ABSTRACT
PROBLEM: Despite reporting significant systemic barriers to providing care, burden among parental caregivers of children with medical complexity (CMC) is often attributed to stressors related to disease management. The relationship between parental caregiver burden and systemic barriers within the healthcare bureaucracy, as defined by Ray's Theory of Bureaucratic Caring (BCT), has not been explored. The purpose of this integrative review was to examine which elements of the bureaucratic healthcare system are contributing to burden among parental caregivers of CMC living at home. ELIGIBILITY CRITERIA: Refereed research articles related to the experiences of parental caregivers of CMC living in the United States published after 2014. SAMPLE: 1967 articles were obtained on initial literature search. Using the PRISMA algorithm, ten articles published between 2018 and 2022 were ultimately selected for appraisal. RESULTS: Parental caregiver burden was consistently attributed to barriers and gaps among social-cultural, physical, political, legal, economic, technological, and educational elements of the bureaucratic healthcare system. CONCLUSIONS: Weaknesses across the bureaucratic elements of the healthcare system prevent CMC from consistently receiving necessary care which in turn, contribute to feelings of burden among their parental caregivers. Efforts to alleviate burden experienced by parental caregivers should focus on addressing gaps within the healthcare bureaucracy. IMPLICATIONS: Nurses are well-positioned to address these gaps through clinical work, advocacy, and research. Future research should further examine the appropriateness of using BCT to better understand the implications of systems-level weaknesses on parental caregiver burden. Parental caregivers of CMC should be closely involved in this process.
Subject(s)
Caregivers , Humans , Child , Caregivers/psychology , United States , Parents/psychology , Home Care Services , Chronic Disease/therapy , Female , Male , Caregiver Burden/psychologyABSTRACT
Objectives: Medicinal plants and herbal medicines are widely used worldwide. However, patients with chronic health conditions or their caregivers do not often disclose these practices to their healthcare providers, leading to potentially severe interactions with current treatments, especially in children. We aimed to describe the prevalence of the use of medicinal plants and herbal medicines by children and adolescents with chronic health conditions and whether their physicians were informed about it. Methods: We conducted a cross-sectional electronic survey on parents and caregivers of children and adolescents with chronic health conditions seen at a university, tertiary-care pediatric outpatient clinic. The common names of the plants cited by respondents were reviewed and Latin names of the species were provided whenever possible. Results: From 20,213 text messages sent in May and June 2021, 521 valid responses were obtained. The prevalence of the use of medicinal plants and herbal medicines was 34.6%, most without a medical prescription (self-medication), and few physicians (4.0%) were aware of it. The five most used species were: Mentha spicata L. (mint), Foeniculum vulgare Mill. (fennel), "cidreira" (a common name possibly corresponding to Cymbopogon citratus (DC.) Stapf, Melissa officinalis L. or Lippia alba (Mill.) N.E. Br. ex Britton & Wilson, P.), Matricaria chamomilla L. (German chamomile), and Plectranthus barbatus Andrews (boldo). Conclusions: The prevalence of the use of medicinal plants and herbal medicines by children and adolescents with chronic health conditions in a tertiary-care outpatient clinic was 34.6%, and only a few physicians were aware of it (AU).
Objetivos: Plantas medicinais e seus derivados são amplamente utilizados no mundo todo. Entretanto, pacientes com condições crônicas de saúde ou seus cuidadores frequentemente não informam essas práticas para seus profissionais de saúde, levando a interações potencialmente graves com os demais tratamentos, especialmente em crianças. Nós objetivamos descrever a prevalência do uso de plantas medicinais e derivados por crianças e adolescentes com condições crônicas de saúde, e se seus médicos foram informados sobre isto. MeÌtodos: Levantamento eletrônico transversal junto a pais e cuidadores de crianças e adolescentes com condições crônicas de saúde atendidos em um serviço ambulatorial pediátrico universitário terciário. Os nomes comuns das plantas citadas pelos participantes foram revisados e os nomes latinos das espécies foram identificados, sempre que possível. Resultados: De 20.213 mensagens de texto enviadas em maio e junho de 2021, 521 respostas válidas foram obtidas. A prevalência de utilização de plantas medicinais e derivados foi de 34,6%, sendo a maioria sem prescrição médica (automedicação), e poucos médicos (4,0%) estavam cientes disto. As cinco plantas mais comumente utilizadas foram: Mentha spicata L. (hortelã), Foeniculum vulgare Mill. (funcho), "cidreira" (possivelmente correspondendo a Cymbopogon citratus (DC.) Stapf, Melissa officinalis L. ou Lippia alba (Mill.) N.E. Br. ex Britton & Wilson, P.), Matricaria chamomilla L. (camomila) e Plectranthus barbatus Andrews (boldo nacional). Conclusões: A prevalência de uso de plantas medicinais e derivados por crianças e adolescentes com condições crônicas de saúde em um serviço ambulatorial pediátrico terciário foi de 34,6%, com grande potencial para interações, e somente poucos médicos estavam cientes disto
Subject(s)
Humans , Child , Adolescent , Plants, Medicinal , Chronic Disease/therapy , Herbal Medicine , PhytotherapyABSTRACT
INTRODUCTION: Ageing entails a variety of physiological changes that increase the risk of chronic non-communicable diseases. The prevalence of these diseases leads to an increase in the use of health services. The care models implemented by health systems should provide comprehensive long-term healthcare. We conducted this systematic review to determine whether any model of care for older persons have proven to be effective. METHODS: A systematic review of literature was carried out to identify randomised clinical trials that have assessed how effective a care model for older patients with chronic diseases. A searches electronic databases such as MEDLINE, Turning Research Into Practice Database, Cochrane Library and Cochrane Central Register of controlled Trials was conducted from January 1966 to January 2021. Two independent reviewers assessed the eligibility of the studies. Interventions were identified and classified according to the taxonomies developed by the Cochrane Effective Practice and Organisation of Care and Cochrane Consumers and Communication groups. RESULTS: Of the 4952 bibliographic references that were screened, 577 were potentially eligible and the final sample included 25 studies that evaluated healthcare models in older people with chronic diseases. In the 25 care models, the most frequently implemented interventions were educational, and those based on the provision of healthcare. Only 22% of the outcomes of interventions were identified as being effective, whereas 21% were identified as being partially effective; thus, more than 50% of the outcomes were identified as being ineffective. CONCLUSIONS: It was not possible to determine a care model as effective. The interventions implemented in the models are variable. The most effective outcomes were focused on improving the patient-healthcare professional relationship in the early stages of the intervention. The interventions addressed in the studies were similar to public health interventions as their main objectives focused on promoting health. Most studies were of low methodological quality.
Subject(s)
Chronic Disease , Comprehensive Health Care , Models, Organizational , Aged , Chronic Disease/therapy , Comprehensive Health Care/organization & administration , Humans , Randomized Controlled Trials as Topic , Treatment OutcomeABSTRACT
Introducción: Los problemas de salud crónicos son considerados enfermedades multidimensionales, por lo que demandan del personal de enfermería una atención integral y holística. Una opción para brindar un cuidado holístico y autónomo son las terapéuticas alternativas y complementarias. Objetivo: Sistematizar las terapias alternativas como solución al cuidado de problemas crónicos de salud. Métodos: Revisión sistemática de documentos publicados desde 2005 hasta 2020 en español e inglés, con una clara metodología y referencial teórico seleccionado durante el 2020. La pregunta se elaboró a través de la estrategia PICO. Se utilizaron las palabras claves identificadas en DeCS y operadores booleanos: "atención de enfermería" AND "terapias complementarias" AND "enfermedades crónicas" y en inglés, las identificadas por MeHS: "Complementary therapies" AND "Nursing care" AND "Chronic disease". La búsqueda fue realizada en las bases de datos: Pubmed, Clinical Key, SciELO, Dialnet, Index, Google Scholar. Se utilizó el diagrama de flujo (PRISMA) para contribuir a la formulación de la estrategia de búsqueda. Mediante los métodos de análisis documental, síntesis y sistematización se dio la posibilidad de organizar e interpretar los conocimientos presentes en las bibliografías encontradas. Conclusiones: Las terapias alternativas como una solución a los problemas de salud, es una herramienta que puede ser usada por el personal de enfermería, para aumentar la gama de cuidados que se les brindan a las personas con problemas de salud crónicos(AU)
Introduction: Chronic health problems are considered multidimensional diseases; therefore, they demand, from the nursing staff, a comprehensive and holistic care. One option to provide holistic and autonomous care is alternative and complementary therapies. Objective: To systematize alternative therapies as a solution for the care of chronic health problems. Methods: A systematic review of documents published from 2005 to 2020 in Spanish and English was developed, with a clear methodology and theoretical references selected during 2020. The question was elaborated through the PICO strategy. In Spanish, the following keywords, identified in the DeCS, as well as Boolean operators were used: "atención de enfermería" AND "terapias complementarias" AND "enfermedades crónicas". In English, the corresponding keywords found in the MeHS were taken into account: "Complementary therapies" AND "Nursing care" AND "Chronic disease". The search was carried out in the Pubmed, Clinical Key, SciELO, Dialnet, Index and Google Scholar databases. The PRISMA flow diagram (Preferred Reporting Items for Systematic Review and Meta-Analyses) was used to contribute to the formulation of the search strategy. The methods of documental analysis, synthesis and systematization permitted to organize and interpret the knowledge present in the theoretical references found. Conclusions: Alternative therapies, as a solution to health problems, are a tool that can be used by the nursing staff, in order to increase the range of care provided to people with chronic health problems(AU)
Subject(s)
Humans , Complementary Therapies/adverse effects , Chronic Disease/therapy , Nursing Care/methods , Nursing Staff , Review Literature as Topic , Methodology as a SubjectABSTRACT
BACKGROUND: Diosmectite, a natural colloidal clay, has been used worldwide for a number of approved indications, including the treatment of chronic functional diarrhea. Here, we used high-resolution whole metagenome shotgun sequencing to assess the impact of a 5 weeks administration of diosmectite (3 g/sachet, 3 sachets/day) on the fecal microbiota of 35 adults with functional chronic diarrhea. RESULTS: Gut microbiota was not impacted by diosmectite administration. In particular, richness remained stable and no microbial species displayed a significant evolution. Segregating patients either by diosmectite response (non responder, early responder, late responder) or by nationality (Great-Britain or Netherlands) yielded the same results. CONCLUSION: We concluded that no microbiota-related physiological alterations are expected upon long-term treatment with diosmectite. TRIAL REGISTRATION: Clinicaltrials.gov NCT03045926.
Subject(s)
Diarrhea/drug therapy , Feces/microbiology , Gastrointestinal Microbiome/drug effects , Gastrointestinal Microbiome/genetics , Metagenome , Silicates/therapeutic use , Adolescent , Adult , Bacteria/classification , Bacteria/genetics , Chronic Disease/therapy , Female , Humans , Male , Middle Aged , Young AdultABSTRACT
BACKGROUND: While conventional medicine (CM) is commonly used to treat non-communicable diseases (NCDs), complementary and alternative medicine (CAM) is gaining popularity as a healthcare option in Bangladesh. We aimed to investigate the prevalence and factors associated with using CAM solely and using CAM in conjunction with CM for chronic illness treatment among NCD patients in Bangladesh. METHODS: A multicenter cross-sectional study was conducted, including 549 adults with a confirmed chronic illness diagnosis from three tertiary care hospitals in Dhaka city. Interviews were used to gather socio-demographic data, while medical records were used to get information on chronic illnesses. A multinomial logistic regression model was used to determine the associated factors of utilizing CAM primarily and CAM use in conjunction with CM to manage the chronic disease. RESULTS: Out of 549 NCD patients (282 women [51.4%], mean [standard deviation] age 45.4 [12.8] years), 180 (32.8%) ever used CAM for the treatment of chronic illness. Also, 15.3% of patients exclusively used CAM among the NCD patients, while 17.5% used CAM in conjunction with CM. Homeopathy medicine was the most prevalent type of treatment among CAM users (52.2%). Furthermore, 55.5% of CAM users said they used it due to its less adverse effects, and 41.6% trusted its effectiveness for chronic illness. Elderly patients (≥60 years) preferred CAM in complementary with CM, but they did not rely only on CAM. According to the multinomial regression analysis, unmarried patients, predominantly in the younger age group, adopted CAM significantly for chronic illness treatment (Relative risk ratio, RRR = 0.29, 95% CI = 0.12-0.71, reference = Unmarried). Patients in the high-income group used CAM in conjunction with CM (RRR = 6.26, 95% CI = 1.35-18.90, reference: low-income), whereas patients in the high-income group did not rely on CAM alone (RRR = 0.99, 95% CI = 0.34-2.85). CONCLUSION: Although CM remains the mainstream of health care in Bangladesh, CAM services play an essential role in people's health care, particularly in treating chronic illnesses. Physicians of Bangladesh should be aware that their patients may be using other services and be prepared to ask and answer questions regarding the risks and benefits of using CAM in addition to regular medical care. Thus, clinicians required to follow best-practice guidelines, which are currently not practiced in Bangladesh, when disseminating information regarding integrative techniques that combine CM and CAM approaches.
Subject(s)
Chronic Disease/therapy , Complementary Therapies/classification , Homeopathy/statistics & numerical data , Adult , Bangladesh/epidemiology , Complementary Therapies/statistics & numerical data , Cross-Sectional Studies , Female , Humans , Interviews as Topic , Logistic Models , Male , Middle Aged , Prevalence , Risk Factors , Socioeconomic Factors , Tertiary Care Centers , Young AdultABSTRACT
INTRODUCTION: This study explores general practitioners' (GPs') and medical specialists' perceptions of role distribution and collaboration in the care of patients with chronic conditions, exemplified by spinal cord injury. METHODS: Semi-structured interviews with GPs and medical specialists caring for individuals with spinal cord injury in Switzerland. The physicians we interviewed were recruited as part of an intervention study. We used a hybrid framework of inductive and deductive coding to analyse the qualitative data. RESULTS: Six GPs and six medical specialists agreed to be interviewed. GPs and specialists perceived the role of specialists similarly, namely as an expert and support role for GPs in the case of specialised questions. Specialists' expectations of GP services and what GPs provide differed. Specialists saw the GPs' role as complementary to their own responsibilities, namely as the first contact for patients and gatekeepers to specialised services. GPs saw themselves as care managers and guides with a holistic view of patients, connecting several healthcare professionals. GPs were looking for relations and recognition by getting to know specialists better. Specialists viewed collaboration as somewhat distant and focused on processes and patient pathways. Challenges in collaboration were related to unclear roles and responsibilities in patient care. CONCLUSION: The expectations for role distribution and responsibilities differ among physicians. Different goals of GPs and specialists for collaboration may jeopardise shared care models. The role distribution should be aligned according to patients' holistic needs to improve collaboration and provide appropriate patient care.
Subject(s)
Attitude of Health Personnel , General Practitioners , Interprofessional Relations , Physician's Role , Specialization , Spinal Cord Injuries , Humans , Chronic Disease/therapy , General Practitioners/psychology , Long-Term Care , Physician's Role/psychology , Qualitative Research , Rural Health Services , Spinal Cord Injuries/therapy , SwitzerlandABSTRACT
Patients with inflammatory bowel disease (IBD) have higher incidence of extraintestinal manifestations (EIM), including liver disorders, sarcopenia, and neuroinflammation. Fermented rice bran (FRB), generated from rice bran (RB), is rich in bioactive compounds, and exhibits anti-colitis activity. However, its role in EIM prevention is still unclear. Here, for the first time, we investigated whether EIM in female C57Bl/6N mice is attenuated by FRB supplementation. EIM was induced by repeated administration of 1.5% dextran sulfate sodium (DSS) in drinking water (4 d) followed by drinking water (12 d). Mice were divided into 3 groups-control (AIN93M), 10% RB, and 10% FRB. FRB ameliorated relapsing colitis and inflammation in muscle by significantly lowering proinflammatory cytokines Tnf-α and Il-6 in serum and advanced glycation end product-specific receptor (Ager) in serum and muscle when compared with the RB and control groups. As FRB reduced aspartate aminotransferase levels and oxidative stress, it might prevent liver disorders. FRB downregulated proinflammatory cytokine and chemokine transcripts responsible for neuroinflammation in the hippocampus and upregulated mRNA expression of G protein coupled receptors (GPRs), Gpr41 and Gpr43, in small and large intestines, which may explain the FRB-mediated protective mechanism. Hence, FRB can be used as a supplement to prevent IBD-associated EIM.
Subject(s)
Colitis/drug therapy , Colitis/immunology , Dietary Fiber/administration & dosage , Oryza/chemistry , Plant Preparations/administration & dosage , Animals , Chemokines/genetics , Chemokines/immunology , Chronic Disease/therapy , Colitis/chemically induced , Colitis/genetics , Dextran Sulfate/adverse effects , Dietary Fiber/analysis , Dietary Supplements/analysis , Disease Models, Animal , Female , Hippocampus/immunology , Humans , Interleukin-6/genetics , Interleukin-6/immunology , Intestines/immunology , Male , Mice , Mice, Inbred C57BL , Muscle, Skeletal/immunology , Oxidative Stress , Tumor Necrosis Factor-alpha/genetics , Tumor Necrosis Factor-alpha/immunologyABSTRACT
BACKGROUND: To evaluate the outcomes of a heterogeneous group of patients with chronic ulcer receiving a combination regimen of full-field and fractional erbium-doped yttrium aluminum garnet (erbium: YAG) laser applications. METHODS: Enrolled in this study were patients with chronic ulcer who had received at least 2 erbium: YAG laser sessions. Fractional applications followed the initial full-field application for debridement. The therapeutic outcomes were evaluated by serial photographs. The primary outcome measure was the proportion of patients achieving complete re-epithelialization at the first year. RESULTS: Forty-three treatment regions from 23 patients between 40 and 90 years (F: M = 11:12; age: 60.3 ± 15.5 years, mean ± SD) were eligible. The ulcers' median duration was 24 months (min-max: 2-240 months). The median number of laser sessions was 5 (min-max: 2-12). Of arterial (n = 13), immunologic (n = 9), venous (n = 8), diabetic (n = 8), and mechanical ulcers (n = 5), the primary outcome measure was achieved in 69%, 77.7%, 75%, 88.8%, and 100% of the groups, respectively. CONCLUSION: Full-field erbium: YAG laser applications preserve the vascular architecture and enable delicate debridement. Ongoing maintenance fractional laser sessions promote wound healing. Similar to the previous reports of erbium: YAG laser in venous and diabetic ulcers, arterial ulcers, and ulcers of immunologic origin demonstrated an objective treatment response along with different adjuvant approaches.
Subject(s)
Laser Therapy/methods , Lasers, Solid-State/therapeutic use , Re-Epithelialization/radiation effects , Skin Ulcer/therapy , Wound Healing/radiation effects , Adult , Aged , Aged, 80 and over , Chronic Disease/therapy , Female , Humans , Laser Therapy/instrumentation , Male , Middle Aged , Retrospective Studies , Treatment OutcomeABSTRACT
Osteoarthritis (OA) is a degenerative inflammatory condition of the joint cartilage that currently affects approximately 58 million adults in the world. It is characterized by pain, stiffness, and a reduced range of motion with regard to the arthritic joints. These symptoms can cause in the long term a greater risk of overweight/obesity, diabetes mellitus, and falls and fractures. Although the current guidelines for the treatment of OA suggest, as the gold standard for this condition, pharmacological treatment characterized by non-steroidal anti-inflammatory drugs (NSAID), opioids, and cyclooxygenase (COX)-2-specific drugs, a great interest has been applied to nutraceutical supplements, which include a heterogeneous class of molecules with great potential to reduce inflammation, oxidative stress, pain, and joint stiffness and improve cartilage formation. The purpose of this review is to describe the potential application of nutraceuticals in OA, highlighting its molecular mechanisms of actions and data of efficacy and safety (when available).
Subject(s)
Dietary Supplements , Osteoarthritis/diet therapy , Chronic Disease/therapy , Humans , Osteoarthritis/prevention & control , Secondary PreventionABSTRACT
Individuals with coexisting chronic diseases or with complex chronic disease are among the most challenging and costly patients to treat, placing a growing demand on healthcare systems. Recommending effective treatments, including nutrition interventions, relies on standardised outcome reporting from randomised controlled trials (RCTs) to enable data synthesis. This rapid review sought to determine how the scope and consistency of the outcomes reported by RCTs investigating nutrition interventions for the management of complex chronic disease compared to what is recommended by the core outcome sets (COS) for individual disease states. Peer-reviewed RCTs published between January 2010 and July 2020 were systematically sourced from PubMed, CINAHL and Embase, and COS were sourced from the International Consortium for Health Outcomes Measurements (ICHOM) and the Core Outcome Measures in Effectiveness Trials (COMET) database. A total of 45 RCTs (43 studies) and 7 COS were identified. Outcomes were extracted from both the RCTs and COS and were organised using COMET Taxonomy Core Areas. A total of 66 outcomes and 439 outcome measures were reported by the RCTs. The RCTs demonstrated extensive outcome heterogeneity, with only five outcomes (5/66, 8%) being reported with relative consistency (cited by ≥50% of publications). Furthermore, the scope of the outcomes reported by studies was limited, with a notable paucity of patient-reported outcomes. Poor agreement (25%) was observed between the outcomes reported in the RCTs and those recommended by the COS. This review urges greater uptake of the existing COS and the development of a COS for complex chronic disease to be considered so that evidence can be better synthesised regarding effective nutrition interventions.
Subject(s)
Chronic Disease/therapy , Nutrition Therapy , Research Report , Humans , Publications , Quality Assurance, Health Care , Randomized Controlled Trials as Topic , Reference Standards , Treatment OutcomeABSTRACT
Integrated Care (IC) is an "umbrella" term, under which numerous definitions are collected, which implies an attempt to coordinate and integrate fragmented and piecemeal health systems with new organizational arrangements. In fact, poor coordination of care is often a major obstacle for patients who access to health services. This adds on concern to the increasing demand for health and the greater proportion of healthcare expenditure induced by aging and chronic multiple comorbidity of patients. IC therefore sets itself the ambitious goal of harmonizing and optimizing patient care, both physical-mental and social, in order to obtain a continuous multi-organizational assistance. Although the principles on which IC is based are intuitive and simple, its extensive application is complicated and difficult to achieve. Within this article, we first try to define the concept of IC through a general review of the scientific literature on the subject. Then, we analyze the main economic and political criticalities of IC. Finally, we try to suggest recommendations about IC that can be extended to the health services of the member countries of the European Union.
Subject(s)
Delivery of Health Care, Integrated , Health Expenditures , Aging , Chronic Disease/economics , Chronic Disease/therapy , Comorbidity , Delivery of Health Care, Integrated/economics , Delivery of Health Care, Integrated/trends , European Union , Health Expenditures/trends , HumansABSTRACT
BACKGROUND: The First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis project was a point-of-care screening program in rural and remote First Nations communities in Manitoba that aimed to identify and treat hypertension, diabetes and chronic kidney disease. The program identified chronic disease in 20% of children screened. We aimed to characterize clinical screening practices before and after intervention in children aged 10-17 years old and compare outcomes with those who did not receive the intervention. METHODS: This observational, prospective cohort study started with community engagement and followed the principles of ownership, control, access and possession (OCAP). We linked participant data to administrative data at the Manitoba Centre for Health Policy to assess rates of primary care and nephrology visits, disease-modifying medication prescriptions and laboratory testing (i.e., glycosylated hemoglobin [HbA1c], estimated glomerural filtration rate [eGFR] and urine albumin- or protein-to-creatinine ratio). We analyzed the differences in proportions in the 18 months before and after the intervention. We also conducted a 1:2 propensity score matching analysis to compare outcomes of children who were screened with those who were not. RESULTS: We included 324 of 353 children from the screening program (43.8% male; median age 12.3 yr) in this study. After the intervention, laboratory testing increased by 5.8% (95% confidence interval [CI] 1.1% to 10.1%) for HbA1c, by 9.9% (95% CI 4.2% to 15.5%) for eGFR and by 6.2% (95% CI 2.3% to 10.0%) for the urine albumin- or protein-to-creatinine ratio. We observed significant improvements in laboratory testing in screened patients in the group who were part of the program, compared with matched controls. INTERPRETATION: Chronic disease surveillance and care increased significantly in children after the implementation of a point-of-care screening program in rural and remote First Nation communities. Interventions such as active surveillance programs have the potential to improve the chronic disease care being provided to First Nations children.
Subject(s)
Child Health Services/organization & administration , Child Welfare/statistics & numerical data , Chronic Disease/epidemiology , Health Services, Indigenous/organization & administration , Preventive Health Services/organization & administration , Adolescent , Child , Child, Preschool , Chronic Disease/therapy , Female , Humans , Infant , Infant, Newborn , Male , Primary Health Care , Prospective StudiesABSTRACT
Importance: Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care. Objective: To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions. Design, Setting, and Participants: This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020. Main Outcomes and Measures: Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders. Results: Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions. Conclusions and Relevance: Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.
Subject(s)
Chronic Disease/therapy , Comprehensive Health Care/organization & administration , Medically Uninsured , Neoplasms/therapy , Stakeholder Participation/psychology , Adult , Ambulatory Care/economics , Ambulatory Care/organization & administration , Cancer Survivors , Comprehensive Health Care/economics , Delivery of Health Care, Integrated/economics , Delivery of Health Care, Integrated/organization & administration , Female , Grounded Theory , Health Services Accessibility/economics , Health Services Accessibility/organization & administration , Humans , Male , Medical Oncology/economics , Medical Oncology/organization & administration , Middle Aged , Multilevel Analysis , Neoplasms/complications , Neoplasms/economics , Primary Health Care/economics , Primary Health Care/organization & administration , Qualitative Research , Safety-net Providers/economics , Safety-net Providers/organization & administrationABSTRACT
OBJECTIVE: To identify opportunities to align care with the personal values of patients from three distinct groups with complex medical, behavioral, and social needs. DATA SOURCES/STUDY SETTING: Between June and August 2019, we conducted semi-structured interviews with individuals with complex care needs in two integrated health care delivery systems. STUDY DESIGN: Qualitative study using semi-structured interviews. DATA COLLECTION METHODS: We interviewed three groups of patients at Kaiser Permanente Washington and Kaiser Permanente Colorado representing three distinct profiles of complex care needs: Group A ("obesity, opioid prescription, and low-resourced neighborhood"), Group B ("older, high medical morbidity, emergency department, and hospital use"), and Group C ("older, mental and physical health concerns, and low-resourced neighborhood"). These profiles were identified based on prior work and prioritized by internal primary care stakeholders. Interview transcripts were analyzed using thematic analysis. PRINCIPAL FINDINGS: Twenty-four patients participated; eight from each complex needs profile. Mean age across groups was 71 (range 48-86) years. We identified five themes common across the three groups that captured patients' views regarding values-aligned care. These themes focused on the importance of care teams exploring and acknowledging a patient's values, providing access to nonphysician providers who have different perspectives on care delivery, offering values-aligned mental health care, ensuring connection to community-based resources that support values and address needs, and providing care that supports the patient plus their family and caregivers. CONCLUSIONS: Our results suggest several opportunities to improve how care is delivered to patients with different complex medical, behavioral, and social needs. Future research is needed to better understand how to incorporate these opportunities into health care.
Subject(s)
Chronic Disease/therapy , Delivery of Health Care, Integrated/standards , Patient-Centered Care/standards , Patients/psychology , Practice Guidelines as Topic , Aged , Aged, 80 and over , Colorado , Female , Humans , Male , Middle Aged , Qualitative Research , Social Determinants of Health , WashingtonABSTRACT
BACKGROUND: Telemedicine is widely used but has uncertain value. We assessed telemedicine to further improve outcomes and reduce costs of comprehensive care (CC) for medically complex children. METHODS: We conducted a single-center randomized clinical trial comparing telemedicine with CC relative to CC alone for medically complex children in reducing care days outside the home (clinic, emergency department, or hospital; primary outcome), rate of children developing serious illnesses (causing death, ICU admission, or hospital stay >7 days), and health system costs. We used intent-to-treat Bayesian analyses with neutral prior assuming no benefit. All participants received CC, which included 24/7 phone access to primary care providers (PCPs), low patient-to-PCP ratio, and hospital consultation from PCPs. The telemedicine group also received remote audiovisual communication with the PCPs. RESULTS: Between August 22, 2018, and March 23, 2020, we randomly assigned 422 medically complex children (209 to CC with telemedicine and 213 to CC alone) before meeting predefined stopping rules. The probability of a reduction with CC with telemedicine versus CC alone was 99% for care days outside the home (12.94 vs 16.94 per child-year; Bayesian rate ratio, 0.80 [95% credible interval, 0.66-0.98]), 95% for rate of children with a serious illness (0.29 vs 0.62 per child-year; rate ratio, 0.68 [0.43-1.07]) and 91% for mean total health system costs (US$33 718 vs US$41 281 per child-year; Bayesian cost ratio, 0.85 [0.67-1.08]). CONCLUSION: The addition of telemedicine to CC likely reduced care days outside the home, serious illnesses, other adverse outcomes, and health care costs for medically complex children.
Subject(s)
Chronic Disease/therapy , Telemedicine , Child , Child, Preschool , Chronic Disease/economics , Comprehensive Health Care , Female , Health Care Costs , Humans , Male , Patient Admission/statistics & numerical data , Quality Improvement , Telemedicine/economics , TexasABSTRACT
OBJECTIVE: To evaluate the effectiveness and adverse events of autologous platelet-rich plasma (PRP) in individuals with lower-extremity diabetic ulcers, lower-extremity venous ulcers, and pressure ulcers. PATIENTS AND METHODS: We searched multiple databases from database inception to June 11, 2020, for randomized controlled trials and observational studies that compared PRP to any other wound care without PRP in adults with lower-extremity diabetic ulcers, lower-extremity venous ulcers, and pressure ulcers. RESULTS: We included 20 randomized controlled trials and five observational studies. Compared with management without PRP, PRP therapy significantly increased complete wound closure in lower-extremity diabetic ulcers (relative risk, 1.20; 95% CI, 1.09 to 1.32, moderate strength of evidence [SOE]), shortened time to complete wound closure, and reduced wound area and depth (low SOE). No significant changes were found in terms of wound infection, amputation, wound recurrence, or hospitalization. In patients with lower-extremity venous ulcers or pressure ulcers, the SOE was insufficient to estimate an effect on critical outcomes, such as complete wound closure or time to complete wound closure. There was no statistically significant difference in adverse events. CONCLUSION: Autologous PRP may increase complete wound closure, shorten healing time, and reduce wound size in individuals with lower-extremity diabetic ulcers. The evidence is insufficient to estimate an effect on wound healing in individuals with lower-extremity venous ulcers or pressure ulcers. TRIAL REGISTRATION: PROSPERO Identifier: CRD42020172817.
Subject(s)
Diabetic Foot/therapy , Platelet-Rich Plasma , Pressure Ulcer/therapy , Varicose Ulcer/therapy , Wound Healing , Blood Transfusion, Autologous/methods , Chronic Disease/therapy , Female , Humans , Male , Observational Studies as Topic , Platelet Transfusion/methods , Randomized Controlled Trials as TopicABSTRACT
BACKGROUND: Functional constipation is a disease with a high incidence, which has a bad effect on general health, mental health, and social functioning. However, current treatment is sometimes unsatisfactory. Acupuncture has been proven effective in some randomized controlled trials. Acupressure is a subtype of acupuncture and can be manipulated by the patients at home. But the evidence is limited now. This study aims to provide some strict evidence for the use of self-administered acupressure in the treatment of functional constipation. METHODS: This 2-armed, parallel, nonspecific controlled, randomized trial will be conducted at The Third Affiliated Hospital of Zhejiang Chinese Medical University in Hangzhou. A total of 154 FC patients will be enrolled into the acupoint group and the sham acupoint group with a ratio of 1:1 into this trial and it will consist of a 2-week run-in period, an 8-week intervention period, and an 8-week follow-up period. The treatment will be done by the patients themselves at home twice a day and they should sign in on the WeChat APP every day to make sure they have done the acupressure. The outcome will also be collected in WeChat APP through the diary and questionnaires. For the one who is unable to use the WeChat, the print edition of the diary and questionnaires are provided and the supervision will be done by the short message. The primary outcome will be the proportion of participants whose CSBM≥3 during week 3 to 10. The secondary outcome will be the proportion of participants whose CSBM ≥3 between 2 groups in week 11 to 18, Spontaneous bowel movements, Bristol Stool Form Scale, Straining severity scores, Patient assessment of constipation quality of life, and Medicine use. DISCUSSION: Acupressure is not an invasive method and can be done by the patient itself at home. We hope this trial will provide credible evidence to the application of self-acupressure for the management of severe chronic functional constipation. TRIAL REGISTRATION: This trial has been registered at the Chinese Clinical Trial Registry (ChiCTR2000038594).
Subject(s)
Acupressure/methods , Constipation/therapy , Self Care/methods , Adult , Chronic Disease/therapy , Constipation/diagnosis , Follow-Up Studies , Humans , Male , Middle Aged , Quality of Life , Randomized Controlled Trials as Topic , Severity of Illness Index , Treatment Outcome , Young AdultABSTRACT
OBJECTIVES//HYPOTHESIS: To determine changes in voice severity when treating chronic cough refractory to medical treatment with cough suppression therapy (CST) in patients with chronic cough and voice complaints. Chronic cough has been reported to be refractory to medical treatment and frequently co-occurs with voice disorders. The possible effects of CST on self-assessed changes in chronic cough and voice disorders have not been demonstrated. STUDY DESIGN: Retrospective analysis of the effects of cough suppression therapy (CST) on self-assessed changes in chronic cough and voice disorder severity in patients with both chronic cough and voice disorders. METHODS: Forty-three adult patients with the primary complaint of chronic refractory cough underwent pre- and post-treatment diagnostic examinations, completed pre- and post-treatment Voice Handicap Index-10 (VHI-10) and Cough Severity Index assessments, and were treated by a licensed speech-language pathologist using CST. Twenty-seven subjects were assigned to the cough (C) group and 16 to the cough-voice (CV) group based on the severity of their VHI-10 scores. RESULTS: Post-test analysis showed significant improvement in cough severity for both groups and significant improvement in voice severity for the CV group. The VHI-10 scores for the C group did not change significantly. The median number of treatment sessions was 3, with a range of 1-13 sessions. Correlation between changes in severity and number of treatment sessions was not found to be significant at the tested level. CONCLUSIONS: CST represents a unifying approach for treatment of patients with CRC and comorbid voice disorders. CST offered cross-over effects to the voice when subjects were treated for their primary complaint of chronic cough. This treatment of the primary complaint improves function in systems that share a common pathway. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2747-2751, 2021.
Subject(s)
Breathing Exercises/methods , Cough/therapy , Severity of Illness Index , Voice Disorders/diagnosis , Adult , Aged , Aged, 80 and over , Chronic Disease/therapy , Cough/complications , Female , Humans , Male , Middle Aged , Retrospective Studies , Treatment Outcome , Voice Disorders/etiology , Voice Disorders/therapy , Voice Quality , Young AdultABSTRACT
Importance: Hospitalizations are costly and may lead to adverse events; hospital-at-home interventions could be a substitute for in-hospital stays, particularly for patients with chronic diseases who use health services more than other patients. Despite showing promising results, heterogeneity in past systematic reviews remains high. Objective: To systematically review and assess the association between patient outcomes and hospital-at-home interventions as a substitute for in-hospital stay for community-dwelling patients with a chronic disease who present to the emergency department and are offered at least 1 home visit from a nurse and/or physician. Data Sources: Databases were searched from date of inception to March 4, 2019. The databases were Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, CINAHL, Health Technology Assessment, the Cochrane Library, OVID Allied and Complementary Medicine Database, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Study Selection: Randomized clinical trials in which the experimental group received hospital-at-home interventions and the control group received the usual in-hospital care. Patients were 18 years or older with a chronic disease who presented to the emergency department and received home visits from a nurse or physician. Data Extraction and Synthesis: Risk of bias was assessed, and a meta-analysis was conducted for outcomes that were reported by at least 2 studies using comparable measures. Risk ratios (RRs) were reported for binary outcomes and mean differences for continuous outcomes. Narrative synthesis was performed for other outcomes. Main Outcomes and Measures: Outcomes of interest were patient outcomes, which included mortality, long-term care admission, readmission, length of treatment, out-of-pocket costs, depression and anxiety, quality of life, patient satisfaction, caregiver stress, cognitive status, nutrition, morbidity due to hospitalization, functional status, and neurological deficits. Results: Nine studies were included, providing data on 959 participants (median age, 71.0 years [interquartile range, 70.0-79.9 years]; 613 men [63.9%]; 346 women [36.1%]). Mortality did not differ between the hospital-at-home and the in-hospital care groups (RR, 0.84; 95% CI, 0.61-1.15; I2 = 0%). Risk of readmission was lower (RR, 0.74; 95% CI, 0.57-0.95; I2 = 31%) and length of treatment was longer in the hospital-at-home group than in the in-hospital group (mean difference, 5.45 days; 95% CI, 1.91-8.97 days; I2 = 87%). In addition, the hospital-at-home group had a lower risk of long-term care admission than the in-hospital care group (RR, 0.16; 95% CI, 0.03-0.74; I2 = 0%). Patients who received hospital-at-home interventions had lower depression and anxiety than those who remained in-hospital, but there was no difference in functional status. Other patient outcomes showed mixed results. Conclusions and Relevance: The results of this systematic review and meta-analysis suggest that hospital-at-home interventions represent a viable substitute to an in-hospital stay for patients with chronic diseases who present to the emergency department and who have at least 1 visit from a nurse or physician. Although the heterogeneity of the findings remained high for some outcomes, particularly for length of treatment, the heterogeneity of this study was comparable to that of past reviews and further explored.