Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?

BACKGROUND: Heart failure is a common and costly condition, particularly in the elderly. A range of models of interventions have shown the capacity to decrease hospitalizations and improve health-related outcomes. Potentially, cardiac rehabilitation models can also improve outcomes. AIM: To assess the impact of a nurse-coordinated multidisciplinary, cardiac rehabilitation program to decrease hospitalizations, increase functional capacity, and meet the needs of patients with heart failure. METHOD: In a randomized control trial, a total of 105 patients were recruited to the study. Patients in the intervention group received an individualized, multidisciplinary 12-week cardiac rehabilitation program, including an individualized exercise component tailored to functional ability and social circumstances. The control group received an information session provided by the cardiac rehabilitation coordinator and then follow-up care by either their cardiologist or general practitioner. This trial was stopped prematurely after the release of state-based guidelines and funding for heart failure programs. RESULTS: During the study period, patients in the intervention group were less likely to have been admitted to hospital for any cause (44 vs. 69%, P = 0.01) or after a major acute coronary event (24 vs. 55%, P = 0.001). Participants in the intervention group were more likely to be alive at 12 months, (93 vs. 79%; P = 0.03) (odds ratio = 3.85; 95% confidence interval=1.03-14.42; P = 0.0042). Quality of life scores improved at 3 months compared with baseline (intervention t = o/-4.37, P<0.0001; control t = /-3.52, P<0.01). Improvement was also seen in 6-min walk times at 3 months compared with baseline in the intervention group (t = 3.40; P = 0.01). CONCLUSION: This study shows that a multidisciplinary heart failure cardiac rehabilitation program, including an individualized exercise component, coordinated by a specialist heart failure nurse can substantially reduce both all-cause and cardiovascular readmission rates, improve functional status at 3 months and exercise tolerance.

Factors associated with civilian mortality in Australian Vietnam veterans three decades after the war.

A prospective cohort study of a random sample of 1,000 Australian Army Vietnam veterans analyzed risk factors for postwar mortality using information from Army records and personal interview assessments of physical and mental health measured approximately 15 years earlier. This enabled examination of the role of combat, military service, and psychiatric status including post-traumatic stress disorder (PTSD) on postwar civilian mortality. Factors predicting mortality were identified using multivariate statistical methods including logistic and Cox regression. Mortality was associated principally with age, enlistment route (regular vs. national service conscripts), and conduct while in service in the whole cohort. Additional analysis using interview data revealed that mortality was predicted by age, smoking status, chronic diabetes, bronchitis and blood diseases, and treatment for cancer and heart disease. Psychiatric status including PTSD diagnosis was not associated with mortality. Veterans' mortality risk may be reduced by attention to smoking and alcohol both in-service and postservice.

Improving patient emotional functioning and psychological morbidity: evaluation of a consultation skills training program for oncologists.

OBJECTIVE: To evaluate whether a consultation skills training (CST) program with oncologists and trainees would improve skills in detecting and responding to patient distress, thereby improving their patients' emotional functioning and reducing psychological distress. METHODS: Randomized-controlled trial with 29 medical and radiation oncologists from Australia randomized to CST group (n=15) or usual-care group (n=14). The CST consisted of a 1.5-day face-to-face workshop incorporating presentation of principles, a DVD modelling ideal behaviour and role-play practice, and four 1.5h monthly video-conferences. At the CST conclusion, patients of participating doctors were recruited (n=192 in CST group, n=183 in usual-care group), completing telephone surveys at baseline, 1 week and 3 months to assess quality of life, anxiety, depression and unmet psychosocial needs. RESULTS: Despite high patient functioning at baseline, anxiety significantly improved at 1-week follow-up in the CST group, compared to the control group. There were no statistically significant differences in emotional functioning, depression or unmet supportive care need between the groups. CONCLUSION: Consistent trends for greater improvements were observed in intervention compared to control group patients, suggesting the CST program deserves wider evaluation. PRACTICE IMPLICATIONS: Video-conferencing after a short training course may be an effective strategy for delivering CST.

The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder.

The long-term health consequences of war service remain unclear, despite burgeoning scientific interest. A longitudinal cohort study of a random sample of Australian Vietnam veterans was designed to assess veterans' postwar physical and mental health 36 years after the war (2005-2006) and to examine its relation to Army service, combat, and post-traumatic stress disorder (PTSD) assessed 14 years previously (1990-1993). Prevalences in veterans (n = 450) were compared with those in the Australian general population. Veterans' Army service and data from the first assessments were evaluated using multivariate logistic regression prediction modeling. Veterans' general health and some health risk factors were poorer and medical consultation rates were higher than Australian population expectations. Of 67 long-term conditions, the prevalences of 47 were higher and the prevalences of 4 were lower when compared with population expectations. Half of all veterans took some form of medication for mental well-being. The prevalence of psychiatric diagnoses exceeded Australian population expectations. Military and war service characteristics and age were the most frequent predictors of physical health endpoints, while PTSD was most strongly associated with psychiatric diagnoses. Draftees had better physical health than regular enlistees but no better mental health. Army service and war-related PTSD are associated with risk of illness in later life among Australian Vietnam veterans.

Unmet needs following hospitalization with heart failure: implications for clinical assessment and program planning.

BACKGROUND: Measuring health status is increasingly important in both clinical practice and research. The Heart Failure Needs Assessment Questionnaire (HFNAQ) is a self-administered, disease-specific, 30-item questionnaire that measures an individual's perception of his/her needs in the physical, psychological, social, and spiritual domains. OBJECTIVES: To assess the prevalence of needs in patients with heart failure (HF) recently discharged from hospital. METHODS: The HFNAQ was administered to participants (n = 132; mean [SD] age, 72.3 [9.69] years; 63% male) consenting to attend an HF-specific cardiac rehabilitation program. RESULTS: The total mean HFNAQ score was 67.3 (95% confidence interval, 65.03-69.75), indicating an average level of need around the midrange of the scale. In this vulnerable postdischarge phase, there was evidence of predominance of psychological and social concerns over physical needs. None of the variables that were examined for associations with the measures of needs reached statistical significance, highlighting the strongly individualized perception of need. CONCLUSIONS: Higher levels of unmet needs in the psychological and social domains, compared with physical needs, identify psychosocial care as an important consideration for nursing interventions for people with HF. This study further demonstrates the importance of assessing the needs from the perspective of the individual to ascertain each person's unique perspective of the HF illness experience. Study findings further underscore the importance of individualized care planning for patients with HF after discharge from hospital to address their unique needs and circumstances.

Prevalence of self-reported risk factors for medication misadventure among older people in general practice.

OBJECTIVE: To describe the prevalence of risk factors for medication misadventures among older people in general practice. DESIGN: Descriptive cross-sectional analysis. SETTING: General practices, New South Wales, Australia. PARTICIPANTS: Twenty general practitioners in 16 practices recruited 849 practice attendees aged 65 years and over. OUTCOME MEASURE: Risk factors for medication misadventures. RESULTS: Almost all participants (95%) had used at least one medication for more than 6 months. More than half of the participants had more than one doctor involved in their care (59%), had three or more health conditions (57%), or used five or more medicines (54%). With regard to potential adverse drug reactions, in the last month 39% of participants experienced difficulties sleeping, one-third felt drowsy or dizzy (34%), and about a quarter had a skin rash (28%), leaked urine (27%), had stomach problems (22%) or had been constipated (22%). The most common compliance problems were experiencing side effects (14%) and having difficulties opening bottles or packets/applying the medicine (10%). CONCLUSION: Risk factors for medication misadventure remain a substantial problem among older people. A Medication Risk Assessment Form completed by patients can be used as an aid to increase general practitioners' awareness of a variety of problem areas associated with medication use in a compact way, and could be used as part of a system for medication review to determine whether actions are required to improve quality use of medicines.

Accuracy of telephone self-report of drug use in older people and agreement with pharmaceutical claims data.

OBJECTIVE: To determine the agreement between two measures of medication use, namely telephone interview self-report and pharmaceutical claims data, in an elderly population. METHODS: An agreement study of 566 community-dwelling, general practice patients aged > or =65 years was conducted to compare self-reported use of medicines with pharmaceutical claims data for different retrieval periods. Classes of drugs commonly used in the elderly were selected for comparison. RESULTS: 1094 people were eligible for the main study. Of these, 697 people completed a follow-up survey and 625 of these patients consented to the release of pharmaceutical claims data. A further 59 participants were excluded from the analysis because they had a home visit instead of a telephone interview. The proportion of observed agreement between the telephone self-report and the various retrieval periods was consistently high. Kappa coefficients showed good to very good agreement (> or = 0.75) with retrieval periods of 30, 60 and 90 days for benzodiazepines, low-risk NSAIDs, thiazide diuretics and most other drugs. The specificity of self-reported medication use compared with claims data was consistently high across all drug classes, suggesting that people usually did not mention drugs that were not included in the claims data. Sensitivity values varied according to drug class and retrieval period, and were lower for NSAIDs than for benzodiazepines and thiazide diuretics. Decline in sensitivity with increased retrieval periods was most marked for benzodiazepines, NSAIDs and low-risk NSAIDs, which are often used on an as-needed basis. Positive predictive values increased with longer retrieval periods CONCLUSION: High agreement and accuracy were demonstrated for self-reported use of medicines when patients were interviewed over the telephone compared with pharmaceutical claims data. The telephone inventory method can be used in future studies for accurately measuring drug use in older people when claims data are not available.

Increasing oncologists' skills in eliciting and responding to emotional cues: evaluation of a communication skills training program.

PURPOSE: Psychological morbidity in cancer patients is common, but often undetected and untreated. We developed a communication skills training (CST) program targeting this issue, and evaluated its impact on doctor behaviour. PATIENTS AND METHODS: Thirty of 35 oncologists from six teaching hospitals in six Australian cities, participated. The CST was a 1.5-day intensive face-to-face workshop incorporating presentation of principles, a DVD modelling ideal behaviour and role-play practice, followed by four 1.5 h monthly video-conferences incorporating role-play of doctor-generated scenarios. Doctors were randomized to receive the CST or not. Simulated patient interviews were videotaped and coded at baseline, after CST and 6 months later. Doctors completed questionnaires assessing stress and burnout at the same time points. RESULTS: Doctors in the intervention group displayed more creating environment and fewer blocking behaviours at both follow-ups; however, these differences did not reach statistical significance. Intervention doctors valued the training highly, but did not report substantial reductions in stress and burnout. CONCLUSIONS: This short training programme demonstrated a positive effect on aspects of doctor behaviour. Video-conferencing after a short training course may be an effective strategy for delivering CST.

Medication review: patient selection and general practitioner's report of drug-related problems and actions taken in elderly Australians.

OBJECTIVES: To investigate which patients general practitioners (GPs) selected for medication review based on risk factors for medication problems and patient demographics; to describe drug-related problems and actions taken to solve those problems during medication review consultations based on GPs' self-report. DESIGN: Cross-sectional. SETTING: General practices. PARTICIPANTS: Four hundred fifty-two patients recruited from 11 GPs. MEASUREMENTS: Patients' self-reported risk factors for medication misadventures collected from Medication Risk Assessment Forms; doctors' report of patients' drug-related problems and actions taken to solve those problems collected from Medication Review Checklists. Patients completed a Medication Risk Assessment Form in the waiting room, which they presented to their doctor, who then decided whether the patient needed a medication review. GPs completed a Medication Review Checklist. RESULTS: GPs completed 124 Medication Review Checklists. The group that had a medication review had a lower proportion of individuals aged 65 to 74 than the group that did not (40% vs 56%). The proportion of people with risk factors for medication misadventure was consistently higher for patients who received a medication review. GPs found that 88% (95% confidence interval (CI) =66-97) of patients who had a medication review had at least one problem with use of their medication. GPs reported taking at least one action for 104 (88%) patients (95% CI=65-97) to rectify medication problems. Most common actions taken were monitoring (55%), improving compliance (50%), dose change (37%), cessation of drug (28%), and ordering of a pathology test (26%). CONCLUSION: A Medication Risk Assessment Form completed by patients can be used to select patients for medication review, and medication reviews conducted by GPs can be beneficial in improving the use of medication in older people living in the community.

Development and psychometric analysis of the systemic lupus erythematosus needs questionnaire (SLENQ).

This study aims to develop a self-administered needs assessment questionnaire for people with systemic lupus erythematosus (SLE), assess its face, content and construct validity and test the reliability of the instrument. Eighty-four people with SLE, registered with a Lupus Resource Centre in New South Wales, Australia participated in a series of focus groups and pre and pilot testing phases in the development of a needs instrument and 594 people from a SLE support association were sent the SLE needs questionnaire (SLENQ) and the MOS-SF-36 and asked to complete both. Face and content validity were found to be high following pre and pilot testing. Principal components analysis identified seven factors with eigenvalues greater than 1, which together accounted for 53% of the total variance (psychological/spiritual/existential, health services, health information, physical, social, daily living and employment/financial needs). Internal reliability coefficients (Cronbach's alpha) of all seven factor-based scales were found to be substantial, ranging from 0.77 to 0.96. Moderately significant correlation between the domains of the SLENQ and the MOS SF-36 were supportive in ascertaining concurrent validity. These findings suggest that the SLENQ provides a reliable and valid index of the global needs of people with SLE.

Is a computer questionnaire of childhood asthma acceptable in general practice?

OBJECTIVES: To determine whether a previously-validated touch screen computer program of symptoms and management of childhood asthma is acceptable to parents who accompany their children to consult a GP, and to examine whether any parent characteristics are associated with acceptability. METHODS: Conducted in general practice in Newcastle, NSW, Australia. A cross sectional pen and paper survey was given to parents of children consulting a GP after completing the computer questionnaire on childhood asthma in the waiting room. Measurements were frequencies of Likert scale responses to statements concerning the computer questionnaire, compared with demographic and personal characteristics. RESULTS: High levels of acceptability of the asthma computer questionnaire were reported by the 198 respondents, with most being willing to do the same program once or twice a year (87%), or to do similar programs on other topics (91%). Most respondents (81%) agreed that the computer program was enjoyable, and very few (8%) would have preferred to answer the asthma questions by pen and paper rather than by computer. Two or more children accompanying the parent was the characteristic most associated with less positive responses. CONCLUSIONS: Overall the high acceptability of this questionnaire suggests that this computerised format is an appropriate method of screening children for asthma and determining their current management. As a large component of underdiagnosis of asthma is lack of reporting to the doctor, this valid and acceptable diagnostic aid has the potential to improve detection of unreported asthma, and also to identify high-risk individuals.

Activities of home-based heart failure nurse specialists: a modified narrative analysis.

BACKGROUND: Heart failure nurse specialists strive to optimize patients' outcomes in home-based settings. OBJECTIVE: To document the activities of home-based heart failure nurse specialists. METHOD: A modified narrative analysis of clinical notes of home-based heart failure nurse specialists during a 12-month period was used. RESULTS: Data analysis revealed 7 key activities of home-based heart failure nurse specialists: (1) monitoring signs and symptoms and reinforcing patients' self-management: identifying trends and appropriate action; (2) organization, liaison, and consultation with other health professionals to deal with changes in clinical status; (3) clarifying and reinforcing patients' self-care strategies; (4) assisting patients in their desire to avoid institutionalized care; (5) identifying patients' psychosocial issues: dealing with social isolation; (6) providing support: journeying with patients and patients' families; and (7) helping patients and patients' families deal with death and dying. CONCLUSIONS: A major proportion of the activities of home-based heart failure nurse specialists are related to facilitating communication between health professionals and providing information and support to patients and patients' families.

Prevalence and correlates of perceived unmet needs of people with systemic lupus erythematosus.

To assess the prevalence and correlates of perceived unmet need among people with systemic lupus erythematosus (SLE) 386 people with SLE, recruited from a support association in NSW, Australia, completed a mail-back survey that included 97 items measuring perceived unmet needs across seven domains: physical, daily living, psychological/spiritual/existential, health services, health information, social support and employment/financial. Ninety-four percent of participants had at least one unmet need. The highest levels of unmet need were tiredness (81%); pain (73%); not being able to do things one used to (72%); fear of exacerbation (72%); sleeping problems (70%); anxiety and stress (69%); and feeling down (68%). Five of the highest levels of unmet needs were in the psychological domain. Researchers concluded that current health care delivery is not adequately meeting some of the needs of people with SLE. A comprehensive needs assessment questionnaire for all SLE patients could help providers manage protocols more effectively.

An evaluation of three community-based projects to improve care for incontinence.

The Australian National Continence Management Strategy commissioned the implementation and evaluation of three community-based projects designed to improve care for people with incontinence by improving the detection and treatment of urinary incontinence. Projects were located in demographically diverse areas, overseen by co-operating professional groups with an interest in continence and aimed at facilitating a pathway of care for those with incontinence. Project activities focused on health care provider training and improving local referral networks, as well as raising public awareness. Multifaceted evaluation of each project was designed to inform principles for a national approach to continence care. The evaluation indicated that providers involved in each project became more confident in their ability to manage incontinence, had significantly increased knowledge of issues around incontinence and became more aware of local options for referral. However, there was little evidence that projects achieved an increase in seeking professional help among those with incontinence. From the evaluation, six principles were developed to guide future models of community-based continence care.

A perspective from countries using organized screening programs.

Cancer screening may be offered to a population opportunistically, as part of an organized program, or as some combination of the preceding two options. Organized screening is distinguished from opportunistic screening primarily on the basis of how invitations to screening are extended. In organized screening, invitations are issued from centralized population registers. In opportunistic screening, however, due to the lack of central registers, invitations to screening depend on the individual's decision or on encounters with health care providers. The current article outlines key differences between organized and opportunistic screening. In the current study, literature searches were performed using PubMed and MEDLINE. Additional data were assembled from interviews with health officials in the five countries investigated and from the authors' personal files. Opportunistic screening was found to be distinguishable from organized screening on the basis of whether screening invitations were issued from centralized population registers. Organized screening programs also assumed centralized responsibility for other key elements of screening, such as eligibility requirements, quality assurance, follow-up, and evaluation. Organized programs focused on reducing mortality and morbidity at the level of the population rather than at the level of the individual. Thus, programs did not necessarily offer the most sensitive screening test for a particular cancer, and tests sometimes were offered at suboptimal intervals with respect to individual-level protection. Nonetheless, organized systems paid greater attention to the quality of screening, as measured by factors such as cancer detection rates, tumor characteristics, and false-positive biopsy rates. As a result, participants in organized screening programs received greater protection from the harmful effects associated with screening. In addition, organized programs worked more systematically toward providing value for money in an inevitably resource-limited environment. Although organized and opportunistic models of screening can yield similar uptake rates, organized programs exhibited greater potential ability to reduce cancer incidence and mortality, because of the higher levels of population coverage and centralized commitment to quality and monitoring; were more likely to be cost-effective; and offered greater protection against the harmful effects associated with poor quality or overly frequent screening.

Patient-centered needs assessment: rationale for a psychometric measure for assessing needs in heart failure.

Determining an individual's unique perspective of an illness experience remains a challenge for clinicians, administrators, and researchers. A range of concepts and psychometric measures have been developed and evaluated to capture this information. These include patient satisfaction, quality of life, and utility measures. Needs assessment as a tool for evaluating perceptions of health status and determining patient satisfaction and treatment plans has been explored in oncology. Studies have demonstrated that a high proportion of patients have unmet needs in relation to activities of daily living, information sources, and comfort. Heart failure (HF), a condition with significant individual and societal burden, mirrors the illness of experience of cancer, as individuals process issues related to prognosis, treatment regimens, and decreased functional status. A needs-based assessment of health status, expectations, and perceptions is patient-centered and has the capacity to not only evaluate current health status but also plan and project care plans. Needs assessment is a dynamic construct rather than a point in time consistent with other assessment modalities, such as quality of life. Multidimensional needs assessment allows for planning and projection of needs, not only on an individual but also a population basis. Implicit in the exploration of needs is an expectation of level of care to be provided, from both the provider and recipient of care. In many instances a misalignment may exist between services and resources available to the individual. This article seeks to provide a theoretical justification for the development of a needs assessment instrument for patients with HF and to discuss the rationale of this method of assessment to create better alignment and resources with patients needs and expectations.

The role of GPs in treating psychological distress: a study of midlife Australian women.

BACKGROUND: Patient satisfaction with general practice care is important for treatment adherence, yet little is known about women's satisfaction with general practice care in relation to emotional problems. OBJECTIVES: The purpose of the present study was to explore women's perceptions of the help provided by GPs for psychological distress. METHODS: Qualitative and quantitative data were gathered using semi-structured telephone interviews in NSW Australia. The respondents were 322 women aged 45-50 who participated in the baseline survey of Women's Health Australia (WHA). RESULTS: Of the 309 women who had had a period of distress in the previous 12 months, 159 [52%, confidence interval (CI) 46.4-57.6] had talked to a GP about their difficulties. Listening was the main help given by GPs (68%, CI 60.7-75.3), followed by a prescription for medication (55%, CI 47.2-62.8) and referral to specialist care (13%, CI 7.8-18.2). Few women reported specific behavioural interventions, such as counselling (4%, CI 0.9-7.1) or relaxation (1%, CI 0 to 2.6). There was a relatively high degree of satisfaction with referral, counselling and relaxation advice amongst those who received these treatments. In contrast, a fifth of women who received a prescription or were listened to found these treatments unhelpful (20%, CI 11.6-28.4; and 21%, CI 14.2-29.8, respectively). Thematic analysis highlighted three main concerns for women, namely structural limitations of the GP-patient consultation, GPs' limited interpersonal skills and GPs' limited interest, knowledge and skills in mental health. CONCLUSION: While most women find their general practic care helpful, many reported shortcomings in terms of both GP skills and structural limitations of the consultation. These findings are useful in informing the development of training programmes for GPs.

Monitoring and educational feedback to improve the compliance of tattooists and body piercers with infection control standards: a randomized controlled trial.

OBJECTIVES: Blood-borne viruses, which present a grim health and economic burden for both developed and developing countries, can be transmitted through tattooing and piercing. Limited data exist concerning intervention strategies for increasing skin penetration operators' compliance with infection control standards. We evaluated the efficacy and acceptability of an educational feedback intervention for tattooists and piercers. METHODS: A randomized controlled trial was conducted in Sydney, NSW, Australia, among 37 tattooing and body-piercing premises in 2002. RESULTS: No effects were found in terms of improved knowledge. There was a significantly greater increase in the experimental group in the perceived risk of being detected and penalized for noncompliance. There was a significantly greater improvement in the demonstration of 2 of 3 infection control procedures and a nonsignificant trend toward greater improvement in inspection scores in the experimental group. The odds of compliance were significantly higher in the experimental group for 2 of the 3 demonstration practices and in 2 of 5 observed infection control practices. CONCLUSION: The findings contribute new information concerning alternative approaches to increasing tattooists and piercers' infection control compliance with regulations/guidelines.

The adequacy of measurement of short and long-term consequences of false-positive screening mammography.

OBJECTIVES: The aim of this study is to review quantitative studies on women's experiences of consequences of false-positive screening mammography to assess the adequacy of the most frequently used instruments for measuring short-term and long-term psychological consequences. METHODS: Relevant papers reporting quantitative studies on consequences of false-positive screening mammography were identified using MEDLINE, CINAHL, EMBASE and PsycInfo databases. Articles citing development and psychometric properties of the most frequently used measures were also retrieved. Finally, the review focused on studies that had used at least one of the most frequently used measures. RESULTS: Twenty-three relevant studies were identified. The most commonly used measures were the General Health Questionnaire (GHQ), the Hospital Anxiety and Depression Scale (HADS), the Psychological Consequences Questionnaire (PCQ) and the State-Trait Anxiety Inventory (STAI). One or more of these was used in 17 of the 23 studies. CONCLUSIONS: The GHQ, the HADS and the STAI have problems with language, content relevance, and content coverage in studies of false-positive screening mammography. These instruments should not be used to measure psychological consequences of any kind of cancer screening. The PCQ is an adequate questionnaire for measuring short-term consequences, and the PCQ is preferable to other measures because of its higher sensitivity. However, there is little evidence that the PCQ is able to adequately detect all long-term consequences of screening mammography. Given the inadequacy of the measurement instruments used, any current conclusions about the long-term consequences of false-positive results of screening mammography must remain tentative.