Burden Of Care For Patients Research Articles

Caregiver burden and coping strategies for patients with schizophrenia: Comparison between Japan and Korea

With the current shift to community-centered mental health services, considerable research on the family burden of caring for patients with schizophrenia has been conducted in developed countries. However, there has been no investigation of families with Japanese or Korean sociocultural backgrounds. Therefore, the present study compared the caregiver burden and coping strategies of families of patients with schizophrenia in Japan and Korea in order to elucidate similarities and differences in the sociocultural factors that affect the care experience of families in Northeast Asia. A total of 99 Japanese (Nagasaki) and 92 Korean (Seoul, Daegu) family members of patients with schizophrenia were surveyed in regards to caregiver burden, coping strategies, and nursing awareness of the caregiver role regarding the patient with schizophrenia. Analysis revealed the following: (i) although no difference in caregiver burden and coping strategy was observed between the countries, the nursing awareness of families' caregiver role was significantly higher in Japan than in Korea; (ii) caregiver burden was significantly associated with the patient's social functioning and care needs in both countries; and (iii) caregiver burden was significantly associated with reduction of social interests, coercion, avoidance, resignation, and nursing awareness of caregiver role in both countries. Although the nursing awareness of families' roles in caring for patients with schizophrenia differed between Japan and Korea, similar trends were observed for the causes of caregiver burden. These findings suggest that in order to provide effective support for reducing caregiver burden, the necessity of such support must be emphasized in both countries.

The Cost of Achalasia: Quantifying the Effect of Symptomatic Disease on Patient Cost Burden, Treatment Time, and Work Productivity

Although the incidence of achalasia is low, the burden of suffering is high because it is a chronic incurable disease that predominantly affects young persons. This article aims to describe the impact of achalasia on health-related quality of life, patient cost burden, time dedicated to treatment, and work productivity. Consecutive patients enrolled in a clinical trial comparing laparoscopic myotomy with pneumatic dilatation from 4 sites across Canada (whose clinical and manometric diagnosis was confirmed) were studied using standardized patient-reported outcomes instruments, including the Achalasia Severity Questionnaire (ASQ), the Medical Outcomes Study 36-item Short Form Questionnaire (SF-36), and the Gastrointestinal Disease-Specific Quality of Life (GIQLI) questionnaire. The authors also measured health care utilization. Questionnaires were completed by 54 patients (median age = 53.5 years; range = 25-78 years; 50.0% male). Patients had been experiencing symptoms for a mean of 4.5 years (standard deviation = 6.1), and 42.6% were on medication for symptom relief. Among them, 74.1% reported that their disease limited their lifestyle. Patients spent an average of CAD$30.70 a month on medication; 37.0% reported that their disease interfered with their work, and patients missed an average of 10.2 days per 6 months. Patients also spent an average of CAD$24.30 on transportation to and from each clinical appointment. Achalasia substantially limits the lifestyle of patients with the disease. It also implies a financial burden of care for patients and leads to decreased work productivity.

Poverty and patient abandonment at Muhimbili National hospital, Tanzania

Background: Poverty is the state of having little or no money and fewor no material possessions. Poverty can be caused by unemployment, low education, deprivation and homelessness Objective: The aim of this study was to assess the relationship between poverty and patient abandonment (PA) in hospitals, and its impact on health care employing Muhimbili National Hospital (MNH) as a prototype and to assess the attitude of health care professionals (HCPs) towards the patient. Methodology: This was a randomized cross-section study involving patients and HCPs at MNH. Nevertheless, the study targeted all patients who were abandoned at MNH and who voluntarily accepted to participate in this study under informed consent and strict confidentiality. A semi-structured interviewer-administered questionnaire was used to obtain information from the HCPs, while personalized interviews with the patient using structured and semistructured questionnaire were conducted. Poverty assessment toolswere possession of resources, level of education, money (income and expenditure per month and year), and accessibility to basic needs.Findings: A total of 84 respondents who were stratified into 27 HCPs and 57 abandoned patients were involved in the research. This is the first study to be conducted in Dar es Salaam with respect to PA in hospital. Results revealed unnecessary overcrowding in wards and overwhelmingly heavy burden of patient care on the HCPs. The study also observed a correlation between poverty and PA, which was to a great extent related to the patient’s level of education. The respondents strongly condemned PA as demonstration of ungodliness and immoral act. Conclusion and recommendation: Poverty and PA can be alleviated by equipping the citizens with an adequate education and appropriate health care services (HCSs). The government should think of re-introducing subsidies on HCSs in order to alleviate the burden of medical expenses incurred by the low income citizens, particularly the unemployed and farmers. The study also recommends that the government should improve HCSs in regional hospitals in order to reduce/avoid travel and general patients careexpenses.Key words: Poverty, patient abandonment, health care services, level of education

The Institute of Medicine Resident Work Hours Recommendations: A Program Director's Viewpoint

Over the past several decades, the practice of medicine has changed dramatically. Hospitalized patients are sicker. The number of medication choices is larger. The pressure to discharge patients quickly is more intense. Despite these changes, the way in which we train residents has remained largely the same. The number of residents and the length of residency training have not changed significantly. Until recently, the hours remained quite long. In recent years, we have discovered that quantity and quality of sleep have a significant impact on the health and well-being of our patients. Driving while sleep-deprived is equivalent to driving under the influence of alcohol. We would never allow our residents to practice medicine while under the influence, and it makes sense to examine the impact of sleep deprivation on our residents' ability to learn and to practice medicine safely. If it is shown that medical mistakes increase with sleep deprivation, we should do what we can to minimize the risk to our patients. This is much more complicated, however, than mandating fewer work hours and protected sleep time for our trainees. With the last reduction in resident work hours, there was no concomitant increase in the number of residents accepted to training programs, nor to the number of supervising physicians. We essentially told our trainees to provide good quality medical care to larger numbers of patients with increased medical complexity. .. faster. Many residency programs have struggled with it, and further limitations in work hours cannot be made in a vacuum. If resident work hours are further limited, hospitals will have to find a way to provide adequate coverage for their patients. A seemingly innocuous solution would be the addition of more residency training positions. This might also be used to train more primary care physicians and other types of doctors for whom a shortage is anticipated. This is easier suggested than done, however. The way in which hospitals are reimbursed for their training of residents is already antiquated and inadequate. The training of more physicians would also require that more supervising physicians be hired. Alternatively, hospitals could forego the hiring of more trainees, and simply shift the burden of patient care to more senior physicians. After all, such physicians have no work hour restrictions. If interns and residents are more prone to mistakes as a result of sleep deprivation, it would follow that sleep-deprived supervising physicians would be less likely to notice and correct the errors of their trainees. Another potential solution would be to increase the duration of residency training programs. Difficulties abound here as well. Residents would require additional years of wages. The wages that they currently receive during their period of training are quite low, given their prior education and the number of hours they are asked to work. This would potentially deter a significant number of prospective physicians from entering the profession. There are innumerable other ways in which the challenges of further limiting work hours can be addressed. All of them are quite costly, as the Institute of Medicine (IOM) freely admits. I wonder where this extra funding will come from? I hope that as President-Elect Obama's incoming administration examines potential changes to our healthcare system, they remember to take a fresh look at how we train physicians.

Disaster Triage Systems for Large-scale Catastrophic Events

Large-scale catastrophic events typically result in a scarcity of essential medical resources and accordingly necessitate the implementation of triage management policies to minimize preventable morbidity and mortality. Accomplishing this goal requires a reconceptualization of triage as a population-based systemic process that integrates care at all points of interaction between patients and the health care system. This system identifies at minimum 4 orders of contact: first order, the community; second order, prehospital; third order, facility; and fourth order, regional level. Adopting this approach will ensure that disaster response activities will occur in a comprehensive fashion that minimizes the patient care burden at each subsequent order of intervention and reduces the overall need to ration care. The seamless integration of all orders of intervention within this systems-based model of disaster-specific triage, coordinated through health emergency operations centers, can ensure that disaster response measures are undertaken in a manner that is effective, just, and equitable.

Hospital Nurses' Experience of Do-Not-Resuscitate in Korea

The purpose of the study was to describe the experiences of do-not-resuscitate (DNR) among nurses. Data were collected by in-depth interviews with 8 nurses in 8 different hospitals. Conventional qualitative content analysis was used to analyze the data. Eight major themes emerged from the analysis: DNR decision-making bypassing the patient, inefficiency in the decision-making process of DNR, negative connotation of DNR, predominance of verbal DNR over written DNR, doubts and confusion about DNR, least amount of intervention in the decision for DNR change of focus in the care of the patient after a DNR order, and care burden of patients with DNR. Decision-making of DNR occurred between physicians and family members, not the patients themselves. Often high medical expenses were involved in choosing DNR, thus if choosing DNR it was implied the family members and health professionals as well did not try their best to help the patient. Verbal DNR permission was more popular in clinical settings. Most nurses felt guilty and depressed about the dying/death of patients with DNR. Clearer guidelines on DNR, which reflect a family-oriented culture, need to be established to reduce confusion and to promote involvement in the decision-making process of DNR among nurses.

Evidence-based Treatment of Chronic Heart Failure

The past two decades have seen a knowledge explosion in the field of cardiovascular diseases, in general, and in the understanding of chronic heart failure (HF) as a complex neurohumoral syndrome in particular. A new staging system for chronic HF has been developed within the last decade to facilitate the evidence-based prescription of medications and medical devices for each of its four stages. The burden of care for patients with chronic HF is substantially provided in primary care settings. Primary care physicians need to understand the underlying pathophysiology of chronic HF, the elements of its evaluation and treatment by stage, and when referral is necessary.

Effect of the Medicare Prescription Drug Improvement and Modernization Act on the bottom line

An historical perspective on the impact of the Medicare Prescription Drug Improvement and Modernization Act (MMA) on pharmaceutical reimbursement, and the financial bottom line at health systems and various strategies to use in the inpatient and outpatient setting to improve the bottom line are described. Implementation of MMA has affected the entire healthcare continuum by reducing pharmaceutical reimbursement rates and health system revenues and increasing prescription drug copayments, emergency department visits, and hospital admissions. Physician-owned clinics are less profitable than in the past because of MMA, which may prompt clinic closures and shift the patient care burden to clinics at public hospitals. Negotiating carve-outs for costly drugs and evaluating the feasibility of obtaining outlier payments can improve the bottom line in the hospital inpatient setting. Ensuring that billing codes are accurate and verifying that reimbursement was received can help minimize the impact of MMA on the financial bottom line in the outpatient setting. Negotiating favorable purchasing contracts and ensuring that drugs are used appropriately by following evidence-based guidelines can improve the financial bottom line in both the inpatient and outpatient settings. Strategies to decrease drug acquisition costs and increase reimbursement rates can help minimize the adverse impact of MMA on the financial bottom line at health systems.

A study of the burden of caring for patients with amyotrophic lateral sclerosis (MND) in Japan

Objective: The purpose of this study was to explain the experiences of caregivers of patients with amyotrophic lateral sclerosis (ALS) receiving invasive ventilation in Japan. Methods: Subjects were 12 primary caregivers of ALS patients receiving invasive ventilation. Subjects were selected by theoretical sampling. Semi-structured interviews were undertaken with each subject. The data were analyzed using a grounded theory approach. Results: Caregivers tried to ‘find a meaning in prolonging life,’ which represented a core category. Two subcategories relate directly to the core category. These were ‘hesitation and regret over the decision’ and ‘feeling of being supported’. Each subcategory had four internal dimensions: ‘uncertainty of the future’, ‘communication’, ‘maintaining their own life’ and ‘support’. Conclusions: The process of caring for ALS patients is dynamic. The success or failure of continuing care depends on ‘finding a meaning of prolonged life’. It is important for nurses to be aware of that. Further investigation is required into appropriate intervention for caregivers of ALS patients.

The burden on informal caregivers of people with bipolar disorder

Caregivers of people with bipolar disorder may experience a different quality of burden than is seen with other illnesses. A better understanding of their concerns is necessary to improve the training of professionals working with this population. Conceptualizing caregiver burden in a conventional medical framework may not focus enough on issues important to caregivers, or on cultural and social issues. Perceptions of caregivers about bipolar disorder have important effects on levels of burden experienced. It is important to distinguish between caregivers' experience of this subjective burden and objective burden as externally appraised. Caregivers' previous experiences of health services may influence their beliefs about the illness. Caregiver burden is associated with depression, which affects patient recovery by adding stress to the living environment. The objective burden on caregivers of patients with bipolar disorder is significantly higher than for those with unipolar depression. Caregivers of bipolar patients have high levels of expressed emotion, including critical, hostile, or over-involved attitudes. Several measures have been developed to assess the care burden of patients with depressive disorders, but may be inappropriate for patients with bipolar disorder because of its cyclical nature and the stresses arising from manic and hypomanic episodes. Inter-episode symptoms pose another potential of burden in patients with bipolar disorder. Subsyndromal depressive symptoms are common in this phase of the illness, resulting in severe and widespread impairment of function. Despite the importance of assessing caregiver burden in bipolar disorder, relevant literature is scarce. The specific effects of mania and inter-episode symptoms have not been adequately addressed, and there is a lack of existing measures to assess burden adequately, causing uncertainty regarding how best to structure family interventions to optimally alleviate burden. The relatively few studies into caregiver burden in bipolar disorder may largely reflect experiences in the US Veterans Affairs health service, but the findings may be limited in their generalizability. Nevertheless, available data suggest that caregiver burden is high and largely neglected in bipolar disorder. Clinically effective, well-targeted and practically viable interventions are needed. However, services cannot be enhanced on a rational basis without an improved understanding and capacity to measure and target caregiver burden the impact of any change in services be evaluated.

Health-related quality of life for caregivers of patients with Alzheimer disease.

We investigated the relationship of caregivers' health-related quality of life (HRQOL) to the burden of caring for patients with Alzheimer disease (AD) and resource utilization. Caregiver HRQOL was assessed using the SF-12 Mental and Physical Summary scores. Compared with a normative, age-adjusted sample, the 2477 caregivers had lower mental and physical scores (for the latter, only those <54 years of age). Increased caregiver mental functioning was associated with caregiver support and perceived quality of patient medical care, fewer hours of caregiving, and fewer patient behavioral symptoms. The burden of caregiving has substantial effects on HRQOL. Interventions that improve AD status and reduce caregiving hours have the potential to improve caregivers' HRQOL.

Medical management of advanced dementia.

A cure for Alzheimer's disease (AD) is still far off, and clinicians face the burden of caring for patients at all stages of dementia for the foreseeable future. Those with advanced disease suffer neurological symptoms and signs that include incontinence; problems with gait and mobility; marked cognitive, language, and functional impairment; and in about 90% of patients, significant behavior problems. Dementia precludes the ability to initiate meaningful activities or social interactions. Whether patients are resident in the community or living in a nursing home, this composite reflects a highly complex medical and neuropsychiatric management challenge. Predictable medical conditions also must be addressed (i.e., those that accompany dementia, such as parkinsonism, and those that are prevalent in any aging population, such as hypertension). Clinicians can better address these problems with awareness of current treatment options. Placebo-controlled trials of some psychotropic agents have shown modest favorable effects on behavior problems. Use of acetylcholinesterase inhibitors (AChEIs) to treat cognitive impairment and secondary behavioral symptoms derives primarily from results of placebo-controlled clinical trials. Trials in patients with moderate to severe AD, outpatients as well as nursing home residents, show overall effects similar to those seen in outpatients with milder dementia. Treatment with AChEIs may delay institutional placement. Memantine has shown benefit in trials in moderate to severe dementia, although it is not yet approved in the United States. Emerging data have expanded physicians' ability to use pharmacotherapy in patients with advanced dementia. Physicians need to enact the principle that something can be done for our afflicted parents and grandparents.

Volume and nature of telephone calls in a specialty headache practice.

No information exists regarding the contribution of patient-related telephone calls to the burden of headache practice. To identify the nature and volume of patient-related telephone calls to a specialty headache practice over a 1-month period. The characteristics of all patient-related calls to a single headache practitioner occurring during July 2001 were documented. Information was obtained on the caller, reason for call, length of call, timing and day of call, stated importance of call, patient's principal headache diagnosis, and principal comorbid psychiatric disorder, if any. One hundred sixty-five outpatient headache-related calls were received in July 2001, 3.17 for every hour of headache clinic scheduled. A total of 65% of all calls was generated by just 36% of callers. Of the 32 patients who placed more than one call during the study period, 50% had chronic daily headache, 53% had a personality disorder, and 38% had both. Twenty-seven percent of all calls were placed by someone other than the patient, 58% involved requests for medication refills, and 17% reported a new symptom or medication side effect. Over half of all calls were placed on Mondays and Tuesdays. Relatively few occurred outside work hours; 18% of calls characterized as "emergency" and 36% of calls characterized as urgent involved requests for controlled substances. Most of these calls were placed by patients with personality disorders. None of the 11 calls characterized as emergency calls was judged so by the physician; only 19% of the urgent calls were judged so by the physician. Telephone calls contribute substantially to the burden of caring for patients in a specialty headache practice. Patients with chronic daily headache and personality disorders contribute disproportionately to this telephone burden. Efforts to identify such patients at presentation and educate them regarding appropriate telephone use seem to be warranted.

What Nurses Can Do in a Rapidly Aging Society? Nursing Care and Research Issues

The number of aged people in Japan is increasing at the fastest rate in history. This growing proportion of elderly people has numerous implications for nursing care, nursing education, and nursing management. This paper presents some of the health problems of the elderly and related nursing research issues.Health problems of the elderly and nursing's role : Westernization of lifestyle has led to changes in the morbidity and mortality patterns of the Japanese. Malignant neoplasm has become the number one cause of death in the 35–84‐year‐olds in Japan. Even though more than 280 000 Japanese die from cancer yearly, only 37 nurses in Japan are certified for pain control management. Nursing educators and nursing researchers need to address the current health status of the Japanese and to plan for future health‐care needs.Health care for the elderly: the burden of care: In response to the increasing number of demented and/or bed‐bound elders, nursing research has begun to focus on the burden of caring for patients. Assessing one's care burden seems to be the main focus of such research. Nurse researchers need to shift their attention from assessment to intervention in order to relieve one's burden of care. Other research issues include clinical judgment, outcomes, and health promotion.Clinical judgment versus evidence‐based nursing: In recent years, evidence‐based nursing has become popular. Clinical judgment needs to integrate the evidence that nurses have accrued. Expert nurses sometimes perform much better than assessment scales do. The following example demonstrates the importance of investigating nurses’ clinical judgment to improve nursing care. A prospective study of falls showed that the nurses’ clinical judgment was better than the assessment scale of falls for the institutionalized elderly. Expert nurses from 10 facilities evaluated 746 elders on admission and then followed them for 3 months. The incidence of falls was six times higher for elders identified as at high risk for falling than those identified as having a low risk of falling. It is believed that investigation of nurses’ clinical judgment will lead to nursing research regarding how to improve nursing care.Outcome research: In the USA the spiraling cost of health care has pushed the federal government to change the insurance payment system from a fee‐for‐service system to a prospective payment system. American nursing researchers have begun to examine nursing care outcomes because the cost of nursing care was not integrated into the prospective payment system. Japan is going through a similar phase in terms of health insurance reform, although the rate of change and the direction of change may differ. Outcome research will become an essential part of nursing research, in the near future, in Japan, as well as in other Asian countries.Importance of health promotion and injury prevention: Nurses who provide direct care to patients may not be familiar with health promotion and injury prevention for the elderly. Promoting a healthy lifestyle from early childhood appears to be the best strategy for successful aging. However, health promotion for the elderly is necessary and can be successful regardless of when it is started. Basic exercise has been shown to be effective in maintaining and improving muscle strength even among the oldest elderly.In summary, nursing research has an opportunity to improve the health status of the elderly. However, in Japan, long‐term strategic goals for nursing research are not well laid out. Nurses have the responsibility of preparing for the aging society in the 21st century.

Drug Treatments for Alzheimer??s Disease

The economic burden of caring for patients with Alzheimer’s disease may shift as a result of drug therapies. Drug therapies might affect the economic burden of care by permitting a delay in institutionalisation or by changing the quality of life of the patient and caregiver as informal care needs change. The adverse effects of drug therapy may also affect costs.

The dermatologic physician's assistant: an overview of one year's experience.

The use of a physician's assistant (PA) in the specialty of dermatology is a relatively new concept. We present briefly the results of a year's trial of such an individual by a three-man corporate group. We found the PA to be a useful addition in relieving some of the burden of patient care, but neither patient flow nor income was favorably affected. Whether in the last analysis a PA generates enough additional income to justify his or her employment must depend on individual circumstances. We recommend a trial period of employment mutually agreeable to the physician and the PA. The use of a physician's assistant (PA) in the specialty of dermatology is a relatively new concept. We present briefly the results of a year's trial of such an individual by a three-man corporate group. We found the PA to be a useful addition in relieving some of the burden of patient care, but neither patient flow nor income was favorably affected. Whether in the last analysis a PA generates enough additional income to justify his or her employment must depend on individual circumstances. We recommend a trial period of employment mutually agreeable to the physician and the PA.