Conventional Care Settings Research Articles

Reproductive justice in pediatric health care: a scoping review protocol.

The objective of this scoping review is to identify the barriers and facilitators of reproductive justice in pediatric health care. Reproductive justice is defined as the right to maintain personal bodily autonomy, to have or not have children, and to parent children in safe and sustainable communities. The reproductive justice framework is often applied to adult women in conventional care settings; however, the need for health care guided by the framework should extend to all females of reproductive age in all care settings, including pediatric settings. This review will consider studies from 1994 to the present that report on the barriers and facilitators of reproductive justice in pediatric health care. Studies from any setting or geographic location will be included. This scoping review will include pediatric patients up to 21 years of age of any gender identity or sexual orientation who may birth a child, and their health care providers. Database searches will include CINAHL (EBSCOhost), MEDLINE (PubMed), Embase (Elsevier), and Web of Science Core Collection. Sources of unpublished studies and gray literature to be searched include MedNar and ProQuest Dissertation and Theses Science and Engineering Collection (ProQuest). The JBI methodology for scoping reviews will be followed. Data extracted will include details about the title, authors, year of publication, type of evidence, participants, context, and concept. The extracted data will be presented in diagrammatic or tabular format in a manner that aligns with the objective and questions of the scoping review. Open Science Framework https://osf.io/d5vf9.

Abstract 369: Secondary Risk Reduction in Patients With Type 2 Diabetes and Cardiovascular Disease: Experience From a Cardiometabolic Center of Excellence

Background: Optimal guideline-directed medical therapy is delivered to only 6.9% of patients with type 2 diabetes (T2D) and cardiovascular disease (CVD) nationally, despite guideline recommendations emphasizing aggressive comprehensive secondary risk reduction. While there are many potential explanations, lack of effective clinical care delivery models is a key contributor. The Haverty Cardiometabolic Center of Excellence at Saint Luke’s Mid America Heart Institute was designed to address this unmet need, by delivering a patient-centric, collaborative model of care which focuses on aggressive and comprehensive secondary risk reduction in patients with T2D and CVD. Patients are managed by a multidisciplinary team comprised of preventative cardiologists, advanced practice providers and nurses cross-trained in T2D and CVD management, certified diabetes educator, dietician, pharmacist, and other professionals, in close coordination with endocrinologists and primary care clinicians. We aimed to determine whether patients receiving care in the Center had experienced better intermediate outcomes with similar patients receiving routine care in conventional settings. Methods: We analyzed data from the initial 60 patients seen in the Center who had at least one follow-up visit, and propensity matched them 1:3 to similar patients with T2D and CVD treated in conventional care settings. Propensity model included age, sex, baseline weight, HbA1c, systolic blood pressure (SBP), history of CVD, and duration between visits. Linear mixed models with a random effect for matched groups was used to compare between-group differences for changes in weight, LDL-C, and HbA1c. Results: At baseline, patients in the Center weighed 241.3 lbs ± 51.0 and had HbA1c 7.4 ± 1.4 and LDL 68.0 ± 27.0 as compared to 245.5 lbs ± 55.3, HbA1c 7.5 ± 1.5, and LDL 79.1 ± 37.1 in controls. Average duration between follow up visits was 138.3 days ± 52.5 in patients seen in the Center and 138.9 days ± 54.7 in controls. Patients seen in the Center had greater degree of weight loss (12.3 lbs vs 3.8 lbs, p <0.001) and reduction in HbA1c (0.5 vs 0.0%, p = 0.04) and LDL-C (-8.4 vs +4.0 mg/dL, p = 0.04) as compared with controls. Patients receiving care at the Center were more likely to be treated with an SGLT-2i (70.0% [42/60] vs 22.8% [41/180], p<0.001) and/or a GLP-1RA (91.7% [55/60] vs 15.6% [28/180], p<0.001) than those in the standard of care cohort. Conclusion: Patients with T2D and CVD, seen in a specialized, comprehensive Cardiometabolic Center experienced higher use of guideline-directed medical therapies and greater reduction in multiple CVD risk factors within ~4 months, as compared to those seen in the conventional setting. Although longer follow up is needed, these preliminary data suggest that such novel clinical care delivery models may improve the implementation of clinical practice guidelines.

Comparative Effectiveness of Usual Care With or Without Chiropractic Care in Patients with Recurrent Musculoskeletal Back and Neck Pain.

Chiropractic care is a popular alternative for back and neck pain, with efficacy comparable to usual care in randomized trials. However, the effectiveness of chiropractic care as delivered through conventional care settings remains largely unexplored. To evaluate the comparative effectiveness of usual care with or without chiropractic care for patients with chronic recurrent musculoskeletal back and neck pain. Prospective cohort study using propensity score-matched controls. Using retrospective electronic health record data, we developed a propensity score model predicting likelihood of chiropractic referral. Eligible patients with back or neck pain were then contacted upon referral for chiropractic care and enrolled in a prospective study. For each referred patient, two propensity score-matched non-referred patients were contacted and enrolled. We followed the participants prospectively for 6months. Main outcomes included pain severity, interference, and symptom bothersomeness. Secondary outcomes included expenditures for pain-related health care. Both groups' (N = 70 referred, 139 non-referred) pain scores improved significantly over the first 3months, with less change between months 3 and 6. No significant between-group difference was observed. (severity - 0.10 (95% CI - 0.30, 0.10), interference - 0.07 (- 0.31, 0.16), bothersomeness - 0.1 (- 0.39, 0.19)). After controlling for variances in baseline costs, total costs during the 6-month post-enrollment follow-up were significantly higher on average in the non-referred versus referred group ($1996 [SD = 3874] vs $1086 [SD = 1212], p = .034). Adjusting for differences in age, gender, and Charlson comorbidity index attenuated this finding, which was no longer statistically significant (p = .072). We found no statistically significant difference between the two groups in either patient-reported or economic outcomes. As clinical outcomes were similar, and the provision of chiropractic care did not increase costs, making chiropractic services available provided an additional viable option for patients who prefer this type of care, at no additional expense.

Development and validation of a tool to evaluate Inpatient Beliefs, Expectations and Attitudes toward Reflexology (IBEAR-16)

BackgroundThe integration of manual therapies, including reflexology, into conventional care settings is growing extensively. Patients’ beliefs, attitudes and expectations toward these therapies interact with their outcomes, but currently there are no validated tools to evaluate these factors. We aimed to design and to validate such a tool specifically targeted into reflexology. MethodsFollowing input of a multidisciplinary team of experts, the self-administered Inpatient Beliefs, Expectations and Attitudes toward Reflexology (IBEAR) questionnaire was constructed, containing 25 items, 8 referring to demographics and 17 specifically addressing reflexology. Cronbach’s alpha was computed to evaluate the questionnaire’s internal reliability, and factor analysis was used for further validation (232 patients). Pearson coefficient and Kappa tests were used to test and retest (within 48 hours) the questionnaire on a group of 199 patients, to assure clarity and reliability. ResultsFor the 232 questionnaires collected, the computed Cronbach’s alpha coefficient was 0.716 (acceptable reliability). Factor analysis pointed to two content areas separated into four items addressing attitudes and expectations and five items focusing on beliefs and attitudes. In the test-retest stage, 199 participants filled in the questionnaire for a second time. The Pearson coefficient for all questions ranged between 0.73 and 0.94 (good to excellent correlation) and Kappa scores ranged between 0.66 and 1.0 (moderate to high reliability). Consequently, one of the questions was removed from the IBEAR. ConclusionsThe present study provides evidence that the proposed IBEAR questionnaire with 16 items is a valid and reliable tool for evaluation of inpatients’ beliefs, expectations and attitudes toward reflexology.

Complementary therapy for treating depressive symptoms: A systematic review

Depression is a mental state characterized by feelings of sadness, loneliness, despair, low self-esteem, and self-reproach; accompanying signs include psychomotor retardation. Complementary therapies span a broad range of treatments for depression. The aim of this review was to determine whether the use of complementary & alternative therapy (CAT) for treatment of depression is supported by evidence of effectiveness from rigorous clinical trials. Database literature searches were performed in a pre-defined manner. Thirteen RCTs were located that investigated Complementary & alternative therapy and depression: Reflexology (1), Cognitively Behavioural Therapy (3), Yoga (1), Mindfulness therapy (1), Reiki intervention (1), Aromatherapy massage (1), Essential oils (1), Creative arts therapy (1), Herbal medicine (1), Music therapy (1) and Massage (1). The evidence is not compelling for any of these therapies, with many trials suffering from significant methodological flaws. There is evidence to suggest some benefit of mindfulness therapy, yoga, creative art, massage and music therapy on reduction of depressive symptoms. Cognitive Behaviour therapy and aromatherapy massage have a short-term beneficial effect on depression. There is no difference in using herbal, reflexology, essential oil and Reiki therapy in depression but Reiki therapy within the bounds of the conventional care setting may be more effective. In all the CATs examined further investigations are needed in the form of rigorous large-scale trials.

The Complementary Medicine Education and Outcomes (CAMEO) program: A foundation for patient and health professional education and decision support programs

ObjectiveThis paper describes the background, design and evaluation of a theory-informed education and decision support program for cancer patients considering complementary medicine (CM). MethodsThe program was informed by the Shared Decision Making theory, the Ottawa Decision Support Framework and the Supportive Care Framework. Previous empirical evidence and baseline research were used to identify patients’ and health professionals’ (HPs) information and decision support needs related to CM. ResultsTo address the continuum of CM needs, a variety of education and decision support interventions were developed, including basic CM information and resources for patients and HPs, a group education program and one-on-one decision support coaching for patients, and an on-line education module for HPs. Evaluation of the program and individual interventions is underway. ConclusionsThis education and decision support program addresses a significant gap in care and offers an evidence-informed framework in which to translate CM evidence to conventional care settings and promote communication about CM. Practice implicationsEvidence-informed CM education and decision support interventions are needed to shift the culture around CM within conventional care settings and promote open communication that will lead to CM therapies being safely integrated into care.

Preferences for Psychiatric Advance Directives Among Latinos: Views on Advance Care Planning for Mental Health

Psychiatric advance directives allow persons with mental illness to declare preferences for future treatment through an advance instruction and/or a health care agent. Initial outcomes are promising (1-5). However, the role of psychiatric advance directives in the cross-cultural context of mental health services has not been examined. These documents may play an important role for Latino individuals in US mental health care settings. Psychiatric advance directives may represent an opportunity to align culturally appropriate services with treatment needs in Latino populations. However, no research has examined the acceptability of these documents by Latino mental health stakeholders. This study assessed demand, interest, and attitudes towards psychiatric advance directives for clients, families and clinicians.

Attitudes of Arab and Jewish patients toward integration of complementary medicine in primary care clinics in Israel: A cross-cultural study

The purpose of this cross-cultural study was to evaluate patient perspectives on complementary and alternative medicine (CAM) integration within primary care clinics. It is one of the first multiethnic studies to explore patients' perspectives on the best model for integrating CAM into the conventional care setting. We developed a 13-item questionnaire that addresses issues of CAM use, expectations from the primary care physicians concerning CAM, and attitudes toward CAM integration within a patient's primary care clinic. We constructed the questionnaire with cross-cultural sensitivity concerning the core concepts of CAM and traditional medicine in both the Arab and Jewish communities in northern Israel. Data for statistical analysis were obtained from 3840 patients attending seven primary care clinics. Of the 3713 respondents who were willing to identify their religion, 2184 defined themselves as Muslims, Christians, or Druze and 1529 as Jews. Respondents in the two groups were equally distributed by sex but differed significantly by age, education, self-rated religiosity, and self-reported chronic diseases in their medical background. Respondents in the two groups reported comparable overall CAM use during the previous year, but the Arab respondents reported more use of herbs and traditional medicine. Respondents in both groups stated that their primary expectation from a family physician concerning CAM was to refer them appropriately and safely to a CAM practitioner. Respondents in both groups greatly supported a theoretical scenario of CAM integration into primary medical care. However, Arab respondents were more supportive of the option that non-physician CAM practitioners would provide CAM rather than physicians.

Breast Biopsy and Distress

The purpose of this randomized pilot was to determine feasibility of testing Reiki, a complementary therapy intervention, for women undergoing breast biopsy (BB). Increasingly women face the possibility of BB, the definitive test for breast cancer. Psychological distress associated with BB includes anxiety and depression. Reiki was proposed as an intervention to decrease anxiety and promote relaxation. Thirty-two women scheduled for BB were randomized to Reiki intervention versus conventional care control. Anxiety and depression were evaluated using self-report questionnaires. Analysis found no significant mean differences between groups over time. Comparably low baseline anxiety levels (possible selection bias) decreased naturally with time allowing little room for observing treatment effect. Reiki, when administered in the naturalistic setting of a complementary therapy office, did not suggest evidence of efficacy. An intervention offered within the bounds of the conventional care setting may be more feasible for addressing BB distress.

Is motivation enough? Responsiveness, patient-centredness, medicalization and cost in family practice and conventional care settings in Thailand

BackgroundIn Thailand, family practice was developed primarily through a small number of self-styled family practitioners, who were dedicated to this professional field without having benefited from formal training in the specific techniques of family practice. In the context of a predominantly hospital-based health care system, much depends on their personal motivation and commitment to this area of medicine. The purpose of this paper is to compare the responsiveness, degree of patient-centredness, adequacy of therapeutic decisions and the cost of care in 37 such self-styled family practices, i.e. practices run by doctors who call themselves family practitioners, but have not been formally trained, and in 37 conventional public hospital outpatient departments (OPDs), 37 private clinics and 37 private hospital OPDs.MethodAnalysis of the characteristics of 148 taped consultations with simulated patients.ResultsThe family practices performed better than public hospital OPDs with regard to responsiveness, patient-centredness and cost of technical investigations (M-W U: p < 0.001). Prescribing patterns were similar, but family practices prescribed fewer drugs and were less costly than private clinics and hospitals (M-W U: p < 0.001). The degree of patient-centredness was not significantly different. Private clinics and private hospitals scored better for responsiveness.ConclusionIn Thailand self-styled family practices, even without specific training, provide a service that is more responsive and patient-centred than conventional care, with less overmedicalization and at a lower cost. Changes in prescription practices may require deeper changes in the medical culture.

An empathy‐based consultation quality measure for use in CAM and conventional‐care settings

An empathy‐based consultation quality measure for use in CAM and conventional‐care settings

Need satisfaction in terminal care settings

Research comparing hospice and conventional programs of care for the terminally ill has identified few measurable differences in the care provided to patients and their families. Nonetheless, hospice recipients frequently express a higher level of satisfaction with their program of care. This study compared the ability of hospice and conventional care settings to meet the basic emotional needs of families during a member's dying and death from cancer. In addition, the relationship of basic needs satisfaction, perceptions about the nurse, and overall satisfaction with the program of care were explored. One hundred bereaved familial care givers completed a mail questionnaire concerning their perceptions of care at the site of a family member's death. The sites were (1) the home, with care provided by a Medicare certified, community-based hospice program; (2) a hospital affiliated with a Medicare certified, community-based hospice program; (3) a hospital with its own hospice program; and (4) a conventional (non-hospice) hospital. Analyses of quantitative data supported two hypotheses about significant differences between hospice and conventional care. The conventional care group demonstrated the lowest levels of basic needs satisfaction, satisfaction with the psycho-social support of the nurse, and overall program satisfaction. As predicted, overall satisfaction with care was consistent across hospice groups. However, home hospice care provided the highest quality of basic needs satisfaction and the highest level of satisfaction with the nurse. Significant Pearson correlations supported the hypothesis that overall satisfaction is negatively related to unmet basic needs ( r = -0.69) and positively related to the psycho-social support received from nurses ( r = 0.73). The results of this study emphasize the importance of the nurse in the familial care giver's feelings of satisfaction with a program of care. In addition, the results indicate that families experiencing a grief reaction are most likely to have basic needs met at home or when inpatient care is within a hospice rather than a conventional hospital.

The effect of treatment setting and patient characteristics on pain in terminal cancer patients: A report from the national hospice study

Debilitating pain is the symptom most often associated with cancer by the general public. The National Hospice Study (NHS) evaluated pain control among terminal cancer patients served in hospital based (HB) and home based (HC) hospices, and in conventional care settings (CC) such as outpatient clinics and oncology units. Pain was reported by the patient when able to respond and by the patients' primary care person (PCP) during repeated interviews until death. Patient and PCP pain reports were correlated at 0.43. PCPs reported that around 16% of patients were pain free in the last weeks of life while 18% were in persistent pain. Statistically adjusting for differences in the CC, HB, and HC samples, HB patients were less likely to report having persistent pain than either CC or HC patients, although there were no differences in the proportion of patients who were pain free. Age was negatively correlated with the level of pain. As expected, brain and bone metastases were related to pain in opposite directions, with more pain among those with bone involvement and less among those with brain involvement. Conclusions about whether HB hospices really are superior at pain control must be made cautiously in view of the relationship between age and pain and the greater age of hospice patients in our study.