Veteran tobacco use, low-density lipoprotein, and glycated hemoglobin levels.

The deidentified electronic medical records of 1,452 veterans with a history of smoking and assigned to an outpatient Department of Veteran Affairs Medical Center were examined. Descriptive statistics and two repeated measures ANCOVA were performed to determine the demographic characteristics of the sample and the relationships between the independent variable of tobacco use group on the dependent variables of LDL cholesterol and HbA1c levels, during the years 2003 through 2007. There was no statistically significant relationship between tobacco use and LDL levels when controlling for weight. There was a statistically significant difference in the tobacco use groups and HbA1c levels. Current smokers had higher HbA1c levels than did former smokers throughout the observational period, but the difference was statistically significant only for the years 2003 and 2007. Thus health care providers are challenged to monitor for cardiovascular risk factors, assist patients with smoking cessation, and prevent tobacco use.

Provider adherence to clinical guidelines related to lipid-lowering medications.

The objective of this study was to determine whether health care providers at the Department of Veterans Affairs Medical Center (VAMC) in Salem, Virginia were adherent to lipid-lowering medication guidelines over a 5-year period. Five hundred randomly chosen electronic medical records of veterans with diabetes, congestive heart failure, and/or coronary artery disease were examined for the use of HMG-CoA reductase inhibitors as part of a larger study on patient-provider adherence to cardiovascular risk-reduction guidelines. Study findings indicated that health care providers prescribed HMG-CoA reductase inhibitors to patients at high risk per evidence-based guidelines. Provider adherence to guidelines rose each year of the study, which coincided with the Department of Veterans Affairs Medical Center efforts to educate health care providers about the evidence-based guidelines, utilization of computer-generated reminders, open access appointment scheduling, and increased collaboration with patients.

Themes in the literature related to cardiovascular disease risk reduction.

PURPOSE: This article aimed to identify themes in the literature related to patient-healthcare provider beliefs, barriers to adherence, and interventions pertaining to cardiovascular disease risk reduction. METHODS: Twenty quantitative and qualitative primary research studies including 2 meta-analyses published between 1995 and 2008 were analyzed for themes and practice implications to synthesize existing research on cardiovascular disease risk reduction. Databases searched included EBSCO, CINAHL, MEDLINE, ScienceDirect, HealthSource, and PsychLit using the search terms patient- provider adherence, adherence and shared decision making, adherence and decision support, patient- provider goal setting, and cardiovascular disease risk reduction. RESULTS: The emergent themes found in this literature review included (1) complex medication regimens; (2) risk perception, quality of life, and competing priorities; (3) motivation for change; (4) provider clinical inertia; and (5) goal setting, feedback, and reminders. Studies reporting the highest rates of adherence to cardiovascular disease risk reduction recommendations incorporated patient-provider goal setting and decision support, self-management techniques, and personalized printed communication. IMPLICATIONS FOR PRACTICE: Goal setting in cardiovascular disease risk reduction is a relatively unexplored area and is an important component of shared decision making and adherence to cardiovascular disease health recommendations. The following review will address the 5 themes identified in more detail and provide a basis for improved clinical practice.

Jaundice in the full-term newborn.

Jaundice is a common problem affecting over half of all full-term and most preterm infants. Jaundice describes the yellow orange hue of the skin caused by excessive circulating levels of bilirubin that accumulate in the skin. In most healthy full-term newborns, jaundice is noticed during the first week of life. Shortened hospital stays and inconsistent follow up, especially for first-time breastfeeding mothers, prompted the American Academy of Pediatrics (AAP) to update management guidelines. Health care providers need to be familiar with the diagnosis and management of jaundice to prevent brain, vision, and hearing damage. Treatment of choice for jaundice remains close observation and frequent feeding followed by phototherapy, and finally exchange transfusion for severe or refractory cases.

Doctoral persistence and doctoral program completion among nurses.

PROBLEM: The United States is experiencing a critical shortage of registered nurses, which is due to multiple factors, including a deficit of full-time doctorally prepared nursing faculty. METHODS AND FINDINGS: This review of the literature addresses doctoral persistence and the challenges faced by doctoral nursing students. Themes found in this review included periods of transition, parenthood and outside demands, delays and "marinating" in the data, and positive aspects. These issues need to be addressed in order to increase doctoral student retention and reverse the nursing shortage.

Healthcare utilization among patients with vocal cord dysfunction.

BACKGROUND: Acute asthma-like symptoms are anxiety producing for patients, and improper diagnosis leads to inappropriate use of asthma medications, unnecessary office and emergency room visits and referral to specialists to determine the cause. Vocal cord dysfunction (VCD) is responsible for 15% of referrals for dyspnea on exertion and frequently leads to multiple emergency room visits. PURPOSE: The purpose of this study was to explore healthcare utilization among patients with VCD compared to patients with asthma and report the demographic characteristics of patients with these diagnoses receiving outpatient specialty care. METHODS: In this retrospective study, the de-identified electronic medical records of 285 participants receiving outpatient specialty care with a documented diagnosis of VCD, asthma, and VCD and asthma during the years 2007-2009 were explored with descriptive statistics, chi square, and Poisson regression. RESULTS: Despite the perception of overuse of medical resources among patients with VCD, participants in this study were seen in the outpatient clinic less frequently than participants with asthma, they used less inhaled controller medication, and there were no reported emergency room visits or hospitalizations. Females were more likely to experience this disorder. Patients with VCD were twice as likely to receive medication for anxiety and/or depression, which suggests that mood is a contributor to this disorder. Past or current allergy immunotherapy was utilized by nearly half the sample, which greatly reduces the triggers associated with VCD symptoms and asthma exacerbations. It is surmised that appropriate management including allergy immunotherapy and patient education impacted the use of hospital and outpatient services. Estimated controller inhaler costs for the entire sample were surprisingly high. Use of a controller inhaler, however, was significantly lower among patients with VCD as compared to patients with asthma which is appropriate. CONCLUSION: Nurse practitioners and other healthcare providers are challenged to reduce unnecessary inhaler prescribing among patients with VCD without asthma and to seek specialty consultation to confirm or refute the diagnosis of asthma when needed.

Concept analysis of adherence in the context of cardiovascular risk reduction.

TOPIC: Cardiovascular disease is the number one cause of death in the United States. Examination of the concept of adherence is essential to provide informed patient-centered care to prevent the development and progression of this largely preventable disease. OBJECTIVE: The purpose of this concept analysis is to explore and clarify the concept of adherence. This analysis will provide a framework for those seeking a better understanding of patient decision-making, reduction of relapse to unhealthy behaviors, and increased long-term adherence to cardiovascular health recommendations. Reviews of major theories related to health behavior are reviewed in the second part of the article and are linked to the concept of adherence. METHOD: Following a review of the literature, Morse's guidelines were utilized to present a concept analysis of adherence and the related terms concordance and compliance from the disciplines of nursing, health psychology, ethics, pharmacy, and medicine. RESULTS: Adherence is dependent on the collaborative relationship between patient and healthcare provider. Adherence is influenced by the meaning of health, heart disease, and sense of personal risk as well as socioeconomic status, decision support, motivation, and desire for change, self-efficacy, and sources of credible health information. Attributes of successful adherence include alignment of patient behavior and health recommendations, mastery of new health knowledge and behavior, continued collaborative relationships between the patient and healthcare provider, and ability to meet outcome targets. CONCLUSION: Adherence is defined as persistence in the practice and maintenance of desired health behaviors and is the result of active participation and agreement. Adherence is dependent on the development of a concordant relationship and its measurement should be specific utilizing the correct tools. Special attention should be paid to shared decision-making between patient and healthcare provider.