Advice Program Research Articles

Identifying and meeting survivorship needs

This article reports on the development and delivery of a nurse-led end of treatment consultation clinic for women who have completed treatment for early breast cancer. Women are invited to attend a 45-minute consultation with an experienced cancer nurse. They are asked to complete a holistic needs assessment before their appointment. The consultation focuses on ongoing physical and psychosocial concerns, plans for follow-up care and surveillance, lifestyle advice and optional survivorship programmes. A care plan is developed that is shared with the patient and her GP. An evaluation of the clinic has been undertaken and this article reports the findings of the clinic observations and the audit of 124 care plans to ascertain main topics discussed and ongoing referrals made.

Position Statement on Tobacco Exposures in Children and Families

Tobacco use was declared a “pediatric disease” in 1995 by the US Food and Drug Administration due to the strong connection between tobacco use/exposure in children (Kessler et al., 1997). Tobacco use and exposure are the single most preventable causes of morbidity and mortality in the United States and worldwide. The health consequences during childhood have been clearly documented, and the US Surgeon General stated in 2006 there are no safe levels of tobacco exposure (US Department of Health and Human Services, 2010a). The first position statement on tobacco exposures was developed by the Society of Pediatric Nurses (SPN) Public Policy Committee in 2004. Tobacco use, particularly among childbearing and childrearing families, has decreased slightly since 2004, though tobacco use and exposure remains a critical health issue for vulnerable populations of children and families. SPN is dedicated to supporting its members in their practice, as well as promoting the health and wellbeing of children and families. Pediatric nurses can play a pivotal role in reducing tobacco use and children’s tobacco exposure. Interventions to reduce tobacco use and exposure can include clinical advice, counseling, referral to smoking cessation, and policy changes. While most pediatric nurses may conduct these interventions in health-related settings, attention must be directed to other settings that serve children, such as preschool programs, schools, recreational programs, community settings, and others. Working together we, as pediatric nurses, can strive for the goal that all children have the right to grow up in a smokefree and healthy environment. Tobacco exposures—that is, tobacco use, secondhand smoke, or thirdhand smoke exposure—are highly prevalent

A Multidisciplinary Clinical Program Is Effective in Stabilizing BMI and Reducing Transaminase Levels in Pediatric Patients With NAFLD

Weight loss is an effective treatment for children with nonalcoholic fatty liver disease (NAFLD), but it is extremely difficult to achieve outside of an intensive weight management program. We hypothesized that one can achieve success in improving NAFLD and weight-related outcomes in a structured and focused multidisciplinary clinical program feasible to implement in a gastroenterology clinic. We prospectively tracked the clinical status of our patients enrolled in a multidisciplinary program of dietary and exercise advice through an institutional review board-approved NAFLD registry. Each patient met with a gastroenterologist and dietitian every 3 months for 30 minutes to set individualized goals and monitor progress. A total of 108 children have been enrolled in the registry, and of the 83 that were eligible for 1-year follow-up and included in the analysis, 39 patients returned, resulting in a 47% follow-up rate. These 39 patients showed statistically significant improvements in mean BMI z score (-0.1 U, P < 0.05), total (-11 mg/dL, P < 0.05) and low-density lipoprotein (9 mg/dL, P < 0.05) cholesterol, and serum alanine aminotransferase levels (-36 U/L) and aspartate aminotransferase levels (-22 U/L) levels. A clinically feasible multidisciplinary program for obese pediatric patients with NAFLD stabilized BMI z score and significantly improved aminotransferase levels at 1-year follow-up.

An identification and brief advice programme for low-risk alcohol consumption in an acute medical setting: an implementation study

ObjectivesTo implement an identification and brief advice (IBA) intervention to detect low-risk/hazardous alcohol consumption.DesignImplementation was guided through the use of quality improvement tools and training.SettingThis study was conducted over an 18-month period from April 2010 to September 2011 on a 42-bed acute medical unit at a central London acute hospital.ParticipantsAll medical patients over the age of 18 admitted to the acute assessment unit were eligible; any patient unable to provide a medical history either through language barriers or due to illness was excluded.Main outcome measuresPercentage of medical patients admitted each week to the acute assessment unit who were screened for low-risk/hazardous alcohol consumption.ResultsWeekly data were analysed in time series run charts and cross-referenced to the date of educational sessions and their effect on the uptake of screening monitored. A demonstrable change in the mean percentage number of patients screened was observed in different time periods, 67.3–80.1%, following targeted teaching on the AAU.ConclusionsOur study demonstrates the successful use of quality improvement methodology to guide the implementation of Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), an IBA intervention, in the acute medical setting. The incorporation of the AUDIT-C into an admission document has been well accepted by the junior doctors, attaining an average (mean) of 80% of patients being screened using the tool. Targeted teaching of clinical staff involved in admitting patients appears to be the most effective method in improving uptake of IBA by junior doctors.

Effects of timing of initiation and planning on smoking cessation outcomes: study protocol for a randomised controlled trial.

BackgroundRecent theoretical and empirical work has led to debate over the benefit of delaying the implementation of a decision to quit smoking in order to plan the attempt. These two need not be linked, planning can occur before a commitment to quit is made, or after it is implemented, as well as in between. This study will test whether there are independent benefits for encouraging smokers to act immediately on a definite decision to quit smoking, and to engage in structured planning.Methods/designA complex randomised controlled trial with a factorial design, testing the presence of a recommendation to quit immediately (or not) and encouragement to structured planning (or not) as additions to standard care, a web-based automated tailored advice program (QuitCoach). Participants are recruited from users of the QuitCoach who reside in Australia, do not report a mental health condition for which they are taking medication, are adult daily smokers, and at least open to the possibility of quitting. For the Immediate arm they could not have committed to quit within 2 days, while the Planning arm included all these and those quit within the last 4 days. This creates 6 groups: 2 × 3, with 2 × 2 fully randomised, and 2 only randomised for the planning arm. Follow-up assessments are conducted around 1 month (targeting two weeks after the quit attempt started), and 6 months later. The primary outcome is 6-month sustained abstinence at 6 months. Secondary outcomes include point-prevalence abstinence at both follow-ups, and making quit attempts during the intervention period. We will also explore differences in actual behaviour (timing and planning) by intervention, and relate this to outcomes.DiscussionThis study will result in a better understanding of the roles of planning and delay in influencing the success of quit attempts.Trial registrationAustralian New Zealand Clinical Trials Registry http://ACTRN12612000613808

Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial

BackgroundThe European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.Methods/designIn a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.DiscussionEffective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.Trial registrationClinicalTrials.gov. Trial identifier: NCT01501552

The First-aid Advice and Safety Training (FAST) parents programme for the prevention of unintentional injuries in preschool children: a protocol

BackgroundUnintentional injury is the leading cause of preventable death in children in the UK, and 0–4-year-olds frequently attend emergency departments following injuries in the home. Parenting programmes designed to support...

Can a Parent Do Too Much for Their Child? An Examination By Parenting Professionals of the Concept of Overparenting

Is there a point where parental effort can be too much? While the link between parenting effort and the wellbeing of children has been firmly established, contemporary discussion has proposed that extreme levels of parental protection of and responsiveness to children could be counterproductive. Research has not yet addressed this phenomenon to ascertain if overparenting is a genuinely different type of parenting approach. The purpose of the present study was to gain insight into the parenting actions considered by parenting professionals (psychologists and school guidance counsellors) to be overparenting. One hundred and twenty-eight professionals responded to an online survey about their observations of overparenting, with eighty-six respondents providing lists of the types of actions they believed were behavioural examples of the term. The survey data revealed that certain types of actions were considered to be indicative of overparenting, and that particular beliefs and outcomes may be involved in this parenting approach. Implications for parenting advice and education programs, and further research are discussed.

Population‐level effects of automated smoking cessation help programs: a randomized controlled trial

To test the population impact of offering automated smoking cessation interventions via the internet and/or by mobile phone. Pragmatic randomized controlled trial with five conditions: offer of (i) minimal intervention control; (ii) QuitCoach personalized tailored internet-delivered advice program; (iii) onQ, an interactive automated text-messaging program; (iv) an integration of both QuitCoach and onQ; and (v) a choice of either alone or the combined program. Australia, via a mix of internet and telephone contacts. A total of 3530 smokers or recent quitters recruited from those interested in quitting, and seeking self-help resources (n = 1335) or cold-contacted from internet panels (n = 2195). The primary outcome was self-report of 6 months sustained abstinence at 7 months post-recruitment. Only 42.5% of those offered one of the interventions took it up to a minimal level. The intervention groups combined had a non-significantly higher 6-month sustained abstinence rate than the control [odds ratio (OR) = 1.48; 95% confidence interval (CI): 0.98-2.24] (missing cases treated as smokers), with no differences between the interventions. Among those who used an intervention, there was a significant overall increase in abstinence (OR = 1.95; CI: 1.04-3.67), but not clearly so when analysing only cases with reported outcomes. Success rates were greater among those recruited after seeking information compared to those cold-contacted. Smokers interested in quitting who were assigned randomly to an offer of either the QuitCoach internet-based support program and/or the interactive automated text-messaging program had non-significantly greater odds of quitting for at least 6 months than those randomized to an offer of a simple information website.

The first-aid advice and safety training (fast) parent programme to prevent unintentional home injuries in preschool children

BackgroundParenting programmes that improve understanding of the relationship between injury risk, parent-child interaction, child behaviour and child development have the potential to reduce child injuries. Educational anticipatory guidance has been...

What Do We Do With Our 15 Minutes?

Primary care pediatricians give parents advice. Academic pediatricians give primary care pediatricians advice about what advice to give parents. Rarely, though, do we subject our advice to empirical trial. In “An Evaluation of Mother‐centered Anticipatory Guidance to Reduce Obesogenic Infant Feeding Behaviors” in this issue of Pediatrics , French et al1 do just that, and they deserve to be commended for the effort. Reasoning that maternal behaviors play an influential role in children’s eating, French’s team contrasted advice directed at how mothers themselves eat with 2 more traditional approaches: a widely disseminated program of feeding advice called Ounce of Prevention, and a set of messages based on Bright Futures . Each intervention was delivered at a different clinic. Children were enrolled on or before 2 months of age. By 12 months of age, there were small but statistically significant differences in parent-reported feeding behaviors favoring the mother-focused advice. The study is far from perfect. It relied on convenience samples, and, … Address correspondence to Robert Needlman, MD, Department of Pediatrics, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109. E-mail: robert.needlman{at}case.edu

Protocolo de intervenciones en Consejo Dietético Intensivo en Atención Primaria

A sedentary lifestyle and inappropriate eating habits are the main causes of major diseases (cardiovascular diseases, type 2 diabetes, and certain types of cancers), as well as a high morbidity and mortality. The Dietary Advice program was designed by the Andalusian Health Department to promote healthy habits (i.e. physical exercise and a balanced diet) to prevent secondary diseases. This program is organised in two phases: Basic Dietary Advice and Intensive Dietary Advice. This paper aims to describe the interventions protocol on the intensive dietary phase of the program focused on the promotion on changes in people's lifestyles from a multi-factorial approach. The program consisted of two individual nurse visits, five workshops and nursing follow up clinics. The individual visits ensured that the team learned of each person needs; likewise, the group activities were aimed at improving the transmission of knowledge and the acquisition of skills, abilities and attitudes towards healthier lifestyles.

Changes in body weight and food choice in those attempting smoking cessation: a cluster randomised controlled trial.

BackgroundFear of weight gain is a barrier to smoking cessation and significant cause of relapse for many people. The provision of nutritional advice as part of a smoking cessation programme may assist some in smoking cessation and perhaps limit weight gain. The aim of this study was to determine the effect of a structured programme of dietary advice on weight change and food choice, in adults attempting smoking cessation.MethodsCluster randomised controlled design. Classes randomised to intervention commenced a 24-week intervention, focussed on improving food choice and minimising weight gain. Classes randomised to control received “usual care”.ResultsTwenty-seven classes in Greater Glasgow were randomised between January and August 2008. Analysis, including those who continued to smoke, showed that actual weight gain and percentage weight gain was similar in both groups. Examination of data for those successful at giving up smoking showed greater mean weight gain in intervention subjects (3.9 (SD 3.1) vs. 2.7 (SD 3.7) kg). Between group differences were not significant (p = 0.23, 95% CI −0.9 to 3.5). In comparison to baseline improved consumption of fruit and vegetables and breakfast cereal were reported in the intervention group. A higher percentage of control participants continued smoking (74% vs. 66%).ConclusionsThe intervention was not successful at minimising weight gain in comparison to control but was successful in facilitating some sustained improvements in the dietary habits of intervention participants. Improved quit rates in the intervention group suggest that continued contact with advisors may have reduced anxieties regarding weight gain and encouraged cessation despite weight gain. Research should continue in this area as evidence suggests that the negative effects of obesity could outweigh the health benefits achieved through reductions in smoking prevalence.Trial registrationCurrent Controlled Trials ISRCTN73824458

‘I know I'm a good mom’: Young, low-income mothers’ experiences with risk perception, intensive parenting ideology and parenting education programmes

Intensive mothering, which fits within neo-liberal notions of individual responsibility and risk management, and is based on middle-class ideals, is widely accepted as the ‘proper’ mode of child rearing. Intensive mothering ideology also intersects culturally with expanding notions of risks to children's wellbeing and increasing portrayals of parents as risk factors in their children's lives. State-driven interventions aimed at promoting intensive mothering practices and maximising child outcomes target young and low-income mothers as particular risk groups. This study explored the experiences of young, low-income mothers with intensive parenting advice and educational programmes that focused on child cognitive development. Intensive mothering expectations, and the mandated programmes that promoted them, were experienced as a prescriptive and regulative force in participants’ lives, and age and social class intersected to influence these experiences. Despite this, participants negotiated their own self-perceptions regarding motherhood by resisting, to some extent, the internalisation of intensive mothering ideals, and critiquing the validity of the advice. As a result, the guilt and self-discipline that often accompany intensive mothering for older middle-class mothers were largely absent for this group. Findings also suggest that the provision of basic needs is a potentially more effective policy direction for improving child and maternal well-being than the current neo-liberal focus on risk targeting, education and surveillance.

Persistence of uncontrolled cardiovascular risk factors in patients treated with percutaneous interventions for stable coronary artery disease not receiving cardiac rehabilitation

Cardiac rehabilitation programmes are strongly recommended for all forms of coronary artery disease to reduce recurrent events and mortality. Few patients seem to participate in these programmes after elective percutaneous coronary intervention (PCI). The aim of this study was to assess changes in lifestyle and risk factors after PCI for patients with stable disease and not included in cardiac rehabilitation programmes. We prospectively enrolled 207 consecutive patients with stable disease who underwent a first elective PCI. Follow up was performed at 13.0 ± 3.2 months for 94.7%; 28 patients were excluded due to participation in a cardiac rehabilitation programme. Baseline values from admission sheets were compared to follow up values collected from the treating physician. At follow up, systolic and diastolic blood pressures dropped (p = 0.001) as well as the prevalence of hypertension (p < 0.001). Significant reductions in cholesterol (p < 0.001) and blood glucose (p = 0.004) were also noted. Low-density lipoprotein levels stayed outside target in 47.2% and high-density lipoprotein levels in 75.0% of patients initially presenting with lipid disorders. Obesity prevalence remained high at follow up. Only 45.6% were performing regular physical exercise and 8.3% of smokers quit smoking. Only 13.3% attended any form of dietary advice programme. HADS-A score was 5.1 ± 3.9 and the HADS-D score was 3.8 ± 3.6. SF 36 questionnaire revealed a good quality of life with a mean value of 45.6 for physical and 42.9 for mental wellbeing. A considerable percentage of patients receiving PCI for stable angina do not achieve lifestyle and risk factor goals and therefore remain at increased risk for recurrent events. Efforts should be initiated to better implement guidelines that strongly recommend secondary prevention through cardiac rehabilitation after elective PCI.

EXERCISE IN KIDNEY DISEASE AND DIABETES: TIME FOR ACTION

SUMMARYPhysical inactivity is well recognised as a major health issue in today's society. Regular exercise is important in maintaining health and preventing chronic disease, it is increasingly accepted as a valuable therapeutic intervention in many long‐term conditions. Unfortunately the role of physical activity in renal disease has been largely overlooked and provision of exercise advice and rehabilitation programmes for kidney patients lags well behind that of cardiology and pulmonary services. Research indicates that exercise can impact positively upon many of the health issues associated with declining renal function and renal replacement therapy, as concluded by a recent Cochrane review on the topic. As exercise should be integral to the management of diabetes, the issue is particularly relevant for patients with diabetic kidney disease. This paper summarises what is known about the main effects of exercise training in chronic kidney disease and diabetic kidney disease, and suggests how adaptations in the attitudes and approaches of the multidisciplinary renal and diabetes healthcare teams can help patients to enjoy the diverse benefits of an appropriately active lifestyle.

What do patients do with access to their medical records?

We sought to study the phenomenon of patients having access to their own medical records in order to determine the impact on them and on their relationship with their health care providers. We created the Patient Clinical Information System (PatCIS) to interface with the clinical data repository at New York Presbyterian Hospital to allow patients to add to and review their medical data. We also provided educational resources and automated advice programs. We provided access to the system to thirteen subjects over a nineteen-month period and reviewed their activities in the system's usage log. We also collected data via questionnaire and telephone interview. We found that patients varied in their use of the system, from once a month or less to one or more times per day. All patients primarily used the system to review laboratory results. Both they and their physicians believed that use of the system enhanced the patients' understanding of their conditions and improved their communication with their physicians. There were no adverse events encountered during the study.

Prescriber Feedback to Improve Quality Use of Medicines among Older People: the Veterans' MATES Program

ABSTRACTSince 2004, the Department of Veterans' Affairs (DVA) has funded the Veterans' Medicines Advice and Therapeutics Education Services (MATES) program. The main intervention of the program is quarterly targeted patient‐specific prescriber feedback. The feedback comprises a list of relevant medications dispensed to each patient and notes about potential medication‐related problems specific to the intervention. Supportive educational material is provided to assist general practitioners (GPs) resolve these medication‐related problems. Veterans identified in the GP mailing are sent an educational brochure highlighting medication issues and encouraging them to speak with their doctor. To enable pharmacists to support this practice change, educational material is also provided to all pharmacies and accredited pharmacists. The most recent of the 28 interventions implemented to date have addressed osteoporosis, opioid‐induced constipation and urinary incontinence. Overall, program materials have been mailed to 249 454 veterans, 34 527 GPs and around 8000 pharmacies and accredited pharmacists. Evaluation has demonstrated a doubling of home medicines review (HMR) rates in the veteran population. Analyses of the DVA data have reported a 45% reduction in hospitalisation for heart failure following HMR among veterans with heart failure (adjusted hazard ratio [HR] 0.6; 95% confidence interval [CI] 0.4–0.8), and a 79% reduction in hospitalisation for haemorrhage (HR 0.2; 95%CI 0.05–0.9) 2 to 6 months after an HMR in veterans dispensed warfarin. Veterans' MATES has resulted in clinically significant improvements in medication and health service use.

PHP38 Market Access for Pharmaceuticals in UK: Number and Speed of Drug Reviews to Improve After Introduction of Value Based Pricing

This study seeks to evaluate the impact on market access for pharmaceuticals in the UK following the introduction of Value Based Pricing (VBP). SMC advice and final NICE guidance issued between 1 June 2010 and 31 May 2011 were assessed to determine the number and outcome of total appraisals, of Single Technology Appraisals (STAs), and of appraisals based on a manufacturer submission. The current duration of a NICE STA review and the time required to provide guidance under the NICE Scientific Advice Programme were also reviewed. Under VBP, all new originator drugs entering the market and all new indications of existing medicines will be reviewed: as is the case currently in Scotland. Over the 12-month period, the SMC reviewed a total of 101 new drugs or indications, of which 18 were resubmissions, so a total of 83 original reviews were performed. NICE – which only reviews treatments it is commissioned to review by the DH – conducted 28 STAs. Some 47% of SMC drug reviews resulted in positive guidance – rising to 58% among reviews based on a manufacturer submission. The average length of a NICE technology appraisal is 18 months; however, NICE scientific guidance can be provided in as little as 15 weeks. Pharmaceutical market access in England and Wales will potentially improve following the introduction of VBP as more products are reviewed in a more timely manner. Three times more originator medicines or new indications will be reviewed in comparison to the number currently reviewed by NICE. The average duration of an appraisal under VBP could to be just 15 weeks – 19.2% of the time currently required. On the negative side, manufacturers would be expected to offer products at an acceptable price – calculated in accordance with yet-to-be-finalised criteria – in exchange for gaining reimbursement.

The development of a new service for the management of Non-inflammatory Musculoskeletal Pain

Methods The business plan was developed by senior multidisciplinary members of the Rheumatology team. The new service was set up and then specific outcome measures were followed after 1 year to monitor the success and effectiveness of the treatments. Results The service was funded to employ af ull time Physiotherapist (PT), occupational therapist (OT), psychologist (Psych) and administrator. Outpatient appointments were established and patients were placed into the new service. The initial appointment was in a new-patient clinic and they were assessed by a Consultant paediatric Rheumatologist and a specialist physiotherapist. This initial assessment ensured that there was no other diagnosis other than a non-inflammatory condition such as hypermobility syndrome; the patient was then referred to PT, OT and Psych as appropriate. The treatments included individualised home muscle strength training programme, life style advice, group patient and parent education programmes and individualised pain management interventions. Specific Outcome measures (OCM) were used to monitor the success of the treatments provided. The most significant OCM’s were:  School attendance which increased from 75% missing at least 1 day a week due to pain to only 7%.  Loss of muscle strength in 98% of children which was resolved in 100% of those who completed the programme given.  Participation in PE also increased from 25% participating to 75% joining in sport at school.  The cost of providing the staff and facilities was only 30% of the revenue the service brought into the hospital. Conclusion The establishment of a dedicated service to the management of NIMPS has been shown to be both clinically and cost effective and has worked extremely well as an AHP led service enabling the medical staff to focus upon inflammatory diseases.