John E. Holman

Effectiveness of home telehealth in comorbid diabetes and hypertension: a randomized, controlled trial.

BACKGROUND Increased emphasis is being placed on the critical need to control hypertension (HTN) in patients with diabetes. OBJECTIVE The objective of this study was to evaluate the efficacy of a nurse-managed home telehealth intervention to improve outcomes in veterans with comorbid diabetes and HTN. DESIGN A single-center, randomized, controlled clinical trial design comparing two remote monitoring intensity levels and usual care in patients with type 2 diabetes and HTN being treated in primary care was used. MEASUREMENTS Primary outcomes were hemoglobin A1c and systolic blood pressure (SBP); secondary outcome was adherence. RESULTS Intervention subjects experienced decreased A1c during the 6-month intervention period compared with the control group, but 6 months after the intervention was withdrawn, the intervention groups were comparable with the control group. For SBP, the high-intensity subjects had a significant decrease in SBP compared with the other groups at 6 months and this pattern was maintained at 12 months. Adherence improved over time for all groups, but there were no differences among the three groups. LIMITATIONS Subjects had relatively good baseline control for A1c and SBP; minorities and women were underrepresented. CONCLUSIONS Home telehealth provides an innovative and pragmatic approach to enhance earlier detection of key clinical symptoms requiring intervention. Transmission of education and advice to the patient on an ongoing basis with close surveillance by nurses can improve clinical outcomes in patients with comorbid chronic illness.

Outcomes of a Home Telehealth Intervention for Patients with Diabetes and Hypertension

BACKGROUND Home telehealth programs often focus on a single disease, yet many patients who need monitoring have multiple conditions. This study evaluated secondary outcomes from a clinical trial evaluating the efficacy of home telehealth to improve outcomes of patients with co-morbid diabetes and hypertension. SUBJECTS AND METHODS A single-center randomized controlled clinical trial compared two remote monitoring intensity levels (low and high) and usual care in patients with type 2 diabetes and hypertension being treated in primary care. Secondary outcomes assessed were knowledge (diabetes, hypertension, medications), self-efficacy, adherence (diabetes, medications), and patient perceptions of the intervention mode. RESULTS Knowledge scores improved in the high-intensity intervention group participants, but upon further analysis, we found the intervention effect was not mediated by gain in knowledge. No significant differences were found across the groups in self-efficacy, adherence, or patient perceptions of the intervention mode. CONCLUSIONS Home telehealth can enhance detection of key clinical symptoms that occur between regular physician visits. While our intervention improved glycemic and blood pressure control, the mechanism of the effect for this improvement was not clear.

Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions

BackgroundThe US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians’ (EPs) and nurses’ (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A’s framework (Ask-Advise-Assess-Assist-Arrange) in the ED.MethodsWe conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts.ResultsThe main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients’ receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A’s in the ED.ConclusionsThere are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies.Trial registrationClinicalTrials.gov registration number NCT00756704

The Emergency Department Action in Smoking Cessation (EDASC) Trial: Impact on Cessation Outcomes

INTRODUCTION The focus on acute care, time pressure, and lack of resources hamper the implementation of smoking cessation guidelines in the emergency department (ED). The purpose of this study was to determine whether an emergency nurse- initiated intervention based on the 5As (Ask-Advise-Assess-Assist-Arrange) framework improves quit rates. METHODS We conducted a pre-post implementation trial in 789 adult smokers who presented to two EDs in Iowa between August 13, 2008 and August 4, 2010. The intervention focused on improving delivery of the 5As by ED nurses and physicians using academic detailing, charting/reminder tools, and group feedback. Performance of ED cessation counseling was measured using a 5As composite score (ranging from 0 to 5). Smoking status was assessed by telephone interview at 3- and 6-month follow-up (with biochemical confirmation in those participants who reported abstinence at 6-month follow-up). RESULTS Based on data from 650 smokers who completed the post-ED interview, there was a significant improvement in the mean 5As composite score for emergency nurses during the intervention period at both hospitals combined (1.51 vs. 0.88, difference = 0.63, 95% confidence interval [CI] [0.41, 0.85]). At 6-month follow-up, 7-day point prevalence abstinence (PPA) was 6.8 and 5.1% in intervention and preintervention periods, respectively (adjusted odds ratio [OR] = 1.7, 95% CI [0.99, 2.9]). CONCLUSIONS It is feasible to improve the delivery of brief smoking cessation counseling by ED staff. The observed improvements in performance of cessation counseling, however, did not translate into statistically significant improvements in cessation rates. Further improvements in the effectiveness of ED cessation interventions are needed.

Patient perceptions of a remote monitoring intervention for chronic disease management.

Use of telecommunications technology to provide remote monitoring for people with chronic disease is becoming increasingly accepted as a means to improve patient outcomes and reduce resource use. The purpose of this project was to evaluate patient perceptions of a nurse-managed remote monitoring intervention to improve outcomes in veterans with comorbid diabetes and hypertension. Postintervention evaluation data were collected using a 12-item questionnaire and an open-ended question. Participants rated the program as generally positive on the questionnaire, but responses to the open-ended question revealed criticisms and suggestions for improvement not captured on the questionnaire. Interviewing participants in these programs may offer richer data for identifying areas for program improvement.

MALES WITH EATING DISORDERS: CHALLENGES FOR TREATMENT AND RESEARCH

Males represent only 10 percent of eating disorder cases. This gender discrepancy is among the most extreme in psychiatry and medicine. Determining what differences in etiology and mechanism best explain the discrepancy presents an intellectual challenge. Beginning at about the third grade, boys and girls diverge in social development. Boys show significantly less desire to lose weight, express dissatisfaction with the upper rather than the lower body, and use dieting to achieve specific external goals rather than as a cultural norm. Males reach a significantly higher body mass index (BMI) than females do before they beginning dieting. (27.2 versus 24.3, p < .01). While overall treatment principles are similar, males in treatment require attainment of a different hormonal milieu (testosterone), attention to past and future sexual role, amelioration of perception of stigma, and preparation for return to male social roles. Males and females suffer comparable degrees of osteopenia and brain shrinkage during anorexia nervosa. The effectiveness of antidepressants in males with eating disorders (compared with that in females) has not been well studied. Male gender is not an adverse factor in short-term or long-term treatment outcome. Understanding the lower frequency of these illnesses in males may lead to more effective means of protecting girls from eating disorders and from the culturally induced distress about normal body size and shape that burdens adolescent development and adult life.

Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial

PURPOSE To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers. DESIGN Pre-post quasi-experimental trial. SETTING General medical units of four US Department of Veterans Affairs hospitals. SUBJECTS 898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively). INTERVENTION The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback. MEASURES The primary outcome was self-reported 7-day point prevalence abstinence at six months. ANALYSIS Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression. RESULTS Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI95)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI95=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001). CONCLUSIONS Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.