Allied Health Care Providers Research Articles

Identifying strategies to improve diabetes care in Alberta, Canada, using the knowledge-to-action cycle.

Strategic clinical networks, a recent development in the health system in Alberta, have been charged with bringing together front-line clinicians, researchers and policy-makers to identify variation in clinical care, and to propose standards, pathways and innovative solutions to improve access and quality of care. Here, we describe a collaborative workshop held between researchers and the Obesity, Diabetes and Nutrition Strategic Clinical Network to describe barriers to and facilitators of care for people with diabetes and to identify quality improvement interventions that should be prioritized. Through collaboration between health researchers and the strategic clinical network, and using principles of the knowledge-to-action cycle, we identified barriers to and facilitators of diabetes care using data from a patient survey and a provider focus group (5 primary care physicians and 1 diabetes educator). In addition, we identified best evidence from a systematic review of quality improvement initiatives in diabetes. This information was reviewed at a multistakeholder workshop where potential quality improvement initiatives were considered at various service levels. A pilot survey involving 59 patients with diabetes and a focus group of primary care and allied health care providers identified several important barriers to optimal outcomes in diabetes care, including patient-level financial barriers to care and difficulty navigating the health system. Our collaborative discussion using the knowledge-to-action cycle prioritized feasible, evidence-based interventions to improve outcomes for patients with diabetes, including enabling care by allied health care providers and creating clear care maps and processes for system navigation. We identified important barriers to achieving optimal outcomes in diabetes that may be overcome through the use of evidence-based quality improvement interventions. As recommended within the knowledge-to-action cycle, future research is required to determine whether program implementation improves outcomes and is cost-effective.

Designing and Using Computer Simulations in Medical Education and Training: An Introduction

Computer-based technologies informed by the science of learning are becoming increasingly prevalent in education and training. For the Department of Defense (DoD), this presents a great potential advantage to the effective preparation of a new generation of technologically enabled service members. Military medicine has broad education and training challenges ranging from first aid and personal protective skills for every service member to specialized combat medic training; many of these challenges can be met with gaming and simulation technologies that this new generation has embraced. However, comprehensive use of medical games and simulation to augment expert mentorship is still limited to elite medical provider training programs, but can be expected to become broadly used in the training of first responders and allied health care providers. The purpose of this supplement is to review the use of computer games and simulation to teach and assess medical knowledge and skills. This review and other DoD research policy sources will form the basis for development of a research and development road map and guidelines for use of this technology in military medicine.

Role of the nurse practitioner in providing palliative care in long-term care homes

The purpose of this study, which was part of a large national case study of nurse practitioner (NP) integration in long-term care (LTC), was to explore the NP role in providing palliative care in LTC. Using a qualitative descriptive design, data was collected from five LTC homes across Canada using 35 focus groups and 25 individual interviews. In total, 143 individuals working in LTC participated, including 9 physicians, 20 licensed nurses, 15 personal support workers, 19 managers, 10 registered nurse team managers or leaders, 31 allied health care providers, 4 NPs, 14 residents, and 21 family members. The data was coded and analysed using thematic analysis. NPs provide palliative care for residents and their family members, collaborate with other health-care providers by providing consultation and education to optimise palliative care practices, work within the organisation to build capacity and help others learn about the NP role in palliative care to better integrate it within the team, and improve system outcomes such as accessibility of care and number of hospital visits. NPs contribute to palliative care in LTC settings through multifaceted collaborative processes that ultimately promote the experience of a positive death for residents, their family members, and formal caregivers.

Patterns of follow-up in oncologic care across Canada.

e20589 Background: With continual advancements in cancer care, improved outcomes and increasing survivor populations, cancer survivorship has become an important area of research. Methods: A 35-question electronic survey was sent to physician members of the Canadian Association of Radiation Oncologists. Based on their scope of practice, respondents were presented with brief clinical scenarios pertaining to various survivor populations. A subsequent series of questions were posed to determine routine follow-up practices. Results: In total, 111 radiation oncologists (RO) responded (44% response rate); 29% were female, 43% were in practice less than 10 years, and most regions of Canada were well represented. Most worked in centers staffed by more than 10 oncologists (69%), and saw more than 200 new patient consults per year (78%). 10% would not follow patients routinely, mainly in cases involving breast or prostate survivors. 73% of such patients (73%) would be followed by their primary care providers (PCP) whereas ROs would follow their CNS, GI, HN and GYNE patients. Lack of resources (55%) and a belief that follow-up by PCPs is equally effective (55%) were the top two reasons for not following patients. Treatment toxicity (92%) and the possibility of salvage or palliative treatment (86%) were the two most common reasons for routine follow-up. The majority (55%) of ROs follow patients for < 5 years, with 36% following for 5-10 years, and a minority (9%) following for longer than 10 years. 54% would not change the frequency of their follow-up, but 39% would decrease and only 7% would make no change. Workload and lack of resources were major barriers to follow-up, but in addition, many felt that follow-up by FPs or Advanced Practice Nurses could be equally effective. Some felt this would require additional training and more guidelines to make this effective. Conclusions: The majority of ROs follow their patients, especially when salvage treatment is possible. A significant portion would decrease their follow-up in frequency because of workload burden, resource limitations and a belief that there can or should be increased involvement from FPs and other allied health care providers.

Translating an Evidence-Based Lifestyle Intervention Program Into Primary Care

The E-LITE (Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care) trial evaluated the feasibility and potential effectiveness of translating an evidence-based lifestyle intervention for the management of obesity and related risk factors in a primary care setting. Delivered by allied health care providers, the intervention promoted at least 7% weight loss and at least 150 minutes per week of moderate-intensity physical activity through gradual, sustainable lifestyle changes. Activities included interactive group lessons, food tasting, guided physical activity, and technology-mediated self-monitoring and behavioral counseling. This article discusses insights and potential areas for improvement to strengthen program implementation for dissemination of the E-LITE program to other primary care settings. We focus on (a) the role of allied health professionals in program delivery, (b) strengthening program integration within a primary care clinic, and (c) the use of information technology to extend the reach and impact of the program. Our experience shows the feasibility of implementing an evidence-based lifestyle intervention program combining group-delivered nutrition and behavioral counseling, physical activity training, and technology-mediated follow-up in a primary care setting. Challenges remain, and we offer possible solutions to overcome them.

2257 MEDICAL EXPULSION THERAPY IS UNDERUTILIZED IN WOMEN PRESENTING TO AN EMERGENCY DEPARTMENT WITH ACUTE URINARY STONE DISEASE

You have accessJournal of UrologyStone Disease: Evaluation & Medical Management (II)1 Apr 20132257 MEDICAL EXPULSION THERAPY IS UNDERUTILIZED IN WOMEN PRESENTING TO AN EMERGENCY DEPARTMENT WITH ACUTE URINARY STONE DISEASE Herman Bagga, Ayesha Appa, Ralph Wang, Thomas Chi, Joe Miller, Jersey Neilson, Rebecca Smith-Bindman, and Marshall Stoller Herman BaggaHerman Bagga San Francisco, CA More articles by this author , Ayesha AppaAyesha Appa San Francisco, CA More articles by this author , Ralph WangRalph Wang San Francisco, CA More articles by this author , Thomas ChiThomas Chi San Francisco, CA More articles by this author , Joe MillerJoe Miller San Francisco, CA More articles by this author , Jersey NeilsonJersey Neilson San Francisco, CA More articles by this author , Rebecca Smith-BindmanRebecca Smith-Bindman San Francisco, CA More articles by this author , and Marshall StollerMarshall Stoller San Francisco, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2166AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Medical expulsion therapy (MET) with alpha-adrenergic blockade (AB) is an established treatment option for the management of ureteral stones. Multiple studies have noted low utilization of MET in the Emergency Department (ED), however specific reasons for this phenomenon remain largely unknown. Given that AB agents are most typically associated with male urologic conditions such as benign prostatic hyperplasia (BPH), we hypothesized that the underutilization of MET would be most pronounced in women as AB medications are typically used for men with BPH. METHODS Retrospective chart review of patients with an ED diagnosis of urinary stone disease between 2006-2012 was undertaken to identify patient variables related to presentation, history, management, and disposition. We excluded patients with incomplete medical records or a known diagnosis of stone disease within the previous month. RESULTS Between 2006-2012, 729 patients presented to an ED with acute renal colic and were diagnosed with urinary stone disease. 92.9% (677) of all patients were discharged from the ED. Amongst discharged patients, 60.3% (408) were prescribed AB (commonly tamsulosin). 5.5% (40) were discharged with steroids for MET, with 90% (36) of these patients also receiving AB. 36.9% (269) of patients were discharged without any MET. Of those discharged without MET, 34.4% (84 patients) had CT or ultrasound imaging evidence of a ureteral stone. 38% (277) of all patients were female. When considering gender, 48.8% of women (120) were discharged without MET compared to 39.2% (177) of men (p < 0.05). Variables predictive of discharge without MET included female gender (OR 1.8, 95% CI 1.3-2.5, p < 0.05) and clinical diagnosis without use of imaging studies (OR 1.95, 95% CI 1.25-3.06, p < 0.05). Neither age nor a history of stone disease were significantly associated with likelihood of discharge with MET. CONCLUSIONS MET was utilized in only 60% of patients diagnosed with an acute urinary stone in a tertiary care ED, despite a significant portion of patients demonstrating the presence of ureteral stone(s) on imaging. Women were nearly half as likely to receive MET compared to men. We propose that this may be due to providers' perception that AB agents are drugs for male urologic conditions such as BPH. Increased awareness of the underutilization of MET, particularly in women, may help to promote its appropriate use amongst emergency department physicians and other allied health care providers. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e925-e926 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Herman Bagga San Francisco, CA More articles by this author Ayesha Appa San Francisco, CA More articles by this author Ralph Wang San Francisco, CA More articles by this author Thomas Chi San Francisco, CA More articles by this author Joe Miller San Francisco, CA More articles by this author Jersey Neilson San Francisco, CA More articles by this author Rebecca Smith-Bindman San Francisco, CA More articles by this author Marshall Stoller San Francisco, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Orthotopic Bladder Substitution (Neobladder)

Bladder replacement following radical cystectomy is widely practiced and in some centers has become the standard method of urinary diversion when possible, rather than the traditional ileal conduit. To minimize the impact of cystectomy and bladder replacement on quality of life and to obtain optimal functional results, postoperative care must be comprehensive and multidisciplinary. Critical team members include the surgeon, urologic nurses, WOC nurses, and allied health care providers such as physiotherapists. This article highlights postoperative considerations for patients undergoing radical cystectomy with orthotopic neobladder construction. The common issues and complications that arise are discussed with a focus on strategies to optimize outcomes.

Current Practice Patterns and Identified Educational Needs of Health Care Providers in Managing Patients With Type 2 Diabetes

IN BRIEF This article describes the results of surveys distributed to a national audience of specialty, primary care, and allied health care providers (HCPs) who manage patients with type 2 diabetes on a daily basis. The results provide insights into current educational needs and can inform the design and development of education programs for these HCPs.

Drug information service awareness program and its impact on characteristics of inquiries at DIS unit in Malaysian public hospital

Objectives: To study the Drug Information Service (DIS) awareness program organized by a DIS unit in Malaysian hospital through utilization of provided services by the healthcare professionals, allied healthcare providers, patients and the public, and to identify the characteristics of inquiries received. Materials and Methods: An awareness program to promote the services of the DIS unit was held throughout the month of March in 2010. Drug information queries forms that have been documented six months prior to (September 2009–February 2010) and six months after (April–September 2010) the awareness program were collected and assessed. Mean monthly inquiries volumes pre- and post-program were compared to evaluate the effectiveness of the program. Types of information requestors, inquiries, reference sources, and drug class information were identified and evaluated. Results: A total of 747 drug information queries forms were received during the study period. The mean total utilization of the DIS unit services after (63.67 ± 18.24) the DIS awareness program was increased but not significant (P < 0.05) when compared to records before (60.83 ± 21.49) the program. Majority of the DIS service users were the pharmacist (67.5%), followed by the doctors (24.9%). Most inquiries were regarding the dosage and route of administration of drugs (61.4%). The most frequently referred sources of information were the Micromedex and the Internet (37.3%). The most common inquiries were related to the anti-infective agents (37.8%). Conclusion: Provision of sufficient and accurate drug information to the healthcare professionals, patients, and the public is crucial to ensure optimization of therapy. The utilization of services provided by the DIS unit should be supported. Frequent DIS awareness program should be undertaken to promote and encourage the use of services.

Defining primary care sensitive conditions: a necessity for effective primary care delivery?

Primary care is a major component of England's National Health Service (NHS), responsible for approximately 300 million consultations per year with GPs in England, which represents 70-90% of all patient contacts with the NHS. In addition to providing healthcare to the registered population, GPs are charged with coordination and gatekeeping of access to services provided by secondary care, tertiary care and other allied healthcare providers. As GPs will be assuming a key role in commissioning health services in England, there is a clear opportunity to re-model care delivery to maximize outcomes, cost efficiency and patient access by focusing on diseases that are most amenable to management in primary care. It is essential that there is evidence to inform what conditions are most sensitive to management in primary care - commonly referred to as primary care sensitive conditions or ambulatory care sensitive conditions. Such definitions would aid resource planning, drafting of local management protocols and simplification of the interface between primary and secondary care for a number of chronic conditions. Indeed, inappropriate utilization of secondary care resources is likely to represent a significant opportunity cost to healthcare providers and may be less desirable for patients.

Perceptions of Cardiac Specialists and Rehabilitation Programs Regarding Patient Access to Cardiac Rehabilitation and Referral Strategies

Access to cardiac rehabilitation (CR) remains at approximately 30%, despite a national target of 70%. This study evaluated cardiac specialist and CR program perceptions of CR access and referral strategies. Postal and online surveys of Canadian CR specialists and CR programs were administered. Responses were received from 71 of 765 CR specialists (9.3%) and 92 of 149 CR programs (61.7%). Respondents rated perceptions on 5-point Likert scales. Specialists rated patient access to CR as moderate (2.9 ± 1.4). While they reported that they refer 65.9% of their patients, they most frequently do not refer because their patients report disinterest (23.4%) or geographic barriers to access (23.4%). Cardiac rehabilitation programs reported having capacity to serve a median of 275 patients annually, yet reportedly serving up to 350. The most commonly used methods of referral included discharge order sets (over 60%) and allied health care provider support. Electronic referral was perceived to be highly effective (4.1 ± 1.0) yet the least frequently used. Cardiac rehabilitation programs perceived more patients are accessing CR because of these referral strategies, but increased patients strain program resources. Some of the least frequently used referral strategies were perceived as, and are also empirically demonstrated to be, most effective. Broader implementation of these strategies, while better-resourcing CR programs, may improve the continuum of care for cardiac patients.

Transition of Patients with COPD Across Different Care Settings: Challenges and Opportunities for Hospitalists

Hospitalists play an important role in treating current and preventing future acute exacerbations of chronic obstructive pulmonary disease (AECOPD), which are associated with high rates of medical resource use and morbidity. Comprehensive admission screening and diagnostic tests are important in enabling hospitalists to reliably identify patients with AECOPD, the severity of the episode, and related issues that may prolong patients' hospital length of stay. Recurring exacerbations, especially those that require repeated acute care, can reduce physical activity and accelerate pulmonary decline and risk of death. Recommended pharmacotherapies for AECOPD should include short-acting bronchodilators, systemic corticosteroids, and appropriate antibiotics in cases of suspected bacterial infection. Patients with demonstrable hypoxemia or respiratory failure may benefit from oxygen and/or ventilatory support. Long-term disease management with the goal of preventing future exacerbations should include ongoing emphasis toward smoking cessation and up-to-date vaccination, in addition to prescribing maintenance pharmacotherapies in accordance with respiratory treatment guidelines. Additional benefits may be derived from nonpharmacologic therapies, such as pulmonary rehabilitation, weight-loss recommendations, and treatment of obstructive sleep dyspnea when present. Effective communication among members of the inpatient and outpatient health care teams, the patient, and his or her caregivers is an important aspect of care transitions. Hospital discharge summaries should be transmitted to the patient's primary care physician and be readily available at the first follow-up visit. Discharge coaches and other allied health care providers can aid hospitalists in reinforcing self-management skills and patient education, and in emphasizing the importance of follow-up visits. Recent findings suggest that health and cost benefits are associated with improved COPD management. This article focuses on the pivotal role of the hospitalist in promoting and facilitating the steps toward improving quality outcomes and transitions of care for patients with COPD.

Oefening Baart Kunst—“Exercise Bears (Gives Birth To) Art”: Symposium for and by the Allied Health Professions of the NVDMG, Medisch Centrum Haaglanden, Den Haag, February 5, 2011

On Saturday, February 5th, 2011, the Dutch Performing Arts Medicine Association (Nederlandse Vereniging voor Dans- en MuziekGeneeskunde, NVDMG) organized a Symposium for and by allied health care professionals, held in the Medisch Centrum Haaglanden (MCH, Medical Centre of The Hague). Allied health care professionals, such as physiotherapists, manual therapists, Mensendieck therapists, speech therapists, and foot therapists, form a vital and indispensable link in the chain of healthcare and cure for dancers, musicians, and singers. The intention of the symposium was to highlight the practical and experience-related approach of allied health care providers, both in the presentations and in the artistic intermezzi. Apart from the exchange of knowledge and experience, there was ample opportunity for informal contact, facilitating and stimulating the formation of an interdependent network of allied health care providers specialized and/or interested in dance, music, and singing in The Netherlands.

From the Editors’ Desk: The July Effect

While the heat outside may be stifling, at America’s teaching hospitals, July brings a waft of fresh air. Senior residents have graduated, new interns have arrived. The wards are abuzz with excitement. We know colleagues who ask for ward duty assignments in July, just for the thrill of it. “The interns hang on your every word,” they say. “It’s a good feeling.” This July brings a surfeit of good feelings, but there will be challenges as well. New residency work hour rules proposed by the Accreditation Council for Graduate Medical Education (ACGME) in 2010 are due to take effect this month. The rules call for increased supervision of physicians-in-training, tighter limits on moonlighting, and reduced work hours for first-year residents. With interns limited to shifts of 16 hours, residency programs have been scrambling to create new call schedules and systems for cross-coverage. No one really knows what will happen. By imposing uniform work hours on a national basis, the ACGIM has impeded our ability to learn about which specific standards result in better outcomes. As SGIM member Kevin Volpp and colleagues pointed out in the Annals of Internal Medicine late last year, “The main disadvantage of the [regulatory] approach is that there is no ability to determine whether different standards would have worked better to reduce resident fatigue while improving patient safety.” Fortunately, other initiatives to improve the quality and safety of patient care are undergoing more careful scientific scrutiny, many in the pages of this journal. For example, in this issue Simon et al. show that online messaging improves patient follow-up for depression compared with usual care. While prior randomized clinical trials have clearly demonstrated that care management programs improve clinical outcomes in depression, this study may well be the first that uses online messaging to deliver follow up care to patients initiating antidepressant treatment. Antidepressant adherence and patient satisfaction both improved in the intervention arm of the study. Conversations about resuscitation status are challenging for doctors. Worse, they often leave patients and families agitated and confused. As Yuen et al. argue in a comprehensive review of the topic, part of the reason is that DNR discussions occur too late to allow patient participation in the process. Proposed solutions include promoting cultural change within hospitals, imposing new standards for DNR discussions, providing better training to clinicians, and creating financial incentives that encourage more comprehensive DNR discussions. With the passage of the Affordable Care Act (ACA), health care reform is certain, but the exact form that it will take (and that will pass muster by the Supreme Court) is still unclear. The only certainty is that reform will be accompanied by acrimonious debate. We are pleased to announce that JGIM is leaping into the fray by launching a new series of Health Policy Perspectives by nationally renowned policy experts. Implementation of reform will impact the delivery system around the country for millions of Americans, and these changes will have important implications for general internists. In the current issue, we begin with a commentary by Mark Hall, JD, one of the nation's leading scholars in health care policy and law. Mr. Hall’s commentary serves as a good example of how health care reform may affect general internists, given the important role that many internists play in safety net organizations that serve those lacking adequate health insurance. In the coming months, stay tuned for more contributions tackling key aspects of health care reform. These Perspectives will explore topics as varied as the role of allied health care providers under the ACA and the impact of the ACA on Medicaid programs. One message that resounds throughout these contributions is that while it is tough to make predictions about where health care reform is going, general internists will continue to be key stakeholders in the debate.

Systematizing Inpatient Referral to Cardiac Rehabilitation 2010

Despite recommendations in clinical practice guidelines, evidence suggests cardiac rehabilitation (CR) referral and use following indicated cardiac events is low. Referral strategies such as systematic referral have been advocated to improve CR use. The objective of this policy position is to synthesize evidence and make recommendations on strategies to increase patient enrollment in CR. A systematic review of 6 databases from inception to January 2009 was conducted. Only primary, published, English-language studies were included. A meta-analysis was undertaken to synthesize the enrollment rates by referral strategy. In all, 14 studies met inclusion criteria. Referral strategies were categorized as systematic on the basis of use of systematic discharge order sets, as liaison on the basis of discussions with allied health care providers, or as other on the basis of patient letters. Overall, there were 7 positive studies, 5 without comparison groups, and 2 studies that reported null findings. The combined effect sizes of the meta-analysis were as follows: 73% (95% CI, 39%-92%) for the patient letters ("other"), 66% (95% CI, 54%-77%) for the combined systematic and liaison strategy, 45% (95% CI, 33%-57%) for the systematic strategy alone, and 44% (95% CI, 35%-53%) for the liaison strategy alone. In conclusion, the results suggest that innovative referral strategies increase CR use. Although patient letters look promising, evidence for this strategy is sparse and inconsistent at present. Therefore we suggest that inpatient units adopt systematic referral strategies, including a discussion at the bedside, for eligible patient groups in order to increase CR enrollment and participation. This approach should be considered best practice for further investigation.

Systematizing Inpatient Referral to Cardiac Rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society Joint Position Paper: Endorsed by the Cardiac Care Network of Ontario

Despite recommendations in clinical practice guidelines, evidence suggests cardiac rehabilitation (CR) referral and use following indicated cardiac events is low. Referral strategies such as systematic referral have been advocated to improve CR use. The objective of this policy position is to synthesize evidence and make recommendations on strategies to increase patient enrollment in CR. A systematic review of 6 databases from inception to January 2009 was conducted. Only primary, published, English-language studies were included. A meta-analysis was undertaken to synthesize the enrollment rates by referral strategy. In all, 14 studies met inclusion criteria. Referral strategies were categorized as systematic on the basis of use of systematic discharge order sets, as liaison on the basis of discussions with allied health care providers, or as other on the basis of patient letters. Overall, there were 7 positive studies, 5 without comparison groups, and 2 studies that reported null findings. The combined effect sizes of the meta-analysis were as follows: 73% (95% CI, 39%-92%) for the patient letters (“other”), 66% (95% CI, 54%-77%) for the combined systematic and liaison strategy, 45% (95% CI, 33%-57%) for the systematic strategy alone, and 44% (95% CI, 35%-53%) for the liaison strategy alone. In conclusion, the results suggest that innovative referral strategies increase CR use. Although patient letters look promising, evidence for this strategy is sparse and inconsistent at present. Therefore we suggest that inpatient units adopt systematic referral strategies, including a discussion at the bedside, for eligible patient groups in order to increase CR enrollment and participation. This approach should be considered best practice for further investigation.

Primary health care service delivery networks for the prevention and management of type 2 diabetes: using social network methods to describe interorganisational collaboration in a rural setting

Adults with type 2 diabetes or with behavioural risk factors require comprehensive and well coordinated responses from a range of health care providers who often work in different organisational settings. This study examines three types of collaborative links between organisations involved in a rural setting. Social network methods were employed using survey data on three types of links, and data was collected from a purposive sample of 17 organisations representing the major provider types. The analysis included a mix of unconfirmed and confirmed links, and network measures. General practices were the most influential provider group in initiating referrals, and they referred to the broadest range of organisations in the network. Team care arrangements formed a small part of the general practice referral network. They were used more for access to private sector allied health care providers and less for sharing care with public sector health services. Involvement in joint programs/activities was limited to public and non-government sector services, with no participation from the private sector. The patterns of interactions suggest that informal referral networks provide access to services and coordination of care for individual patients with diabetes. Two population subgroups would benefit from more proactive approaches to ensure equitable access to services and coordination of care across organisational boundaries: people with more complex health care needs and people at risk of developing diabetes.

Mayer D. Essential evidence based medicine.

Mayer D. Essential Evidence-Based Medicine. 2nd edition. Cambridge, UK: Cambridge University Press, 2010. ISBN: 9780521540278, 392pp, £29.99. The aim of this impressive book is to improve the reader’s ability to critically analyse scientific and clinical studies in order to practice evidence-based medicine. Topics covered include searching the medical literature, errors and bias in studies, diagnostic tests, randomized controlled trials (RCTs), decision analysis and quantifying patient values, and meta-analysis and systematic reviews. Each of the topics is presented with plenty of useful clearly explained examples. The target audience is people new to evidence-based medicine including medical students, residents, allied healthcare providers and practising physicians. The book provides an easy-to-follow introduction to the main areas, and …

Osteoporosis Knowledge Among Individuals With Recent Fragility Fracture

To evaluate osteoporosis knowledge among patients with fractures and to evaluate factors associated with osteoporosis knowledge. Patients with fragility fractures participated in a telephone interview. Participants were asked what they thought osteoporosis was. Unadjusted odds ratios (OR, 95% CI) were calculated to identify factors associated with a correct definition. Predictors identified in univariate analysis were entered into multivariable logistic regression models. A subset also completed the Facts on Osteoporosis Quiz. One hundred twenty-seven patients (82% women) participated in the study, with mean (SD) age being 67.5 (12.7) years. Ninety-five (75%) respondents gave correct osteoporosis definitions. The odds of an individual providing a correct definition of osteoporosis were higher for those who reported a diagnosis of osteoporosis or those who reported higher education levels, but the odds decreased with increasing age. A total of 49 (39%) respondents completed the Facts on Osteoporosis Quiz; the average score was 13.6 (3.8) of 21. Areas that respondents scored poorly on were related to key risk factors. Many patients with fractures are unaware of important risk factors. Education initiatives aimed at improving osteoporosis knowledge should be directed at individuals at high risk of fracture. Nurses and other allied healthcare providers working in fracture clinics, acute care, and rehabilitation settings are in an ideal position to communicate information about osteoporosis and fracture risk to individuals with a recent fragility fracture.

Who Helps the Helper? Lessons on Grieving for Athletic Trainers

Context: Grief is something that will touch all of us. We expect loss to occur in our personal lives and seem to be somewhat prepared for how to cope with it when it happens. In the profession of athletic training, we may not expect loss to occur as readily--especially if we are working with a young, seemingly healthy population. As such, when an athlete, student, or colleague suffers a catastrophic injury, illness, or death, we may not be able to process the loss and be left with unresolved grief. Objective: The purpose of this article is to review theories on grief, identify successful interventions by allied health care providers and offer suggestions on how to implement teaching strategies within athletic training curriculum regarding the issues of death, dying, and coping strategies. Data Sources: We searched various databases, including MEDLINE, ERIC, SportDiscus, and CINAHL Information Systems using the terms grieving, death, bereavement, loss, and coping. Data Synthesis: Pertinent articles were cross-referenced to gain additional information regarding the search terms. Conclusions: Athletic trainers should consider using strategies that introduce issues concerning bereavement, death, dying, and healthy coping skills into the athletic training curriculum. Additionally, it is critical to create a support network for athletic training professionals and students to use in time of loss.