Effective Care For People Research Articles

Clinical standards for the diagnosis and management of asthma in low- and middle-income countries.

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Revisiting the anatomy and physiology of the lower gastrointestinal tract

Nurses working within any aspect of gastrointestinal nursing could benefit from a review of the anatomy and physiology of the gastrointestinal tract. This article aims to provide a refresher on the topic, enabling nurses to better recognise the cause of bowel changes and provide more effective care for people with bowel conditions

An Ethics Checklist for Digital Health Research in Psychiatry: Viewpoint.

BackgroundPsychiatry has long needed a better and more scalable way to capture the dynamics of behavior and its disturbances, quantitatively across multiple data channels, at high temporal resolution in real time. By combining 24/7 data—on location, movement, email and text communications, and social media—with brain scans, genetics, genomics, neuropsychological batteries, and clinical interviews, researchers will have an unprecedented amount of objective, individual-level data. Analyzing these data with ever-evolving artificial intelligence could one day include bringing interventions to patients where they are in the real world in a convenient, efficient, effective, and timely way. Yet, the road to this innovative future is fraught with ethical dilemmas as well as ethical, legal, and social implications (ELSI).ObjectiveThe goal of the Ethics Checklist is to promote careful design and execution of research. It is not meant to mandate particular research designs; indeed, at this early stage and without consensus guidance, there are a range of reasonable choices researchers may make. However, the checklist is meant to make those ethical choices explicit, and to require researchers to give reasons for their decisions related to ELSI issues. The Ethics Checklist is primarily focused on procedural safeguards, such as consulting with experts outside the research group and documenting standard operating procedures for clearly actionable data (eg, expressed suicidality) within written research protocols.MethodsWe explored the ELSI of digital health research in psychiatry, with a particular focus on what we label “deep phenotyping” psychiatric research, which combines the potential for virtually boundless data collection and increasingly sophisticated techniques to analyze those data. We convened an interdisciplinary expert stakeholder workshop in May 2020, and this checklist emerges out of that dialogue.ResultsConsistent with recent ELSI analyses, we find that existing ethical guidance and legal regulations are not sufficient for deep phenotyping research in psychiatry. At present, there are regulatory gaps, inconsistencies across research teams in ethics protocols, and a lack of consensus among institutional review boards on when and how deep phenotyping research should proceed. We thus developed a new instrument, an Ethics Checklist for Digital Health Research in Psychiatry (“the Ethics Checklist”). The Ethics Checklist is composed of 20 key questions, subdivided into 6 interrelated domains: (1) informed consent; (2) equity, diversity, and access; (3) privacy and partnerships; (4) regulation and law; (5) return of results; and (6) duty to warn and duty to report.ConclusionsDeep phenotyping research offers a vision for vastly more effective care for people with, or at risk for, psychiatric disease. The potential perils en route to realizing this vision are significant; however, and researchers must be willing to address the questions in the Ethics Checklist before embarking on each leg of the journey.

Home Treatment for Acute Mental Health Care: Protocol for the Financial Outputs, Risks, Efficacy, Satisfaction Index and Gatekeeping of Home Treatment (FORESIGHT) Study.

BackgroundCrisis Resolution and Home Treatment (CRHT) teams represent a community-based mental health service offering a valid alternative to hospitalization. CRHT teams have been widely implemented in various mental health systems worldwide, and their goal is to provide care for people with severe acute mental disorders who would be considered for admission to acute psychiatric wards. The evaluation of several home-treatment experiences shows promising results; however, it remains unclear which specific elements and characteristics of CRHT are more effective and acceptable.ObjectiveThis study aims to assess the acceptability, effectiveness, and cost-effectiveness of a new CRHT intervention in Ticino, Southern Switzerland.MethodsThis study includes an interventional, nonrandomized, quasi-experimental study combined with a qualitative study and an economic evaluation to be conducted over a 48-month period. The quasi-experimental evaluation involves two groups: patients in the northern area of the region who were offered the CRHT service (ie, intervention group) and patients in the southern area of the region who received care as usual (ie, control group). Individual interviews will be conducted with patients receiving the home treatment intervention and their family members. CRHT members will also be asked to participate in a focus group. The economic evaluation will include a cost-effectiveness analysis.ResultsThe project is funded by the Swiss National Science Foundation as part of the National Research Program NRP74 for a period of 48 months starting from January 2017. As of October 2021, data for the nonrandomized, quasi-experimental study and the qualitative study have been collected, and the results are expected to be published by the end of the year. Data are currently being collected for the economic evaluation.ConclusionsCompared to other Swiss CRHT experiences, the CRHT intervention in Ticino represents a unique case, as the introduction of the service is backed by the closing of one of its acute wards. The proposed study will address several areas where there are evidence gaps or contradictory findings relating to the home treatment of acute mental crisis. Findings from this study will allow local services to improve their effectiveness in a challenging domain of public health and contribute to improving access to more effective care for people with severe mental disorders.Trial RegistrationISRCTN registry ISRCTN38472626; https://www.isrctn.com/ISRCTN38472626International Registered Report Identifier (IRRID)DERR1-10.2196/28191

Physiotherapist Adaptations to Cancer, HIV/AIDS, and Hospice and Palliative Care in the COVID-19 Era: A Global Perspective Paper

In the early stages of the COVID-19 pandemic, physiotherapists (PTs) across the globe were required to rapidly adapt clinical practice to provide safe and effective care for people with HIV/AIDS and cancer and those in hospice and palliative care. These rapid decisions included developing criteria for in-person versus remote care and developing equitable platforms for telehealth and telerehabilitation. Most decisions were made with limited guidelines or evidence for practice related to the pandemic. The purpose of this perspective was to provide a synopsis of the experiences of 25 PTs from 16 countries regarding their clinical decisions for (1) rapid adaptation of patient care delivery, (2) evaluation criteria to treat in-person or remotely, (3) utilization decisions for telerehabilitation, (4) determinations for future practice and research needs, and (5) promotion of health equity in an environment rapidly transformed by a highly infectious and deadly disease.

Towards community-based and recovery-oriented care for severe mental disorders in Southern and Eastern Europe: aims and design of a multi-country implementation and evaluation study (RECOVER-E)

BackgroundSubstantial strides have been made around the world in reforming mental health systems by shifting away from institutional care towards community-based services. Despite an extensive evidence base on what constitutes effective care for people with severe mental ill-health, many people in Europe do not have access to optimal mental health care. In an effort to consolidate previous efforts to improve community mental health care and support the complex transition from hospital-based to community-based care delivery, the RECOVER-E (LaRge-scalE implementation of COmmunity based mental health care for people with seVere and Enduring mental ill health in EuRopE) project aims to implement and evaluate multidisciplinary community mental health teams in five countries in Central and Eastern Europe. This paper provides a brief overview of the RECOVER-E project and its methods.MethodsFive implementation sites were selected (Sofia, Bulgaria; Zagreb, Croatia; Skopje, North Macedonia; Kotor, Montenegro; Siret-Suceava, Romania) where hospital-based mental health services are available (care as usual, CAU) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia). The intervention consists of the introduction of a new service delivery model in each site, consisting of community-based recovery-oriented care delivered by trained multidisciplinary community mental health teams (including a peer worker with lived experience of a severe mental disorder). The implementation outcomes of the teams and the effect of the team’s approach on patient and service utilisation outcomes will be evaluated using a mix of research methods. The study includes five planned hybrid implementation-effectiveness trials (1 per site) with patient-level randomization (n = 180, with patients randomised to either care as usual or intervention condition). Effectiveness is evaluated using a pragmatic non-blinded design with patients randomised into two parallel groups: receiving new community-based care or receiving usual care in the form of institutional, hospital-based mental health care. Trial-based health economic evaluation will be conducted; implementation outcomes will be evaluated, with data aligned with dimensions from the RE-AIM framework. Pathways to sustaining project results will be developed through policy dialogue sessions, which will be carried out in each country and through ongoing policy engagement activities at the European level.DiscussionThe RECOVER-E project has been developed and conducted to demonstrate the impact of implementing an evidence-based service delivery model for people with severe mental illness in different contexts in middle-income countries in Central and Eastern Europe. It is expected that the results will contribute to the growing evidence-base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition.Trial registration Each trial was registered before participant enrolment in the clinicaltrials.gov database: Site—Croatia, Zagreb (Trial Reg. No. NCT03862209); Montenegro, Kotor (Trial Reg. No. NCT03837340); Romania, Suceava (Trial Reg. No. NCT03884933); Macedonia, Skopje (Trial Reg. No. NCT03892473); Bulgaria, Sofia (Trial Reg. No. NCT03922425)

Better data to drive more effective care for people with latent tuberculosis infection in Canada.

KEY POINTS Seventy percent of recent migrants to Canada come from areas where tuberculosis (TB) is endemic, and 50% are estimated to have latent TB infection.[1][1] People with latent TB infection in Canada currently number over 1.5 million,[2][2] but this could rise by 120 000 new cases each year

Does the community-based combined Meeting Center Support Programme (MCSP) make the pathway to day-care activities easier for people living with dementia? A comparison before and after implementation of MCSP in three European countries.

An exploratory, descriptive, qualitative, cross-country design was applied to investigate the pathways to day care in several regions in four European countries (Italy, Poland, United Kingdom, and the Netherlands). Before implementation of MCSP, of the four countries the United Kingdom had the most structured pathway to post-diagnostic support for people with dementia. MCSP introduction had a positive impact on the pathways to day-care activities in all countries. MCSP filled an important gap in post-diagnostic care, increasing the accessibility to support for both people with dementia and carers. Key elements such as program of activities, target group, and collaboration between healthcare and social services were recognized as success factors. This study shows that MCSP fills (part of) the gap between diagnosis and residential care and can therefore be seen as a pillar of post-diagnostic care and support. Further dissemination of Meeting Centers in Europe may have a multiple impact on the structure of dementia services in European countries and the pathways to day care for people with dementia and their carer(s).

End of Life Care: A Scoping Review of Experiences of Advance Care Planning for People with Dementia.

Despite increasing attention given to dementia by international governments and policy makers, the focus of end of life care has been on the dying trajectory of malignant disease. People with severe dementia have complex physical and psychological needs, yet the disease is not always recognised as terminal. Advance Care Planning involving people with dementia and their families can provide opportunities to discuss and later, initiate timely palliative care. We conducted a scoping review of studies exploring decisions associated with the EoLC of people with dementia. Eligible studies had to report on decision making at the end of life and by whom (the dying person, clinician/health professional or relative/family member). Twenty-five eligible studies reported on Advance Care Planning and end of life care decisions for individuals with dementia. The papers highlight several challenges that need to be addressed in order to provide adequate and effective care for people with dementia as they near the end of their life.

A systematic literature review on nurses' and health care support workers' experiences of caring for people with dementia on orthopaedic wards.

To review literature on nurses' and health care workers' experiences of caring for people with dementia on orthopaedic wards. Dementia is a condition that affects a large number of the older population worldwide. It is estimated that there are 47·5 million people worldwide living with dementia with 4·6 million new cases being diagnosed annually. This number is said to increase to 75·6 million by 2030 and triple by 2050. It is also acknowledged that older people are at a greater risk of falls that are a devastating problem causing a tremendous amount of morbidity, mortality and use of health care services (Rubestein, Age and Ageing, 35, 2006, 37). Falls usually result from identified risk factors such as weakness, unsteady gait, confusion and certain medication. Therefore, it is reasonable to assume that a large population of older people suffering from dementia may be admitted to orthopaedic wards with various injuries. Nurse and support health workers may experience a range of difficulties when caring for this population of patients. A systematic review. An extensive literature search using; CINAHL, MEDLINE, Academic Search Complete, National Health Service Evidence, websites like Department of Health, Dementia and Alzheimer's Society. The search generated several articles on dementia in general, however, only 14 articles dealing with care of these people in an acute hospital setting were found. No studies dealing with the care of people with dementia on orthopaedic wards were found; therefore, this review has taken a generalist nature and applies the findings to orthopaedic wards. The main themes identified from the review were: challenging behaviour and unsuitable care environment; lack of education on dementia; strain from nursing patients with dementia; and ethical dilemmas arising from care of people with dementia. It would be an over-simplification to say that the care of people with dementia on medical wards is the same as the care of trauma patients with dementia. Therefore, there is a need for a study to explore nurses' and health care worker's experiences of caring for trauma patients with dementia on orthopaedic wards. The results of this study could provide guidance on the effective care of people with dementia on orthopaedic wards.

Integrating care for chronic mental ill-health: the Partners in Recovery Western Sydney Study

Our paper focuses on the implementation in practice of an integrated care policy for severe and complex mental ill-health: Partners in Recovery. In order to be effective care for people experiencing chronic and complex mental ill-health must be supported by a framework which takes in multiple services whose focus extends throughout and beyond the health system (for example, targeted mental health, medical care, social care, housing). In Australia this landscape is populated by services whose priorities and policy frameworks are disconnected. Services working within the same policy environment also frequently compete with each other for funding, further complicating the integration of services for the benefit of consumers. Objective of the policies and targeted population: Partners in Recovery (PIR) is a national initiative designed and funded to improve the system response to, and outcomes for, people with severe and persistent mental illness who have complex needs through better coordination of clinical and other support needs for individuals and at the system level. PIR was funded by the Federal Gillard Government at $430 million over 2012-2016 and was implemented by Lead Organisations in 48 Medicare Local regions across Australia. Lead Organisations are designed to “work at a systems level and be the mechanism to drive collaboration between relevant sectors, services and supports within the region to ensure that all relevant needs of people in the target group are identified and met.” This study focuses on two Lead Organisations in the Western Sydney region – covering a population of more than 1.4 million and with a concentration of some of the largest unmet needs in Australia. Methods: PIR is a case study in integrated care in a ‘difficult’ setting. Our study is a prospective evaluation of three elements of PIR: 1) recovery based outcomes for individual consumers, 2) recovery orientation of service delivery and processes and 3) outcomes in relation to system integration. We are collecting cyclical qualitative and quantitative data over a three year period, comprising of interviews with service providers, mapping of referral patterns and service connections, World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116630– http://www.ijic.org/ quantitative measures of need and recovery collected from PIR participants and quantitative measures of service recovery orientation. Interviews with service providers focus on enablers and disablers of service collaboration, the use of knowledge in service design and the development of new knowledge through the PIR collaboration. The evaluation has developed concurrently with the PIR initiative and organically in collaboration with the Lead Organisations. Our research is led by a project advisory group comprising researchers, service providers and consumer advocates. Highlights: The evaluation is set in the context of two significant policy and implementation limitations: there are currently no accurate ways of measuring the scale of either the target population or the issues they encounter. This knowledge is only being discovered through actually rolling out services. A second corollary is that the services needed by the PIR target population will only be identified as work with the consumers progresses. This is thus the enactment of integrated care in an unknown setting which can cause difficulties for implementation. However, there are benefits to this situation as it is possible that the practice-based enactment of the policy will have the potential for positive innovation and adaptive regional variation. Conclusions: We will present preliminary findings from the first year of the study. We will describe what indications we found of system integration, what factors have facilitated the process of integration and what barriers or challenges have impeded the process.

GOLDMAN ET AL. RESPOND

Regrettably, New York City Health Department Commissioner Thomas R. Frieden continues to misunderstand the points made in our article. We share with the New York City Department of Health and Mental Hygiene (DOHMH) a keen desire to promote access to comprehensive, effective care for people with diabetes and HIV/AIDS, as well as increased resources for prevention and community education. However, our overarching concern is that the DOHMH’s approaches will discourage patients from seeking and continuing care and will undermine medical professionalism. We respond to two particular issues raised by Frieden.

Providing more effective care for people with epilepsy

Primary care nurses can take a lead role in addressing epilepsy patients' unmet needs with the help of tailored toolkits

Research into Communication Patterns and Consequences for Effective Care of People with Alzheimer’s and Their Carers

This article offers a critical account of the ethical issues arising from the conduct of a research project investigating communication with and between people who have a dementia. These issues are examined with the background knowledge that there are no legal precedents to guide ethical procedures when carrying out research with this client group. Yet, if such research were not undertaken, there would be no opportunity to empirically evaluate present communication and care, or to recommend alternatives to this care. To address this situation, this article outlines a protocol for addressing a variety of ethical considerations. Finally, a working model of ethical procedures when undertaking research with people who have a dementia is presented. It is recognized that this is a dynamic process and will change over time. However, a starting point is needed to begin the process of accounting for ethical issues when undertaking research with this vulnerable group.

First among Equals?

Despite various problems associated with the introductionand use of the new generation of drugs for Alzheimer’s disease(cholinesterase inhibitors), expenditure on this aspect of patient care tends to eclipse expenditure on caring and support services. Even though evidence for the effectiveness of many patient-centred approaches is increasingly available, in the UK fixed budgets for various types of service usually means that increased expenditure on medication ensures that support services will inevitably have their funding eroded. Is this the best way to provide effective care for people with dementia? The role of drug companies in this process is examined critically.

The palliative care needs of people with learning disabilities

This article examines many of the issues and difficulties associated with caring for people with learning disabilities who require palliative intervention. Providing palliative care for this client group is both complex and challenging for all those involved in the patient’s care. The Composite Model of palliative care is outlined and the needs of the person with a learning disability, those of the carer and the family are discussed. Finally, recommendations are made to help health professionals address the challenges posed by this client group and to assist them in providing more effective care for people with a learning disability who require palliative care.

The palliative care needs of people with learning disabilities

This article examines many of the issues and difficulties associated with caring for people with learning disabilities who require palliative intervention. Providing palliative care for this client group is both complex and challenging for all those involved in the patient's care. The Composite Model of palliative care is outlined and the needs of the person with a learning disability, those of the carer and the family are discussed. Finally, recommendations are made to help health professionals address the challenges posed by this client group and to assist them in providing more effective care for people with a learning disability who require palliative care.