Cristina C. Hendrix

Effects of Nurse-Managed Protocols in the Outpatient Management of Adults With Chronic Conditions: A Systematic Review and Meta-analysis

Medical management of chronic illness consumes 75% of every health care dollar spent in the United States (1). Thus, provision of economical and accessibleyet high-qualitycare is a major concern. Diabetes mellitus, hypertension, and hyperlipidemia are prime examples of chronic diseases that cause substantial morbidity and mortality (2, 3) and require long-term medical management. For each of these disorders, most care occurs in outpatient settings where well-established clinical practice guidelines are available (47). Despite the availability of these guidelines, there are important gaps between the care recommended and the care delivered (810). The shortage of primary care clinicians has been identified as 1 barrier to the provision of comprehensive care for chronic disease (11, 12) and is an impetus to develop strategies for expanding the roles and responsibilities of other interdisciplinary team members to help meet this increasing need. The patient-centered medical home concept was developed in an effort to serve more persons and improve chronic disease care. It is a model of primary care transformation that builds on other efforts, such as the chronic care model (13), and includes the following elements: patient-centered orientation toward the whole person, team-based care coordinated across the health care system and community, enhanced access to care, and a systems-based approach to quality and safety. Care teams may include nurses, primary care providers, pharmacists, and behavioral health specialists. An organizing principle for care teams is to utilize personnel at the highest level of their skill set, which is particularly relevant given the expected increase in demand for primary care services resulting from the Patient Protection and Affordable Care Act. With this increased demand, the largest health care workforce, registered nurses (RNs), may be a valuable asset alongside other nonphysician clinicians, including physician assistants, nurse practitioners, and clinical pharmacists, to serve more persons and improve chronic disease care. Robust evidence supports the effectiveness of nurses in providing patient education about chronic disease and secondary prevention strategies (1419). With clearly defined protocols and training, nurses may also be able to order relevant diagnostic tests, adjust routine medications, and appropriately refer patients. Our purpose was to synthesize the current literature describing the effects of nurse-managed protocols, including medication adjustment, for the outpatient management of adults with common chronic conditions, namely diabetes, hypertension, and hyperlipidemia. Methods We followed a standard protocol for all steps of this review. A technical report that fully details our methods and presents results for all original research questions is available at www.hsrd.research.va.gov/publications/esp/reports.cfm. Data Sources and Searches In consultation with a master librarian, we searched MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL from 1 January 1980 through 31 January 2014 for English-language, peer-reviewed publications evaluating interventions that compared nurse-managed protocols with usual care in studies targeting adults with chronic conditions (Supplement 1). Supplement 1. Search Strategy We selected exemplary articles and used a Medical Subject Heading analyzer to identify terms for nurse protocols. We added selected free-text terms and validated search terms for randomized, controlled trials (RCTs) and quasi-experimental studies, and we searched bibliographies of exemplary studies and applicable systematic reviews for missed publications (15, 17, 2029). To assess for publication bias, we searched ClinicalTrials.gov to identify completed but unpublished studies meeting our eligibility criteria. Study Selection, Data Extraction, and Quality Assessment Two reviewers used prespecified eligibility criteria to assess all titles and abstracts (Supplement 2). Eligibility criteria included the involvement of an RN or a licensed practical nurse (LPN) functioning beyond the usual scope of practice, such as adjusting medications and conducting interventions based on a written protocol. Potentially eligible articles were retrieved for further evaluation. Disagreements on inclusion or exclusion were resolved by discussion or a third reviewer. Studies excluded at full-text review are listed in Supplement 3. Abstraction and quality assessment were done by 1 reviewer and confirmed by a second. We piloted the abstraction forms, designed specifically for this review, on a sample of included articles. Key characteristics abstracted included patient descriptors, setting, features of the intervention and comparator, match between the sample and target populations, extent of the nurse interventionists training, outcomes, and quality elements. Supplements 4 and 5 summarize quality criteria and ratings, respectively. Supplement 2. Eligibility Criteria Supplement 3. List of Excluded Studies Supplement 4. Criteria Used in Risk of Bias Assessment Supplement 5. Detailed Study Characteristics Because many studies were done outside the United States, we queried the authors of such studies about the education and scope of practice of the nurse interventionists. Authors were e-mailed a table detailing the credentialing and scope of practice of various U.S. nurses and asked to classify their nurse interventionist. Data Synthesis and Analysis The primary outcomes were the effects of nurse-managed protocols on biophysical markers (for example, glycosylated hemoglobin or hemoglobin A1c [HbA1c]), patient treatment adherence, nurse protocol adherence, adverse effects, and resource use. When quantitative synthesis (that is, meta-analysis) was feasible, dichotomous outcomes were combined using odds ratios and continuous outcomes were combined using mean differences in random-effects models. For studies with unique but conceptually similar outcomes, such as ordering a guideline-indicated laboratory test, we synthesized outcomes across conditions if intervention effects were sufficiently homogeneous. We used the Knapp and Hartung method (30, 31) to adjust the SEs of the estimated coefficients. For categories with several potential outcomes (for example, biophysical markers) that may vary across chronic conditions, we selected outcomes for each chronic condition a priori: HbA1c level for diabetes, blood pressure (BP) for hypertension, and cholesterol level for hyperlipidemia. In 1 example (32), we imputed missing SDs using estimates from similar studies. We computed summary estimates of effect and evaluated statistical heterogeneity using the Cochran Q and I 2 statistics. We did subgroup analyses to examine potential sources of heterogeneity, including where the study was conducted and intervention content. Subgroup analyses involved indirect comparisons and were subject to confounding; thus, results were interpreted cautiously. Publication bias was assessed using a ClinicalTrials.gov search and funnel plots when at least 10 studies were included in the analysis. When quantitative synthesis was not feasible, we analyzed data qualitatively. We gave more weight to evidence from higher-quality studies with more precise estimates of effect. The qualitative syntheses identified and documented patterns in efficacy and safety of the intervention across conditions and outcome categories. We analyzed potential reasons for inconsistency in treatment effects across studies by evaluating variables, such as differences in study population, intervention, comparator, and outcome definitions. We followed the approach recommended by the Agency for Healthcare Research and Quality (33) to evaluate the overall strength of the body of evidence. This approach assesses the following 4 domains: risk of bias, consistency, directness, and precision. These domains were considered qualitatively, and a summary rating of high, moderate, low, or insufficient evidence was assigned. Role of the Funding Source The Veterans Affairs Quality Enhancement Research Initiative funded the research but did not participate in the conduct of the study or the decision to submit the manuscript for publication. Results Our electronic and manual searches identified 2954 unique citations (Figure 1). Of the 23 potentially eligible studies, 4 were excluded because we could not verify whether nurses had the authority to initiate or titrate medications and the author did not respond to our query for clarification (3437). We excluded a trial of older adults in which we could not differentiate the target illnesses (38). Approximately two thirds of the authors we contacted for missing data or clarification responded. Figure 1. Summary of evidence search and selection. * Methods or follow-up articles. We included 18 unique studies (23004 patients) that focused on patients with elevated cardiovascular risk (Table) (32, 3955). Of these, 16 were RCTs and 2 were controlled before-and-after studies on diabetes (49, 53). The comparator was usual care in all but 1 study, in which a reverse-control design was used, and each intervention served as the control for the other. Eleven studies were done in Western Europe and 7 in the United States. Median age of participants was 58.3 years (range, 37.2 to 72.1 years) based on 16 studies. Approximately 47% of the participants were female. Race was not reported in 84% of the studies. Supplement 5 gives detailed study characteristics. No outstanding studies were identified through ClinicalTrials.gov. Supplement 6 provides funnel plots that assess publication bias. Table. Study and Patient Characteristics of Included Diabetes, Hypertension, and Hyperlipidemia Studies Supplement 6. Assessment of Publication Bias: Funnel Plots Overall, these studies displayed moderate risk of bias. Two studies were judged as having a high risk of bias because of inadequate randomization (44, 5

Effects of an Individualized Caregiver Training Intervention on Self-Efficacy of Cancer Caregivers

Caring for older cancer patients after hospital discharge is challenging and many of their caregivers lack confidence to do so. This study investigated the effects of an individualized caregiver training program on self-efficacy in home care and symptom management. A total of 120 patient–caregiver dyads were randomly assigned to either the treatment (n = 60) or control group (n = 60). The training focused on prevention of infection, pain control, maintenance of nutrition and adequate elimination, and specific care issues identified by the caregiver. Control group received information about community-based resources. Results revealed a significant increase in self-efficacy after the training in the treatment group but not in the control group. No intervention effect was seen on caregiver’s psychological well-being (depression, anxiety, and quality of life) and patient’s physical symptoms.

Palliative Sedation in End-of-Life Care

The goals for care at the end of life include relief of pain and suffering. Despite excellent palliative care, some patients continue to experience intolerable, unrelieved pain and suffering from refractory symptoms. Palliative sedation, although controversial, is an accepted option for relieving pain and suffering at the end of life and can spark a great deal of emotion and debate for all involved. Hospice and palliative care nurses play a critical role in symptom management at the end of life and need to have a basic understanding of the principles of palliative sedation. Nurses must continue to advocate for their patients and provide education to other members of the healthcare team who are less knowledgeable about palliative sedation. This article explores these principles and some of the challenges associated with providing palliative sedation.

A pilot study on the influence of an individualized and experiential training on cancer caregiver's self-efficacy in home care and symptom management.

The aim of this pilot study was to investigate if an individualized and experiential training can promote family caregivers confidence (self-efficacy) in home care and symptom management. The study was conducted in a hematology/oncology unit in a southeastern regional medical center. Twenty informal cancer caregivers participated in the study. The individualized and experiential training was conducted at the bedside prior to patients hospital discharge. Self-efficacy in home care and cancer symptom management was measured using the Cancer Caregiver Self-Efficacy Measure before and after training, and at 1 week after hospital discharge of cancer patients. Results of the study showed mean Cancer Caregiver Self-Efficacy Measure increased by 41.1 points immediately after the training (z = 4.49, p < 0.001) and was 31.7 points higher at 1-week follow-up (z = 3.22, p < 0.01). The findings of this study suggest that individualized and experiential training may be another avenue for nurses, including home care nurses, to support family home caregiving. By helping family members in home care, favorable patient outcomes may be achieved, enabling older patients with cancer to stay longer in the comfort of their homes.

Clinical trial recruitment challenges with older adults with cancer.

Older adults continue to be disproportionately represented in research studies and cancer-related clinical trials. As survival rates for patients with cancer continue to increase, it is critical that we begin to gather data on how to provide the best care to the patient population where cancer is most prevalent. The purpose of this article was to provide an overview of barriers encountered during recruitment to clinical trials of older patients with cancer. Two clinical trials involving older patients with cancer are presented to describe strategies used by the principal investigators to enhance recruitment and enrollment to their clinical research trials. These two exemplars suggest that planning and regular meetings by the research team and transparent communication are essential for successful clinical trial recruitment of older patients with cancer.

Chronic care management for the elderly: an opportunity for gerontological nurse practitioners.

Purpose To discuss the role that gerontological nurse practitioners (GNPs) may play in providing chronic care management for the elderly. Data sources Review of recent literature on chronic care management, personal experience of the authors in caring for older adults under the chronic care management model, and a case study. Conclusions GNPs are the most appropriate practitioners to provide and coordinate chronic care management to the population that needs it most—the elderly. Implications for practice Demographic shifts in the United States have increased the number of people with chronic illnesses; however, the nations healthcare delivery system has not significantly evolved to meet the changing needs of its population. As a result, many people, especially older adults, suffer needlessly, and healthcare costs continue to rise. Chronic care management may alleviate older adults’ chronic health problems, reduce expenditures for their health care, and promote their satisfaction and quality of life.

The Duke-NICHE program: an academic-practice collaboration to enhance geriatric nursing care.

The Duke-Nurses Improving Care of Healthsystem Elders (NICHE) is an example of an academic-practice partnership between a university-based school of nursing and a health system that aims to improve care of older adults by simultaneously enhancing the expertise of frontline nursing staff, accelerating the implementation of evidence-based care approaches, and generating scientific knowledge at the point of care. This article describes the processes used to develop the partnership, and reports initial outcomes and lessons learned. Although challenging to develop and sustain, academic-health system partnerships hold potential to improve care through both improved implementation of evidence and stimulating new research at the point of care.

Informal caregiver training on home care and cancer symptom management prior to hospital discharge : A feasibility study

PURPOSE/OBJECTIVES To determine the feasibility of individualized caregiver training for home care and symptom management conducted at the bedside of older patients with cancer prior to hospital discharge. DESIGN Pilot study. SETTING The Extended Care Rehabilitation Center at the Durham Veterans Affairs Medical Center in North Carolina. SAMPLE 7 female informal caregivers with a mean age of 56 (range = 26-76). More than half were African American. Most commonly, caregivers were spouses of the patients with cancer. METHODS Individualized and experiential training on home care and cancer symptom management was conducted at the bedside of patients before hospital discharge. Caregiver demographic data were collected. An informal interview at the end of the training asked about the usefulness of the training in preparing for home caregiving. MAIN RESEARCH VARIABLES Feasibility of the training. FINDINGS Individualized bedside training to caregivers prior to hospital discharge is feasible. All caregivers noted the relevance of the content as well as the approach to the training. CONCLUSIONS When given an opportunity for training on symptom management and home care, informal caregivers were very interested in participating. The individualized approach gave caregivers an opportunity to have their particular needs met. The flexibility of when to conduct the training proved to be crucial when soliciting attendance. The biggest challenge was in recruiting caregiver subjects through patients with cancer. IMPLICATIONS FOR NURSING The impetus now is to look at the effects of the training on caregiver-patient variables as well as the cost-effectiveness and sustainability of such an approach to caregiver training.

Management of patients with Parkinson disease.

Patients with Parkinson disease have prolonged motor and nonmotor symptoms affecting their ability to perform activities of daily living. Providers are tasked not only to provide quality care to afflicted patients but also to offer assistance to their informal caregivers who play a critical supportive role along the illness trajectory.

Transitional Care Partners: A hospital-to-home support for older adults and their caregivers

Purpose: To describe the development, implementation, and preliminary results of the Transitional Care (TLC) Partners, a clinical demonstration program that supports the transition from hospital to home of older veterans. Data sources: Hospital records of TLC patients to track their hospital and emergency department visits before and after the TLC Partners enrollment. Caregivers of patients completed Preparedness in Caregiving and the Short Form Zarit Burden Scale during the first week of the TLC Partners enrollment and on the week when the services ended. Conclusions: The proportion of patients with one or more emergency department visits and rehospitalization is consistently lower among TLC patients compared to non‐TLC patients at 30 and 60 days of hospital discharge. The mean preparedness and burden scores before and after the program essentially remained the same. Implications for practice: The description of the implementation of the TLC Partners offers an example of how nurse practitioner‐led interprofessional care models can be adapted to the needs of specific healthcare systems, and how they can be monitored to evaluate their reach, effectiveness, and fidelity to the core components of proved care models.