Provision of Medications for Self-Managed Abortion Before and After the Dobbs v Jackson Women's Health Organization Decision.

Importance: The Supreme Court decision in Dobbs v Jackson Women's Health Organization overturned the right to choose abortion in the US, with at least 16 states subsequently implementing abortion bans or 6-week gestational limits. Prior research indicates that in the 6 months following Dobbs, approximately 32 360 fewer abortions were provided within the US formal health care setting. However, trends in the provision of medications for self-managed abortion outside the formal health care setting have not been studied. Objective: To determine whether the provision of medications for self-managed abortion outside the formal health care setting increased in the 6 months after Dobbs. Design, Setting, and Participants: Cross-sectional study using data from sources that provided abortion medications outside the formal health care setting to people in the US between March 1 and December 31, 2022, including online telemedicine organizations, community networks, and online vendors. Using a hierarchical bayesian model, we imputed missing values from sources not providing data. We estimated the change in provision of medications for self-managed abortion after the Dobbs decision. We then estimated actual use of these medications by accounting for the possibility that not all provided medications are used by recipients. Exposure: Abortion restrictions following the Dobbs decision. Main Outcomes and Measures: Provision and use of medications for a self-managed abortion. Results: In the 6-month post-Dobbs period (July 1 to December 31, 2022), the total number of provisions of medications for self-managed abortion increased by 27 838 (95% credible interval [CrI], 26 374-29 175) vs what would have been expected based on pre-Dobbs levels. Excluding imputed data changes the results only slightly (27 145; 95% CrI, 25 747-28 246). Accounting for nonuse of medications, actual self-managed medication abortions increased by an estimated 26 055 (95% CrI, 24 739-27 245) vs what would have been expected had the Dobbs decision not occurred. Conclusions and Relevance: Provision of medications for self-managed abortions increased in the 6 months following the Dobbs decision. Results suggest that a substantial number of abortion seekers accessed services despite the implementation of state-level bans and restrictions.

Trends in diabetes self-management education: where are we coming from and where are we going? A narrative review.

AIMS: To summarize the history, development and efficacy of diabetes self-management education on glycaemic control and mental health in adults and children or adolescents with type 1 diabetes and people with type 2 diabetes. A further aim was to review the status of implementation of diabetes self-management education into routine care and outline current gaps in implementation and research. METHODS: We searched PubMed and Google scholar for German- and English-language articles regarding diabetes self-management education, glycaemic control and mental health, and restricted this search to meta-analyses. RESULTS: Diabetes education has evolved from a compliance- and knowledge-oriented approach to an empowerment- and self-management-oriented approach. Diabetes self-management education seems to have a greater impact on glycaemic outcomes than on mental health outcomes, but the latter are rarely assessed. Technological development and digitalization can provide chances and challenges for diabetes self-management education. Digital solutions show promising results and great potential for improving the efficacy of diabetes self-management education further and providing ongoing support. The implementation of diabetes self-management education into routine clinical care frequently remains a challenge. CONCLUSION: Diabetes self-management education has been acknowledged as an essential part of diabetes therapy; however, current gaps regarding the efficacy of diabetes self-management education on mental health, and the need for education on the use of diabetes technology, are future avenues for research.

Factors influencing pharmacists' over-the-counter drug recommendations.

BACKGROUND: Self-care is a growing trend all over the world, and pharmacists have a major role in it since they are the most easily accessible medical experts. OBJECTIVES: Our aim was to investigate factors influencing pharmacists' over-the-counter (OTC) drugs recommendations in Croatia. SETTING: A random sample of 565 (50%) of all pharmacies in Croatia. METHODS: A cross-sectional study with a five-point Likert scale online questionnaire covering medical and non-medical factors influencing OTC drug recommendation was distributed in October 2017 to a random sample of pharmacies. RESULTS: 206/565 (response rate 36.5%) responses were collected. The most important factors influencing pharmacists' recommendation were: composition of the OTC product and its active component (4.76±0.47), scientific evidence of effectiveness (4.54±0.60), feedback from the patients (4.32±0.61) and information from professional journals (4.22±0.67). On average, medical factors had greater importance (4.5±0.58) for pharmacists' OTC recommendation than marketing (3.18±0.84) and social factors (3.15±0.79). Female pharmacists appeared less inclined to recommend an OTC product based on advice of other pharmacists (OR=0.61, CI=0.43 to 0.86, p=0.005) and pharmacists working directly in a pharmacy attached more importance to active components of OTC products during their OTC product counselling (OR=2.28, CI=0.92 to 5.65, p=0.03). CONCLUSION: It is vital to know that pharmacists' OTC recommendations are mainly influenced by medical factors and to a lesser degree by marketing and social factors.

Atenção integral à saúde do adolescente pela Atenção Primária à Saúde no território brasileiro: uma revisão integrativa / Comprehensive health care of teenagers by the Primary Health Care in the Brazilian territory: an integrative review / Atención integral a la salud del adolescente por la Atención Primaria de la Salud en el territorio brasileño: una revisión integradora

A adolescência, fase de transformações biopsicossociais, requer da Atenção Primária à Saúde (APS) um modelo de cuidado à saúde abrangente, integral e promotor da saúde e da autonomia, aspectos abordados nesta revisão. Objetivou-se sistematizar experiências de cuidado ao adolescente pela APS. Realizou-se uma revisão integrativa nas bases de dados da Biblioteca Virtual em Saúde e Biblioteca Eletrônica Científica Online, selecionando-se 21 artigos publicados entre 2008 a 2019. Os dados foram interpretados pela análise temática de conteúdo. Observaram-se estigmas no cuidado ao adolescente; lacunas na formação profissional; acolhimento centrado na enfermagem; fragilidades dos vínculos; escassez de recursos estruturais e humanos; ações educativas, porém normativas; fragmentação das práticas; e barreiras de acesso à rede de saúde e intersetorial. Conclui-se, portanto, que, para alcançar um cuidado ampliado, é preciso repensar as práticas e dar voz ao adolescente.(AU)

Adolescence, a phase of biopsychosocial transformations, requires a comprehensive primary health care model that promotes health and autonomy, aspects covered in this review. The objective was to systematize the experiences of care of teenagers by the Primary Health Care. An integrative review was conducted on the Virtual Health Library (BVS) and Scientific Electronic Library Online databases, selecting 21 published papers from 2008 to 2019. Data were interpreted through the thematic content analysis. The following were observed in teenager care: stigmata; gaps in professional education; nursing-focused reception; weakness of bonds; lack of structural and human resources; educational but normative actions; fragmentation of practices; and barriers to the health and intersectoral networks. Therefore, the conclusion is that in order to achieve an expanded care it is necessary to rethink practices and give voice to teenagers.(AU)

La adolescencia, fase de transformaciones biopsicosociales, requiere de la Atención Primaria de la Salud (APS), un modelo de cuidado a la salud incluyente, integral y promotor de la salud y de la autonomía, aspectos abordados en esta revisión. El objetivo fue sistematizar experiencias de cuidado al adolescente por parte de la APS. Se realizó una revisión integradora en las bases de datos Biblioteca Virtual en Salud y Biblioteca Electrónica Científica Online, seleccionándose 21 artículos publicados de 2008 a 2019. Los datos se interpretaron por el análisis temático de contenido. Se observaron estigmas en el cuidado del adolescente; lagunas en la formación profesional; acogida centrada en la enfermería; fragilidades de los vínculos; escasez de recursos estructurales y humanos; acciones educativas, pero normativas; fragmentación de las prácticas y barreras de acceso a la Red de Salud e Intersectorial. Se concluyó, por lo tanto, que para alcanzar un cuidado ampliado es preciso repensar las prácticas y dar voz al adolescente.(AU)

Self-care behaviors in patients with type 2 diabetes: Education intervention base on social cognitive theory.

AIM: This study aimed to determine the effect of education intervention, based on social cognitive theory, on self-care behaviors in patients with type 2 diabetes. METHODS: This study was conducted in descriptive and interventional stages. The effective factors and constructs of social cognitive theory were identified in a descriptive study (n = 320). After that, a quasi-experimental study was conducted to determine the effect of intervention on 120 diabetic patients whom were randomly assigned to experimental and control groups. The educational intervention was implemented in six 40 -minute sessions for the experimental group. The questionnaires were completed before, immediately after and three months after the intervention. RESULTS: The results of regression showed that emotional adaptation (P < 0.05), self-efficacy to overcome barriers (P < 0.05) and self-regulation (P < 0.05) could predict self-care. There was no significant difference between the experimental and control groups before the educational intervention, however, after the intervention, there was a significant difference in self-care (p < 0.001), knowledge (p < 0.001), outcome expectations (p < 0.001), outcome value (p < 0.001), self-efficacy (p < 0.001), self-efficacy to overcome barriers(P < 0.001) p), environment (p < 0.001), observational learning (P < 0.05), situational perception (p < 0.001), self-regulation (p < 0.001) and emotional adaptation (p < 0.001)) in the intervention group. CONCLUSION: The results of this study showed that intervention, based on social cognitive model, has a positive effect on diabetes self-care in the patients. Emotional adaptation, self-efficacy to overcome barriers and self-regulation have the biggest impact on diabetes self-care.

The role of gender in the active attitude toward treatment and health among older patients in primary health care-self-assessed health status and sociodemographic factors as moderators.

BACKGROUND: Active attitude toward treatment and health (ATH) leads to improved cooperation and better health outcomes in patients. Supporting it in the population of older adults is a growing need in primary care. Recognising the role of gender, health and other sociodemographic factors can help to distinguish patients who need the most assistance in activation from general practitioners (GPs). The objective of the study was to investigate gender differences in ATH as well as the moderating role of self-assessed health (SAH) and selected sociodemographic factors (age, education, financial status, marital status). METHODS: A cross-sectional, multicentre study among 4936 primary care older patients (aged 50+) was conducted. The PRACTA-Attitude toward Treatment and Health questionnaire (PRACTA-ATH) was used to measure the cognitive, emotional (positive and negative affect), and motivational dimensions of ATH. Patients were approached before and after their visits in the primary health-care facilities randomly selected in Central Poland. RESULTS: Generalised linear models (GENLIN) revealed the main effects of gender, SAH, and sociodemographic characteristics, such as financial status, marital status and education. Interaction effects of gender and age (Wald's χ2 = 24.767, p < 0.001 for ATH Global), as well as gender and SAH (Wald's χ2 = 16.712, p < 0.002 for ATH Global) on ATH were found. The most assistance in regard to ATH was required by men aged 50-74 and men declaring good self-assessed health. Generally, women declared a more active attitude than men, showing more knowledge (M = 5.40, SD = 0.07 and M = 5.21, SD = 0.07, for women and men, respectively, p = 0.046), positive emotion (M = 5.55, SD = 0.06 and M = 5.33, SD =0.06, for women and men, respectively, p = 0.015) and motivation to be involved in their health issues (M = 5.71, SD = 0.07 and M = 5.39, SD = 0.07, for women and men, respectively, p = 0.001). The level of negative emotions related to health was not significantly different between genders (p = 0.971). CONCLUSIONS: The need to create health promoting programmes taking account of particular gender differences in older adults emerges. In regard to clinical practice, building a sense of efficacy and individual responsibility for health, providing information about the means of health promotion and prevention, and recognising health-related cognitions, is recommended especially for men who feel well and are less advanced in age (50-74).

Autocuidado e quimioterapia oral domiciliar: avaliação das práticas educativas dos enfermeiros sob a perspectiva de pacientes / Self-care and home oral chemotherapy: evaluation of nurses' educational practices from the perspective of patients / Autocuidado y quimioterapia oral en el domicilio: evaluación de las prácticas educativas de enfermería desde la perspectiva de los pacientes

Introdução: Ante a vida prática dos pacientes, indaga-se sobre a melhor forma de aquisição de saberes para o autocuidado. Objetivo: Avaliar, na perspectiva dos pacientes, convergências e divergências entre orientações para o autocuidado, compreensão quanto às orientações e sua aplicação. Método: Estudo avaliativo, qualitativo, sob a perspectiva hermenêutico-dialética, em hospital oncológico no Rio de Janeiro. Quinze participantes com câncer de cólon e reto com delimitação amostral distribuída por três grupos (ciclos iniciais, centrais e finais) do protocolo de tratamento XELO X. Adoção da amostra por conveniência sob os critérios: maioridade, ciência do tratamento, lucidez, funções cognitivas preservadas, ausência de metástase cerebral e em quimioterapia oral domiciliar. Produção de dados por entrevistas semiestruturadas entre setembro e outubro de 2012, levadas ao ponto da saturação teórica, numa cooperação entre participantes e pesquisadores para iluminar a experiência a ser explorada. Resultados: Oitenta e nove recortes de falas agrupados em três categorias empíricas e suas respectivas subcategorias, a saber: a categoria da orientação à compreensão, com oito subcategorias; a categoria descrição das práticas educativas, com quatro subcategorias; a categoria da compreensão à aplicação, com 11 subcategorias. Conclusão: Como há aprimoramentos possíveis ao longo do processo, na transição de uma etapa para a outra, são propostas uma ação anterior de identificação dos fatores socioculturais, uma ação posterior de caráter avaliativo e ações de acompanhamento entre um ciclo e outro.

Introduction: Given the real life of the patients, the best way of acquiring knowledge for self-care was examined. Objective: To evaluate, from the perspective of the patients, convergences and divergences between orientations for self-care, understanding of the orientations and their application. Method: Evaluative study, from a hermeneuticdialectic perspective, at a cancer hospital in Rio de Janeiro. Fifteen participants with colon and rectum cancer formed the sample, distributed into three groups (initial, central and final cycles) of the XELO X treatment protocol. Convenience sampling was adopted, with the following criteria: adult, treatment consciousness, lucidity, preserved cognitive functions, absence of cerebral metastasis and oral home chemotherapy. Data were produced using semi-structured interviews between September and October 2012, until theoretical saturation was reached, in a cooperation between participants and researchers to illuminate the experience to be explored. Results: Eighty-nine speech extracts grouped into three empirical categories and their respective subcategories, namely: the orientation-to-understanding category, with eight subcategories; the description of educational practices category, with four subcategories; and the understanding the application category, with 11 subcategories. Conclusion: As there are possible improvements throughout the process, in the transition from one stage to the next, we propose a previous activity to identify sociocultural factors, a later activity of avaliative feature and monitoring activities between one cycle and the next.

Introducción: Ante la vida práctica de los pacientes, se pregunta sobre la mejor manera de adquirir conocimientos para el autocuidado. Objetivo: Evaluar, desde la perspectiva de los pacientes, las convergencias y divergencias entre las directrices para el autocuidado, la comprensión de las directrices y su aplicación. Método: Estudio evaluativo cualitativo, sobre la perspectiva hermenéutica-dialéctica, en un hospital oncológico en Río de Janeiro. Quince participantes con cáncer de colon y recto con la muestra de conveniencia distribuida en tres grupos del protocolo de tratamiento XELO X, bajo los criterios: adultez, conciencia sobre el tratamiento, lucidez, funciones cognitivas conservadas, ausencia de metástasis cerebral y en quimioterapia oral en el domicilio. Producción de los datos por medio de entrevistas semiestructuradas entre septiembre y octubre de 2012, llevados hasta la saturación teórica, en una cooperación entre participantes y investigadores para iluminar la experiencia a ser explorada. Resultados: Ochenta y nueve recortes de hablas agrupados en tres categorías empíricas y sus subcategorías, a saber: la categoría de la orientación a la comprensión, con ocho subcategorías; la categoría descripción de las prácticas educativas, con cuatro subcategorías; y la categoría de la comprensión a la aplicación, con 11 subcategorías. Conclusión: Debido a que hay posibles mejoras en el proceso, se propone una acción anterior para identificar los factores socioculturales, una posterior, en carácter de evaluación, y acciones de seguimiento de un ciclo a otro.

Home Mechanical Ventilation: An Overview.

Prevalence studies have shown heterogeneous use of home mechanical ventilation in different conditions, with a marked increase in uptake especially in users of noninvasive ventilation. Although randomized controlled trials have examined noninvasive ventilation in acute exacerbations of chronic obstructive pulmonary disease, for weaning from invasive ventilation and for postextubation respiratory failure, the evidence base for long-term noninvasive ventilation and comparisons with invasive ventilation are less well developed. The combination of noninvasive ventilation and cough-assist devices has reduced the indications for tracheotomy ventilation in some situations (e.g., Duchenne muscular dystrophy, spinal muscular atrophy, myopathies, and amyotrophic lateral sclerosis) and has also prolonged survival. Several excellent overviews have been written on the history of home mechanical ventilation and its evolution from negative pressure to positive pressure techniques, including a systematic review of outcomes. This review, instead, will cover recent trials, trends in the field, outcomes, and safety. Because the greatest growth has been in home noninvasive ventilation, this will be the main focus of this article.

Motor and Cognitive Functional Status Are Associated with 30-day Unplanned Rehospitalization Following Post-Acute Care in Medicare Fee-for-Service Beneficiaries.

BACKGROUND: The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood. OBJECTIVE: To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care. DESIGN: This was a retrospective cohort study. SETTING: Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013. PARTICIPANTS: Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406). INTERVENTIONS: Not applicable. MAIN MEASURES: Thirty-day unplanned rehospitalization following post-acute rehabilitation. KEY RESULTS: The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %). CONCLUSIONS: The functional domains identified in the IMPACT Act were associated with 30-day unplanned rehospitalization following post-acute care in this large national sample. Further research is needed to better understand and improve the functional measures, and to determine if their association with rehospitalizations varies across post-acute settings, patient populations, or episodes of care.

Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review.

BACKGROUND: Prevention of foot ulcers in patients with diabetes is extremely important to help reduce the enormous burden of foot ulceration on both patient and health resources. A comprehensive analysis of reported interventions is not currently available, but is needed to better inform caregivers about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to prevent first and recurrent foot ulcers in persons with diabetes who are at risk for ulceration. METHODS: The available medical scientific literature in PubMed, EMBASE, CINAHL and the Cochrane database was searched for original research studies on preventative interventions. Both controlled and non-controlled studies were selected. Data from controlled studies were assessed for methodological quality by two independent reviewers. RESULTS: From the identified records, a total of 30 controlled studies (of which 19 RCTs) and another 44 non-controlled studies were assessed and described. Few controlled studies, of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, multiple RCTs with low risk of bias show the benefit for the use of daily foot skin temperature measurements and consequent preventative actions, as well as for therapeutic footwear that demonstrates to relieve plantar pressure and that is worn by the patient. To prevent recurrence, some evidence exists for integrated foot care when it includes a combination of professional foot treatment, therapeutic footwear and patient education; for just a single session of patient education, no evidence exists. Surgical interventions can be effective in selected patients, but the evidence base is small. CONCLUSION: The evidence base to support the use of specific self-management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong, but is small for the use of other, sometimes widely applied, interventions and is practically nonexistent for the prevention of a first foot ulcer and non-plantar foot ulcer.

A shift in priority in diabetic foot care and research: 75% of foot ulcers are preventable.

Diabetic foot ulceration poses a heavy burden on the patient and the healthcare system, but prevention thereof receives little attention. For every euro spent on ulcer prevention, ten are spent on ulcer healing, and for every randomized controlled trial conducted on prevention, ten are conducted on healing. In this article, we argue that a shift in priorities is needed. For the prevention of a first foot ulcer, we need more insight into the effect of interventions and practices already applied globally in many settings. This requires systematic recording of interventions and outcomes, and well-designed randomized controlled trials that include analysis of cost-effectiveness. After healing of a foot ulcer, the risk of recurrence is high. For the prevention of a recurrent foot ulcer, home monitoring of foot temperature, pressure-relieving therapeutic footwear, and certain surgical interventions prove to be effective. The median effect size found in a total of 23 studies on these interventions is large, over 60%, and further increases when patients are adherent to treatment. These interventions should be investigated for efficacy as a state-of-the-art integrated foot care approach, where attempts are made to assure treatment adherence. Effect sizes of 75-80% may be expected. If such state-of-the-art integrated foot care is implemented, the majority of problems with foot ulcer recurrence in diabetes can be resolved. It is therefore time to act and to set a new target in diabetic foot care. This target is to reduce foot ulcer incidence with at least 75%.

The costs of offering HPV-testing on self-taken samples to non-attendees of cervical screening in Finland.

BACKGROUND: Offering self-sampling to non-attendees of cervical screening increases screening attendance. METHODS: We used observations from two Finnish studies on the use of self-sampling among the non-attendees to estimate in a hypothetical screening population of 100,000 women the possible costs per extra screened woman and costs per extra detected and treated CIN2+ with three intervention strategies; 1) a primary invitation and a reminder letter, 2) a primary invitation and a mailed self-sampling kit and 3) two invitation letters and a self-sampling kit. The program costs were derived from actual performance and costs in the original studies and a national estimate on management costs of HPV related diseases. RESULTS: The price per extra participant and price per detected and treated CIN2+ lesion was lower with a reminder letter than by self-sampling as a first reminder. When self-sampling was used as a second reminder with a low sampler price and a triage Pap-smear as a follow-up test for HPV-positive women instead of direct colposcopy referral, the eradication of a CIN2+ lesion by self-sampling was not more expensive than in routine screening, and the addition of two reminders to the invitation protocol did not increase the price of an treated CIN2+ lesion in the entire screened population. CONCLUSIONS: As a first reminder, a reminder letter is most likely a better choice. As second reminder, the higher costs of self-sampling might be compensated by the higher prevalence of CIN2+ in the originally non-attending population.

Interactive Care Model: A Framework for More Fully Engaging People in Their Healthcare.

Transformation of care delivery requires rethinking the relationship between the person and clinician. The model described provides a process to more fully engage patients in their care. Five encounters include assessing capacity for engagement, exchanging information and choices, planning, determining interventions, and evaluating the effectiveness of engagement interventions. Created by researchers and validated by experts, implications for practice, education, and policy are explored.

The Diabetes Educator and the Diabetes Self-management Education Engagement: The 2015 National Practice Survey.

PURPOSE: The National Practice Study (NPS) is conducted biannually to assess current diabetes education practices in the United States with the goal of understanding current trends in the work in which diabetes educators engage. METHODS: The 2015 NPS contained 54 questions about the individuals providing diabetes education, people with diabetes participating in education, and programs providing the education. The survey was sent electronically to approximately 21 975 people who were members of the American Association of Diabetes Educators (AADE) or who were Certified Diabetes Educators with the National Certification Board for Diabetes Educators but were not currently AADE members. In addition, both the AADE and the National Certification Board for Diabetes Educators promoted participation in the NPS via social media. The combination of efforts resulted in completion of the survey by 4855 respondents. Testing was completed with a significance level of 0.05 or 95% confidence. RESULTS: Diabetes educators continue to represent a diverse group of health care professionals-nurses (50%), dietitians (35%), pharmacists (6%), and others (6%). By far, the most commonly held credential for the specialty continues to be the Certified Diabetes Educator (86%), with only 5% of survey respondents indicating that they held the Board Certified-Advanced Diabetes Management credential. Diabetes educators are working with individuals across the diabetes continuum, as well as with people who do not have diabetes but have other chronic conditions. The data demonstrate that much of the diabetes educator's work with people with diabetes is beyond the first year of diagnosis. Diabetes educators are increasingly seen to be providing a broader array of the integrated AADE7 Self-Care Behaviors™. CONCLUSIONS: The specialty of diabetes educator continues to be populated by a professionally diverse workforce, meeting the needs of people across a wide spectrum. Diabetes educators can be found providing services in primary prevention of diabetes, education and management for those diagnosed with diabetes, prevention of secondary complications, and more complex management of diabetes and its secondary complications. While diabetes educators were found to work with those newly diagnosed with diabetes, they continue to engage with people with diabetes at various times other than the year that they were diagnosed. There are still issues with participant readiness, as evidenced by program completion rates. Nonetheless, diabetes educators are increasingly seen to be providing the integrated engagement that is needed to better ensure that people with diabetes attain and maintain competency in self-management skills.

Trends in Warfarin Monitoring Practices Among New York Medicare Beneficiaries, 2006-2011.

Anticoagulation with warfarin requires frequent evaluation of the international normalized ratio (INR), and less invasive testing devices are available for use by clinicians at the point-of-care (POC) and by patients who self-test (PST). Despite commercial availability and positive results of published studies, evidence suggests that adoption of less invasive (POC/PST) testing in the United States is slow. Considering the equivalence of results and logistical advantages of POC/PST testing, slow uptake may indicate a gap in quality of care warranting evaluation and possibly intervention. This study used Medicare fee for service claims data to explore the uptake of POC/PST INR monitoring across New York State over a 6 year time frame (2006-11), with additional analyses based on beneficiary age, sex, race and ethnicity and income by county. In 2006, only 28.3% of 103,410 analyzable beneficiaries presumed to be chronic warfarin users based on INR testing patterns were monitored by POC/PST, and increased to only 37.6% by 2011. Utilization of POC/PST testing varied widely by county (baseline range 1.2-89.4%), and uptake of these testing modalities in New York State was significantly lower among the very elderly, women, and ethnic minorities. We hypothesize that poor penetration of these less invasive INR testing modalities into highly populated New York City and barriers to POC utilization in long term care facilities may account for a portion of the variability in INR testing patterns observed in this study. However, additional research is needed to further explore whether disparities in warfarin monitoring practices exist.

The evolution of mobile apps for asthma: an updated systematic assessment of content and tools.

BACKGROUND: Interest in mobile apps that support long-term conditions such as asthma is matched by recognition of the importance of the quality and safety of apps intended for patient use. We assessed how changes over a 2-year period affected the clinical suitability of apps providing self-management information and tools for people with asthma by updating a review first performed in 2011. METHODS: Systematic content assessment of all apps for iOS and Android examining the comprehensiveness of asthma information, consistency with the evidence base for asthma self-management and adherence to best practice principles for trustworthy content, comparing the quality of apps available in 2011 to those released since. RESULTS: Between 2011 and 2013, numbers of asthma apps more than doubled from 93 to 191, despite withdrawal of 25% (n = 23/93) of existing apps. Newer apps were no more likely than those available in 2011 to include comprehensive information, such as the use of action plans, or offer guidance consistent with evidence; 13% (n = 19/147) of all apps, and 39% (n = 9/23) of those intended to manage acute asthma, recommended self-care procedures unsupported by evidence. Despite increases in the numbers of apps targeting specific skills, such as acute asthma management (n = 12 to 23) and inhaler technique (from n = 2 to 12), the proportion consistent with guidelines (17%, n = 4/23) and inhaler instructions (25%, n = 3/12), respectively, was low, and most apps provided only either basic information about asthma (50%, n = 75/147) or simple diary functions (24%, n = 36/147). CONCLUSIONS: In addition to persisting questions about clinical quality and safety, dynamic aspects of app turnover and feature evolution affect the suitability of asthma apps for use in routine care. The findings underline the need for coordinated quality assurance processes that can adapt to changing clinical and information governance-related risks, ensure compliance with the evidence base and reflect local variations in clinical practice. It is unclear if substantial clinical benefits can be realized from a landscape dominated by low quality generic information apps and tools that do not adhere to accepted medical practice.