Katherine Hunt

Complementary and alternative medicine use in England: results from a national survey.

Objectives:  In many countries, recent data on the use of complementary and alternative medicine (CAM) are available. However, in England, there is a paucity of such data. We sought to determine the prevalence and predictors of CAM use in England.

Rethinking the patient: Using Burden of Treatment Theory to understand the changing dynamics of illness

BackgroundIn this article we outline Burden of Treatment Theory, a new model of the relationship between sick people, their social networks, and healthcare services. Health services face the challenge of growing populations with long-term and life-limiting conditions, they have responded to this by delegating to sick people and their networks routine work aimed at managing symptoms, and at retarding – and sometimes preventing – disease progression. This is the new proactive work of patient-hood for which patients are increasingly accountable: founded on ideas about self-care, self-empowerment, and self-actualization, and on new technologies and treatment modalities which can be shifted from the clinic into the community. These place new demands on sick people, which they may experience as burdens of treatment.DiscussionAs the burdens accumulate some patients are overwhelmed, and the consequences are likely to be poor healthcare outcomes for individual patients, increasing strain on caregivers, and rising demand and costs of healthcare services. In the face of these challenges we need to better understand the resources that patients draw upon as they respond to the demands of both burdens of illness and burdens of treatment, and the ways that resources interact with healthcare utilization.SummaryBurden of Treatment Theory is oriented to understanding how capacity for action interacts with the work that stems from healthcare. Burden of Treatment Theory is a structural model that focuses on the work that patients and their networks do. It thus helps us understand variations in healthcare utilization and adherence in different healthcare settings and clinical contexts.

International study of the place of death of people with cancer: a population-level comparison of 14 countries across 4 continents using death certificate data

Background:Where people die can influence a number of indicators of the quality of dying. We aimed to describe the place of death of people with cancer and its associations with clinical, socio-demographic and healthcare supply characteristics in 14 countries.Methods:Cross-sectional study using death certificate data for all deaths from cancer (ICD-10 codes C00-C97) in 2008 in Belgium, Canada, Czech Republic, England, France, Hungary, Italy, Mexico, the Netherlands, New Zealand, South Korea, Spain (2010), USA (2007) and Wales (N=1 355 910). Multivariable logistic regression analyses evaluated factors associated with home death within countries and differences across countries.Results:Between 12% (South Korea) and 57% (Mexico) of cancer deaths occurred at home; between 26% (Netherlands, New Zealand) and 87% (South Korea) occurred in hospital. The large between-country differences in home or hospital deaths were partly explained by differences in availability of hospital- and long-term care beds and general practitioners. Haematologic rather than solid cancer (odds ratios (ORs) 1.29–3.17) and being married rather than divorced (ORs 1.17–2.54) were most consistently associated with home death across countries.Conclusions:A large country variation in the place of death can partly be explained by countries’ healthcare resources. Country-specific choices regarding the organisation of end-of-life cancer care likely explain an additional part. These findings indicate the further challenge to evaluate how different specific policies can influence place of death patterns.

Nutritional Supplements and Other Complementary Medicines for Infantile Colic: A Systematic Review

BACKGROUND: Complementary and alternative medicines often are advocated for infantile colic, yet there has been no synthesis of the evidence to inform current practice about their use. OBJECTIVE: To critically evaluate all randomized clinical trials of nutritional supplements and other complementary and alternative medicines as a treatment for infantile colic. METHODS: Five electronic databases were searched from their inception to February 2010 to identify all relevant randomized clinical trials of complementary and alternative medicines and supplements for infantile colic. Reference lists of retrieved articles were hand searched. Data were extracted by two independent reviewers, and methodological quality was assessed using the Jadad score and key aspects of the Cochrane risk of bias. RESULTS: Fifteen randomized clinical trials met the inclusion criteria and were included. Thirteen studies were placebo controlled. Eight were of good methodological quality. Eleven trials indicated a significant result in favor of complementary and alternative medicines. However, none of these randomized clinical trials were without flaws. Independent replications were missing for most modalities. CONCLUSIONS: Some encouraging results exist for fennel extract, mixed herbal tea, and sugar solutions, although it has to be stressed that all trials have major limitations. Thus, the notion that any form of complementary and alternative medicine is effective for infantile colic currently is not supported from the evidence from the included randomized clinical trials. Additional replications are needed before firm conclusions can be drawn.

End-of-life care and achieving preferences for place of death in England: Results of a population-based survey using the VOICES-SF questionnaire

Background/aim: Health policy places emphasis on enabling patients to die in their place of choice, and increasing the proportion of home deaths. In this article, we seek to explore reported preferences for place of death and experiences of care in a population-based sample of deaths from all causes. Design: Self-completion post-bereavement survey. Setting/Participants: Census of deaths registered in two health districts between October 2009 and April 2010. Views of Informal Carers – Evaluation of Services Short Form was sent to each informant (n = 1422; usually bereaved relative) 6–12 months post-bereavement. Results: Response was 33%. In all, 35.7% of respondents reported that the deceased said where they wanted to die, and 49.3% of these were reported to achieve this. Whilist 73.9% of those who were reported to have a preference cited home as the preferred place, only 13.3% of the sample died at home. Cancer patients were more likely to be reported to achieve preferences than patients with other conditions (p < .01). Being reported to have a record of preferences for place of death increased the likelihood of dying at home (odds ratio = 22.10). When rating care in the last 2 days, respondents were more likely to rate ‘excellent’ or ‘good’ for nursing care (p < .01), relief of pain (p < .01) and other symptoms (p < .01), emotional support (p < .01) and privacy of patient’s environment (p < .01) if their relative died in their preferred place. Conclusions: More work is needed to encourage people to talk about their preferences at the end of life: this should not be restricted to those known to be dying. Increasing knowledge and achievement of preferences for place of death may also improve end-of-life care.

Participant recruitment in sensitive surveys: a comparative trial of ‘opt in’ versus ‘opt out’ approaches

BackgroundAlthough in health services survey research we strive for a high response rate, this must be balanced against the need to recruit participants ethically and considerately, particularly in surveys with a sensitive nature. In survey research there are no established recommendations to guide recruitment approach and an ‘opt-in’ system that requires potential participants to request a copy of the questionnaire by returning a reply slip is frequently adopted. However, in observational research the risk to participants is lower than in clinical research and so some surveys have used an ‘opt-out’ system. The effect of this approach on response and distress is unknown. We sought to investigate this in a survey of end of life care completed by bereaved relatives.MethodsOut of a sample of 1422 bereaved relatives we assigned potential participants to one of two study groups: an ‘opt in’ group (n=711) where a letter of invitation was issued with a reply slip to request a copy of the questionnaire; or an ‘opt out’ group (n=711) where the survey questionnaire was provided alongside the invitation letter. We assessed response and distress between groups.ResultsFrom a sample of 1422, 473 participants returned questionnaires. Response was higher in the ‘opt out’ group than in the ‘opt in’ group (40% compared to 26.4%: χ2 =29.79, p-value<.01), there were no differences in distress or complaints about the survey between groups, and assignment to the ‘opt out’ group was an independent predictor of response (OR=1.84, 95% CI: 1.45-2.34). Moreover, the ‘opt in’ group were more likely to decline to participate (χ2=28.60, p-value<.01) and there was a difference in the pattern of questionnaire responses between study groups.ConclusionGiven that the ‘opt out’ method of recruitment is associated with a higher response than the ‘opt in’ method, seems to have no impact on complaints or distress about the survey, and there are differences in the patterns of responses between groups, the ‘opt out’ method could be recommended as the most efficient way to recruit into surveys, even in those with a sensitive nature.

Inflammation in aging part 1: physiology and immunological mechanisms

During the aging process, remodeling of several body systems occurs, and these changes can have a startling effect upon the immune system. The reduction in sex steroids and growth hormones and declines in vitamin D concentration that accompany the aging process are associated with increases in the baseline levels of inflammatory proteins. At the same time, inflammation arising from atherosclerosis and other chronic diseases further contributes to the inflammatory milieu and effects a state of chronic inflammation. This chronic inflammation, or ‘‘inflammaging’’ as it has been termed, seems to be associated with a host of adverse effects contributing to many of the health problems that increase morbidity and decrease both quality of life and the ability to maintain independence in old age. For nurses to be truly informed when caring for older people and to ensure that they have a detailed understanding of the complexities of older people’s health needs, they must have a knowledge of the physiological and immunological changes with age. This is the first of a two-part article on inflammatory processes in aging. These age-related changes are presented here, including an examination of the impact of genetic and lifestyle factors. The effect of these changes on the health of the individual and implications for practice are described in Part 2.

The evidence-base for complementary medicine in children: a critical overview of systematic reviews

Background The use of complementary and alternative medicine (CAM) in paediatric populations is common yet, to date, there has been no synthesis of the evidence of its effectiveness in that population. This overview of systematic review evaluates the evidence for or against the effectiveness of CAM for any childhood condition. Methods Medline, AMED and Cochrane were searched from inception until September 2009. Reference lists of retrieved articles were hand-searched. Experts in the field of CAM were contacted. No language restrictions were applied. Results 17 systematic reviews were included in this overview, covering acupuncture, chiropractic, herbal medicine, homeopathy, hypnotherapy, massage and yoga. Results were unconvincing for most conditions although there is some evidence to suggest that acupuncture may be effective for postoperative nausea and vomiting, and that hypnotherapy may be effective in reducing procedure-related pain. Most of the reviews failed to mention the incidence of adverse effects of CAMs. Conclusions Although there is some encouraging evidence for hypnosis, herbal medicine and acupuncture, there is insufficient evidence to suggest that other CAMs are effective for the treatment of childhood conditions. Many of the systematic reviews included in this overview were of low quality, as were the randomised clinical trials within those reviews, further reducing the weight of that evidence. Future research in CAM for children should conform to the reporting standards outlined in the CONSORT and PRISMA guidelines.

Living with, managing and minimising treatment burden in long term conditions: a systematic review of qualitative research.

Background ‘Treatment burden’, defined as both the workload and impact of treatment regimens on function and well-being, has been associated with poor adherence and unfavourable outcomes. Previous research focused on treatment workload but our understanding of treatment impact is limited. This research aimed to systematically review qualitative research to identify: 1) what are the treatment generated disruptions experienced by patients across all chronic conditions and treatments? 2) what strategies do patients employ to minimise these treatment generated disruptions? Methods and Findings The search strategy centred on: treatment burden and qualitative methods. Medline, CINAHL, Embase, and PsychINFO were searched electronically from inception to Dec 2013. No language limitations were set. Teams of two reviewers independently conducted paper screening, data extraction, and data analysis. Data were analysed using framework synthesis informed by Cumulative Complexity Model. Eleven papers reporting data from 294 patients, across a range of conditions, age groups and nationalities were included. Treatment burdens were experienced as a series of disruptions: biographical disruptions involved loss of freedom and independence, restriction of meaningful activities, negative emotions and stigma; relational disruptions included strained family and social relationships and feeling isolated; and, biological disruptions involved physical side-effects. Patients employed “adaptive treatment work” and “rationalised non-adherence” to minimise treatment disruptions. Rationalised non-adherence was sanctioned by health professionals at end of life; at other times it was a “secret-act” which generated feelings of guilt and impacted on family and clinical relationships. Conclusions Treatments generate negative emotions and physical side effects, strain relationships and affect identity. Patients minimise these disruptions through additional adaptive work and/or by non-adherence. This affects physical outcomes and care relationships. There is a need for clinicians to engage with patients in honest conversations about treatment disruptions and the ‘adhere-ability’ of recommended regimens. Patient-centred practice requires management plans which optimise outcomes and minimise disruptions.

Inflammation in Aging Part 2: Implications for the Health of Older People and Recommendations for Nursing Practice

Aging is accompanied by declining function and remodeling of body systems. In particular, changes to the immune and endocrine systems have far-reaching effects that cause an increase in cytokine release and decrease in anti-inflammatory feedback systems. The chronic inflammation that ensues has been named ‘‘inflammaging.’’ Inflammaging is associated with many detrimental effects that combine to increase morbidity and mortality. The sickness behavior that arises from inflammatory processes and the side effects of chronic diseases lead to a constellation of symptoms that decrease quality of life and affect the well-being of the individual. Part 2 of this two-part article provides an overview of the health effects of inflammaging, addressing the extent to which it contributes to the syndromes of frailty and disability with aging.