Venous thromboembolism knowledge among older post-hip fracture patients and their caregivers.

Patient education about venous thromboembolism (VTE) prevention is needed to prevent complications and costly re-hospitalization. Nurses are uniquely positioned to provide vital education as patients transition from the inpatient setting to after discharge. Still, little is known about patient knowledge deficits and those of their caregivers. The purpose of this study was to explore VTE prevention knowledge in a sample of older hip fracture patients and family caregivers. At the time of hospital discharge, surveys were completed by hip fracture surgery patients (≥65; n=30) and family caregivers (n=30). Participants reported needs for more prophylactic anticoagulation and side effects education. Mean education satisfaction was 3.49 out of 5 among patients and 3.83 among caregivers. Focused patient education regarding the wisdom of VTE prevention, potential risks involved, and patient and caregiver roles in advocating for better prevention measures is needed for these patients at risk for hospital readmission secondary to VTE.

Evaluation of hospital nurses' perceived knowledge and practices of venous thromboembolism assessment and prevention.

Venous thromboembolism (VTE) is a preventable cause of hospital death. Bedside registered nurses (RNs) are a key group that can be the first to recognize risks of patients in acute care settings. The purpose of this study was to identify bedside hospital RNs' perceived knowledge of VTE, their assessment practices, their self-efficacy in conducting VTE prevention care, and their perceived barriers to performing VTE risk assessment. An anonymous web-based survey on VTE risk assessment and prevention was conducted with RNs who provided direct patient care at two hospitals. RNs who were not directly involved in bedside patient care such as managers and educators were excluded. A total of 221 RNs completed the survey. Most participants rated their overall knowledge of VTE risk assessment between "good" (44%) and "fair" (28%). VTE assessment frequencies performed by participants varied widely. Participants reported high confidence in their ability to educate patients and families about VTE symptoms, prevention, and treatments. Participants were least confident in their own ability to conduct a thorough VTE risk assessment. Greater self-reported VTE knowledge was associated with greater VTE assessment frequency and self-efficacy for VTE preventive care. The most common perceived barriers in performing VTE risk assessment were lack of knowledge (21%) and lack of time (21%). The findings demonstrate a substantial need for focused education about VTE prevention for hospital nurses and support for hospital systems to monitor VTE care. Despite the Joint Commission emphasis on VTE risk assessment in all hospitalized patients, there remains a gap between current, evidence-based recommendations for VTE prevention and reported nursing practices.

Treatment of post-traumatic stress disorder in patients with severe mental illness: a review.

Although the prevalence of post-traumatic stress disorder (PTSD) is high among those with severe mental illness, little is known about the use of interventions to lessen the burden of PTSD in this population. Currently, there are limited data about safe and effective interventions to treat these individuals. This systematic published work review presents the scientific published work reporting studies of psychological treatment approaches for individuals with comorbid PTSD and severe mental illness. A secondary aim of this study was to identify the specific models implemented and tested, and their impact upon patient outcomes. A review of the published work from January 2001 through January 2012 of English-language publications retrieved from the Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, and the American Psychological Association generated abstracts (PsycINFO) databases was conducted. Six studies met the inclusion criteria for the review. The treatment programs described were cognitive-behavioural therapy, psychoeducation, exposure-based cognitive-behavioural therapy, and eye movement desensitization and reprocessing. Evidence of the effectiveness of these programs is examined. Data to support the use of these interventions are limited, indicating the need for further research and efficacy trials. Future areas of research and implications for nursing are discussed.

The nurse's role in primary care antidepressant medication adherence.

Depression remains one of the most common conditions seen in primary care settings. Antidepressant medications (ADMs) are considered standard treatment for moderate to severe depression, and in some instances, for minor depression. When ADM adherence is low, patients are at risk for treatment failure and poor quality of life. Nurses may be key in ensuring the success of ADM therapy; however, little is known about the interventions nurses use or the consequent patient outcomes. The objectives of this article were to identify studies in which nurses managed ADM adherence and to collect evidence about the efficacy of these interventions. A systematic literature review of clinical trial studies was conducted, which specifically included the role of the nurse. Nurse interventions identified were: patient care management, medication monitoring, depression education, and referrals to specialty providers. Nurses use a range of interventions to manage ADM adherence. In most studies, these approaches, including collaborative care, were efficacious.

Determinants of health-promoting lifestyle behaviors among Arab immigrants from the region of the Levant.

Arab immigrants in the United States are at risk for heart disease, stroke, and diabetes. We explored health-promoting lifestyle behaviors among Arab immigrants to the United States from the Middle Eastern region of the Levant. In 218 male and female Arab adults surveyed with the revised Health-Promoting Lifestyle Profile (HPLP-II), the mean for the HPLP-II was 2.73 (range 1-4), with spiritual growth and interpersonal relations the most frequently reported practices and physical activity the least frequently practiced dimension of health-promoting behaviors. Multiple linear regression analysis highlighted four determinants of health-promoting lifestyle behaviors: health insurance, acculturation, self-efficacy, and social support. Health promotion programs serving Arab immigrants should take these determinants into consideration.

Predictors and outcomes of early adherence to the use of a home telehealth device by older veterans with heart failure.

OBJECTIVES: The present study examined home telehealth (HT) adherence, and its potential predictors and outcomes, in older Veterans with heart failure (HF) using the Health Buddy (Bosch Healthcare, Palo Alto, CA) device. SUBJECTS AND METHODS: This was a retrospective study using secondary data from the Department of Veterans Affairs (VA) databases, describing adherence rates and patterns in the first 90 days after enrollment in 248 older Veterans with HF enrolled in the VA HT Programs using the Health Buddy at five medical centers in Southern California and Nevada, between June 1, 2006 and June 1, 2008. Adherence to the use of Health Buddy was defined as the number of days the patient completed an HT session over different time frames during the study period. RESULTS: Significant differences occurred between average adherence across all three 30-day time frame increments, with adherence decreasing over time. Despite the use of standardized VA HT protocols and equipment, the department in which the HT program was embedded was a consistent significant predictor of patient adherence in all time frames, with odds ratios of 2.2-4.0 for the department with the consistent best adherence versus that with the worse adherence (confidence intervals varying with the time frame, p<0.03). Increased co-morbidity burden was associated with decreased adherence only in the first 30 days after enrollment. In this short-term study, no relationship was found between adherence to the use of the Health Buddy and outcomes. CONCLUSIONS: Program and patient characteristics warrant further study as potential predictors of HT device adherence. Additional research is also needed to further examine the relationships between HT device adherence and various outcomes.

Factors associated with antidepressant medication adherence and adherence-enhancement programmes: a systematic literature review.

Medication adherence is critical to the efficacy of available treatment for depression in primary care settings. This review identifies factors associated with adherence and what is known about the effectiveness of adherence-enhancement programmes. A comprehensive systematic review of English language publications from January 2002 to October 2011 was conducted using the following databases: PUBMED/MEDLINE, PsycINFO and the Cochrane database. Twenty-one studies met the inclusion criteria for adherence-enhancement evaluations. Eleven of the studies evaluated demonstrated significantly positive effects on adherence; the remaining 10 reported mixed or no effects. Similar to previous literature reviews, factors shown to be associated with adherence were multifactorial and in this analysis were grouped as patient, condition and comorbidities, therapy or treatment, patient-provider relationship and healthcare system level. Adherence improved most notably in studies that included sustainable system and patient-targeted changes. Evaluating adherence-enhancement interventions is key to promoting successful approaches; however, a number of gaps exist between intervention and implementation: (1) the cost in resources and time to implement and sustain these programmes is unknown, (2) specific details about which subgroups of patients are best helped with such programmes is not clear, and (3) what specific processes or content are critical to programme success is still to be identified. There are sufficient data supporting the substantial need for planning and implementing adherence interventions despite reported mixed results. Primary care providers are often positioned to impact patients' adherence; however, practice constraints can limit their implementation.

Efficacy of green tea in the prevention of cancers.

Understanding the literature about the efficacy of green tea consumption in preventing and slowing the progression of cancers is critical. A systematic review of the literature was conducted using an electronic search to identify studies from 2000 to 2008 in the following database: Alt HealthWatch, CINAHL, Medline, Health Source--Consumer Edition, Health Source: Nursing/Academic Edition, Web of Science (ISI), and the Cochrane Library. Although the evidence from this review suggested associations between green tea consumption and a decreased risk for some cancers, the findings were inconclusive. In selected cases, green tea was effective in slowing the progression of the earlier stages of cancer. However, contrary evidence is reported and the dose and duration of use is variable. Most evidence stems from self-reports. Research using more rigorous designs to investigate the efficacy of green tea in humans is needed.

Insight into dementia care management using social-behavioral theory and mixed methods.

BACKGROUND: For health organizations (private and public) to advance their care-management programs, to use resources effectively and efficiently, and to improve patient outcomes, it is germane to isolate and quantify care-management activities and to identify overarching domains. OBJECTIVES: The aims of this study were to identify and report on an application of mixed methods of qualitative statistical techniques, based on a theoretical framework, and to construct variables for factor analysis and exploratory factor analytic steps for identifying domains of dementia care management. METHODS: Care-management activity data were extracted from the care plans of 181 pairs of individuals (with dementia and their informal caregivers) who had participated in the intervention arm of a randomized controlled trial of a dementia care-management program. Activities were organized into types, using card-sorting methods, influenced by published theoretical constructs on self-efficacy and general strain theory. These activity types were mapped in the initial data set to construct variables for exploratory factor analysis. Principal components extraction with varimax and promax rotations was used to estimate the number of factors. Cronbach's alpha was calculated for the items in each factor to assess internal consistency reliability. RESULTS: The two-phase card-sorting technique yielded 45 activity types out of 450 unique activities. Exploratory factor analysis produced four care-management domains (factors): behavior management, clinical strategies and caregiver support, community agency, and safety. Internal consistency reliability (Cronbach's alpha) of items for each factor ranged from.63 for the factor "safety" to.89 for the factor "behavior management" (Factor 1). DISCUSSION: Applying a systematic method to a large set of care-management activities can identify a parsimonious number of higher order categories of variables and factors to guide the understanding of dementia care-management processes. Further application of this methodology in outcome analyses and to other data sets is necessary to test its practicality.

Comparison of Latina and non-Latina white women's beliefs about communicating genetic cancer risk to relatives.

Breast cancer accounts for 30% of cancer among Latinas, and ovarian cancer is more common in Latinas than in non-Latina Whites. Latinas with a personal or family history of these cancers are increasingly referred for genetic cancer risk assessment (GCRA), but little is known about their perspectives regarding informing relatives of genetic cancer risk. We described and compared the pre-GCRA beliefs about informing relatives of genetic cancer risk, using survey data previously collected within a larger study. The sample included 475 Latina (N=183; 39%) and non-Latina (N=292; 61%) White women with a personal or family history of breast or ovarian cancers. Data analysis used descriptive statistics, chi-square and Wilcoxon rank-sum tests, and logistic regression. Findings revealed that most women believed their relatives should be informed of genetic cancer risk (92%), that informing was strictly a personal duty (88%), and that informing should be done only in person (60%). Multiple logistic regression demonstrated that education (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.15-5.66), Latina ethnicity (odds ratio [OR] 0.22, 95% CI, 0.09-0.53), and Spanish as primary language (OR, 0.17, 95% CI, 0.06-0.47) were independently associated with the belief that a clinician should be the informant.

Determining care management activities associated with mastery and relationship strain for dementia caregivers.

OBJECTIVES: To identify specific care management activities within a dementia care management intervention that are associated with 18-month change in caregiver mastery and relationship strain. DESIGN: Exploratory analysis, using secondary data (care management processes and caregiver outcomes) from the intervention arm of a clinic-level randomized, controlled trial of a dementia care management quality improvement program. SETTING: Nine primary care clinics in three managed care and fee-for-service southern California healthcare organizations. PARTICIPANTS: Two hundred thirty-eight pairs: individuals with dementia and their informal, nonprofessional caregivers. MEASUREMENTS: Care management activity types extracted from an electronic database were used as predictors of caregiver mastery and relationship strain, which were measured through mailed surveys. Multivariable linear regression models were used to predict caregiver mastery and relationship strain. RESULTS: For each care manager home environment assessment, caregiver mastery increased 4 points (range 0-100, mean+/-standard deviation 57.1+/-26.6, 95% confidence interval (CI)=2.4-5.7; P=.001) between baseline and 18 months. For every action linking caregivers to community agencies for nonspecific needs, caregiver mastery decreased 6.2 points (95% CI=-8.5 to -3.9; P<.001). No other care management activities were significantly associated with this outcome, and no specific activities were associated with a change in caregiver relationship strain. CONCLUSION: Home assessments for specific needs of caregivers and persons with dementia are associated with improvements in caregivers' sense of mastery. Future work is needed to determine whether this increase is sustained over time and decreases the need for institutionalization.

Selection of family members for communication of cancer risk and barriers to this communication before and after genetic cancer risk assessment.

PURPOSE: The impact of genetic cancer risk assessment on communication of cancer risk information within families is not fully known. We compared women's selection of family members for cancer risk communication and perceived barriers to this communication before genetic cancer risk assessment and 6 months afterward. METHODS: Mailed surveys were used to collect prospective data from consenting women undergoing genetic cancer risk assessment because of a personal and/or family history of breast or ovarian cancers. Analysis included descriptive statistics, chi-square and McNemar tests, and paired t tests. RESULTS: A total of 122 women met the study criteria. Although risk communications increased with first-degree relatives (84%-90% for females; 53%-62% for males) and decreased with non-first-degree relatives (21%-9%) before and after genetic cancer risk assessment, the degree of change was nonsignificant. The most commonly cited communication barrier was loss of contact (30%). Demographics, personal or family cancer history, and BRCA status did not significantly influence findings. CONCLUSIONS: There was a high degree of cancer risk communications with female first-degree relatives, but less so with male first-degree relatives, both before and after genetic cancer risk assessment. For the majority of women, interpersonal barriers did not preclude risk discussions. Further research is needed to identify how best to facilitate risk communication.

Continuity of care and quality care outcomes for people experiencing chronic conditions: A literature review.

Continuity of patient care is frequently linked to quality care outcomes. The purpose of this paper is to examine the clinical trial literature in order to determine the extent to which informational, management, and relational continuity of care are associated with quality care indicators. A MEDLINE search of the literature via PubMed was conducted for clinical trials that were carried out from 1 January 1996-1 June 2005. Analyses of 32 unduplicated citations revealed a focus on one or more aspects of continuity and its association with quality care outcomes. Management continuity interventions were identified most often, followed by informational and relational continuity interventions. The outcomes were primarily patient-focused with a wide range of functional status, quality of life, and patient satisfaction indicators. This analysis provides implications for research that could contribute to an understanding of the types of continuity of patient care and their relationships to quality care.

Supportive relationships and medication adherence in HIV-infected, low-income Latinos.

Inadequate social support and poor communications with health care providers can affect adherence to antiretroviral therapy. The magnitude of independent effects of these factors on adherence is not fully known. This study examined the relationship of perceived emotional or informational social support from family and friends, quality of physician-patient communications and relationships, and medication adherence in a sample of low-income, Spanish-speaking, HIV-positive Latino men and women receiving treatment in community-based clinics (n = 85). Results of the study indicated that, whereas emotional or informational support was significantly associated with level of dose adherence (OR, 1.04, 95% CI, 1.01-1.08; p = .03), quality of physician-patient communications or relationships was significantly associated with adherence to medication schedule,t(6, 71) = 4.45,p < .001. Quality of patient-physician relationship accounted for 22% of the variance in adherence to medication schedule. Both kinds of support were associated with better adherence in this population but may affect adherence behaviors in different ways.

Effects of a treatment adherence enhancement program on health literacy, patient-provider relationships, and adherence to HAART among low-income HIV-positive Spanish-speaking Latinos.

The impact of an adherence enhancement program for low income HIV-infected Spanish-speaking Latinos on health literacy, patient-provider relationships, and adherence to HAART was examined. Evaluations were conducted at baseline, 6 weeks, and 6 months for participants (n = 85) randomly assigned to either the intervention group or a comparison group; 69 (81%) remained in the study for the entire 6-month duration. The intervention group scored significantly better than the comparison group on 3 of 5 measures of HIV health literacy at 6 weeks and on 2 of 5 measures, at 6 months. While there was a weak trend for the intervention group to report an increase in self-efficacy of medication adherence management, baseline to 6 weeks, no other changes were significant. Perceptions of the quality of relationship and communications with their HIV-treating physicians improved both at 6 weeks (p = 0.04) and at 6 months (p < 0.001). The comparison group showed little change baseline to 6 weeks and baseline to 6 months. While there was a trend for the pilot group to report better medication adherence, these differences were not statistically significant. Further evaluation of the impact of this adherence enhancement program is needed.

Factors associated with complementary therapy use in people living with HIV/AIDS receiving antiretroviral therapy.

OBJECTIVES: This study examined the extent to which people living with HIV/AIDS (PLWHIV) taking combination antiretroviral therapy used complementary therapy, and the relationship of their reported symptoms to the use of complementary therapy and health-related outcomes. DESIGN: A descriptive design was used in which data were obtained from individual interviews and medical records. SETTINGS: PLWHIV were identified through flyers distributed in five HIV clinics in urban and suburban locations in a Western state of the United States. SUBJECTS: The sample consisted of 182 people living with HIV/AIDS, self-identified as white (24.12%), black (44%), and Hispanic (31.88%) with a mean age of 38 (range, 22-66) years. The majority (n = 160; 87.91%) was using as least one category of complementary therapy. Approximately 56% were experiencing symptoms from HIV or their treatment, and 51% discussed their complementary therapy therapies with their health care providers. OUTCOME MEASURE: Three categories of complementary therapy--physical/body-mind therapies, religion, herbs and supplements--and two health-related outcomes--CD4 count and viral load--were explored. RESULTS: Complementary therapy use was associated with higher education, being Christian, white or black, and working part or full time. Significantly more PLWHIV with symptoms used physical/body-mind therapies than those without symptoms. No differences were found between users and nonusers of complementary therapy with respect to CD4 count and viral load. The use of herbs/supplements was significantly associated with the use of protease inhibitors. Among the categories of complementary therapy, religion, especially prayers, were most frequently used. CONCLUSIONS: A substantial proportion of PLWHIV reported using complementary therapy, most predominantly religion (specifically prayers). Further study is recommended to explore the PLWHIV's perceived benefits of using complementary therapy, and to examine the effect of complementary therapy on the patients' symptoms and disease progression. Health care providers need to be alert to potentials of interactions between combination antiretroviral therapies and specific complementary therapy in PLWHIV.

Health literacy in low-income Latino men and women receiving antiretroviral therapy in community-based treatment centers.

Health literacy is an important and well known predictor of health-seeking behaviors and health status. Some populations of persons living with HIV/AIDS (PLHA) are reported to have low levels of health literacy. Factors contributing to low levels of health literacy in traditionally underserved ethnic minority groups seeking community-based treatment services are many and include individual level predisposing and enabling factors as well as system enabling factors. The purpose of this study was to describe deficits in health literacy in a sample of 90 low-income HIV-infected Latino men and women reported to have problems with treatment adherence. Additionally, correlates of health literacy were examined to identify the relative impact of these factors in predicting lower levels of health literacy in this at-risk population. Results of the study indicated that years of education was associated with understanding HIV terms and accurately reading and understanding instructions on prescription bottles. In a multivariate context, individual predisposing and system enabling factors accounted for 22% of the variance in patients' understanding HIV terms. Individual predisposing and individual enabling factors accounted for 17% of the variance in reading and understanding instructions on prescription bottles. Further research is needed to examine the role of treatment programs in mediating relationships between individual predisposing factors and health literacy and the linkages between health literacy, health promotion behaviors, and subsequent health status in at-risk populations.

Program to enhance health literacy and treatment adherence in low-income HIV-infected Latino men and women.

This paper reports the initial results of a pilot study to evaluate the acceptability and effectiveness of a program to enhance health literacy in low-income HIV-infected Latino men and women receiving antiretroviral therapy. Participants rated the program highly on measures of satisfaction, providing evidence of its acceptability. The effectiveness of the program was assessed in comparisons of the intervention (n = 41) and standard care only (n = 40) groups at baseline and 6-week intervals. Program participants showed significant improvement over comparison group participants on measures of HIV/AIDS and treatment-related knowledge and recognition and understanding of HIV terms. Although there were no significant changes in adherence mastery and behaviors during the 6-week follow up period, there were significant changes in program participants' knowledge about medication adherence. Future steps to examine the sustainability of the program in the medical management of patients are planned in addition to determining its long-range relative impact.

Detection and documentation of actual and potential medication adherence problems in patients receiving combination therapies.

This article identifies problems in the documentation of antiretroviral medication adherence in medical records of clients seen in community-based treatment centers. Medical record data abstraction was conducted in community-based clinics providing HIV treatment services in a major HIV epicenter. Medical records of a purposive sample of 146 clients in four clinics were reviewed. Results revealed that adherence issues, in both frequency and type, were inadequately documented. Furthermore, when documented, reasons for patient adherence problems were not given. Documentation of follow-up of adherence issues was also absent in the medical records of study participants. There may be several unique and overlapping reasons for problems in documenting adherence issues: (a) provider experience and expertise in assessing adherence problems, (b) lack of sensitivity and specificity in clinician's assessments of adherence, (c) absence of adequate clinic protocol, and (d) available time to both assess adherence and complete thorough progress notes. This article provides data for the formulation of a summary adherence measure to enhance providers' abilities to detect and monitor actual and potential adherence problems.

Individual and system level factors associated with treatment nonadherence in human immunodeficiency virus-infected men and women.

Antiretroviral treatment nonadherence is complex, implicating more than a patient's ability and motivation to be compliant. The bulk of the research to date focuses on individual level barriers with less emphasis on the many system level factors that potentially impact patients' adherence behaviors. This study examined the effects of system enabling factors in addition to the frequently studied individual predisposing and enabling factors upon nonadherence to treatment. One hundred eighty-two patients from five community-based clinics were interviewed and their medical charts examined. Patients' self-reported nonadherence was correlated with clinicians' assessments of medication and appointment nonadherence. Seven individual predisposing factors (gender, ethnicity, birthplace, years of education, HIV Overview of Problems-Evaluation System [HOPES] psychosocial, Hospital Anxiety and Depression Scale [HADS] anxiety, and HADS depression scores) were found to be significantly associated with treatment adherence/nonadherence. Individual enabling factors (hopefulness and access to health care), as well as treatment by clinic staff, a system enabling factor, were significantly associated with adherence/nonadherence. In a multivariate analysis, six factors - age (younger), gender (female), birth outside the United States, level of hopefulness (lower), access to health care (lower), and treatment by clinic staff (poorer) - accounted for 19.3% of the variance in nonadherence. Results of this study indicated that several individual predisposing and enabling factors were potential predictors of treatment nonadherence; however, system enabling factors, e.g., treatment by clinic staff were also associated with treatment nonadherence. Further studies are needed to examine the complex relationships of individual and system related factors in predicting treatment nonadherence.