Spiritual distress and spiritual care in advanced heart failure.

As patients face serious and chronic illness, they are confronted with the realities of dying. Spiritual and existential issues are particularly prominent near the end of life and can result in significant distress. It is critical that healthcare professionals know how to address patients' and families' spiritual concerns, diagnose spiritual distress and attend to the deep suffering of patients in a way that can result in a better quality of life for patients and families. Tools such as the FICA spiritual history tool help clinicians invite patients and families to share their spiritual or existential concerns as well as sources of hope and meaning which can help them cope better with their illness. This article presents ways to help clinicians listen to the whole story of the patient and support patients in their care.

Short-term and long-term effectiveness of a post-hospital care transitions program in an older, medically complex population.

BACKGROUND: Care transition programs can potentially reduce 30 day readmission; however, the effect on long-term hospital readmissions is still unclear. OBJECTIVE: We compared short-term (30 day) and long-term (180 day) utilization of participants enrolled in care transitions versus those matched referents eligible but not enrolled. DESIGN: This cohort study was conducted from January 1, 2011 until June 30, 2013 within a primary care academic practice. PARTICIPANTS: Patients at high risk for hospital readmission based on age and comorbid health conditions had participated in care transitions group (cases) or usual care (referent). MAIN MEASURES: The primary outcomes were 30, 90, and 180 day hospital readmissions.. Secondary outcomes included: mortality; emergency room visits and days; combined rehospitalizations and emergency room visits; and total intensive care unit days. Cox proportional hazard models using propensity score matching were used to assess rehospitalization, emergency room visits and mortality. Poisson regression models were used to compare the numbers of hospital days. KEY RESULTS: Compared to referent (n=365), Mayo Clinic Care Transitions patients exhibited a lower 30 day rehospitalization rate compared to referent; 12.4% (95% CI 8.9-15.7) versus 20.1% (95% CI 15.8-24.1%), respectively (P=0.002). At 180-days, there was no difference in rehospitalization between transitions and referent; 39.9% (95% CI 34.6-44.9%) versus 44.8% (95% CI 39.4-49.8%), (P=0.07). CONCLUSION: We observed a reduction in 30 day rehospitalization rates among those enrolled in care transitions compared to referent. However, this effect was not sustained at 180 days. More work is needed to identify how the intervention can be sustained beyond 30 days.

Effect of insulin sensitizer therapy on atherothrombotic and inflammatory profiles associated with insulin resistance.

OBJECTIVE: To determine whether targeted pharmacological improvement of insulin sensitivity will normalize the associated elevations of thrombotic and inflammatory cardiovascular disease (CVD) biomarkers in individuals with insulin resistance. PATIENTS AND METHODS: Study 1 was a cross-sectional study of Asian Indians with and without diabetes mellitus and Northern European Americans without diabetes (n=14 each) conducted between December 11, 2003, and July 14, 2006. Study 2 was a secondary analysis of a double-blind randomized controlled study conducted between August 19, 2005, and August 24, 2010, that included 25 individuals with untreated diabetes or impaired fasting glucose who were randomized to receive placebo (n=13) or a combination of metformin, 1000 mg twice daily, and pioglitazone, 45 mg daily (n=12), for 3 months. In both studies, measurements of insulin sensitivity (euglycemic-hyperinsulinemic clamp) and plasma inflammatory and thrombotic factor concentrations were obtained on enrollment (studies 1 and 2) and after intervention (study 2). RESULTS: Study 1 demonstrated significant correlations between insulin sensitivity and plasma adiponectin, high-density lipoprotein cholesterol, plasminogen activator inhibitor 1, interleukin 6, tumor necrosis factor α, and triglycerides. Insulin sensitizer therapy significantly improved insulin sensitivity, inflammatory cytokines except interleukin 6, and thrombotic factors except fibrinogen, without concomitant changes in weight, blood pressure, or body composition. CONCLUSION: Insulin sensitizer therapy ameliorates inflammatory and thrombotic factors implicated in developing CVD. Interventions to improve insulin sensitivity may thus be considered as therapeutic options to reduce CVD burden in insulin-resistant states, although further research is needed to determine long-term effects on morbidity and mortality.

Stress ratings and health promotion practices among RNs: a case for action.

OBJECTIVE: : The objective of this study was to investigate associations between RN perceptions of their stress levels, health-promoting behaviors, and associated demographic variables. BACKGROUND: : Stress and burnout are occupational hazards resulting in absenteeism, illness, and staff turnover, factors important to nurse administrators. Personal health behaviors among nurses have been linked to less stress and the delivery of health-promotion teaching. METHOD: : An electronic survey with 2 standardized measures and demographic questions was completed by 2,247 staff nurses from a large Midwestern academic medical center. FINDINGS: : Stress levels were inversely correlated with overall health-promoting behavior scores. Outside caregiver responsibilities were associated with higher stress and lower health-promoting behaviors scores. CONCLUSIONS: : Findings support work-site interventions that promote nurses' health and wellness, reduce work and home stress, and influence positive patient care and outcomes.

Effects of a worksite physical activity intervention for hospital nurses who are working mothers.

Hospital nurses who are working mothers are challenged to maintain their personal health and model healthy behaviors for their children. This study aimed to develop and test an innovative 10-week worksite physical activity intervention integrated into the work flow of hospital-based nurses who were mothers. Three volunteer adult medical-surgical nursing units participated as intervention units. Fifty-eight nurses (30 intervention and 28 control) provided baseline and post-intervention repeated measurements of physical activity (steps) and body composition. Intervention participants provided post-intervention focus group feedback. For both groups, daily steps averaged more than 12,400 at baseline and post-intervention. No significant effects were found for physical activity; significant effects were found for fat mass, fat index, and percent fat (p < .03). Focus group findings supported the intervention and other data collected. The worksite holds promise for targeting the health of working mothers. Future research is warranted with a larger sample, longer intervention, and additional measures.

Should clinicians deliver decision aids? Further exploration of the statin choice randomized trial results.

BACKGROUND: Statin Choice is a decision aid about taking statins. The optimal mode of delivering Statin Choice (or any other decision aid) in clinical practice is unknown. METHODS: To investigate the effect of mode of delivery on decision aid efficacy, the authors further explored the results of a concealed 2 x 2 factorial clustered randomized trial enrolling 21 endocrinologists and 98 diabetes patients and randomizing them to 1) receive either the decision aid or pamphlet about cholesterol, and 2) have these delivered either during the office visit (by the clinician) or before the visit (by a researcher). We estimated between-group differences and their 95% confidence intervals (CI) for acceptability of information delivery (1-7), knowledge about statins and coronary risk (0-9), and decisional conflict about statin use (0-100) assessed immediately after the visit. Follow-up was 99%. RESULTS: The relative efficacy of the decision aid v. pamphlet interacted with the mode of delivery. Compared with the pamphlet, patients whose clinicians delivered the decision aid during the office visit showed significant improvements in knowledge (difference of 1.6 of 9 questions, CI 0.3, 2.8) and nonsignificant trends toward finding the decision aid more acceptable (odds ratio 3.1, CI 0.9, 11.2) and having less decisional conflict (difference of 7 of 100 points, CI -4, 18) than when a researcher delivered the decision aid just before the office visit. CONCLUSIONS: Delivery of decision aids by clinicians during the visit improves knowledge and shows a trend toward better acceptability and less decisional conflict.

Clinician's use of the Statin Choice decision aid in patients with diabetes: a videographic study nested in a randomized trial.

OBJECTIVE: To describe how clinicians use decision aids. BACKGROUND: A 98-patient factorial-design randomized trial of the Statin Choice decision vs. standard educational pamphlet; each participant had a 1:4 chance of receiving the decision aid during the encounter with the clinician resulting in 22 eligible encounters. DESIGN: Two researchers working independently and in duplicate reviewed and coded the 22 encounter videos. SETTING AND PARTICIPANTS: Twenty-two patients with diabetes (57% of them on statins) and six endocrinologists working in a referral diabetes clinic randomly assigned to use the decision aid during the consultation. MAIN OUTCOME MEASURES: Proportion and nature of unintended use of the Statin Choice decision aid. RESULTS: We found eight encounters involving six clinicians who did not use the decision aid as intended either by not using it at all (n = 5; one clinician did use the decision aid in three encounters), offering inaccurate quantitative and probabilistic information about the risks and benefits of statins (n = 2), or using the decision aid to advance the agenda that all patients with diabetes should take statin (n = 1). Clinicians used the decision aid as intended in all other encounters. CONCLUSIONS: Unintended decision aid use in the context of videotaped encounters in a practical randomized trial was common. These instances offer insights to researchers seeking to design and implement effective decision aids for use during the clinical visit, particularly when clinicians may prefer to proceed in ways that the decision aid apparently contradicts.

A treatment decision aid may increase patient trust in the diabetes specialist. The Statin Choice randomized trial.

AIMS: Decision aids in practice may affect patient trust in the clinician, a requirement for optimal diabetes care. We sought to determine the impact of a decision aid to help patients with diabetes decide about statins (Statin Choice) on patients' trust in the clinician. METHODS: We randomized 16 diabetologists and 98 patients with type 2 diabetes referred to a subspecialty diabetes clinic to use the Statin Choice decision aid or a patient pamphlet about dyslipidaemia, and then to receive these materials from either the clinician during the visit or a researcher prior to the visit. Providers and patients were blinded to the study hypothesis. Immediately after the clinical encounter, patients completed a survey including questions on trust (range 0 to total trust = 100), knowledge, and decisional conflict. Researchers reviewed videotaped encounters and assessed patient participation (using the OPTION scale) and visit length. RESULTS: Overall mean trust score was 91 (median 97.2, IQR 86, 100). After adjustment for patient characteristics, results suggested greater total trust (trust = 100) with the decision aid [odds ratio (OR) 1.77, 95% CI 0.94, 3.35]. Total trust was associated with knowledge (for each additional knowledge point, OR 1.3, 95% CI 1.1, 1.6), patient participation (for each additional point in the OPTION scale, OR 1.1, 95% CI 1.1, 1.2), and decisional conflict (for every 5-point decrease in conflict, OR 1.5, 95% CI 1.2, 1.9). Total trust was not associated with visit length, which the decision aid did not significantly affect. There was no significant effect interaction across the trial factors. CONCLUSIONS: Preliminary evidence suggests that decision aids do not have a large negative impact on trust in the physician and may increase trust through improvements in the decision-making process.

Helping patients with type 2 diabetes mellitus make treatment decisions: statin choice randomized trial.

BACKGROUND: Poor quality of information transfer about the benefits and risks of statin drug use may result in patients not making informed decisions that they can act on in a timely fashion. METHODS: The effect of a decision aid about statin drugs on treatment decision making in 98 patients with diabetes was determined in a cluster randomized trial of decision aid vs control pamphlet, with concealed allocation, blinding of participants to study goals, and adherence to the intention-to-treat principle. Twenty-one endocrinologists conducted specialty outpatient metabolic consultations. Patients in the intervention group received Statin Choice, a tailored decision aid that presents the estimated 10-year cardiovascular risk, the absolute risk reduction with use of statin drugs, and the disadvantages of using statin drugs. Patients in the control group received the institution's pamphlet about cholesterol management. We measured acceptability, knowledge about options and cardiovascular risk, and decisional conflict immediately after the visit, and adherence to pill taking was measured 3 months later. RESULTS: Patients favored using the decision aid (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.2-6.9); patients who received the decision aid (n = 52) knew more (difference, 2.4 of 9 points; 95% CI, 1.5-3.3), had better estimated cardiovascular risk (OR, 22.4; 95% CI, 5.9-85.6) and potential absolute risk reduction with statin drugs (OR, 6.7; 95% CI, 2.2-19.7), and had less decisional conflict (difference, -10.6; 95% CI, -15.4 to -5.9 on a 100-point scale) than did patients in the control group (n = 46). Of 33 patients in the intervention group taking statin drugs at 3 months, 2 reported missing 1 dose or more in the last week compared with 6 of 29 patients in the control group taking statin drugs (OR, 3.4; 95% CI, 1.5-7.5). CONCLUSIONS: A decision aid enhanced decision making about statin drugs and may have favorably affected drug adherence.

A pen-and-paper coronary risk estimator for office use with patients with type 2 diabetes.

OBJECTIVE: To develop a pen-and-paper coronary heart disease (CHD) 10-year risk estimator for patients with type 2 diabetes based on the United Kingdom Prospective Diabetes Study (UKPDS) risk equation (based on 4000 patients with diabetes but only available electronically). PATIENTS AND METHODS: We used data collected from adults with type 2 diabetes from 6 primary care practices that participated in a randomized trial in Rochester, Minn; patients were enrolled in the study from July 2001 to December 2003, with follow-up through June 2004. We used multivariable linear regression of the CHD risk estimate to formulate prediction equations to estimate average (<15%), elevated, or high (>30%) 10-year CHD risk according to sex, age, diabetes duration, smoking, hemoglobin A1c level, systolic blood pressure, ratio of total cholesterol to high-density lipoprotein cholesterol, and microalbuminuria categories. We selected cut points for the predicted score, seeking to (1) maximize the number of patients with total agreement between our estimator and the UKPDS risk equation, (2) avoid any patient's risk being either overestimated or underestimated by 2 risk categories, and (3) overestimate rather than underestimate coronary risk. RESULTS: A total of 535 patients with type 2 diabetes participated in this study, 400 in the generation cohort and 135 in the validation cohort. Of the 400 patients in the generation cohort, our estimator had an 82% total agreement with the UKPDS calculation, 11% overestimated risk, and 7% underestimated UKPDS coronary risk (weighted kappa=0.77). Results were similar in the 135 patients in the validation cohort (kappa=0.79) and in an independent validation cohort of 52 patients attending a referral diabetes clinic (kappa=0.68). CONCLUSION: The pen-and-paper estimator facilitates the point-of-care estimation of coronary risk in situations in which use of a desktop or handheld version of the electronic UKPDS risk engine is not practical or feasible. In our experience, estimation of risk using this tool, when done with patients, can further patients' insight into their risk of coronary events, often leading to enlightened discussions about modification of Individual risk factors.