Type 1 Diabetes Management and Health Care Experiences Across Rural Nebraska.

INTRODUCTION: This study aimed to explore the unique health care needs of rural Nebraska families with a child with type 1 diabetes mellitus (T1DM). METHOD: Using a phenomenological approach, the researchers conducted four focus groups across Nebraska. The focus groups gathered input from children, caregivers, and health care providers (n = 23). The researchers coded data and generated themes. Member checking, researcher triangulation, reflexivity, a thick description of the process, and an audit trail established trustworthiness. RESULTS: Four themes emerged: dramatic family and lifestyle changes following diagnosis, lack of access to specialized care resulting in complications, isolation improved health management resourcefulness, and technology improved health management and flexibility. DISCUSSION: Lifestyle changes persist after a child's diagnosis with T1DM. Rural families reported unpredictable health status of their child, reduced health care services, and limited information access. Conversely, limited specialty health care access, resources, and community support led to creative self-education, advocacy, and health care management strategies. Diabetes technology offered opportunities for improved provider-patient communication and continuous glucose monitoring.

Fidelity Protocol Development for a Telehealth Type 1 Diabetes Occupation-Based Coaching Intervention.

Background. Preserving fidelity ascertains that the intervention is delivered as intended in occupational therapy (OT) contexts. The process of conceptualizing and developing fidelity standards, however, is seldom documented in the existing literature. Purpose. The purpose of this methodological description paper was to (a) describe the process of generating a comprehensive fidelity plan based on the National Institutes of Health Behavioral Change Consortium's five-domain fidelity framework and (b) evaluate the development process and utility of the end product, the Occupation-Based Coaching (OBC) Fidelity Protocol. Key Issues. There is no known research that documents the process of developing fidelity standards and tools to support the OBC intervention. Implications. The OBC Fidelity Protocol proposes an example of how a comprehensive fidelity plan and tools can be developed from a well-established scientific framework. This can also inform OT practitioners and researchers to deliver OBC sessions with consistency across clients, providers, and interventions/studies.

A MIXED-METHODS EVALUATION OF STANDALONE PERSONAL HEALTH RECORD USE BY PATIENTS WITH TYPE 2 DIABETES.

Background: Self-management of diabetes is key for achieving positive clinical outcomes, with personal health records (PHRs) proposed as a patient-centered technology for facilitating self-care. However, few studies have described patient engagement with a PHR, including facilitators and barriers to use from the perspective of actual users. Objectives: To compare use of a standalone PHR by patients with Type 2 diabetes to usual care through assessment of self-care behaviors, and short-term impact on social cognitive outcomes and hemoglobin A1c (HbA1c). Methods: A mixed-methods design combining a comparative effectiveness pilot with qualitative interviews was used. Qualitative interviews explored the primary outcome of changes in self-care behaviors, while quantitative data obtained from health records and a survey focused on social cognitive and clinical outcomes. Results: A total of 117 participants completed the study (intervention group = 56, control group = 61). Only 23 individuals used the PHR at least once after baseline. Five themes emerged from the qualitative analysis describing participants' experiences with the PHR and identifying reasons for lack of engagement. Quantitative findings supported qualitative results with no significant changes in HbA1c and only a significant increase in diabetes knowledge in the intervention group. Conclusions: Study findings revealed low PHR uptake and minimal impact on study outcomes, including lack of communication and information-sharing between patients and providers. Future research should explore the fit of PHRs within the context of other self-management tools, integration with provider workflow, and the need for enhanced functionalities beyond an information repository to optimally support patient self-care.

A Qualitative Case Study Exploring Nurse Engagement With Electronic Health Records and E-Prescribing.

There is a national focus on the adoption and use of electronic health records (EHRs) with electronic prescribing (e-Rx) for the goal of providing safe and quality care. Although there is a large body of literature on the benefits of adoption, there is also increasing evidence of the unintentional consequences resulting from use. As little is known about how use of EHR with e-Rx systems affects the roles and responsibilities of nurses, the purpose of this qualitative case study was to describe how nurses adapt to using an EHR with e-Rx system in a rural ambulatory care practice. Six themes emerged from the data. Findings revealed that nurses adjust their routine in response to providers' preferential behavior about EHR with e-Rx systems yet retained focus on the patient and care coordination. Although perceived as more efficient, EHR with e-Rx adoption increased workload and introduced safety risks.

A qualitative study of how patients with type 2 diabetes use an electronic stand-alone personal health record.

BACKGROUND: Patient use of personal health records (PHRs) to manage their health information has been proposed to enhance patient knowledge and empower patients to make changes in their self-care behaviors. However, there remains a gap in understanding about patients' actual PHR use behaviors. The purpose of this qualitative study was to explore how patients with type 2 diabetes used a PHR to manage their diabetes-related health information for self-care. MATERIALS AND METHODS: Fifty-nine patients with type 2 diabetes were interviewed 3-6 months after receiving initial training on a free-of-charge, Web-based PHR. Interviews were audio-recorded, transcribed, and analyzed using an iterative process of in vivo coding, categorization, and theme development. RESULTS: Nine themes emerged, three of which expressed positive experiences: complete and accessible record; increased awareness; and behavioral changes. The remaining six themes expressed negative experiences: out of sight, out of mind; I would have used it if I were sicker; economic, infrastructure, and computer literacy barriers; lack of patient-provider engagement; double tracking; and privacy and security concerns. CONCLUSIONS: Despite some potential positive benefits resulting from PHR use, several barriers inhibited sustained and effective use over time. Provider and patient education about the benefits of PHR use and about the potential for filling in information gaps in the provider-based record is key to engage patients and stimulate PHR adoption and use.

Ensuring effective medication reconciliation in home healthcare.

A patient was readmitted two days after discharge with severe hypoglycemia. The treating team discharged the patient on a new insulin regimen without realizing that the patient also had insulin 70/30 at home. The patient continued to take her previous regimen as well as the new one, and was found unresponsive by her husband. The patient was in the ICU with the incident likely resulting in permanent neurological deficits. ()A patient was admitted to a hospital from a home health agency. The list of medications provided by the agency did not completely match the list provided by the patient's family physician (i.e., the antihypertensive agent metoprolol tartrate [Lopressor] was not listed by the agency as one of the medications that the patient was currently taking). Therefore, metoprolol tartrate was not initially ordered. The patient developed atrial fibrillation shortly after hospital admission and required a transfer to the ICU [intensive care unit]. A diltiazem (Cardizem) infusion was started and the patient's family physician became aware that the patient had not been receiving their antihypertensive medication and initiated an order for the metoprolol tartrate ().

Patient safety perspectives of providers and nurses: the experience of a rural ambulatory care practice using an EHR with E-prescribing.

PURPOSE: The purpose of this study was to identify and describe safety improvements and concerns indicated by providers and nurses in a rural community ambulatory care practice using an electronic health record with an e-prescribing feature (EHR with eRx). METHODS: Two focus groups were conducted; 1 with providers and the other with nurses. Participants responded to questions and discussed their perceptions of safety improvements and concerns with use of an EHR with eRx. Transcripts were analyzed using sequential and continuous analytic methods. FINDINGS: Three themes centered on efficiency and patient safety emerged from data analysis: (1) EHR with eRx adoption has led to new improvements and concerns for patient safety, (2) the EHR with eRx has affected efficiency in the clinic, and (3) EHR with eRx adoption has led to workarounds. CONCLUSIONS: Concerns remain among providers and nurses regarding the use of EHR with eRx applications, although concerns differed between groups. Therefore, When EHR improvements are planned, it is important to consider the differing needs of the professionals who deliver care.

Exploring care transitions from patient, caregiver, and health-care provider perspectives.

Care transitions involve coordination of patient care across multiple care settings. Many problems occur during care transitions resulting in negative patient outcomes and unnecessary readmissions. The purpose of this study was to describe the experience of care transitions from patient, caregiver, and health-care provider perspectives in a single metropolitan Midwest city. A qualitative descriptive design was used to solicit patients', caregivers', and health-care providers' perceptions of care transitions, their role within the process, barriers to effective care transitions, and strategies to overcome these barriers. Five themes emerged: preplanned admissions are ideal; lack of needed patient information upon admission; multiple services are needed in preparing patients for discharge; rushed or delayed discharges lead to patient misunderstanding; and difficulties in following aftercare instructions. Findings illustrated provider difficulty in meeting multiple care needs, and the need for patient-centered care to achieve positive outcomes associated with quality measures, reduced readmissions, and care transitions.

How baccalaureate nursing students value an interprofessional patient safety course for professional development.

Nursing students need foundation knowledge and skills to keep patients safe in continuously changing health care environments. A gap exists in our knowledge of the value students place on interprofessional patient safety education. The purpose of this exploratory, mixed methods study was to understand nursing students' attitudes about the value of an interprofessional patient safety course to their professional development and its role in health professions curricula. Qualitative and quantitative data were collected from formative course performance measures, course evaluations, and interviews with six nursing students. The qualitative themes of awareness, ownership, and action emerged and triangulated with the descriptive quantitative results from student performance and course evaluations. Students placed high value on the course and essential nature of interprofessional patient safety content. These findings provide a first step toward integration of interprofessional patient safety education into nursing curricula and in meeting the Institute of Medicine's goals for the nursing profession.

Sensory evaluation ratings and moisture contents show that soy is acceptable as a partial replacement for all-purpose wheat flour in peanut butter graham crackers.

Fortification can help individuals achieve adequate nutritional intake. Foods may be fortified with soy flour as a source of protein for individuals limiting their intake of animal products, either due to personal dietary preference or to reduce their intake of saturated fat, a known risk factor for heart disease. This study determined the feasibility of fortifying peanut butter graham crackers by substituting soy flour for all-purpose wheat flour at 25%, 50%, 75%, or 100% weight/weight. Graham crackers fortified with soy flour were compared to similarly prepared nonfortified peanut butter graham crackers. Moisture contents of all graham crackers were similar. Consumers (n=102) evaluated each graham cracker using a hedonic scale and reported liking the color, smell, and texture of all products. However, unlike peanut butter graham crackers fortified with lower levels of soy, graham crackers fortified with 100% weight/weight soy flour had less than desirable flavor, aftertaste, and overall acceptability. Overall, this study shows that fortification of peanut butter graham crackers up to 75% weight/weight with soy flour for all-purpose wheat flour is acceptable.

Symptom burden clusters and their impact on psychosocial functioning following coronary artery bypass surgery.

Although there is extensive literature on symptoms experienced by patients after coronary artery bypass surgery (CABS), there is a paucity of data on symptom clusters and their impact on functional outcomes. The purpose of these descriptive, secondary analyses was to identify and describe cluster subgroups of 226 elderly CABS patients at discharge and to examine the cluster's impact on psychosocial functioning over time (baseline, 6 weeks, and 3 months) using the 36-item Medical Outcome Study Short Form subscales. Cluster analysis revealed a 3-cluster solution with low, low-moderate, and moderate symptom burden clusters. Significant differences were detected for Duke Activity Status Index (F(2,223) = 5.12, P = .007), Barnason Efficacy Expectation Scale (F(2,223) = 9.60, P < .0001), Hospital Anxiety and Depression Scale (F(2,219) = 15.14, P < .0001), and New York Heart Association classification (chi = 17.44, P = .008). Significant differences were noted on all variables between the low and moderate symptom burden clusters with differences between the low-moderate and moderate clusters for only the Barnason Efficacy Expectation Scale and the Hospital Anxiety and Depression Scale. Those in the moderate symptom burden cluster had more symptoms, anxiety, and depression along with lower self-efficacy and physiological functioning than those in the other 2 clusters. There was no interaction or simple main effects for the role-emotional or social subscales as measured by the 36-item Medical Outcome Study Short Form. There was no significant interaction for mental functioning by time and cluster (F(4,641) = .30, P = .88); however, there was a simple main effect for cluster (F(2,641) = 4.11, P = .02). Follow-up analysis indicated significant differences between the low and low-moderate clusters, indicating that those with low symptom burden had significantly better mental health functioning than those with moderate symptom burden. Findings provide a foundation of knowledge on symptom clusters in CABS populations and may be useful to clinicians to identify patients at risk for slowed or delayed recovery and for early intervention.

Symptom profiles of coronary artery bypass surgery patients at risk for poor functioning outcomes.

The purpose of this secondary analysis was to profile or cluster 226 patients, who had participated in a randomized controlled trial, on symptoms after coronary artery bypass surgery and to examine how these profiles could potentially be used by clinicians to identify groups at risk for impaired functioning during the first 6 months after surgery. Variables measured were symptom presence and burden and functioning. The model-based clustering method was used for cluster analysis of the symptom burden measure, and analyses of covariance were used to determine if there were differences on functioning (physical functioning and physical activity) by symptom burden group at 6 weeks and at 3 and 6 months after dismissal. The majority of the 226 subjects were married (86%), male (83%), and had a mean age of 71 (SD, 4.96) years. Eight symptoms were used in the model-based clustering method-shortness of breath, fatigue, depression, sleep disturbances, pain, swelling, anxiety, and appetite problems-and demonstrated that there were 3 patient clusters of symptom burden. Cluster 1 had low symptom burden on all 8 symptoms, cluster 3 had moderate symptom burden on all 8 symptoms, and cluster 2 had a combination of low (shortness of breath, fatigue, depression, pain, and anxiety) and moderate symptom burden (sleep problems, swelling, and appetite problems). Analyses of covariance revealed no significant cluster x time interactions for any of the variables. However, there were significant main effects (P < .01) for symptom burden groups for physical functioning (physical and vitality functioning) and physical activity (estimated energy expenditure and mean daily total activity counts). Significant main effects for time indicated physical functioning and physical activity measures, except bodily pain, improved over time (P < .05). Study results indicate that the use of profiling coronary artery bypass surgery patients on their symptoms prior to hospital discharge may assist health care providers to identify patients who could be at risk for having more difficulty with physical functioning and physical activity during the first 6 months after surgery.

The relationship between physician practice characteristics and physician adoption of electronic health records.

BACKGROUND: Health information technologies, such as electronic health records (EHRs), can potentially improve patient safety in our health care system. The potential advantages include increased quality and more efficiency in the care of patients. Adoption of EHRs has been slow despite these advantages and a national call for EHR implementation. PURPOSES: This article explores factors associated with the adoption of EHR systems using organizational theory to derive hypotheses as to why physicians would adopt EHRs. METHODOLOGY/APPROACH: : A survey was administered to all office-based physicians in Nebraska and South Dakota using a modified Dillman technique between July and November 2007. The main outcome variable measured physician EHR adoption status at three levels: not planning to use an EHR, planning to use an EHR, and using an EHR. Factors associated with EHR status were analyzed using a multinomial logistic regression. FINDINGS: Approximately 30% of physicians reported using an EHR in his or her practice. Physicians adopting EHRs were younger and had access to internal health information technologies support. In addition, working in an independent practice decreased the likelihood of physicians using and adopting EHRs. PRACTICE IMPLICATIONS: This research provides further evidence of the barriers impeding EHR adoption. One such barrier includes the lack of access to internal information technology support staff versus having to outsource for technical support services. From a resource dependency perspective, barriers illustrated by this example may place undue dependencies on physicians if they pursue an EHR system. By addressing these barriers, physicians may be in a better position to adopt EHR system into his or her practice.

Storytelling: a clinical application for undergraduate nursing students.

Faculty from Creighton University School of Nursing participating in a grant set out to design and implement a model for teaching health care management in community-based settings. The goal of the grant was to cross-educate acute care faculty on how to provide holistic care to patients transitioning between acute care and the community with a focus on underserved and vulnerable populations and to incorporate this into acute care clinical experiences with students. One of the recurring topics during grant discussions was the importance of getting to know the patient's story and how it impacts the nurse-patient relationship. Key themes related to storytelling that emerged during grant meetings were listening, partnership, reciprocity, and solidarity. Grant participants identified various methods in which stories could be obtained and shared with others for educational purposes. Various storytelling techniques were implemented in the classroom and clinical settings as a means for teaching and learning. Examples of specific techniques implemented included case studies, journals, stories from practice, life reviews, and reminiscence therapy. The aim of the storytelling projects was to get students to gather information from multiple sources and to put it into a cohesive story in order to provide comprehensive, holistic, and individualized care.

Venous oxygen levels during aerobic forearm exercise: An index of impaired oxidative metabolism in mitochondrial myopathy.

A cardinal feature of impaired skeletal muscle oxidative metabolism in mitochondrial myopathies is a limited ability to increase the extraction of O(2) from blood relative to the increase in O(2) delivery by the circulation during exercise. We investigated whether aerobic forearm exercise would result in an abnormal increase in venous effluent O(2) in patients with impaired skeletal muscle oxidative phosphorylation attributable to mitochondrial disease. We monitored the partial pressure of O(2) (PO(2)) in cubital venous blood at rest, during handgrip exercise, and during recovery in 13 patients with mitochondrial myopathy and exercise intolerance and in 13 healthy control and 11 patient control subjects. Resting and recovery venous effluent PO(2) were similar in all subjects, but during exercise venous PO(2) paradoxically rose in mitochondrial myopathy patients from 27.2 +/- 4.0mmHg to 38.2 +/- 13.3mmHg, whereas PO(2) fell from 27.2 +/- 4.2mmHg to 24.2 +/- 2.7mmHg in healthy subjects and from 27.4 +/- 9.5mmHg to 22.2 +/- 5.2mmHg in patient controls. The range of elevated venous PO(2) during forearm exercise in mitochondrial myopathy patients (32 to 82mmHg) correlated closely with the severity of oxidative impairment as assessed during cycle exercise. We conclude that measurement of venous PO(2) during aerobic forearm exercise provides an easily performed screening test that sensitively detects impaired O(2) use and accurately assesses the severity of oxidative impairment in patients with mitochondrial myopathy and exercise intolerance.