff including: commissioners, healthcare professionals, managers, general practitioners and diabetes educators. Data gathering was prolonged as it proved challenging to engage with healthcare staff as a result of frequent local restructuring and service disruption. RESULTS: Local audits revealed discrepancies in basic data such as referral and attendance numbers compared with national audit data. There was a commonality in the themes identified from interviews: diabetes education was rarely embedded in service structure; where education uptake was poor, a lack of central support to delivery teams was noticeable; and where education uptake was positive, delivery teams were actively engaged, sometimes relying on enthusiastic individuals. Both situations put the local sustainability of diabetes education at risk. CONCLUSIONS: There appears to be a link between attendance rates and organizational issues, therefore, when considering how to increase attendance rates, the state of the diabetes education infrastructure should be reviewed. Good uptake of diabetes education can be too reliant on the enthusiastic commitment of small teams or individuals delivering the education.

Pilot feasibility study examining a structured self-management diabetes education programme, DESMOND-ID, targeting HbA1c in adults with intellectual disabilities.

AIM: To report on the outcomes of a pilot feasibility study of a structured self-management diabetes education programme targeting HbA1c . METHODS: We conducted a two-arm, individually randomized, pilot superiority trial for adults with intellectual disability and Type 2 diabetes mellitus. A total of 66 adults with disabilities across the UK met the eligibility criteria. Of these, 39 agreed to participate and were randomly assigned to either the DESMOND-ID programme (n = 19) or a control group (n = 20). The programme consisted of seven weekly educational sessions. The primary outcome was HbA1c level, and secondary outcomes included BMI, diabetes illness perceptions, severity of diabetes, quality of life, and attendance rates. RESULTS: This study found that the DESMOND-ID programme was feasible to deliver. With reasonable adjustments, the participants could be recruited successfully, and could provide consent, complete the outcome measures, be randomized to the groups and attend most of the sessions, with minimal loss to follow-up. The fixed-effects model, the interaction between occasion (time) and condition, showed statistically significant results (0.05 level) for HbA1c ; however, the CI was large. CONCLUSION: This is the first published study to adapt and pilot a national structured self-management diabetes education programme for adults with intellectual disability. This study shows it is possible to identify, recruit, consent and randomize adults with intellectual disabilities to an intervention or control group. Internationally, the results of this pilot are promising, demonstrating that a multi-session education programme is acceptable and feasible to deliver. Its effectiveness should be further tested in an adequately powered trial.

Exploring why young people with Type 1 diabetes decline structured education with a view to overcoming barriers.

AIMS: To identify factors that influence lack of engagement of young adults with Type 1 diabetes (aged 13-21 years) with structured diabetes education (SDE) to inform and broaden the reach of future SDE. METHODS: A quantitative, cross-sectional survey was undertaken of 227 young people with Type 1 diabetes drawn from 11 health trusts across Northern Ireland and England, deemed to be representative of the wider population. Participants were asked to complete a questionnaire exploring non-attendance, along with the Diabetes Care Profile, the Diabetes Empowerment Scale (Short Form), the Diabetes Knowledge Test and the 12-item General Health Questionnaire. Demographic, health and diabetes-specific variables including HbA1c were also collected. RESULTS: The five most commonly cited reasons for non-attendance were 'Had other things to do' (68.3%), 'No time' (62.2%), 'Could not get time off school/college or work' (60.8%), 'Learnt about diabetes from other sources' (55.5%) and 'Feel able to cope on own' (52.9%). CONCLUSIONS: Greater emphasis is required on communication with young people about the benefits of SDE. In addition, efforts need to be directed to making diabetes education more accessible without losing the quality of structured programmes.

Reasons why patients referred to diabetes education programmes choose not to attend: a systematic review.

AIMS: To identify the reasons why those offered a place on diabetes education programmes declined the opportunity. BACKGROUND: It is well established that diabetes education is critical to optimum diabetes care; it improves metabolic control, prevents complications, improves quality of life and empowers people to make informed choices to manage their condition. Despite the significant clinical and personal rewards offered by diabetes education, programmes are underused, with a significant proportion of patients choosing not to attend. METHODS: A systematic search of the following databases was conducted for the period from 2005-2015: Medline; EMBASE; Scopus; CINAHL; and PsycINFO. Studies that met the inclusion criteria focusing on patient-reported reasons for non-attendance at structured diabetes education were selected. RESULTS: A total of 12 studies spanning quantitative and qualitative methodologies were included. The selected studies were published in Europe, USA, Pakistan, Canada and India, with a total sample size of 2260 people. Two broad categories of non-attender were identified: 1) those who could not attend for logistical, medical or financial reasons (e.g. timing, costs or existing comorbidities) and 2) those who would not attend because they perceived no benefit from doing so, felt they had sufficient knowledge already or had emotional and cultural reasons (e.g. no perceived problem, denial or negative feelings towards education). Diabetes education was declined for many reasons, and the range of expressed reasons was more diverse and complex than anticipated. CONCLUSION: New and innovative methods of delivering diabetes education are required which address the needs of people with diabetes whilst maintaining quality and efficiency.

Comparing patient-generated blood glucose diary records with meter memory in diabetes: a systematic review.

AIMS: To synthesize evidence relating to comparisons between patient-generated blood glucose records and meter memory in diabetes and to identify any predictors of agreement. METHODS: A systematic literature search was performed to identify articles comparing meter and diary records in those unaware of this assessment. RESULTS: Eleven observational studies, covering patients with Type 1, Type 2 and gestational diabetes were included spanning 1984-2009. Failure to record blood glucose measurements in the diary was the most extensive 'error', but addition of values, which were not measured, was a greater cause for concern. When present to a high degree, 'errors' lead to decreased variability in diary records compared with meter records. Allowing for a minimal amount of disagreement, just over 50% of adult diaries can be considered as 'accurate/reliable'. Disagreements were most extensive in teenagers and young adults, but the pregnant populations were only slightly better. Agreement was not related to sex, number of insulin injections or duration of monitoring. Those who were younger were more likely to have 'errors', while those who monitored more frequently had more 'accurate' diaries. CONCLUSIONS: The lack of meter-diary agreement suggests that the real reason for monitoring is not understood by many patients, raising issues about motivation, perceived need to impress healthcare providers and denial of poor control. Considering that diaries are used to inform decisions about therapy when HbA1c is raised or in pregnancy, when HbA1c is not suitable, there is significant cause for concern in relation to their clinical utility.

Management and quality indicators of diabetes mellitus in people with intellectual disabilities.

BACKGROUND: People with intellectual disabilities (ID) are at a higher risk of developing diabetes compared with the non-intellectually disabled population, as a consequence of genetic syndromes and because this cohort are more exposed to many of the identified risk factors. However, little is known about the management of diabetes in this population. The aim of this study was to examine the demographics, health and the diabetes quality of care indicators used with people with ID in one region of the UK. METHODOLOGY: This was a quantitative study using a postal survey design. An anonymised questionnaire was posted to all community ID teams and supported living/residential facilities requesting information on the demographics, health and quality of care indicators for people with ID who have diabetes on their caseloads. RESULTS: In total 186 questionnaires were returned. Results showed that 125 people with ID had Type 2 diabetes (67%) and 61 people had Type 1 (33%). Significantly more people with Down syndrome and Autistic Spectrum Disorder had Type 1 diabetes. This study found that 6% had glycossylated glucose levels (HbA1c) greater than 9.5% and for 52% the levels were between 6.5% and 9.4%. Individuals reported to have poor glycaemic control were statistically more likely to have Type 1 diabetes and be younger, live with parents or independently and be obese. Results also illustrate that the national standards for good diabetes management were only partially met. DISCUSSION: Because of their enhanced predisposition for the development of diabetes this population merits particular attention with regards to screening for the onset of diabetes. The extent to which the quality of diabetes care indicators were achieved was variable but results suggest that for many people the indices were not met, that glycaemic control was poor, that only a quarter were of normal weight, that many were hypertensive and that almost a quarter had no record of their lipid levels. These findings provoke two important questions: first, who should be responsible for promoting diabetes management in this client group and second, how can service provision be tailored to better meet their needs? Greater collaborative working and education is required between ID services, primary healthcare and diabetes clinicians in order to promote the health and meet the quality indicators of diabetes care among this population.

Hyperglycaemia monitoring and management in stroke care: policy vs. practice.

AIM: To evaluate the extent to which hyperglycaemia was monitored and managed among patients admitted to hospital with acute stroke and transient ischaemic attack. METHODS: We conducted a retrospective cohort study involving a review of the records of 112 patients consecutively admitted with acute stroke or transient ischaemic attack to all three district general hospitals in one Health and Social Care Trust in Northern Ireland from 1 January to 15 April 2008. Glucose results for each of the first 5 days of hospital admission were ascertained. We compared interventions, clinical outcome and discharge planning between patients who experienced glucose ≥ 7.8 mmol/l in the first 5 days, and patients with lower glucose results. RESULTS: The daily prevalence rate of hyperglycaemia > 7.8 mmol/l across the first 5 days ranged from 24 to 34%. A total of 41 (37%) patients experienced hyperglycaemia on at least one occasion during the first 5 days. A history of diabetes mellitus prompted near patient glucose testing, but, among patients without diagnosed diabetes, glycaemia was under-monitored. Hyperglycaemia was a persisting trend, was under-treated and under-reported to general practitioners. Elevated glucose results failed to influence higher rates of fasting plasma glucose tests and BMI assessment. CONCLUSIONS: There is a need for greater vigilance in the detection of hyperglycaemia and undiagnosed diabetes mellitus among patients admitted to hospital with stroke or transient ischaemic attack.

Reticulocytosis in response to dietary antioxidants.

Alpha-tocopheryl acetate, 1, 2, dihydro-6-ethoxy-2, 2, 4-trimethylquinoline, and butylated hydroxytoluene increased the number of circulating reticulocytes when added to the diet of chickens. Hematocrit values were not reduced and erythrocyte life-spans were not shortened by the antioxidants. The reticulocytosis is attributed to delayed loss of reticular material from the maturing erythrocytes. components.

Knowledge and diabetes self-management.

This paper discusses the role of knowledge in the self-management of diabetes mellitus and addresses limitations in the measurement of knowledge in studies which have been undertaken. In addition, the findings of a recent investigation related to knowledge of diabetes in young adults with the condition are reported. The results showed high levels of knowledge and glycosylated haemoglobin values which were acceptable when length of time with diabetes was considered. However, no relationship between knowledge and level of glycaemic control was demonstrated. In the light of recent research confirming the need for tighter metabolic control, the implications of these findings in relation to future research and the education of health care professionals are considered. Although this paper related to diabetes mellitus many of the issues raised are equally applicable to the wider forum of chronic illness management.

The evolving concept of health in nursing research: 1988-1998.

This article concerns the evolution of the concept of health, as reported in selected nursing journals, over the last 10 years. It builds on an analysis reported by Reynolds [Reynolds CL. The measurement of health in nursing research. Adv Nurs Sci 1988;10(4):23-31.] who initially investigated the concept of health and the means by which it was measured during the period 1977-1987. Using the same journals as Reynolds, the methodology of systematic review is used to analyse the way in which health is defined, the frequency with which it is investigated and the means by which it is measured, and these data are compared with Reynolds findings. The results indicate that; three times as many studies have been conducted in the last 10 years, a more holistic concept of health has emerged, and the instruments used are becoming more sophisticated. These findings are discussed and the implications for patient education and health care professionals considered.

Disability under Social Security for patients with ESRD: an evidence-based review.

PURPOSE: In the United States, all individuals with end-stage renal (ESRD) disease are automatically eligible for disability benefits under the Social Security Act. Recently, there have been questions about whether the diagnosis of ESRD alone is an appropriate criterion for determining disability under Social Security. METHODS: We conducted a systematic review of the published literature and de novo analysis of data from the United States Renal Data System (USRDS) in an attempt to identify the best predictors of inability to work that might be useful during the disability determination process. RESULTS: The published literature yielded little relevant evidence. The USRDS provided a prospectively-collected set of data on 4,026 incident dialysis patients over their first year on dialysis, a time period particularly applicable to the key questions. However. data from over half of the patients were missing for the most important variables to this project, and only 42% of patients completed the one-year follow-up questionnaire. These limitations rendered de novo analyses unreliable. However, summary statistics did reveal a decreasing number of working individuals over time, from 41.9% before the initiation of dialysis. to 21.1% at initiation, and 6.6% a year later.

The American Dental Network. Dentistry's information source.

A brief history of the development of telematics and electronic information retrieval was presented. Electronic information services of special interest to the dental professional were outlined. The American Dental Network, which provides the most comprehensive online services specifically for dentists, was described in detail.

Self-management of chronic illness: implications for nursing.

Health problems and disease have changed during the last century with an increase in the numbers of people with chronic illness. Literature reveals the role of patients changing from passive to active participation in care management. A study of factors influencing self-management using both quantitative and qualitative methods was carried out. Selected results, with the major focus on the qualitative data, are presented to support discussion of a number of issues related to self-management of diabetes. However, many of the implications of the results also apply to those with chronic illness.

Diagnosed with Hepatitis C: a descriptive exploratory study.

A descriptive exploratory study was carried out to elicit the felt-experience of Hepatitis C infection. A non-probability sampling strategy was employed which generated a sample of nine participants for in-depth interview. Data analysis revealed that the diagnosis had precipitated a transition in the participants' lives. Factors were identified that served as barriers and facilitators to their transition experience. At the time of data collection all of the participants were not experiencing indicators of a healthy transition. It was evident that the transitional experience was neither time-bound nor linear in nature.

The health behaviours of Chinese people with chronic illness.

This study was undertaken to elucidate the type and range of health-promoting behaviours that Chinese people with chronic illness perform to enhance their health. Eight people with a diagnosed chronic illness were interviewed using a semi-structured interview schedule. From the perspectives of these subjects, health behaviour comprises three dimensions: physical, psychosocial and spiritual. The results of this study clarify health behaviours amongst Chinese people with a chronic illness and illustrate the important influence that culture has upon such activity. Additionally, exploring the health behaviours of these Chinese people can be used to inform and enable nurses to adjust their practices to relate more appropriately to patients' perspectives.

Measuring constructs accurately: a prerequisite to theory testing.

Accurate identification and measurement of constructs is particularly relevant to mental health nurses, who often have to work with clients that have intangible needs and problems. In this paper, the measurement of constructs, the relevance of construct validity to nursing research and, in particular, to theory testing will be discussed. Constructs within the health belief model are used to illustrate the discussion and procedure of factor analysis. Analysis of data based on a survey of health beliefs of 276 adults with the chronic condition of insulin-dependent diabetes is presented, interpreted and discussed. Whilst the paper focuses upon specific constructs and study population in order to provide a worked example, the issues raised and principles outlined relate to an analytical model that can be applied to other research problems and settings.

Evaluation of tools to assess clinical competence.

Assessment of student nurses' clinical skills is an important issue in nurse education. However suitable instruments are difficult to locate, and also to design. In the course of this article the need for scientifically designed and tested assessment instruments is discussed. The thoroughness with which 11 clinical assessment documents were developed was evaluated using specific criteria. It was found that in the majority of cases use of a systematic research process to guide development was not evident. However it must be noted that the assessment documents were only evaluated via their presentation in journal articles. Full details of the entire project had perhaps not been published. The implications of the results, some of the difficulties inherent in instrument design and the limitations of this small review are considered.