Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?

BACKGROUND: Heart failure is a common and costly condition, particularly in the elderly. A range of models of interventions have shown the capacity to decrease hospitalizations and improve health-related outcomes. Potentially, cardiac rehabilitation models can also improve outcomes. AIM: To assess the impact of a nurse-coordinated multidisciplinary, cardiac rehabilitation program to decrease hospitalizations, increase functional capacity, and meet the needs of patients with heart failure. METHOD: In a randomized control trial, a total of 105 patients were recruited to the study. Patients in the intervention group received an individualized, multidisciplinary 12-week cardiac rehabilitation program, including an individualized exercise component tailored to functional ability and social circumstances. The control group received an information session provided by the cardiac rehabilitation coordinator and then follow-up care by either their cardiologist or general practitioner. This trial was stopped prematurely after the release of state-based guidelines and funding for heart failure programs. RESULTS: During the study period, patients in the intervention group were less likely to have been admitted to hospital for any cause (44 vs. 69%, P = 0.01) or after a major acute coronary event (24 vs. 55%, P = 0.001). Participants in the intervention group were more likely to be alive at 12 months, (93 vs. 79%; P = 0.03) (odds ratio = 3.85; 95% confidence interval=1.03-14.42; P = 0.0042). Quality of life scores improved at 3 months compared with baseline (intervention t = o/-4.37, P<0.0001; control t = /-3.52, P<0.01). Improvement was also seen in 6-min walk times at 3 months compared with baseline in the intervention group (t = 3.40; P = 0.01). CONCLUSION: This study shows that a multidisciplinary heart failure cardiac rehabilitation program, including an individualized exercise component, coordinated by a specialist heart failure nurse can substantially reduce both all-cause and cardiovascular readmission rates, improve functional status at 3 months and exercise tolerance.

Factors associated with civilian mortality in Australian Vietnam veterans three decades after the war.

A prospective cohort study of a random sample of 1,000 Australian Army Vietnam veterans analyzed risk factors for postwar mortality using information from Army records and personal interview assessments of physical and mental health measured approximately 15 years earlier. This enabled examination of the role of combat, military service, and psychiatric status including post-traumatic stress disorder (PTSD) on postwar civilian mortality. Factors predicting mortality were identified using multivariate statistical methods including logistic and Cox regression. Mortality was associated principally with age, enlistment route (regular vs. national service conscripts), and conduct while in service in the whole cohort. Additional analysis using interview data revealed that mortality was predicted by age, smoking status, chronic diabetes, bronchitis and blood diseases, and treatment for cancer and heart disease. Psychiatric status including PTSD diagnosis was not associated with mortality. Veterans' mortality risk may be reduced by attention to smoking and alcohol both in-service and postservice.

The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder.

The long-term health consequences of war service remain unclear, despite burgeoning scientific interest. A longitudinal cohort study of a random sample of Australian Vietnam veterans was designed to assess veterans' postwar physical and mental health 36 years after the war (2005-2006) and to examine its relation to Army service, combat, and post-traumatic stress disorder (PTSD) assessed 14 years previously (1990-1993). Prevalences in veterans (n = 450) were compared with those in the Australian general population. Veterans' Army service and data from the first assessments were evaluated using multivariate logistic regression prediction modeling. Veterans' general health and some health risk factors were poorer and medical consultation rates were higher than Australian population expectations. Of 67 long-term conditions, the prevalences of 47 were higher and the prevalences of 4 were lower when compared with population expectations. Half of all veterans took some form of medication for mental well-being. The prevalence of psychiatric diagnoses exceeded Australian population expectations. Military and war service characteristics and age were the most frequent predictors of physical health endpoints, while PTSD was most strongly associated with psychiatric diagnoses. Draftees had better physical health than regular enlistees but no better mental health. Army service and war-related PTSD are associated with risk of illness in later life among Australian Vietnam veterans.

Increasing oncologists' skills in eliciting and responding to emotional cues: evaluation of a communication skills training program.

PURPOSE: Psychological morbidity in cancer patients is common, but often undetected and untreated. We developed a communication skills training (CST) program targeting this issue, and evaluated its impact on doctor behaviour. PATIENTS AND METHODS: Thirty of 35 oncologists from six teaching hospitals in six Australian cities, participated. The CST was a 1.5-day intensive face-to-face workshop incorporating presentation of principles, a DVD modelling ideal behaviour and role-play practice, followed by four 1.5 h monthly video-conferences incorporating role-play of doctor-generated scenarios. Doctors were randomized to receive the CST or not. Simulated patient interviews were videotaped and coded at baseline, after CST and 6 months later. Doctors completed questionnaires assessing stress and burnout at the same time points. RESULTS: Doctors in the intervention group displayed more creating environment and fewer blocking behaviours at both follow-ups; however, these differences did not reach statistical significance. Intervention doctors valued the training highly, but did not report substantial reductions in stress and burnout. CONCLUSIONS: This short training programme demonstrated a positive effect on aspects of doctor behaviour. Video-conferencing after a short training course may be an effective strategy for delivering CST.

Accuracy of telephone self-report of drug use in older people and agreement with pharmaceutical claims data.

OBJECTIVE: To determine the agreement between two measures of medication use, namely telephone interview self-report and pharmaceutical claims data, in an elderly population. METHODS: An agreement study of 566 community-dwelling, general practice patients aged > or =65 years was conducted to compare self-reported use of medicines with pharmaceutical claims data for different retrieval periods. Classes of drugs commonly used in the elderly were selected for comparison. RESULTS: 1094 people were eligible for the main study. Of these, 697 people completed a follow-up survey and 625 of these patients consented to the release of pharmaceutical claims data. A further 59 participants were excluded from the analysis because they had a home visit instead of a telephone interview. The proportion of observed agreement between the telephone self-report and the various retrieval periods was consistently high. Kappa coefficients showed good to very good agreement (> or = 0.75) with retrieval periods of 30, 60 and 90 days for benzodiazepines, low-risk NSAIDs, thiazide diuretics and most other drugs. The specificity of self-reported medication use compared with claims data was consistently high across all drug classes, suggesting that people usually did not mention drugs that were not included in the claims data. Sensitivity values varied according to drug class and retrieval period, and were lower for NSAIDs than for benzodiazepines and thiazide diuretics. Decline in sensitivity with increased retrieval periods was most marked for benzodiazepines, NSAIDs and low-risk NSAIDs, which are often used on an as-needed basis. Positive predictive values increased with longer retrieval periods CONCLUSION: High agreement and accuracy were demonstrated for self-reported use of medicines when patients were interviewed over the telephone compared with pharmaceutical claims data. The telephone inventory method can be used in future studies for accurately measuring drug use in older people when claims data are not available.

Unmet needs following hospitalization with heart failure: implications for clinical assessment and program planning.

BACKGROUND: Measuring health status is increasingly important in both clinical practice and research. The Heart Failure Needs Assessment Questionnaire (HFNAQ) is a self-administered, disease-specific, 30-item questionnaire that measures an individual's perception of his/her needs in the physical, psychological, social, and spiritual domains. OBJECTIVES: To assess the prevalence of needs in patients with heart failure (HF) recently discharged from hospital. METHODS: The HFNAQ was administered to participants (n = 132; mean [SD] age, 72.3 [9.69] years; 63% male) consenting to attend an HF-specific cardiac rehabilitation program. RESULTS: The total mean HFNAQ score was 67.3 (95% confidence interval, 65.03-69.75), indicating an average level of need around the midrange of the scale. In this vulnerable postdischarge phase, there was evidence of predominance of psychological and social concerns over physical needs. None of the variables that were examined for associations with the measures of needs reached statistical significance, highlighting the strongly individualized perception of need. CONCLUSIONS: Higher levels of unmet needs in the psychological and social domains, compared with physical needs, identify psychosocial care as an important consideration for nursing interventions for people with HF. This study further demonstrates the importance of assessing the needs from the perspective of the individual to ascertain each person's unique perspective of the HF illness experience. Study findings further underscore the importance of individualized care planning for patients with HF after discharge from hospital to address their unique needs and circumstances.

Medication review: patient selection and general practitioner's report of drug-related problems and actions taken in elderly Australians.

OBJECTIVES: To investigate which patients general practitioners (GPs) selected for medication review based on risk factors for medication problems and patient demographics; to describe drug-related problems and actions taken to solve those problems during medication review consultations based on GPs' self-report. DESIGN: Cross-sectional. SETTING: General practices. PARTICIPANTS: Four hundred fifty-two patients recruited from 11 GPs. MEASUREMENTS: Patients' self-reported risk factors for medication misadventures collected from Medication Risk Assessment Forms; doctors' report of patients' drug-related problems and actions taken to solve those problems collected from Medication Review Checklists. Patients completed a Medication Risk Assessment Form in the waiting room, which they presented to their doctor, who then decided whether the patient needed a medication review. GPs completed a Medication Review Checklist. RESULTS: GPs completed 124 Medication Review Checklists. The group that had a medication review had a lower proportion of individuals aged 65 to 74 than the group that did not (40% vs 56%). The proportion of people with risk factors for medication misadventure was consistently higher for patients who received a medication review. GPs found that 88% (95% confidence interval (CI) =66-97) of patients who had a medication review had at least one problem with use of their medication. GPs reported taking at least one action for 104 (88%) patients (95% CI=65-97) to rectify medication problems. Most common actions taken were monitoring (55%), improving compliance (50%), dose change (37%), cessation of drug (28%), and ordering of a pathology test (26%). CONCLUSION: A Medication Risk Assessment Form completed by patients can be used to select patients for medication review, and medication reviews conducted by GPs can be beneficial in improving the use of medication in older people living in the community.

Prevalence and correlates of perceived unmet needs of people with systemic lupus erythematosus.

To assess the prevalence and correlates of perceived unmet need among people with systemic lupus erythematosus (SLE) 386 people with SLE, recruited from a support association in NSW, Australia, completed a mail-back survey that included 97 items measuring perceived unmet needs across seven domains: physical, daily living, psychological/spiritual/existential, health services, health information, social support and employment/financial. Ninety-four percent of participants had at least one unmet need. The highest levels of unmet need were tiredness (81%); pain (73%); not being able to do things one used to (72%); fear of exacerbation (72%); sleeping problems (70%); anxiety and stress (69%); and feeling down (68%). Five of the highest levels of unmet needs were in the psychological domain. Researchers concluded that current health care delivery is not adequately meeting some of the needs of people with SLE. A comprehensive needs assessment questionnaire for all SLE patients could help providers manage protocols more effectively.

Activities of home-based heart failure nurse specialists: a modified narrative analysis.

BACKGROUND: Heart failure nurse specialists strive to optimize patients' outcomes in home-based settings. OBJECTIVE: To document the activities of home-based heart failure nurse specialists. METHOD: A modified narrative analysis of clinical notes of home-based heart failure nurse specialists during a 12-month period was used. RESULTS: Data analysis revealed 7 key activities of home-based heart failure nurse specialists: (1) monitoring signs and symptoms and reinforcing patients' self-management: identifying trends and appropriate action; (2) organization, liaison, and consultation with other health professionals to deal with changes in clinical status; (3) clarifying and reinforcing patients' self-care strategies; (4) assisting patients in their desire to avoid institutionalized care; (5) identifying patients' psychosocial issues: dealing with social isolation; (6) providing support: journeying with patients and patients' families; and (7) helping patients and patients' families deal with death and dying. CONCLUSIONS: A major proportion of the activities of home-based heart failure nurse specialists are related to facilitating communication between health professionals and providing information and support to patients and patients' families.

Estimating the contribution of individual risk factors to disease in a person with more than one risk factor.

Various measures have been proposed to express the excess risk of an outcome attributable to one particular risk factor, such as attributable risk and risk fraction. However, there is sometimes a need, both in epidemiological studies and in awarding compensation in legal cases, to simultaneously consider the contribution of several risk factors to a disease outcome, when a biological model is not available. We propose a method that allocates the proportional contribution of several risk factors to a disease outcome, based on the weighted contribution of the risk fraction for each risk factor. We demonstrate the use of this method using figures for renal cell carcinoma, and discuss the caveats in using this method for epidemiologic studies, and in awarding compensation in legal cases.

Monitoring and educational feedback to improve the compliance of tattooists and body piercers with infection control standards: a randomized controlled trial.

OBJECTIVES: Blood-borne viruses, which present a grim health and economic burden for both developed and developing countries, can be transmitted through tattooing and piercing. Limited data exist concerning intervention strategies for increasing skin penetration operators' compliance with infection control standards. We evaluated the efficacy and acceptability of an educational feedback intervention for tattooists and piercers. METHODS: A randomized controlled trial was conducted in Sydney, NSW, Australia, among 37 tattooing and body-piercing premises in 2002. RESULTS: No effects were found in terms of improved knowledge. There was a significantly greater increase in the experimental group in the perceived risk of being detected and penalized for noncompliance. There was a significantly greater improvement in the demonstration of 2 of 3 infection control procedures and a nonsignificant trend toward greater improvement in inspection scores in the experimental group. The odds of compliance were significantly higher in the experimental group for 2 of the 3 demonstration practices and in 2 of 5 observed infection control practices. CONCLUSION: The findings contribute new information concerning alternative approaches to increasing tattooists and piercers' infection control compliance with regulations/guidelines.

Fecal incontinence after high-risk delivery.

OBJECTIVE: To investigate the prevalence of and factors associated with fecal incontinence and its precursors among high-risk women at 12 months postpartum. METHODS: A survey of women in the immediate and later postpartum was conducted. Participants were 568 women at higher risk of anal sphincter damage, namely those who had an instrumental delivery and/or delivered a high birth weight infant (4000 g or more) at tertiary teaching hospitals in Australia. Women participated in a baseline hospital-based interview and a 12-month follow-up telephone interview. The main outcome measures were frank fecal incontinence (solid and/or liquid stool) and precursor symptoms (flatal incontinence, soiling, and/or fecal urgency) at 12 months postpartum. RESULTS: Prevalence rates were 2.6% for solid stool incontinence and 4.9% for liquid stool incontinence. Overall, 6.9% women had either one or both of these symptoms of frank fecal incontinence. Prevalence rates were 24.4% for flatal incontinence, 10.9% for soiling, and 14.8% for fecal urgency. Overall, 32.4% women had at least one of these precurser symptoms. Concurrent urinary incontinence and postpartum constipation were significantly associated with both frank fecal incontinence and precursor symptoms. In addition, joint hypermobility and older maternal age were associated with frank fecal incontinence, whereas inability to stop the urine flow and multiparity was associated with precursor symptoms. CONCLUSION: The present findings suggest that older and multiparous women, and women with joint hypermobility are at increased risk of postpartum anal incontinence symptoms after a high-risk delivery. Concurrent urinary incontinence, flow-stopping inability, and constipation are also associated with postpartum anal incontinence symptoms after high-risk deliveries.

The adequacy of measurement of short and long-term consequences of false-positive screening mammography.

OBJECTIVES: The aim of this study is to review quantitative studies on women's experiences of consequences of false-positive screening mammography to assess the adequacy of the most frequently used instruments for measuring short-term and long-term psychological consequences. METHODS: Relevant papers reporting quantitative studies on consequences of false-positive screening mammography were identified using MEDLINE, CINAHL, EMBASE and PsycInfo databases. Articles citing development and psychometric properties of the most frequently used measures were also retrieved. Finally, the review focused on studies that had used at least one of the most frequently used measures. RESULTS: Twenty-three relevant studies were identified. The most commonly used measures were the General Health Questionnaire (GHQ), the Hospital Anxiety and Depression Scale (HADS), the Psychological Consequences Questionnaire (PCQ) and the State-Trait Anxiety Inventory (STAI). One or more of these was used in 17 of the 23 studies. CONCLUSIONS: The GHQ, the HADS and the STAI have problems with language, content relevance, and content coverage in studies of false-positive screening mammography. These instruments should not be used to measure psychological consequences of any kind of cancer screening. The PCQ is an adequate questionnaire for measuring short-term consequences, and the PCQ is preferable to other measures because of its higher sensitivity. However, there is little evidence that the PCQ is able to adequately detect all long-term consequences of screening mammography. Given the inadequacy of the measurement instruments used, any current conclusions about the long-term consequences of false-positive results of screening mammography must remain tentative.

Counselling interventions to address the psychological consequences of screening mammography: a randomised trial.

We examined the effectiveness of offering counselling to women undergoing screening mammography who are recalled for further investigations that do not lead to a diagnosis of cancer. Women were randomised to being offered either face-to-face (n = 66) or telephone counselling (n = 68) or usual care (n = 71) at the recall clinic after being told that their screen-detected abnormality was not cancer. The PCQ (a reliable and valid measure of the psychological consequences of screening mammography) measured the emotional, social and physical functioning of women at the recall clinic (Time 1) and after the counselling intervention (Time 2). Analyses of covariance (ANCOVA) showed no main effects for intervention on Time 2 levels of functioning after adjustment for the respective covariate of Time 1 functioning. Time 1 levels significantly predicted Time 2 levels of functioning. When data were analysed according to whether women actually received any type of counselling versus not receiving counselling, participation in counselling was associated with lower scores on dysfunction scales at Time 2, after adjusting for Time 1 levels.

Screening for bowel cancer among NSW adults with varying levels of risk: a community survey.

OBJECTIVE: To estimate the extent and modality of screening for colorectal cancer in NSW among community-dwelling adults aged over 40 with varying degrees of familial risk. DESIGN: Cross-sectional telephone survey with participants randomly selected from the electronic NSW telephone directory. MAIN RESULTS: 5.7% of people at average risk aged 40-49 report having had at least one faecal occult blood test (FOBT) in the previous five years, compared with 18.4% of those at average risk aged 50 and over. Of those at above-average risk (by age and familial risk), 7.9% reported that they had had an FOBT in the previous five years. Around 5% of respondents aged 40-49 and 10% of those aged 50+ reported having had a colonoscopy/sigmoidoscopy for screening within the previous five years, compared with 30% of those at above-average risk. People with medical insurance were more likely to have undergone a screening test (either FOBT or sigmoidoscopy/colonoscopy), than those without insurance (PR = 1.30; 95% CI 1.02-1.67). Compared with those employed full time, those who were retired (PR = 1.45 95% CI 1.01-2.09) and those who reported home duties (PR = 1.54 95% CI 1.01-2.36) were slightly, but significantly more likely to report having had a test. As perception of personal risk for colorectal cancer increased, so did the likelihood of having had a screening test within the previous five years (PR = 1.19; 95% CI 1.05-1.35). CONCLUSION: We have reported important baseline data with which to compare the progress of both pilot screening programs and more widespread implementation of colorectal screening in Australia. In particular, we have highlighted the need for greater participation in screening for those at increased familial risk.

Cardiorespiratory nurses' perceptions of palliative care in nonmalignant disease: data for the development of clinical practice.

Nurses lack a comprehensive body of scientific knowledge to guide the palliative care of patients with nonmalignant conditions. Current knowledge and practice reveal that nurses in many instances are not well prepared to deal with death and dying. Focus groups were used in an exploratory study to examine the perceptions of palliative care among cardiorespiratory nurses (n = 35). Content analysis was used to reveal themes in the data. Four major themes were found: (1) searching for structure and meaning in the dying experience of patients with chronic disease, (2) lack of a treatment plan and a lack of planning and negotiation, (3) discomfort in dealing with death and dying, and (4) lack of awareness of palliative care philosophies and resources. The information derived from this sample of cardiorespiratory nurses represents a complex interplay between personal, professional, and organizational perspectives on the role of palliative care in cardiorespiratory disease. The results of the study suggest a need for nurses to be equipped on both an intellectual and a practical level about the concept of palliative care in nonmalignant disease.

The development of a physiotherapy continence promotion program using a customer focus.

Health promotion programs provide information, education for health and opportunity for the development of the skills that people need to make healthy choices. The current climate of health care practice also directs its focus to the needs and wants of the health care consumers. This entails active input from the target group. The present study used focus groups in an attempt to ensure input from women in early postpartum into the development of a postpartum continence promotion program. The focus groups revealed anomalies in women's perceived susceptibility to, and knowledge about, urinary incontinence and pelvic floor exercises, while highlighting other areas of need. Focus groups proved an invaluable tool in the development of a more effective physiotherapy continence promotion program.

Delay in seeking advice for symptoms that potentially indicate bowel cancer.

OBJECTIVES: To document knowledge, behavior and experiences of adults regarding potential signs and symptoms of bowel cancer. METHODS: Telephone interviews with 1332 randomly selected adults, using similar questions to a survey conducted in 1988. RESULTS: Twenty three percent (n=306) of respondents reported that they had experienced blood in bowel motions and about one third of these reported that they did not seek medical advice at all. CONCLUSIONS: As there has been no change in help seeking for potential symptoms of bowel cancer from similar studies conducted 15 years ago, there are concerns for encouraging behaviors that will result in the early detection of colorectal cancer.

Skin penetration operators' knowledge and attitudes towards infection control.

OBJECTIVES: To assess the knowledge and attitudes of owners/managers of commercial skin-penetration premises regarding infection control. METHODS: A telephone survey was conducted with a randomly selected sample of 874 owners/managers. RESULTS: Participants appeared to lack knowledge of essential infection-control practices. Less than 39% correctly identified recommended disinfection procedures, and between 12% to 67% were not aware of inappropriate sterlization procedures. Almost all participants accepted the need for guidelines. Half acknowledged a need to improve their infection-control compliance, and most accepted having their premises regularly checked by the councils. CONCLUSIONS: There is a considerable opportunity to increase infection-control compliance among skin-penetration operators.

Are the components of the Asthma Management Plan important in managing childhood asthma? A survey of general practitioners.

AIM: To gauge the importance and relevance placed by general practitioners on components of the National Asthma Campaign's 'Six step' Asthma Management Plan for childhood asthma. METHOD: A cross sectional postal survey of a national randomised sample of 824 GPs. RESULTS: Each component was considered to be 'quite' or 'very' important by at least 70% of respondents. All 11 components were rated to be either 'quite' or 'very' important by 44%, and 91% of respondents considered eight or more of the components to be 'quite' or 'very' important. Two characteristics were consistently associated with the rating of importance: gender, (women GPs generally showing higher ratings), and reported frequency of use of the Asthma Management Plan (frequent users rate importance more frequently). CONCLUSION: There were high levels of endorsement of the Asthma Management Plan for children with asthma.