[ Herbal Remedies ]

BMC Health Services Research

The objective of this study was to evaluate the short-term impact of a 7-h type 2 diabetes continuing medical education (CME) program. Ten PHC were distributed randomly into two groups: five PHC in the intervention group and five PHC in the control group. The EuroQoL-five-dimensional (EQ-5D) scale was used to assess HRQoL. The results are presented descriptively. The scores identify the attitude regarding five key areas of diabetes, namely need for special training, seriousness of diabetes, value of tight control, psychosocial impact and patient autonomy. ISSN 1680-5348. A descriptive correlational cross-sectional survey of 178 adults recruited from urban residential areas of the San Francisco Bay Area was conducted.

India takes one rank better when FM distress is measured on the DAWN Impact of Diabetes Profile Family Member scale: India scores 54.5 (51.8-57.2) against a global mean of 51.8. Currently, we are conducting usability and playability tests, with PCPs and medical students playing the game on a desktop computer. Nurses and midwives provide information and advice to women with gestational diabetes. For analysis, data were transferred to SAS 9.0 software. The final model showed a good fit to the data: RMSEA = .045 (90% CI: .009, .071; Clfit = .601), CFI = .950, SRMR = .058. These findings mimic much of the research on knowledge retention following CME. For them the assessment of emotional burden is a necessity to make emotional support in diabetes patients, and to improve their quality of life through empowerment strategies [16].

A significant number of analyses were conducted, raising issues of multiple hypotheses testing, which might have been avoided through adjustment of the significance level used. However, given the exploratory nature of the work, we wanted to avoid missing any potentially important relationships early into the development process. All participants were recruited from three general practices and within an inner-city area of North West of England. Sampling was restricted to responders who opted-in to the interview study and on completion of a postal survey. Nurses and midwives provide information and advice to women with gestational diabetes. Ethical requirements meant that respondents had to opt-in to both studies, and such participants may demonstrate certain characteristics, whereas a more diverse sample may have given different results. The potential for bias may be especially high in terms of the limited range of deprivation in the sample, as patients from less deprived backgrounds may have markedly different views.

Hence, even though patients themselves are primarily responsible for managing their illness, it seems important that partners are structurally involved in diabetes care. An innovative approach and a real paradigm shift is required to recognize that patients are in control of and responsible for the daily self-management of diabetes [6]. It was not possible to explore characteristics of non-respondents as current ethical guidelines do not allow data recording on patients who do not consent to participate. As outlined previously, the existence of five distinct dimensions of empowerment suggested by the qualitative work were not supported by the quantitative findings in study 2. The factor analyses suggested that responses to items concerning ‘identity’ and ‘control’ were related, as were issues of ‘knowledge and understanding’ and ‘decision making’, and these relationships make conceptual sense. The meaning of the third factor was very unclear, but the fact that items related to ‘enabling others’ only loaded on this factor might suggest that further tests using only these items would be useful, to see if the validity of this factor was supported. The factor was derived from the patient interviews, and is interesting as it relates to current self-management initiatives in the NHS, such as the Expert Patients Programme [88], and the Health Trainers initiative [89], which both rely on non-professionals to teach and empower patients who may be coping less well with their long-term conditions [46].

We would suggest that further psychometric work on this scale is indicated as it has potential wider utility. The scale’s banner was put on top of every page of the questionnaire, guiding the respondents to refer consistently, the right scale. In terms of construct validity, the majority of hypotheses were supported from the regression results. Seeing a preferred GP, being educationally qualified and general health were strong predictors of increases in total empowerment. Hypotheses that were not confirmed included the importance of continuity of care and GP confidence and total empowerment. It is noteworthy that seeing a preferred GP emerged as a key predictor in the analysis, but continuity with the doctor and GP confidence were found to be weak predictors of empowerment. It should be noted that nearly half (49.8%) of responders had not seen their GP/practice nurse for at least 7 to 9 months, which may have introduced a bias in responses on empowerment items that related to GP variables.

Fear of hypoglycemia is important to discuss with patients to educate them that hypoglycemic episodes can often be avoided through adjustment of insulin and careful vigilance in self-monitoring of blood glucose. It is possible that other measures of continuity may have given different results. For instance, twelve continuity measures have been developed to measure various types of continuity [90], each emphasizing different elements of the patient-practitioner relationship, such as density of visits and subjective perception of visit [91]. It may also reflect the fact that nurses provide the bulk of long-term condition care in the United Kingdom. Future testing of the measure may also benefit from confirmatory factor analysis to more rigorously test hypotheses about scale structure, given that ambiguities remain concerning the validity of the three factor solution and the concern over scale length. We are aware routine use of the new measure is likely to be enhanced by reducing the number of items. Following future large-scale validation of the measure, a short-form version should be developed and tested to lower response burden and increase the possibility of routine use of the measure.

The development and testing of the short-version should follow state of the art methodology for shortening composite measurement scales [92]. A high PTMEA Corr means that an item is able to distinguish between the ability of respondents. Interventions that might be expected to lead to increased empowerment might include: GP communication skills training [93]; patient decision aid interventions [94]; and self-management support, such as the chronic disease self-management programme [45]. Future research might also explore the relationship between measures of illness perceptions, such as the Illness Perception Questionnaire [95], which is designed to capture representations of specific illnesses, rather than generic feelings of empowerment. Exploring relationships between the measures may be fruitful, as it is possible that certain types of illness representations (such as those around controllability) may be predictive of levels of empowerment. The new measure has similarities with the Patient Activation Measure [96] and a formal comparison might highlight advantages and disadvantages of each. Both measures have different psychometric properties and underlying scale structure.

The Patient Activation Measure [96] has stronger psychometric properties than the current measure and was developed from the Rasch Rating Scale Model [97], an alternative statistical method to factor analysis, used to test scale structure. As a result, the elements of knowledge, belief, and skill that constitute activation have a hierarchical order; thus what is needed to increase activation depends on where the person is on the activation continuum. There are many other factors not measured in the current study that could be used to assess construct validity. For instance, a quality of life measure or other measures of psychological functioning may have been useful. It was also evident from the qualitative data (not presented here), that health literacy was a key issue in this group of patients, and this could have been examined by administering a health literacy measure [98]. However, such scales can be difficult to use in the context of a postal survey.

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[ Herbal Remedies ]

BMC Health Services Research

Background Mortality in people with and without diabetes often exhibits marked social patterning, risk of death being greater in deprived groups. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF). The underlying pathophysiology has been characterized as microvasculopathy, myocardial hypertrophy, and cardiac fibrosis; however, these evidences are mostly obtained under a preclinical setting, and its clinical application on DMC in terms of its diagnosis and therapeutic intervention yet has reached practical. The incidence of legal blindness among diabetics is 25 fold that of non diabetics.2, 3 In the developed world, diabetic retinopathy is the leading cause of legal blindness in individuals over 40 years old, while in the US alone diabetic retinopathy is responsible for 12% of new cases of legal blindness annually.2 According to the Wisconsin Epidemiologic Study of Diabetic Retinopathy, after 20 years with the disease, nearly all the patients suffering from Diabetes Type I and 60% of patients with Diabetes Type II, present with Diabetic Retinopathy that is potentially sight threatening.4, 5 Moreover, diabetic patients often neglect the need for ophthalmologic monitoring6. When patients were stratified according to IDDM and NIDDM, there was no difference in the prevalence of all eating disorders (point prevalence 5.5% vs. Comorbidity was determined by linkage with a national register including all individuals entitled to special reimbursement for drug treatment for a range of chronic diseases. These steps should be repeated, especially when the patient’s clinical status changes.

The overall percentage of individuals experiencing each health outcome was higher in Cohort 1 than Cohort 2 with the exception of ESRD. Similar results were obtained for the 4 other comorbidity measures used. As expected, the average scores for the comorbidity measures increased with age.

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[ Diabetes Solutions ]

BMC Health Services Research

Health plan investment in medical group practice redesign to improve management of chronically ill patients results in significant improvement in the quality of care — notwithstanding expense and equity sweat. Since chronic diseases not only impact individuals’ quality of life but also represent a tremendous economical burden, many approaches have been made to increase patients’ quality of life and to reveal affordable disease management tools. Determine if redesigning the system of care for treating diabetic patients who do not have primary care doctors is feasible, acceptable to patients and effectively lowers patients’ haemoglobin A1c, blood pressure and cholesterol levels. A chronic condition is any that requires ongoing adjustment by the affected person and interactions with the health-care system. The interviews focused on each project’s chosen chronic illness (diabetes, eating disorders, COPD, multi-morbidity, CVRM) and project plan, barriers to development and implementation, the project leaders’ action and reactions, as well as their roles and responsibilities, and disease management strategies. The evidence-based clinical care guidelines of the institution were the basis of feedback to clinicians about the quality of their care to patients with diabetes, asthma, coronary artery disease, and chronic heart failure. Of 1823 respondents reporting diabetes and other chronic diseases, one-quarter endorsed intrapersonal adherence barriers, while 23% restricted medication due of cost.

Terms Related to the Moving Wall Fixed walls: Journals with no new volumes being added to the archive. Quality of care measures were the most diverse (eighteen distinct measures) and were collected through three methods: provider perspectives of quality, patient perspectives of quality, and patient-related care processes. It is also a major cause of heart disease and stroke among US adults, and is the leading cause of non-traumatic lower-extremity amputations and kidney failure. In total 4947 patients were included in the audit. Facilitating more complete CCM implementation in clinics with a basic level of CCM that serve a population of patients who are sedentary may realize the most benefit. Journal of Evaluation in Clinical Practice 19(5): 753–62. It was repeated annually in all intervention centers during the intervention.

To learn more about the facility, visit the Fort Yuma Health Care Center project page. An overall coordinator (LMB) facilitated the coordination and the running of the project. In Do the intervention evolved from communicating the baseline audit results prior to inaugurating changes in settings or resources. In addition a one day workshop for health professionals, on cardiovascular risk factors was conducted at the end of 2004 highlighting assessment and management of risk by means of the Framingham risk score. NPs can provide motivation for change that can influence healthcare delivery design. After informed consent was obtained, each patient completed a patient survey, providing the following personal information: race, age, height, health status, perceived continuity of care within the practice as well as receipt of diet, weight loss, or physical activity counseling in the past year by either a clinician or someone else within the practice. Other components of the intervention are shown in Table 1.

The intervention was initially piloted in the academic health center where medical students and family medicine residents receive their training. All tools used in the project, such as forms, registers, policies and guidelines were piloted, tested and improved in this phase. The additional intervention consisted of facilitating system change, developing decision making aids, educational activities, and a self-management program. Each clinic was managed coequally by a physician and an administrator, who reported to a similar leadership dyad for all of primary care. Members will also participate in a physical activity program and/or cooking lessons. She also helped the nurses with patient education on such topics as dietetics and foot care. All patients were provided with “self management cards” which they were encouraged to take to each consultation.

Whether this or any other CCM elements can help to improve healthcare practices and health outcomes for disadvantaged populations more generally is not as clear. Initial efforts were with geriatric patients. ICSI and NICE [19] for Diabetes and NICE [20], JNC 7 [21] and European Hypertension society guideline for hypertension [22]. Also the SNAP [23] guideline was included for therapeutic life style changes. * Seven of the top 10 causes of death in 2010 were due to chronic diseases. Finally, the 6 element scores were averaged to arrive at an overall score for each clinic. In the medium sized centers, with lower patient flow, patients were seen in-between other patients, but with appointments distributed throughout the days of the week for better time management.

A telephone visit reminder system was introduced in order to decrease the non-attendance rate. A total of 784 participants who were diagnosed with hypertension, diabetes mellitus and/or hyperlipidemia, and treated with pharmacotherapy were enrolled into the study: 527 in the intervention arm and 257 in the usual care arm (Figure 1). Finally, self management was promoted by means of hand held booklets that included all relevant patient data, space for communication with hospital based specialists, as well as self-management measures agreed upon between doctor and patient. Diabetes patients were issued free blood glucose monitoring devices for home monitoring. The first audit in July 2004 perused 672 files, then after the implementation of the project in the pilot center in 2005 164 files were audited. Many international collaborations, such as Innovations in Healthcare  and the World Innovation Summit for Health, are also taking a closer look at how to learn from innovations in health care and in policy reforms to accelerate improvements in seemingly diverse settings around the world. The auditing was conducted by specially selected nurses temporarily made available by participating health centers.

In 2007 information was extracted from 1402 files. For all patients measures were recorded both before (2006) and after (2007) the intervention. This was repeated in 2008 (715 files). In 2008 three centers were not audited for organizational reasons, and the pilot center was neither audited in 2006 nor in 2008. In order to determine the effect of the intervention the 2008 audit included the same patients audited in 2007, as well as a sample of new patients for comparison. 2009;9:152. For large centers a total of around 100, and for medium size centers 60-80 patients was targeted.

The attendances for large, medium and small centers are 250-300, 150-200 and 100-150 patients per day respectively. The chronic disease clinics attracted around 3000 patients per month in the ten centers. Data are not available to determine how many diabetic or hypertensive patients are registered at each center. Although registers are available and each patient has a unique “disease specific identifier” (e.g DM91) in these registers, we still found deficiencies and duplications in the registers. In order to avoid problem with sampling from these imperfect registries, a sample was extracted instead from the appointment books of patients attending in the three month period prior to the audit. Satisfaction of patients about the project was sought through annual interviews. Staff satisfaction was monitored by a constant feedback from the health care professionals to the implementation team.

Comments on feasibility and problems associated with the project were elicited during face-to-face interviews by facilitators during regular (more than once weekly) visits to the centres.

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[ Herbal Remedies ]

BMC Health Services Research

Jerry Meece is a pharmacist, certified diabetes educator, owner and director of Clinical Services at Plaza Pharmacy and Wellness Center in Gainesville, Texas. Join us for coffee, socialization, and discussion regarding diabetes and chronic diseases. * Promotes, refers to, & advocates the InSTEP program. “But think about pharmacists. A Certified Diabetes Educator (CDE) is a healthcare professional with a passion for diabetes education. Dr. July 2010-present.

Neumiller has been an active ADA member and is editor for the organization’s journal Diabetes Spectrum. Neumiller is a member of the WSU Geriatrics Team and the WSU Clinical Trials Research Team. We know that cholesterol andblood pressure are of paramount importancein patients with diabetes, and that bloodglucose control needs to be tighter in bothtype 1 and type 2 patients to prevent or delaycomplications. Those who reported a relationship with their pharmacist were more likely to discuss their diabetes with a CDE pharmacist and schedule an appointment if a fee was charged. For more information, call (716) 592-9643. Study auditors reviewed the charts of patients who provided written informed consent and collected year of birth, year of T2DM diagnosis, glycosylated haemoglobin (HbA1c) values and glucose-lowering medications. The remaining charts of patients who either, did not consent or did not respond, were reviewed by the physician to determine insulin-eligibility.

Cross was awarded the University of Tennessee National Alumni Association Outstanding Teacher Award as well as being recognized as the teacher of the year by the pharmacy class of 2008. Lantus® or NPH insulin was available free of charge for 6 months to all insulin-eligible patients. All eligible physicians were stratified by the study geographic site and their level of comfort prescribing insulin (determined by questionnaire) and randomly allocated (1:1) in a blocked manner to an insulin initiation strategy (intervention) or usual care (control) by the Coordinating Center. Which Medicare Part D plan will best meet my needs (not just with my diabetes meds, but all my meds)? (2014). Sam Grossman discusses some of the studies’ findings of this medicine and whether people with DR may want to inquire with their healthcare providers about it. She wholeheartedly believes that it takes a community to raise a pharmacist!

Pharmacists attended the same program but were educated separately to avoid contamination. He has also written two cookbooks for the American Diabetes Association and hosted cooking segments on many television programs. Yes, there over just under 1000 pharmacist CDEs in the United States and these pharmacists work in a variety of practice settings. 2014; 26(3):81-88. Practical approach to determining costs and frequency of adverse events in health care network. Intervention physicians had the opportunity to meet pharmacist(s) with whom they were matched. Physicians randomized to the intervention group were provided with a 12-month insulin initiation strategy consisting of (1) diabetes specialist/educator consultation support (active diabetes specialist/educator consultation support for 2 months [the educator initiated contact every 2 weeks] and passive consultation support for 10 months [family physician initiated as needed]); and (2) community retail pharmacist support (option to refer patients to the pharmacist(s) for a 1-hour insulin-initiation session).

The session checklist included education on insulin action, injection sites, the pen device, and hypoglycemia awareness and treatment. * Certification by the National Certification Board for Diabetes Educators (CDE) or a minimum of 2 years of educational or work experience in diabetes, adult learning principles and behavioral strategies can be initially substituted for certification. However, he doubts that science will develop a way to cure those who develop diabetes. For those patients prescribed insulin during the intervention, additional outcomes included: number of days from study start to insulin initiation; the change of HbA1c, FPG, and OAD score; and type(s) of insulin prescribed from initiation of insulin to 3 and 6 months post-initiation. The physician knowledge, attitude and self-efficacy questionnaire was used to create change scores (pre – post intervention) to measure physician knowledge, attitude and self-efficacy [ 36 , 37 ] for both glycemia control and insulin initiation and titration. Curr Pharm Teach Learn 2014; 6(3): 359-366. With a standard deviation of 7.1 estimated from Poisson regression, two-sided alpha of 0.05 and power of 0.90, the sample size required was 89 physicians per group (n = 178).

Protocol modifications due to recruitment challenges included inclusion of group practice physicians (excluded in original protocol), and reduction of the minimum required number of patients with T2DM (original protocol = 50) and insulin-eligible patients (original protocol = 8). The unit of analysis was the physician. Intention-To-Treat analysis was performed on the primary outcome with the IPR imputed as zero if data were not available. The analyses of secondary outcomes were based on all available data. A p value of ≤ 0.05 was deemed statistically significant. Analyses were generated using SAS Version 9.1. All data were examined and the appropriate analyses were employed.

The IPR was analyzed using Poisson regression with intervention group as a class effect and mean HbA1c at baseline as a covariate from which the mean number of people started on insulin per 12 months, standard error (SE) and 95% confidence intervals (CIs) were calculated. Continuous variable changes from workshop to 15 months post-workshop were examined using analysis of covariance (ANCOVA) with the intervention group, baseline mean HbA1c, insulin comfort stratum and pooled site as class effects, and corresponding baseline value of the variable of interest as a covariate. ANOVA procedures were used to compare intervention and control baseline physician and practice demographics for continuous variables and chi-square tests for categorical variables. Kebodeaux C, Grise W, Hudspeth B, Divine H.

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[ Diabetes Solutions ]

BMC Health Services Research

Background & Aims: Applying “Roy adaptation model” for diabetes patients need carefully assessment and care planning based on principles of this model. It is directed to people who are likely to have to use too much of their income to pay for related healthcare services, who are not receiving those services that give them the best chance to stay healthy, or who are receiving services that are not well coordinated with one another. CDM items are not available to public in-patients of a hospital or care recipients in a residential aged care facility, except before discharge from a hospital or an approved day-hospital facility. Because the statute database is maintained primarily for legislative drafting purposes, statutory changes are sometimes included in the statute database before they take effect. If a provider accepts the Medicare benefit as full payment for the service, there will be no out-of-pocket cost. The signs of both types of diabetes are very similar because they both stem from too much glucose in the blood. When the body is unable to control its insulin levels, diabetes occurs.

David Briggs, General Manager at London Medical, explains: “The Diabetes Care Plan is a totally new concept, offering access to the highest level of care for a minimal cost. Severe hypoglycemia in the school setting is rare but it is important that staff understand how to respond quickly. ATSM can be used to promote collaborative goal-setting through behavioral action plans, by which patients set and achieve short-term goals to improve their self-management [35]. Average of age was 48 ±7/3 .Comparison of HgA1c before and after intervention in case group by paired t-test was significant (p >0.05). The effectiveness of disease and case management for people with diabetes: a systematic review. The Improving Diabetes Efforts Across Language and Literacy (IDEALL) study – a randomized controlled trial of ATSM among English-, Spanish-, and Chinese-speaking patients with poorly controlled diabetes – demonstrated high engagement with ATSM, particularly among participants with limited health literacy and limited English proficiency [32]. Compared with patients receiving usual care or group medical visits, patients exposed to ATSM had greater improvements in their experiences of chronic illness care, self-management behavior, fewer bed days per month, less interference in their daily activities, with a cost utility for functional outcomes comparable to other diabetes prevention and treatment interventions [33, 37].

Referral arrangements The need for allied health services must be directly related to a patient’s chronic condition and identified in their care plan. Research indicates that weight loss plays a major factor in preventing type 2 diabetes and cardiovascular disease as well. To help keep the disease at bay, monitor your blood sugar, blood pressure, and cholesterol levels. We hypothesized that intervention participants would demonstrate greater improvements in diabetes self-management, patient-centered outcomes, and cardiometabolic outcomes compared to wait-list controls and that improvements would be greatest for patients exposed to ATSM with an enhanced medication activation communication strategy triggered by pharmacy claims and self-reported medication non-adherence.

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[ Herbal Remedies ]

BMC Health Services Research

The patient pathway is the time from when you develop a condition needing treatment to the time the problem is either resolved or under control. The glycemic control is a critical element of inpatient care that has received increasing focus and attention from the healthcare community and several national agencies over the last few years. Applying evidence-based care is expected of all of our physicians as they serve our patients in providing the ideal patient experience. Payment is processed automatically in the background without any additional work for those who manage physician billings at your office. Additionally, the U.K. Generalized linear models were used to determine associations between use of diabetes flow sheets and adherence to guidelines. Primary Care Development Corporation (PCDC) Practice Coaching and Learning Collaborative: CCBC has engaged PCDC, which throughout 2012 is providing hands-on practice coaching and implementing learning collaboratives with 18 primary care practices.

The Maternity Network Initiative helps family physicians form “shared care networks” to share the responsibilities of providing continuous obstetrical coverage and full-scope maternity care through links with midwives, specialists, and other GPs. These care guides alone may not always suggest the most suitable or medically appropriate care – that decision will be made by a qualified health care provider. Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada Diabetes Flow Sheet – The Diabetes Flow Sheet consolidates all the diabetes flow data that clinicians rely on for assessing progress of the condition. HbA1c levels in the GetGoal-L-Asia Study, which compared lixisenatide versus placebo in people with Type 2 diabetes mellitus and inadequate glycemic control receiving basal insulin with or without a sulfonylurea. Enhancing the model of care the team provided was really about improving access to care for patients as described by Carla Curto-Correia, Patient Care Manager, Ambulatory Care Centre, GI/Endoscopy and Fracture Clinic. This study, along with others we have conducted, has found improvements in knowledge, decisional comfort, and patient participation in decision making, and little impact on adherence and other patient health outcomes. In 2012, 11.7% of adult Australians were estimated to have diabetes.

The first Statin Choice randomized trial [5] conducted in a specialty setting found that patients who received the decision aid were 22.4 times more likely to know their estimated cardiovascular risk than those in the usual care group, had greater decisional comfort (10.6 points higher on a 100 point scale), and better self-reported adherence at 3 months, odds ratio 3.4 (95% CI 1.5, 7.5). Among other health care quality improvement initiatives, Nurse Bolton and her colleagues use patient lists to identify smokers who have not received smoking cessation counseling so they can schedule counseling appointments for the patients. Our findings, while imprecise, are consistent with these prior results suggesting it is feasible to observe similar outcomes in academic and nonacademic practices, provided that the decision aids are implemented. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs. In these contexts, the decision aids have been well received by patients and clinicians, and have improved decisional outcomes. This effectiveness has not necessarily translated into a favorable impact on clinical measures of effect or on medication adherence. The target group consisted of workers registered at RHC and diagnosed with DM.

This might result from two closely related issues. If your condition does not get any worse you will be returned to the care of your GP (or primary care provider) and advice will be given to them about what to do if your condition gets worse. Implementation of the MUSC hypoglycemia treatment protocol significantly reduced the number of moderate to severe hypoglycemic episodes. The results of the audit are obtained by calculating the quotient of opportunities achieved divided by the total number of opportunities, which is then expressed as a POA (Percent of Opportunities Achieved). The second closely related issue is that shared decision making is appropriate when there is more than one sensible management option. Patients without a subsequent MI were censored at the earliest occurrence of patient death, transfer out of the general practice, or the end of the study (29 July 2013). Diabetes target attainment scores consisted of documentation in the medical record of attainment of 3 targets: hemoglobin A1c level less than 8%, LDL-cholesterol level less than or equal to 100 mg/dL, and blood pressure less than or equal to 130/85 mm Hg.

When more than one option is acceptable, however, the effect of different patients opting for different treatments will contribute to the overall variability in outcomes. Therefore, in the absence of a superior treatment choice, the only way shared decision making can improve patient outcomes is through improvements in adherence to the selected treatment option. Thus, there is no a priori reason to believe that shared decision making should improve clinical outcomes beyond its effect on adherence to treatment. Research to select patients most likely to benefit from SDM and to explore ways to improve high-fidelity delivery of the tools may improve their clinical utility. We have discussed above that the observed fidelity of use could suggest that some effectiveness might not have been realized because of insufficient clinician training. An alternative explanation is that patient-centered care sometimes necessitates deviation from the expected use of the tools in order to accommodate emerging patient issues. Whether this means that more effort to improve optimal use of the tools is necessary warrants further exploration.

Accordingly, the primary hypothesis is that glycaemic control of patients with T2DM who have their treatment delivered through management by a community-based multidisciplinary integrated primary-secondary healthcare team (including an Endocrinologist) using protocol driven care, will be comparable to glycaemic control achieved in a hospital outpatient clinic setting. DAs promote patient-centered practice to the extent that they support both parties in having an evidence-based discussion in which patient participation in deliberation is dynamically and empathically negotiated by the parties. DAs do not guarantee patient-centered care to the extent that the practices, norms, rituals, and policies of the practice may fail to support it [21]. Similarly, patient engagement is facilitated by the common ground offered by the decision aid, but it might not happen if the patient is not in a position to participate or feels threatened by such participation [22]. Thus, DAs are tools to promote and facilitate participatory forms of decision making, but much work is needed to increase the likelihood that shared decision making results from their use. We do not think the results from this and past trials will satisfy those pursuing legislation of SDM seeking reductions in healthcare utilization and costs [23]. To this extent, the Patient Protection and Affordable Care Act of 2010 did not fund, but promoted the establishment of SDM Resource Centers.

In contrast, the staff’s adherence rates at the GPC to quality guidelines were far beyond the standardized target for almost all the indicators. In our view, current federal policy strikes the right balance, supporting additional research rather than mandating implementation. State legislatures, however, have been more sanguine in their approach [8]. Clearly large studies outside of academia will be needed to know the full extent of intended and unintended consequences of SDM.

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[ Diabetes Solutions ]

BMC Health Services Research

01 Jul 2016 People with mental health problems can be so unwell that they do not recognise or seek help for serious symptoms of physical illness in themselves. With the anticipated expansion of Medicaid under health reform, it is particularly important to develop national estimates of the magnitude and correlates of quality deficits related to mental comorbidity among Medicaid enrollees. William Polonsky once said, “I would be concerned if someone does not show some signs of depression after diagnosis”. A new study in Diabetologia by Peter de Jonge and his international colleagues has used the framework of the World Mental Health surveys to examine the relation between a wide range of mental health disorders and diabetes diagnosis. Given the shortcomings in the social determinants of health for this population (income, housing, and food in particular), strategies to support self-management and prevention must be accessible, affordable and practical. et al. The World Psychiatric association also reviewed the evidence for the association between severe mental illness and physical illnesses and proposed recommendations both on the individual level and a systems level to achieve somatic health care on a par with that of the general population[2][8].

Over the five-year follow-up period, those with major depression had a 36 percent higher risk of developing microvascular complications and a 25 percent higher risk of developing macrovascular complications compared with patients without major depression. The mental health burden that patients with diabetes face is worrisome. Dr. An understanding of the bi-directional pathophysiological relationship between diabetes and depression has been elucidated by Rustad et al,4 but key posited aetiologies are activation of the innate immune system and increased activity of the hypothalamic – pituitary – axis, in addition to the psychological burden of the illness. Second, the clinical intervention is conducted entirely over the telephone. It is the policy of AKH Inc. However, prior studies conducted within the VA suggest that the effectiveness of telephone-based depression treatment with Veterans may produce limited treatment effects [45].

Additional research studies on programs that provide telemental health treatment, like HOPE, are needed. As a third level of innovation, the clinical intervention, as well as facets of the implementation strategy, seek to increase the overall potency of outcomes through directed efforts to communicate clinical information, e.g., presence of clinically significant depressive symptoms in medically ill patients, to each patient’s primary care treatment team. The inclusion of the patient’s existing provider team is seen as critical, not only for improving intervention potency but also for reconciling discrepant definitions of treatment adherence and health-related goals between patients and providers, and avoiding potential clinical pitfalls related to hypoglycemia and worsening emotional health. From an implementation standpoint, the project enlists coach-based “interventions” to increase the fidelity and adoption of HOPE by PACT providers with varying levels of clinical experience. The training of nonmental health experts is viewed as an important step to address the limited supply of such providers in primary care and in clinical settings outside academic medical centers. To adequately train and support these nonmental health specialists, the project team collaborated with stakeholders to create print and online training materials, a focused four-hour training workshop for clinician coaches, and a comprehensive mentor program to enhance the professional development and clinical skills of HOPE coaches. As others have noted, strategies to improve access to care must be balanced with the need to retain intervention fidelity and effectiveness to keep these innovative treatments from being “brilliant, but irrelevant” [46].

To this end, HOPE attempts to balance the need to document the effectiveness of the clinical intervention while maintaining and supporting the use of the treatment in real-world primary care settings. adults with diagnosed diabetes and SPD (∼1.4 million), about 45% (∼0.6 million) received no treatment for any mental health problems. Further, the inclusion of study coaches will allow an exploration of data to determine whether HOPE is more effective when provided by the study coaches, who operate outside the fast-paced, competing-demand setting of primary care. Remission of type 2 diabetes was defined as HbA1c < 42.1 mmol mol−1, fasting glucose < 5.6 mmol L−1, and no medication. We do not fully understand the link between mental health and diabetes, but we do understand the link between successful treatment of mental health issues and diabetes outcomes. Because of the multifaceted nature of the trial, it is anticipated that the HOPE intervention will provide meaningful clinical information for the treatment of complex patients with diabetes and depression. This trial will also supply critical implementation data for the potential use of telephone-based coaching interventions in the primary care setting. It is believed that hybrid effectiveness-implementation designs, although complex and not without sacrifices to internal validity, are useful for not only reducing lag time between efficacy and implementation but also for providing opportunities to identify potential pitfalls, including information to better understand a negative clinical trial.

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[ Diabetes Type 1 ]

BMC Health Services Research

A1 If a disease lasts for a long time or for your life time, it’s considered a chronic disease. Bosu WK. Thus, we aim to investigate psychometric characteristics of the PACIC including the content and stability of its construct over time. Most probably you will have to agree to register with the practice for your chronic disease health care and agree to attend that practice for care. What do the team members other than the doctor do to support patient care? Diabetes and Stress Similarly to depression and diabetes, stress and diabetes as well as stress and depression are often linked. problem-solving orientation, (c).

In contrast, the present qualitative study demonstrated that patients and carers with chronic illnesses, who receive care from a wide range of health services, faced a range of challenges in utilizing those services and had serious concerns about their unmet needs and wants within the health system. The staff can send you written information and put you in touch with services in your local area. James so she can tell him what to do. Antidepressant drugs may aggravate the patient’s medical condition, there is the potential for drug interactions, and the presence of impaired renal, hepatic, or gastrointestinal function may alter drug metabolism.14 Thus, selecting an antidepressant requires careful assessment of the risks and benefits.14 However, antidepressant drugs are effective in people who are medically ill,14 and antidepressants are tolerated in up to 80% of patients with cancer without adverse effects.15 The optimal treatment of depression in patients with chronic conditions also involves using a combination of cognitive and supportive psychotherapies that incorporate awareness of the grief and loss that are consequences of the disease process. Lack of reimbursement should simply put a higher premium on providing these aspects of care more efficiently and at a lower cost. While patient centredness has not been defined in these documents, patient needs have quite clearly been identified as the principal element in providing optimal care for chronically ill patients [25]. Currently, there are several chronic care programs running in NSW [17, 26], ACT [27], and other Australian states [28–31], all of which are intended to address the challenges of caring for chronically ill patients and to assist them to better manage their conditions.

According to the national strategy, these policies should contain implementation plans [24]. The DPCS, HDSPS, and AGEC provide funding for clinics to participate in the 13 month collaborative. Although the term patient centredness has not been mentioned in the first phase of the NSW Chronic Care Program, the concept has been introduced as the first principle of the program in its second phase [32, 33]. Patient centredness has not been defined clearly in any of the program’s relevant documents, but rather it has been taken to mean “placing patients at the centre of care [which] has implications for what, how, where and when care is delivered” [32]. The aim has been mentioned in order to have an impact on the health services delivered locally so that it is more responsive to local and individual patient needs [32]. As part of the Perfecting Health Care Delivery Initiative (Maggie Program) of Hunter New England Area Health Service, a qualitative study was conducted by NSW Health to investigate the concerns of patients and carers in receiving services from the health system. Top Team approach Dr David Lester-Smith, general paediatrician at the Children’s Hospital at Westmead, says while teachers may feel uncomfortable about administering medications, many doses are pre-prepared and there is minimal risk of harming the child by giving them their medication in an emergency.

These findings are confirmed by those of the present study. However, these have not been reflected in the NSW Chronic Care Program as performance goals. Rather, to ensure that the program remains truly patient focused, it was suggested that working parties refer continually to the question, “What is best for the patient?” [34]. This approach does not provide sufficient direction about how health systems can best address the needs and wants of patients. The first question is “How important is it to you to make this change, on a scale of 0 to 10 with 10 being extremely important?” This question puts the physician and patient on the same page with regard to goals. 3. “Conceptualizing Chronic Poverty”.

Furthermore, there is no clear implementation plan to achieve the goal of patient centred care in the draft program which was published in 2008. Potentially, the ACT definition of patient centredness can be used for resource allocation and goal setting to a greater degree than the NSW Chronic Care Program. Thus, policies to ameliorate health disadvantage, to close health gaps and to reduce health gradients need to be pursued together, and not at the expense of each other” [31]. This may be due to unclear definitions of patient centredness in the chronic care programs. Despite this gap, a number of patient centred outcomes have been used as measures to identify the successful implementation of strategies to evaluate various models of care in NSW [38]. She got counseling from a clinic social worker to deal with her grief. Alan and I have known each other for awhile now.

The people in these households have said to us, “if you teach us more about how to reduce the risk of diabetes, you are also teaching us things that will benefit the other people in our household as well as our friends and neighbours who also want to reduce their risk, including the risk of diabetes complications that can ultimately lead to blindness, amputations and renal failure”. We owe it to America’s patients to continue this progress, underscoring the need to maintain an ecosystem that fosters the development of tomorrow’s treatments and cures. At a state level, the concept of patient-centredness has also been identified by the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals as an essential ingredient in the reform of the NSW hospital system [39]. The report says that effective care for people with chronic illness must be based on the needs of patients rather than on the management of specific medical conditions, an approach that has been confirmed by the people we spoke to during the course of this study. I do not go out and take walks if I have a whole lot of pain in my feet” (rheumatism, 30 months after diagnosis). To put it starkly, the latest statistics show that because of Haart, HIV now no longer reduces your life expectancy, while having type 2 diabetes typically reduces it by ten years. As this paper has shown, patient centredness has been placed rhetorically at the centre of national and NSW chronic disease programs.

However, there is neither a clear definition of patient centredness nor are there clear performance goals, implementation plan, and evaluation criteria in place. Findings from this study have confirmed the importance of integrating the needs and wants of patients into chronic care programs. As HCPs have indicated, close attention can be paid to these needs and wants of patients by improving patient health literacy, improving communication with HCPs, enhancing access to information technology and addressing other communication related issues. This study has clearly identified what patients and carers want from the health system and these are similar to those identified by NSW Health [34]. These can be used to set up strategies and implementation plans with key performance areas to achieve patient centredness. These must then be translated into health system redesign features to address the unmet goal of the NSW Chronic Care Program. Ideally, this needs to be replicated in ACT and across Australia.

The finding of this study may be limited by the fact that they are based on interviews conducted in two specific locations in Australia and as a result, they may not be generalisable to other locations. The transcriber was unable to identify individual HCPs so it was not possible to ascribe comments to specific people or to recognise their organisation.

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[ Nutrition ]

BMC Health Services Research

Copyright © 2015 Sonali Kar et al. (Nov. Results: We describe diabetic foot care strategies that can be categorized within defined domains for the purpose of helping clinicians to remember them. A structured pre-tested questionnaire was administered to the outpatients of a rural health center with type 2 diabetes. The outcome variables were knowledge and practice regarding foot care. They are sores that do not heal if unattended to. The data were analysed using content analysis, descriptive statistics and inferential statistics.

Through the dialogue between primary health care and specialist health care they became more conscious and reflected on their work and this developed their competence. Of the study population, 68.5% (85/124) consisted of men. Orthopaedic foot and ankle surgeons use medical, physical and rehabilitative methods as well as surgery to treat patients of all ages. Information and communication technologies may also provide those using it with an innovative learning situation such that stimulation and learning processes are enhanced, also seen in a Spanish study with students and general influences on student learning [21]. Low education status, old age and low awareness regarding diabetes were the risk factors for poor practice of foot care. In our study the health care professionals in primary health care experienced a development of a professional wound care language which enabled them to participate in discussions with colleagues in a more confident way. Cotton socks or those made from natural fibers that breathe are better than socks made of man-made fibers.

Their increased wound assessment knowledge and skills when using telemedicine seemed to facilitate their confidence in their own skills, and they learned and grew as health care professionals. Similar findings were seen in Danish and Finnish studies [11, 24]. Diabetes mellitus (DM) is a major public health problem depicting a rising prevalence worldwide. Change in technology or using new technology impels change in practice. It has been suggested that using this new technology might lead to “tunnel vision” or becoming preoccupied with the technology [25]. Interestingly, in our study health care professionals did not report any narrowing of perspective. On the contrary, they explained that the technology helped them actually to see the patient in a more holistic way as the new technology stimulated a broader assessment of the patient’s situation.

This article was published by Michigan State University Extension. In this way, using this web based ulcer record seemed to provide them with a tool which helped them see a larger bit of the whole picture. Similar findings are reported in other studies [11, 24]. Evidence suggests that consistent patient education with prophylactic foot care for those judged to be at high risk may reduce foot ulceration and amputations. The documentation aspect in our study was seen as time consuming partly because of the double documentation they had to do. Ongoing development in the technology might reduce time spent on documentation, and this seems important to prevent frustration that may discourage the adoption of this new technology. Nevertheless, it didn’t change their enthusiasm.

This might be a result of the good quality of the telemedicine equipment and the follow-up support when using it. It was easy to learn and to use. They experienced the possibility of influencing the design of the technology application when needed, and this is in accordance with a Swedish study [25] where health care professionals reported the importance of being able to influence in the introduction of this new technology. Having equipment which is easy to learn and use, and being able to trust the technology together with a good technical support is important for health care professionals using telehealth technologies [7, 28]. As specified the assessment aimed at knowing the current foot care practices among the diabetics attending the clinic and through a detailed questionnaire also finds out the determinants of foot ulcer in this population. The participants in both health care levels experienced that the web based ulcer record functioned as a kind of guideline in wound care treatment because the web based ulcer record was specific in what to document. This led to increased quality of their written documentation.

The follow-up by specialists when using this web based ulcer record made the participants in primary health care more confident in what to document and created a positive learning spiral. Increased confidence is also noted in the literature [24]. This follow-up from specialist health care seemed to be crucial for their satisfaction and acceptance of the intervention when using telemedicine, an element that has also been noted by others [7]. It seems that the telemedicine system, and the web based ulcer record in particular, complemented their existing knowledge and supported them in decision making by giving them confidence and security in practice. This element of the positive effects of working with guidance from experts as well as obtaining support from the system has also been reported in other studies [23, 24]. The operational definition of foot ulcer for this study was taken as “a breakdown in the skin below the ankle that may extend to involve the subcutaneous tissue or even to the level of muscle or bone which is non-healing or poorly healing” [9, 10]. One could ask why the health care professionals were so enthusiastic when being introduced to telemedicine.

One of the explanations for this could be the fact that there has been little communication between primary health care and specialist health care in this context prior to the introduction of telemedicine. The lack of communication and coordination between primary health care and specialist health care in a more general sense has also been a main concern for politicians in Norway [29]. The new informal communication between health care levels when using telemedicine was valued very highly by those involved in our study. This communication made it easier to make ongoing adjustments and plans for further treatments. This form of contact between sectors was something new, predictable and believed to be ultimately very timesaving by all the health care professionals. Thus, telemedicine may be one means to bridge the gap between the primary health care and specialist health care. Housewives accounted for 56.4% (22/39) of the female study participants, unskilled workers 10.4%, and farmers, shop owners, and clerical job holders 9.6% of study participants.

Our findings highlight the need for tailoring an intervention to the context in which it will take place, and insights from the health care professionals’ experiences might help us this regard. Clearly, if telemedicine is to become more widely implemented it will be important to give practical training and education about it to all health care professionals in primary health care, not simply to a few. Our findings should be seen as a contribution to gain a better understanding on how it is for health care professionals to start using new technology in an already established working practice. The findings represent one angle of vision and cannot automatically be transferred to other settings and patient groups. Nevertheless we consider them to have potentially important implications for using telemedicine across levels of care. A strength in this study is that the participants varied in their place of work, working experience with foot ulcers, their age and their profession, thereby proving a wide variety of experiences and perspectives on the use of telemedicine. Those working in specialist health care were more experienced than those working in primary health care, but all participants were in the initial stages of using telemedicine and thereby provided useful insights to consider when launching new technology.

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[ Diabetes Solutions ]

BMC Health Services Research

Diabetic kidney disease is currently responsible for 45% of new patients reaching end-stage chronic kidney disease in New Zealand. HCUP examined trends in the rates of potentially preventable pediatric visits for asthma and diabetes, which have increased by 21 percent in recent years after seven years of decline. However, the only positive side is that we can identify some factors that put us at risk of developing this type of diabetes. There are three types of diabetes, specifically Type I diabetes, Type II diabetes, and diabetes during pregnancy which is known as gestational diabetes, with Type II diabetes being the most common and is usually a lifestyle-related disease. Bayer suggested a combination of factors leading to the overall decline in visits. During the initial 18 months of follow-up, CCHT enrollees were less likely to be admitted for a preventable hospitalization than their nonenrollee counterparts, and this difference diminished during the rest of the 4-year follow-up period. News.

It is critical to determine why individuals with IDDM in the United States have a poorer outcome. From these findings, we developed a model to understand an individual’s pathways to a PPH through immediate, precipitating, and underlying factors, which could help identify potential intervention foci. Apart from differences in the magnitude of the burdens, another important difference is the trend that each burden follows. The young — those aged 18 to 34 — and females are much more likely to be on Medicaid. Medical records or hospital assessments were used to assess previous heart attack, mechanical valve or heart rhythm problems. In 2012, treating diabetes and related health complications accounted for $245 billion in medical costs and lost work and wages. 1 show the comparison of the financial burden per target population and the total health burden of IMSS and of SHMs for 2007–2011.

Both IMSS burdens show a decreasing trend while the opposite is observed for the SHMs. Of course the idea of developing gestational diabetes is very scary. Prevention is always the best way to avoid diabetes. If you need to lose weight, the ACSM recommends 60 minutes of moderate exercise daily. In addition, it should be noted that, paradoxically, as people with diabetes live longer they become more likely to suffer diabetic complications; therefore, it is important to develop new strategies that can prevent the onset or progression of diabetic complications [27]. During recent years, IMSS has implemented a number of strategies to improve the control of chronic conditions among its beneficiaries, especially those with diabetes. Choose fresh or frozen items.

Since the absolute financial burden increased more than 8 %, there are likely to be opportunities to shift resources from expensive hospital care to more cost-effective primary care interventions; especially since the hospitalisation costs for diabetic foot and amputations are increasing, and these are avoidable with good diabetes management, specifically, with regular foot examination [1]. However, studies show that people with prediabetes can prevent these complications by returning their blood glucose levels to normal. Furthermore, it is necessary to tackle misconceptions that primary care is basic health care, health care for the poor or rural health care, among the sector of the population that still prefers hospital over primary care [29]. The fact that the total health burden decreases while both the number of preventable hospitalisations and the total financial burden increase is due to the way in which DALYs are computed. The contribution of a patient to the DALYs count of a specific condition only takes into account the first hospitalisation of the patient for the same cause over the period in order to avoid double-counting. Therefore, multiple admissions of the same patient for the same cause do not contribute to the health burden. However, every hospitalisation, whether or not it is the first or a subsequent one, represents a cost to the hospital.

This weight fluctuation is often combined with drowsiness or a general lack of energy. This analysis is subject to a limitation present in early work [2]. Since the severity of the condition for which patients were hospitalised is not recorded, and there is a lack of disability weights for different severity levels of kidney failure and retinopathy, all kidney failure and retinopathy admissions were assumed to have the same severity level: stage IV and blindness, respectively. This assumption causes an overestimation of the associated DALYs and should be taken as the upper bound of the health burden associated with preventable diabetic hospitalisations. As opposed to Lugo-Palacios and Cairns [2], by tracking multiple discharges from the same patient over the study period, the present paper avoids the double-counting of DALYs when patients are admitted more than once for the same cause throughout the period and/or if patients died in any of their hospitalisations in a given year. A second limitation is that both dimensions of the burden associated with preventable diabetic hospitalisations only consider affiliates receiving care in IMSS hospitals; however, affiliates seeking care elsewhere or not seeking care at all are not taken into account (around 30 % of IMSS affiliates seek primary care from the private sector [29]). In addition, IMSS-DRG costs do not necessarily represent what IMSS hospitals are actually spending on each treatment, but rather are used as a benchmark, and IMSS-DRG costs do not consider rural-urban nor big-small city price differentials [2].

Nevertheless, these costs are the most robust hospital cost data available for IMSS.

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[ Diabetes Type 2 ]

BMC Health Services Research

July 12, 2011 (Prague, Czech Republic) — Among patients with preexisting congestive heart failure (CHF) who started chronic maintenance renal dialysis, mortality risk was significantly higher for patients on peritoneal dialysis (PD) than for those on hemodialysis (HD). In other words, congestive heart failure doesn’t mean the heart has stopped pumping, but it does mean that the heart isn’t able to pump enough blood to supply the body’s oxygen needs. In an open uncontrolled study we investigated the effect of correcting this anaemia [haemoglobin (Hb) 9.5–11.5 g%] with subcutaneous (s.c.) erythropoietin (Epo) and intravenous (i.v.) iron (Fe) in 179 patients, 84 type II diabetics and 95 non‐diabetics, with moderate to severe CHF which was resistant to maximally tolerated doses of standard CHF medications. Otherwise, foods high in calories and carbohydrate will contribute to the presence of glucose in the bloodstream. The cardiologists and hospitalists round on patients together and make medical decisions collaboratively. The bibliographies of retrieved articles were also checked. Read the target audience, learning objectives, and author disclosures.

Angiotensin 2 increases proliferation of early erythroid progenitors but not the progenitors of other cell lines and ARB completely abolishes this effect [19]. Please refer to Additional file 1 for details of the studies included in this review. ConclusionsStress hyperglycemia with MI is associated with an increased risk of in-hospital mortality in patients with and without diabetes; the risk of CHF or cardiogenic shock is also increased in patients without diabetes. Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down. Here we describe these procedures and the data used in greater detail. However, in cases of posthepatic obstruction, hepatocytes retain their function of converting indirect bilirubin to direct bilirubin. The most common cause of CHF was IHD, and the second was hypertension.

This open approach, however, has allowed us to identify and confirm the commonly occurring concepts across various settings and sample characteristics based on a larger pool of studies. Therapy with beta-blockers should be administered cautiously in patients with diabetes or predisposed to spontaneous hypoglycemia. We discovered this following the completion of the review by comparing our search outcomes with those of a recently published review on a similar topic by Welstand [51]. Examination of the concepts described in those additional references included in Welstand et al.’s review is consistent with the core and sub-concepts identified in our review, confirming the validity and relevance of our findings. Our patients were to some extent adequately pharmacologically treated, as their cardiac filling pressure was only moderately raised, i.e., prior to randomization all patients had acutely received intravenous diuretics because of cardiac decompensation. Given the similarities in subject matter and methodology chosen by the current study and those chosen by Yu et al. Rarely, these events have involved hepatic failure with and without fatal outcome, although causality has not been established.

[51], distinctions between these studies must be made. Using an integrative or inclusive review approach Welstand and her colleagues [51] unpacked the experience of CHF under five concepts, namely: ‘Diagnosis and manifestations of heart failure’, ‘Perceptions of day-to-day life’, ‘Coping behaviours’, ‘Role of others’, and ‘Concept of self’, which is identified as an overarching concept influencing the other four. Yu et al. After extensive chart/radiographic review of each subject, five patients were excluded for an inability to confirm the diagnosis of CHF according to the Framingham criteria [12]. N Engl J Med. The earlier two studies attempted to develop some form of theoretical interpretation of the phenomenon, or discovery of a particular process that people with CHF undergo, either by using a predetermined theory of stress and coping as an analytical lens [9], or by focusing on elaboration of emerging conceptual categories and linking them to a particular process of people with CHF taking on a new identity [51]. The current study, however, has attempted to provide a wide-ranging, descriptive, and nevertheless practical, overview of what has been reported in the existing qualitative literature on the experience of people with CHF.

In doing so, and in quantifying the trends of qualitative research on the subject matter and summarising the findings under the key questions, we have elicited the most commonly reported factors that influence self care and the provision of good care, as well as the impact of CHF and coping strategies. Critique of the two earlier reviews is beyond the scope of this paper, however we are confident that our review has provided additional insights to the existing knowledge as well as some key answers that are often overlooked in the process of theorising or conceptualising the human experience.

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