Carolyn T. Thorpe

Facilitating Healthy Coping in Patients with Diabetes: A Systematic Review

Purpose The purpose of this study is to summarize recent literature on approaches to supporting healthy coping in diabetes in 2 specific areas: (1) the impact of different approaches to diabetes treatment on healthy coping and (2) the effectiveness of interventions specifically designed to support healthy coping. Methods A PubMed search identified 129 articles published August 1, 2006, to April 30, 2011, addressing diabetes in relation to emotion, quality of life, depression, adjustment, anxiety, coping, family therapy, behavior therapy, psychotherapy, problem solving, couples therapy, or marital therapy. Results Evidence suggests that treatment choice may significantly influence quality of life, with treatment intensification in response to poor metabolic control often improving quality of life. The recent literature provides support for a variety of healthy coping interventions in diverse populations, including diabetes self-management education, support groups, problem-solving approaches, and coping skills interventions for improving a range of outcomes; cognitive behavior therapy and collaborative care for treating depression; and family therapy for improving coping in youths. Conclusions Healthy coping in diabetes has received substantial attention in the past 5 years. A variety of approaches show positive results. Research is needed to compare the effectiveness of different approaches in different populations and determine how to overcome barriers to intervention dissemination and implementation.

Improving the measurement of self-reported medication nonadherence

OBJECTIVEnMedication nonadherence is a significant clinical problem in chronic disease management. Self-report measures have inadequate reliability and poor distributional properties. We demonstrate how two fundamental measurement issues have limited the usefulness of self-reported medication nonadherence measures and offer recommendations for improving measurement.nnnSTUDY DESIGN AND METHODSnWe reviewed existing self-report measures of medication nonadherence in the context of hypertension, one of the most common chronic conditions in which medication nonadherence is a paramount concern. We evaluated these measures with regard to two issues: (1) conflation of causal indicators (which give rise to a latent construct) and effect indicators (which are determined by a latent construct), and (2) a lack of evidence regarding the stability of nonadherence over time.nnnRESULTSnNonadherence measurement could be improved by using effect indicators to assess the extent of nonadherence and causal indicators to assess reasons for nonadherence. Moreover, nonadherence should be assessed longitudinally, so that recent developments in statistical modeling can illuminate the extent to which medication nonadherence is transient vs. stable.nnnCONCLUSIONnAttention to these measurement issues can improve the assessment of self-reported nonadherence, thereby allowing more accurate conclusions to be drawn about medication-taking behavior and informing the development of improved interventions that target medication nonadherence.

Medication acquisition and self-reported adherence in veterans with hypertension.

Objectives:To examine factors associated with oversupply and undersupply of antihypertensive medication, and examine evidence for medication acquisition as distinct from self-reported adherence. Research Design:Analysis of pharmacy refill records, medical charts, and in-person interviews. Subjects:Five hundred sixty-two male veterans with hypertension enrolled in a randomized controlled trial to improve BP control. Measures:Patients were classified as having undersupply (<0.80), appropriate supply (≥0.80 and ≤1.20), or oversupply (>1.20) of antihypertensive medication in the 90 days before trial enrollment based on the ReComp algorithm. Determination of BP control was based on clinic measurements at enrollment. Demographic, clinical, psychosocial, and behavioral factors relevant to medication-taking behavior and BP were assessed at enrollment. Results:Twenty-three percent of the patients had undersupply, 47% had appropriate supply, and 30% had oversupply of antihypertensive medication. Multinomial logistic regression revealed that using fewer classes of antihypertensive medications and greater perceived adherence barriers were independently associated with greater likelihood of undersupply. Current employment was associated with decreased likelihood of oversupply, and greater comorbidity and being married were associated with increased likelihood of oversupply. Agreement between ReComp and self-reported adherence was poor (&kgr; = 0.19, P < 0.001). Undersupply, oversupply, and self-reported nonadherence were all independently associated with decreased likelihood of BP control after adjusting for each other and patient factors. Conclusions:Antihypertensive oversupply was common and may arise from different circumstances than undersupply. Measures of medication acquisition and self-reported adherence appear to provide distinct, complementary information about patients medication-taking behavior.

Hypertension Improvement Project (HIP) Latino: results of a pilot study of lifestyle intervention for lowering blood pressure in Latino adults

Objectives. To assess the feasibility of a culturally tailored behavioral intervention for improving hypertension-related health behaviors in Hispanic/Latino adults. Design. Feasibility pilot study in a community health center and a Latino organization in Durham, North Carolina. Intervention. The culturally adapted behavioral intervention consisted of six weekly group sessions incorporating motivational interviewing techniques. Goals included weight loss if overweight, adoption of the Dietary Approaches to Stop Hypertension dietary pattern, and increased physical activity. Participants were also encouraged to monitor their daily intake of fruits, vegetables, dairy and fat, and to record physical activity. Cultural adaptations included conducting the study in familiar places, using Spanish-speaking interventionist, culturally appropriate food choices, and physical activity. Main outcomes. Systolic blood pressure (BP), weight, body mass index (BMI), exercise, and dietary pattern were measured at baseline and at 6 weeks follow-up. Qualitative evaluations of the recruitment process and the intervention were also conducted. Results. There were 64 potential participants identified via healthcare provider referrals (33%), printed media (23%), and direct contact (44%). Seventeen participants completed the intervention and had main outcome data available. Participants ‘strongly agreed/agreed’ that the group sessions provided them with the tools they needed to achieve weight loss, BP control, and the possibility of sustaining the lifestyle changes after completing the intervention. At the end of the intervention, all physiological, diet, and exercise outcomes were more favorable, with the exception of fat. After 6 weeks, systolic BP decreased an average of −10.4±10.6 mmHg, weight decreased 1.5±3.2 lbs, BMI decreased 0.3±0.5, and physical activity increased 40 minutes per week. Conclusion. Our findings suggest that lifestyle interventions for preventing and treating hypertension are feasible and potentially effective in the Hispanic/Latino population.

Health-related quality of life for patients with vasculitis and their spouses

OBJECTIVEnChronic disease affects both patients and spouses, yet the effect of vasculitis on the spouses of patients has not been systematically examined. We addressed this research gap by describing 8 dimensions of health-related quality of life (HRQOL) for antineutrophil cytoplasmic antibody-associated vasculitis (AAV) patients and their spouses and compared patients and spouses with norms for the general US population. We also determined whether the impact of AAV on HRQOL differs by sex for patients or their spouses.nnnMETHODSnNinety-seven patients with AAV and their spouses completed a mailed questionnaire that included demographic information and a measure of HRQOL (Medical Outcomes Study Short Form 36.) Using the RAND method, we calculated 8 HRQOL dimensions: general health, physical functioning, emotional role limitations, physical role limitations, social functioning, mental health, bodily pain, and energy/vitality. Using norm-based scores, we compared the HRQOL of patients and spouses with the general US population. We then used multivariate analysis of covariance (MANCOVA) test for sex differences in HRQOL for patients and spouses.nnnRESULTSnPatients with AAV scored lower than the US norm on all HRQOL subscales with the exception of bodily pain. In contrast, spouses scored similarly to national norms. When age, education, race, illness duration, and disease severity were controlled, there were no significant sex differences in HRQOL for patients or spouses.nnnCONCLUSIONnAAV negatively impacts HRQOL for patients; whereas, spouses do not appear to be as negatively impacted. Long-term marriages may attenuate the effect of sex on HRQOL. Quality of life should be assessed throughout the disease course for both patients and spouses.

Receipt of Monitoring of Diabetes Mellitus in Older Adults with Comorbid Dementia

To examine the extent to which receipt of recommended monitoring of diabetes mellitus (DM) differed for participants with and without comorbid dementia, as well as the effect of other comorbidities on monitoring of DM in individuals with comorbid dementia.

Provider Characteristics, Clinical-Work Processes and Their Relationship to Discharge Summary Quality for Sub-Acute Care Patients

ABSTRACTBACKGROUNDDischarge summaries play a pivotal role in the transitional care of patients discharged to sub-acute care facilities, but the best ways to facilitate document completeness/quality remain unknown.OBJECTIVETo examine the relationship among clinical-work processes, provider characteristics, and discharge summary content to identify approaches that promote high-quality discharge documentation.DESIGNRetrospective cohort study.SUBJECTSAll hip fracture and stroke patients discharged to sub-acute care facilities during 2003–2005 from a large Midwestern academic medical center (Nu2009=u2009489). Patients on hospice/comfort care were excluded.MAIN MEASURESWe abstracted 32 expert-recommended components in four categories (‘patient’s medical course,’ ‘functional/cognitive ability at discharge,’ ‘future plan of care,’ and ‘name/contact information’) from the discharge summaries of sample patients. We examined predictors for the number of included components within each category using Poisson regression models. Predictors included work processes (document completion in relation to discharge day; completion time of day) and provider characteristics (training year; specialty).KEY RESULTSHistorical components (i.e., ‘patient’s medical course’ category) were included more often than components that directly inform the admission orders in the sub-acute care facility (i.e., ‘future plan of care’). In this latter category, most summaries included a discharge medication list (99%), disposition (90%), and instructions for follow-up (91%), but less frequently included diet (68%), activity instructions (58%), therapy orders (56%), prognosis/diagnosis communication to patient/family (15%), code status (7%), and pending studies (6%). ‘Future plan of care’ components were more likely to be omitted if a discharge summary was created >24 h after discharge (incident rate ratiou2009=u20090.91, 95% confidence intervalu2009=u20090.84–0.98) or if an intern created the summary (0.90, 0.83–0.97).CONCLUSIONCritical component omissions in discharge summaries were common, and were associated with delayed document creation and less experienced providers. More research is needed to understand the impact of discharge documentation quality on patient/system outcomes.

Patterns of perceived barriers to medical care in older adults: a latent class analysis

BackgroundThis study examined multiple dimensions of healthcare access in order to develop a typology of perceived barriers to healthcare access in community-dwelling elderly. Secondary aims were to define distinct classes of older adults with similar perceived healthcare access barriers and to examine predictors of class membership to identify risk factors for poor healthcare access.MethodsA sample of 5,465 community-dwelling elderly was drawn from the 2004 wave of the Wisconsin Longitudinal Study. Perceived barriers to healthcare access were measured using items from the Group Health Association of America Consumer Satisfaction Survey. We used latent class analysis to assess the constellation of items measuring perceived barriers in access and multinomial logistic regression to estimate how risk factors affected the probability of membership in the latent barrier classes.ResultsLatent class analysis identified four classes of older adults. Class 1 (75% of sample) consisted of individuals with an overall low level of risk for perceived access problems (No Barriers). Class 2 (5%) perceived problems with the availability/accessibility of healthcare providers such as specialists or mental health providers (Availability/Accessibility Barriers). Class 3 (18%) perceived problems with how well their providers operations arise organized to accommodate their needs and preferences (Accommodation Barriers). Class 4 (2%) perceived problems with all dimension of access (Severe Barriers). Results also revealed that healthcare affordability is a problem shared by members of all three barrier groups, suggesting that older adults with perceived barriers tend to face multiple, co-occurring problems. Compared to those classified into the No Barriers group, those in the Severe Barrier class were more likely to live in a rural county, have no health insurance, have depressive symptomatology, and speech limitations. Those classified into the Availability/Accessibility Barriers group were more likely to live in rural and micropolitan counties, have depressive symptomatology, more chronic conditions, and hearing limitations. Those in the Accommodation group were more likely to have depressive symptomatology and cognitive limitations.ConclusionsThe current study identified a typology of perceived barriers in healthcare access in older adults. The identified risk factors for membership in perceived barrier classes could potentially assist healthcare organizations and providers with targeting polices and interventions designed to improve access in their most vulnerable older adult populations, particularly those in rural areas, with functional disabilities, or in poor mental health.

Rural-urban differences in preventable hospitalizations among community-dwelling veterans with dementia

CONTEXTnAlzheimers patients living in rural communities may face significant barriers to effective outpatient medical care.nnnPURPOSEnWe sought to examine rural-urban differences in risk for ambulatory care sensitive hospitalizations (ACSH), an indicator of access to outpatient care, in community-dwelling veterans with dementia.nnnMETHODSnMedicare and Veteran Affairs inpatient claims for 1,186 US veterans with dementia were linked to survey data from the 1998 National Longitudinal Caregiver Survey. ACSH were identified in inpatient claims over a 1-year period following collection of independent variables. Urban Influence Codes were used to classify care recipients into 4 categories of increasing county-level rurality: large metropolitan; small metropolitan; micropolitan; and noncore rural counties. We used the Andersen Behavioral Model of Health Services to identify veteran, caregiver, and community factors that may explain urban-rural differences in ACSH.nnnFINDINGSnThirteen percent of care recipients had at least 1 ACSH. The likelihood of an ACSH was greater for patients in noncore rural counties versus large metropolitan areas (22.6% vs 12.8%, unadjusted odds ratio [OR]= 1.99; P < .01). The addition of other Andersen behavioral model variables did not eliminate the disparity (adjusted OR = 1.97; P < .05).nnnCONCLUSIONSnWe found that dementia patients living in the most rural counties were more likely to have an ACSH; this disparity was not explained by differences in caregiver, care recipient, or community factors. Furthermore, the annual rate of ACSH was higher in community-dwelling dementia patients compared to previous reports on the general older adult population. Dementia patients in rural areas may face particular challenges in receiving timely, effective ambulatory care.

Preventive service gains from first contact access in the primary care home.

Background:The patient-centered medical home (PCMH) concept recently has garnered national attention as a means of improving the quality of primary care. Preventive services are one area in which the use of a PCMH is hoped to achieve gains, though there has been limited exploration of PCMH characteristics that can assist with practice redesign. The purpose of this study was to examine whether first-contact access characteristics of a medical home (eg, availability of appointments or advice by telephone) confer additional benefit in the receipt of preventive services for individuals who already have a longitudinal relationship with a primary care physician at a site of care. Methods:This was a secondary analysis examining data from 5507 insured adults with a usual physician who participated in the 2003 to 2006 round of the Wisconsin Longitudinal Study. Using logistic regression, we calculated the odds of receiving each preventive service, comparing individuals who had first-contact access with those without first-contact access. Results:Eighteen percent of the sample received care with first-contact access. In multivariable analyses, after adjustment, individuals who had first-contact access had higher odds of having received a prostate examination (odds ratio [OR], 1.62; 95% CI, 1.20–2.18), a flu shot (OR, 1.36; 95% CI, 1.01–1.82), and a cholesterol test (OR, 1.36; 95% CI, 1.01–1.82) during the past year. There was no significant difference in receipt of mammograms (OR, 1.23; 95% CI, 0.94–1.61). Conclusions:In the primary care home, first-contact accessibility adds benefit, beyond continuity of care with a physician, in improving receipt of preventive services. Amid increasing primary care demands and finite resources available to translate the PCMH into clinic settings, there is a need for further studies of the interplay between specific PCMH principles and how they perform in practice.