Veteran stroke survivors' lived experiences after being discharged home: a phenomenological study.

BACKGROUND: Stroke is a leading cause of disability in adults and third cause of death in the United States. Survivors face challenges postdischarge, including risks in self-management (SM) following prescribed regimens. Although SM education can help develop skills to control risk factors for stroke recurrence, little is known about lived experiences of patients adopting SM. AIMS: To examine Veterans' lived poststroke experiences after discharge and their experiences in SM goal setting/attainment. METHODS: Patients within one year of discharge from a Veterans Administration Medical Center in the United States with two risk factors for stroke recurrence were enrolled and received an SM workbook. Eight patients were interviewed (six males, two females; mean age 62: range 45-80). Part I concerned lived experience. Part II described experiences with goal setting and attainment. Data were analyzed inductively, identifying common experiences. Deductive analysis described goal setting and attainment. Transcript reviews identified SM themes and strategies. RESULTS: Lived experiences included 1) uncertainty about life, 2) anger and frustration, and 3) healthcare system challenges. Coping skills and setting goals to manage risks were critical for physical and emotional functioning. CONCLUSIONS: SM coping and goal setting aided recovery and improved life quality among Veterans after stroke. SM interventions assisted in regaining physical and emotional function. Findings may help in design of interventions for survivors, using SM and goal setting and attainment.IMPLICATIONS FOR REHABILITATIONSeveral implications for clinical practice were identified:Providers should acknowledge Veterans' challenges and struggles after their stroke and help Veterans to re-establish social identity, enhance self-esteem and improve mood.More emphasis should be given to the Veterans' caregivers' availability and willingness to help with their loved one's recovery, work reinstatement status and financial struggles.Recognition of the importance of the social context of recovery after a stroke is important, as nonmedical social interaction is often overlooked.Improvements are needed in the area of providers working with social workers and physical, occupational and mental health therapists to arrange more inpatient and outpatient treatments, including more frequent home visits.Veterans should be strongly encouraged to attend self-management diabetes education classes and smoking cessation and weight-loss programs offered for free within the Veterans Health Administration system.Self-management strategies using goal-setting and attainment concepts may assist individuals with stroke to regain physical and emotional functions, subsequently preventing another stroke.

Using Mobile Video-Teleconferencing to Deliver Secondary Stroke Prevention Interventions: A Pilot Study.

Objectives: Patient self-management support (SMS) interventions help stroke survivors control stroke risk factors and assist with secondary prevention. We examined utility and preliminary effectiveness of mobile video-teleconferencing (VT) to deliver SMS to stroke survivors in rural and low-income urban Texas communities. Methods: We applied a within-subjects design to assess improvement in self-management behaviors and stroke risk factors among stroke survivors receiving SMS intervention through mobile VT. Adults with stroke and two or more uncontrolled stroke risk factors were eligible. The SMS program, Video-teleconference-Self-management TO Prevent stroke (V-STOP) was delivered over 6 weeks by trained health coaches through VT. We applied Generalized Estimating Equations with site and time in intervention as covariates to evaluate psychological, social, physiological outcomes, self-management behaviors, and quality of life. Results: Mean age of 106 participants was 59.3 (±10.9); most were White, Hispanic men, living with someone, with low income. Approximately 69% completed all measures at 6 weeks. Median number of sessions attended was 5 (interquartile range 3) potentially avoiding 210 km of travel per person. Satisfaction with V-STOP and VT delivery was high, at (4.8 [±0.5]) and (4.7 [±0.5]), respectively. Stroke knowledge was improved from 8.8 (±1.0) at baseline to 9.6 (±0.7) at 12 weeks, (p < 0.0001). Improvements were observed in self-efficacy, exercise behaviors, depression and anxiety, disability, and quality of life. Conclusion: Implementation of SMS is feasible and shows good utility and preliminary effectiveness of using mobile VT to provide stroke follow-up care to stroke survivors. Participants improved self-management behaviors and stroke risk factors.

The role of relationships in the professional formation of physicians: case report and illustration of an elicitation technique.

OBJECTIVE: Studies of physicians' professional development highlight the important effect that the learning environment has in shaping student attitudes, behaviors, and values. The objective of this study was to better understand the interplay among relationships and experiences in mediating the effects of the learning environment. METHODS: We randomly recruited 2nd- and 4th-year students from among volunteers at each of five medical schools. One interviewer at each school conducted a face-to-face, open-ended, semi-structured interview with each student. The interviewers used a method called 'life-circle diagramming' to direct the student to draw a picture of all of the relationships in his/her life that had an influence on the sort of doctor that each student saw him/herself becoming. Interviews lasted between 60 and 120 min. Using a narrative framework that focuses on elements of students' stories (e.g., setting, characters, plot), we analyzed transcripts through an iterative process of individual reading and group discussion to derive themes and relationships among themes. RESULTS: Twenty students completed interviews. These students are embedded in complex webs of relationships with colleagues, friends, family, role models, patients, and others. Most students entered medical school with formed notions of what they wanted to 'be like' as physicians. While students generally gravitated toward relationships with like-minded people, their experiences varied, and some students could sense themselves changing as they moved through school. Such changes were often related to important events or issues. The relationships that students found themselves in during the context of these events had an important effect on students' beliefs about what kinds of behaviors and attitudes were possible and desirable in their future practice. CONCLUSIONS: Students proceed through medical school embedded in complex webs of relationships that exert a powerful influence (both positive and negative) on their formation as physicians. PRACTICE IMPLICATIONS: Educational interventions that foster adoption of professional values need to acknowledge the influence of relationships, and assist students to harness and shape relational effects on their growth and development. The life-circle diagramming activity holds potential to promote reflection and self-knowledge, and to provide a foundation for professional growth.

[Psychosis sight from the complexity research--a model for the examination of the self organisation of a dysfunctional self]. / Psychose aus Sicht der Komplexitätsforschung - Ein Modell zur Untersuchung der Selbstorganisation eines dysfunktionalen Selbst.

UNLABELLED: Nowadays the multifactorial genesis of psychotic illnesses is undisputed. The question of the integration of the multilayered results is open from the biological, emotional and social area. Based on the results of the complexity research (chaos theory, theory of the self organisation) the hypothesis was formulated for the emergence of psychotic illnesses that these are understood themselves as an expression of a dysfunctional self. Such a dysfunctional self arises in a self organizing process. MATERIAL AND METHOD: The definition of the self was newly formulated. This happened on the knowledge of the complexity research and a bio- psycho-social model of illness and health. Ten main categories were defined, which seem essential for the development of a healthy, this means a flexible and autonomous self. In further consequence, based on these categories, a semistructured interview guide was developed. With this interview guide the information about the quality of the self organising process of the development of the self was collected. This guide was tested in the context of a master thesis in a multidimensional interview with a schizophrenic patient and his family. This interview was taken on video tap. The information on video became transcribed. Than the information was examined qualitatively to two aspects. This happened with the help of a qualitative contents analysis. The first aspect concerned the decision of the assignment to one or several of the ten categories. In a 2nd step it was judged, whether the examined information has to be classified as beneficial for the development of a healthy self or as impeding. RESULTS: The developed and used examination model is suitable to make the investigation of a self organizing self possible. At the individual case analysis of a patient with a schizophrenic psychosis the inhibiting influences for the development of a healthy self predominated at a large part of the 10 categories. This corresponded to the hypothesis. CONCLUSIONS: The used examination model seems suitable, to examine qualitatively the development of the self in psychotic people. At a more comprehensive study it is necessary to shorten the duration of the interview and to carry out the evaluation directly of video or CD-ROM The result of the qualitative contents analysis showed obviously, in which categories the impeding effect on the development of a healthy self outweighed. This result supports the idea of an individualized multidimensional therapeutic concept, which supports the development of a healthy self. Out of this could surrender to consequences regarding an individual, multidimensional therapy which promotes the development of a healthy itself.

The role of formative evaluation in implementation research and the QUERI experience.

This article describes the importance and role of 4 stages of formative evaluation in our growing understanding of how to implement research findings into practice in order to improve the quality of clinical care. It reviews limitations of traditional approaches to implementation research and presents a rationale for new thinking and use of new methods. Developmental, implementation-focused, progress-focused, and interpretive evaluations are then defined and illustrated with examples from Veterans Health Administration Quality Enhancement Research Initiative projects. This article also provides methodologic details and highlights challenges encountered in actualizing formative evaluation within implementation research.

Lessons learned about implementing research evidence into clinical practice. Experiences from VA QUERI.

The mission of the Veterans Health Administration's (VHA) quality enhancement research initiative (QUERI) is to enhance the quality of VHA health care by implementing clinical research findings into routine care. This paper presents lessons that QUERI investigators have learned through their initial attempts to pursue the QUERI mission. The lessons in this paper represent those that were common across multiple QUERI projects and were mutually agreed on as having substantial impact on the success of implementation. While the lessons are consistent with commonly recognized ingredients of successful implementation efforts, the examples highlight the fact that, even with a thorough knowledge of the literature and thoughtful planning, unexpected circumstances arise during implementation efforts that require flexibility and adaptability. The findings stress the importance of utilizing formative evaluation techniques to identify barriers to successful implementation and strategies to address these barriers.

The effect of a locally adapted, secondary stroke risk factor self-management program on medication adherence among veterans with stroke/TIA.

We targeted stroke/transient ischemic attack (TIA) survivors to engage in self-management practices to manage secondary stroke risk factors. We conducted a randomized, regional pilot trial of a locally adapted, secondary stroke prevention program. We implemented the program at two Veterans Administration Medical Centers. Program sessions targeted stroke risk factor self-management. Specifically, we evaluated the effect of the program on the reach, implementation, and effectiveness on patient self-efficacy; stroke-specific, health-related quality of life; and medication adherence for the prevalent stroke risk factors: (1) diabetes, (2) hypertension, and (3) hyperlipidemia. Medication possession ratios were calculated to evaluate medication adherence using VA pharmacy benefits data pre (6 months prior) and post (6 months after) the stroke/TIA event. Based upon the literature standard of 80 % compliance rate, we dichotomized compliance and modeled the data using logistical regression. Final sample included 174 veterans with an acute stroke or TIA who were randomized to receive either the intervention (n = 87) or attention control program (n = 87). Patient self-efficacy and stroke-specific, health-related quality of life at 6 months did not significantly differ between groups. We found improvements in medication adherence within the intervention group. In the intervention group, the odds of compliance with diabetes medications post-stroke were significantly larger than the odds of compliance prior to the stroke (odds ratio = 3.45 (95 % CI = 1.08-10.96). For compliance to hypertension medications, the intervention group showed significantly greater odds of compliance post intervention than pre intervention (odds ratio = 3. 68 (95 % CI = 1.81-7.48). The control group showed no difference in compliance rates from baseline to follow-up. For adherence to hypercholesterolemia medications, both the intervention (odds ratio = 5.98 (95 % CI = 2.81-12.76) and control groups (odds ratio = 3.83 (95 % CI = 1.83-8.01), had significant increases in the odds of compliance to statin medications; however, the comparison of changes in log odds of compliance between these two groups showed that the increases were not significantly different. We observed within group improvements in medication adherence among those receiving a post-stroke risk factor self-management program suggesting that a self-management format may be feasible to enable adherence to prescribed medications to reduce secondary stroke risk after stroke in concordance with guideline care. Additional research is needed to enhance intervention components to improve effectiveness outcomes.

Accessibility, usability, and usefulness of a Web-based clinical decision support tool to enhance provider-patient communication around Self-management TO Prevent (STOP) Stroke.

This article reports redesign strategies identified to create a Web-based user-interface for the Self-management TO Prevent (STOP) Stroke Tool. Members of a Stroke Quality Improvement Network (N = 12) viewed a visualization video of a proposed prototype and provided feedback on implementation barriers/facilitators. Stroke-care providers (N = 10) tested the Web-based prototype in think-aloud sessions of simulated clinic visits. Participants' dialogues were coded into themes. Access to comprehensive information and the automated features/systematized processes were the primary accessibility and usability facilitator themes. The need for training, time to complete the tool, and computer-centric care were identified as possible usability barriers. Patient accountability, reminders for best practice, goal-focused care, and communication/counseling themes indicate that the STOP Stroke Tool supports the paradigm of patient-centered care. The STOP Stroke Tool was found to prompt clinicians on secondary stroke-prevention clinical-practice guidelines, facilitate comprehensive documentation of evidence-based care, and support clinicians in providing patient-centered care through the shared decision-making process that occurred while using the action-planning/goal-setting feature of the tool.

Poor reporting of search strategy and conflict of interest in over 250 narrative and systematic reviews of two biologic agents in arthritis: a systematic review.

OBJECTIVE: To evaluate the quality of reviews about etanercept (ETN) and infliximab (IFX), two biologic treatments for rheumatoid arthritis (RA). STUDY DESIGN: A comprehensive, systematic review, including searches of MEDLINE, EMBASE, and other electronic databases and hand-searches for published and unpublished literature. Two raters independently examined each article and identified systematic reviews as those including either a description of: (1) sources for identification and data retrieval; or (2) search strategy. They applied the quality of reporting of meta-analyses (QUOROM) instrument to systematic reviews. RESULTS: Of 3,620 total citations, 281 were identified as reviews. Of these, 26 (9%) qualified as systematic rather than narrative. Overall, few reviews described selection of sources, critical appraisal, or quantitative summary or synthesis. Systematic reviews most often failed to explain validity assessment. Several articles did not disclose authors' participation in industry-funded clinical trials. Most reviews published in high impact factor and rheumatology journals did not meet many quality standards. Significant associations existed between review type (narrative vs. systematic) and reported funding (P=0.05), conflicts of interest (P=0.005), and country of publication (P<0.0001). CONCLUSION: More than 90% of the published reviews were narrative and did not report methods and conflicts of interest in sufficient detail, raising concerns about selection and reporting bias.

A quasi-experimental test of an intervention to increase the use of thiazide-based treatment regimens for people with hypertension.

BACKGROUND: Despite recent high-quality evidence for their cost-effectiveness, thiazides are underused for controlling hypertension. The goal of this study was to design and test a practice-based intervention aimed at increasing the use of thiazide-based antihypertensive regimens. METHODS: This quasi-experimental study was carried out in general medicine ambulatory practices of a large, academically-affiliated Veterans Affairs hospital. The intervention group consisted of the practitioners (13 staff and 215 trainees), nurses, and patients (3,502) of the teaching practice; non-randomized concurrent controls were the practitioners (31 providers) and patients (18,292) of the non-teaching practices. Design of the implementation intervention was based on Rogers' Diffusion of Innovations model. Over 10.5 months, intervention teams met weekly or biweekly and developed and disseminated informational materials among themselves and to trainees, patients, and administrators. These teams also reviewed summary electronic-medical-record data on thiazide use and blood pressure (BP) goal attainment. Outcome measures were the proportion of hypertensive patients prescribed a thiazide-based regimen, and the proportion of hypertensive patients attaining BP goals regardless of regimen. Thirty-three months of time-series data were available; statistical process control charts, change point analyses, and before-after analyses were used to estimate the intervention's effects. RESULTS: Baseline use of thiazides and rates of BP control were higher in the intervention group than controls. During the intervention, thiazide use and BP control increased in both groups, but changes occurred earlier in the intervention group, and primary change points were observed only in the intervention group. Overall, the pre-post intervention difference in proportion of patients prescribed thiazides was greater in intervention patients (0.091 vs. 0.058; p = 0.0092), as was the proportion achieving BP goals (0.092 vs. 0.044; p = 0.0005). At the end of the implementation period, 41.4% of intervention patients were prescribed thiazides vs. 30.6% of controls (p < 0.001); 51.6% of intervention patients had achieved BP goals vs. 44.3% of controls (p < 0.001). CONCLUSION: This multi-faceted intervention appears to have resulted in modest improvements in thiazide prescribing and BP control. The study also demonstrates the value of electronic medical records for implementation research, how Rogers' model can be used to design and launch an implementation strategy, and how all members of a clinical microsystem can be involved in an implementation effort.