Healthcare provider targeted interventions to improve medication adherence: systematic review and meta-analysis.

OBJECTIVE: This systematic review applied meta-analytic procedures to synthesise medication adherence (also termed compliance) interventions that focus on healthcare providers. DESIGN: Comprehensive searching located studies testing interventions that targeted healthcare providers and reported patient medication adherence behaviour outcomes. Search strategies included 13 computerised databases, hand searches of 57 journals, and both author and ancestry searches. Study sample, intervention characteristics, design and outcomes were reliably coded. Standardised mean difference effect sizes were calculated using random-effects models. Heterogeneity was examined with Q and I(2) statistics. Exploratory moderator analyses used meta-analytic analogue of ANOVA and regression. RESULTS: Codable data were extracted from 218 reports of 151,182 subjects. The mean difference effect size was 0.233. Effect sizes for individual interventions varied from 0.088 to 0.301. Interventions were more effective when they included multiple strategies. Risk of bias assessment documented larger effect sizes in studies with larger samples, studies that used true control groups (as compared with attention control), and studies without intention-to-treat analyses. CONCLUSION: Overall, this meta-analysis documented that interventions targeted to healthcare providers significantly improved patient medication adherence. The modest overall effect size suggests that interventions addressing multiple levels of influence on medication adherence may be necessary to achieve therapeutic outcomes.

Endophytic actinobacteria induce defense pathways in Arabidopsis thaliana.

Endophytic actinobacteria, isolated from healthy wheat tissue, which are capable of suppressing a number wheat fungal pathogens both in vitro and in planta, were investigated for the ability to activate key genes in the systemic acquired resistance (SAR) or the jasmonate/ethylene (JA/ET) pathways in Arabidopsis thaliana. Inoculation of A. thaliana (Col-0) with selected endophytic strains induced a low level of SAR and JA/ET gene expression, measured using quantitative polymerase chain reaction. Upon pathogen challenge, endophyte-treated plants demonstrated a higher abundance of defense gene expression compared with the non-endophyte-treated controls. Resistance to the bacterial pathogen Erwinia carotovora subsp. carotovora required the JA/ET pathway. On the other hand, resistance to the fungal pathogen Fusarium oxysporum involved primarily the SAR pathway. The endophytic actinobacteria appear to be able to "prime" both the SAR and JA/ET pathways, upregulating genes in either pathway depending on the infecting pathogen. Culture filtrates of the endophytic actinobacteria were investigated for the ability to also activate defense pathways. The culture filtrate of Micromonospora sp. strain EN43 grown in a minimal medium resulted in the induction of the SAR pathway; however, when grown in a complex medium, the JA/ET pathway was activated. Further analysis using Streptomyces sp. strain EN27 and defense-compromised mutants of A. thaliana indicated that resistance to E. carotovora subsp. carotovora occurred via an NPR1-independent pathway and required salicylic acid whereas the JA/ET signaling molecules were not essential. In contrast, resistance to F. oxysporum mediated by Streptomyces sp. strain EN27 occurred via an NPR1-dependent pathway but also required salicylic acid and was JA/ET independent.

Metabolic effects of interventions to increase exercise in adults with type 2 diabetes.

AIMS/HYPOTHESIS: The aim of this meta-analysis was to integrate the results of primary research testing the effect of diabetes self-management interventions that included recommendations to increase exercise on metabolic outcomes among adults with type 2 diabetes. MATERIALS AND METHODS: Extensive literature searching strategies were used to identify published and unpublished intervention studies that measured glycated haemoglobin outcomes. Primary study results were coded. Fixed- and random-effects meta-analytic procedures included moderator analyses. RESULTS: Data were synthesised across 10,455 subjects from 103 research reports. The overall mean weighted effect size for two-group comparisons was 0.29 (higher mean for treatment than control). This effect size is consistent with a difference in HbA1c means of 0.45% (e.g. 7.38% for treatment subjects vs 7.83% for control subjects). For single-group studies, the overall mean weighted effect size was 0.32-0.34. Control group subjects experienced no improvement in metabolic control during participation in the studies. Interventions that targeted multiple health behaviours resulted in smaller effect size estimates (0.22) than interventions that focused only on exercise behaviours (0.45). Funded studies reported greater improvements in metabolic controls. Studies with a greater proportion of female subjects reported lower effect sizes. Baseline HbA1c and BMI were unrelated to metabolic outcomes. CONCLUSIONS/INTERPRETATION: These findings suggest that self-management interventions that include exercise recommendations improve metabolic control, despite considerable heterogeneity in the magnitude of the intervention effect. Interventions that emphasise exercise may be especially effective in improving metabolic control. Primary research testing interventions in randomised trials to confirm causal relationships would be constructive.

Designing effective nursing interventions.

The purpose of this article is to present issues scientists must consider to design effective experimental interventions. The efforts of nurse-researchers to test diverse interventions are consistent with the central role of interventions for the nursing discipline. Despite the importance of interventions, limited literature has addressed the actual design of these interventions. Many experimental interventions lack content validity, and others are inadequate to affect outcomes. Eight issues to consider in the development of interventions are discussed, including the conceptual basis of the intervention, descriptive research linking key concepts to the proposed outcome, previous intervention literature testing similar or related interventions, the intervention target, intervention specificity/generality, single or bundled interventions, intervention delivery, and intervention dose. Strategies are recommended for designing effective experimental interventions.

Randomized clinical trial of a quality improvement intervention in nursing homes.

PURPOSE: The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practices and subsequently improve resident outcomes, or if a stronger intervention, expert clinical consultation with nursing facility staff, is needed. DESIGN AND METHODS: Nursing facilities (n = 113) were randomly assigned to one of three groups: workshop and feedback reports only, workshop and feedback reports with clinical consultation, and control. Minimum Data Set (MDS) Quality Indicator (QI) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year. Clinical consultation by a gerontological clinical nurse specialist (GCNS) was offered to those in the second group. RESULTS: With the exception of MDS QI 27 (little or no activity), no significant differences in resident assessment measures were detected between the groups of facilities. However, outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls, behavioral symptoms, little or no activity, and pressure ulcers (overall and for low-risk residents). IMPLICATIONS: Simply providing comparative performance feedback is not enough to improve resident outcomes. It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly.

Physical activity research in nursing.

PURPOSE: To present exemplars of physical activity research in nursing, illustrate the importance of physical activity research across the lifespan, and recommend directions for theory development and research. METHODS: Studies of physical activity and exercise currently being conducted by nurse investigators were reported and critiqued by attendees of the Midwest Nursing Research Society 2000 Preconference session entitled "Promoting Physical Activity Among Diverse Groups Across the Health Continuum." Physical activity and exercise literature during the past decade was reviewed. Databases searched included Medline, CINAHL, Wilson, and ERIC. FINDINGS: Investigators have emphasized the need to evaluate the effects of theory-based physical activity interventions designed to alter key correlates of physical activity identified through descriptive research. CONCLUSIONS: Regular physical activity is necessary for health promotion and disease prevention for all populations. Continued research in this important area of health behavior is critical to identify the most effective interventions to increase physical activity among diverse populations.

Exercise and quality of life in elderly individuals.

1. Exercise is important and recommended for older adults. Nurses in community settings are in ideal positions to facilitate older adults' use of exercise programs. 2. Quality of life is complex and multidimensional. Dimensions include well-being, functional status, socioeconomic status, and self-esteem. 3. This article contains a review of empirical evidence that states older adults who exercise have improved quality of life.

Prevalence, incidence, management, and predictors of venous ulcers in the long-term-care population using the MDS.

OBJECTIVE: To describe the prevalence, incidence, management, and predictors of venous ulcers in residents of certified long-term-care facilities using the Minimum Data Set. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: 32,221 residents admitted to long-term-care facilities in Missouri between January 1, 1996, and October 30, 1998. MAIN OUTCOME MEASURES: Version 2.0 of the Minimum Data Set was utilized. Assessment items included selected measures from background information, disease diagnoses, physical functioning and structural problems, health conditions, oral/nutritional status, and skin condition. MAIN RESULTS: Venous ulcer prevalence on admission was 2.5%. The incidence of venous ulcer development for long-term-care residents admitted without an ulcer at 90, 180, 270, and 365 days after admission was 1.0%, 1.3%, 1.8%, and 2.2%, respectively. The most frequent skin treatments for residents with a venous ulcer were ulcer care, dressings, and ointments. Factors associated with venous ulcer development within a year of admission were diabetes mellitus, peripheral vascular disease, and edema. CONCLUSION: Venous ulcer prevalence and incidence are greater in the long-term-care population than in the community at-large. Residents with a venous ulcer are likely to have comorbid conditions such as diabetes mellitus, peripheral vascular disease, congestive heart failure, edema, wound infection, and pain. Based on these data, risk factors such as history of leg ulcers, recent edema, diabetes mellitus, congestive heart failure, or peripheral vascular disease should prompt clinicians to carefully plan care that will manage a resident's risk for venous ulcer development.

Initial field testing of an instrument to measure: observable indicators of nursing home care quality.

The "Observable Indicators of Nursing Home Care Quality" instrument was developed as a new measure of nursing home care quality. The instrument is based on a theoretical model of quality nursing home care grounded in data from provider and consumer focus groups. The instrument was piloted in 10 Missouri nursing homes. Subsequent versions were tested in 109 Missouri and 11 Icelandic nursing homes. Content validity was established using experts. Concurrent and known groups validity was evaluated using Minimum Data Set quality indicators, survey citations, and a process of care measure. Interrater and test-retest reliabilities were calculated as well as coefficient alpha. The "Observable Indicators of Nursing Home Care Quality" instrument is a new measure that can be used by researchers, and potentially by regulators, consumers, or providers, to observe and score specific indicators of quality care following a 20- to 30-minute inspection of a nursing home.

Improving quality of care in nursing facilities. Gerontological clinical nurse specialist as research nurse consultant.

It is becoming increasingly common for nursing facilities to use Quality Indicators (QI) derived from Minimum Data Set (MDS) data for quality improvement initiatives within their facilities. It is not known how much support facilities need to effectively review QI reports, investigate problems areas, and implement practice changes to improve care. In Missouri, the University of Missouri-Columbia MDS and Nursing Home Quality Research Team has undertaken a Quality Improvement Intervention Study using a gerontological clinical nurse specialist (GCNS) to support quality improvement activities in nursing homes. Nursing facilities have responded positively to the availability of a GCNS to assist them in improving nursing facility care quality.

Nursing home care quality: a multidimensional theoretical model integrating the views of consumers and providers.

This exploratory study was undertaken to discover the defining dimensions of nursing home care quality from the viewpoint of consumers of nursing home care. Eleven focus groups were conducted in five Missouri communities. The seven dimensions of the consumer multidimensional model of nursing home care quality are: staff, care, family involvement, communication, environment, home, and cost. The views of consumers and families are compared with the results of a previous study of providers of nursing home services. An integrated, multidimensional theoretical model is presented for testing and evaluation. An instrument based on the model is being tested to observe and score the dimensions of nursing home care quality.

Older women's beliefs about physical activity.

Physical activity may contribute to important health and well-being outcomes among older adults. Efforts to understand determinants of physical activity are necessary to plan effective interventions. The theory of planned behavior has been successfully applied to a variety of health behaviors. Previous research using the theory of planned behavior has not addressed beliefs about overall physical activity among community-dwelling older women. Qualitative interviews were conducted with 30 older women to identify behavioral beliefs, perceived control beliefs, and normative beliefs, which influence physical activity decisions. Content analyses of responses revealed three major themes: social influences on physical activity, psychosocial benefits of activity, and joint problems and fatigue as factors that interfere with activity. These findings about physical activity were compared with published findings about episodic exercise among 30 similar women who took part in an episodic exercise study. The result was the discovery that the women in this study talked about physical activity as embedded in their social lives while the women in the episodic exercise study viewed exercise as separate from their daily lives. These findings of beliefs about overall physical activity suggest a social model may be useful in planning public health interventions to increase activity among older women.

Older adults and exercise: path analysis of self-efficacy related constructs.

BACKGROUND: Despite the potential benefits of exercise, rates of exercise among older adults remain low. Self-efficacy expectation is the strongest correlate of exercise behavior or exercise behavior change. OBJECTIVES: To develop and test the predictive ability of a model of exercise among older adults. METHOD: The model's constructs related to exercise and self-efficacy included outcome expectancy, perceived barriers to exercise, perceived health, age, and lifelong leisure exercise among adults 65 to 100 years years of age (N=147). Data were collected by personal interview and analyzed with path analysis. RESULTS: Self-efficacy expectation had a strong direct effect on exercise. Outcome expectancy contributed little to exercise in the model. Perceived barriers and self-efficacy expectation, followed by age, exerted the most total influence on exercise scores. CONCLUSIONS: Lifelong leisure exercise exerts its influence on exercise through self-efficacy beliefs, further emphasizing the importance of efficacy. Also important are perceived barriers to exercise. Further research should examine self-efficacy expectations, perceived barriers, and age as predictors of exercise among older adults at different stages of health behavior change.

Nursing home care quality: a multidimensional theoretical model.

This exploratory study was undertaken to discover the defining dimensions of nursing home care quality and to propose a conceptual model to guide nursing home quality research and the development of instruments to measure nursing home care quality. Three focus groups were conducted in three central Missouri communities. A naturalistic inductive analysis of the transcribed content was completed. Two core variables (interaction and odor) and several related concepts emerged from the data. Using the core variables, related concepts, and detailed descriptions from participants, three models of nursing home care quality emerged from the analysis: (1) a model of a nursing home with good quality care; (2) a model of a nursing home with poor quality care; and (3) a multidimensional model of nursing home care quality. The seven dimensions of the multidimensional model of nursing home care quality are: central focus, interaction, milieu, environment, individualized care, staff, and safety. To pursue quality, the many dimensions must be of primary concern to nursing homes. We are testing an instrument based on the model to observe and score the dimensions of nursing home care quality.

Verifying nursing home care quality using minimum data set quality indicators and other quality measures.

Researchers, providers and government agencies have devoted time and resources to the development of a set of Quality Indicators derived from Minimum Data Set (MDS) data. Little effort has been directed toward verifying that Quality Indicators derived from MDS data accurately measure nursing home quality. Researchers at the University of Missouri-Columbia have independently verified the accuracy of QI derived from MDS data using four different methods; 1) structured participative observation, 2) QI Observation Scoring Instrument, 3) Independent Observable Indicators of Quality Instrument, and 4) survey citations. Our team was able to determine that QIs derived from MDS data did differentiate nursing homes of good quality from those of poorer quality.

Assessing contributors to cost of care in nursing homes.

In 1994 12.7% of the population was 65 and over, while 10.6% were 85 and over. Expenditures for nursing homes reached $72.3 billion in 1994 (much of which is tax-supported) accounting for 8.7% of all personal health money spent. Data from the 1993 Missouri Medicaid cost reports for 403 nursing homes were reviewed to determine differences in costs per resident day (PRD) and discover which factors most influenced these differences. Mid-sized facilities with 60-120 beds reported the lowest resident-related PRD costs. PRD expenses for aides and orderlies were higher in tax-exempt facilities, which was thought to be related to their "more altruistic" mission. Investor-owned facilities showed significantly greater administrative costs PRD, which may relate to higher administrative salaries and fancier offices. The authors suggest further study that would incorporate location, occupancy rate, quality of care, case mix, and payer mix data.

Older women: social cognitive theory correlates of health behavior.

Most research about health promoting behaviors has focused on pre-old adults and men, despite clear evidence that the leading cause of death among postmenopausal women is related to health behaviors. This study applied social cognitive theory constructs to exercise, dietary, and stress management health behavior. The purpose of this study was to examine the ability of self-efficacy expectation and outcome expectancy to predict health behavior among older women. Community-dwelling women aged 65 to 92 years were interviewed with previously developed instruments and instruments designed specifically for this study (N = 225). Self-efficacy was the strongest predictor of each of the health behaviors (beta weights: dietary behavior .50; exercise, .39; stress management, .32). Outcome expectancy was not a significant predictor of exercise or dietary behavior. Outcome expectancy was a significant predictor of stress management behavior. The findings of this study, combined with the importance of health promotion behaviors among older women, justify the need for continued research about self-efficacy and health behavior among this vulnerable population.

An evaluation of the effectiveness of competency-based code blue education.

Two types of mock code programs were compared. The specific factors investigated were nurse satisfaction, comfort, and retention of knowledge and skills. A sample of 48 nurses initially participated in the mock code program, with 45 nurses participating in the 6-month follow-up evaluation. The study revealed that competency-based and group code blue programs resulted in similar levels of satisfaction, knowledge, and rate of performance of critical elements 6 months after the initial program.