Support Intervention For Patients Research Articles

Evaluation of a Behavior Support Intervention for Patients With Poorly Controlled Diabetes

Disease management programs that include ongoing telephone support for patients with diabetes have shown promise, but published studies have enrolled few socially and economically disadvantaged patients. We conducted a randomized controlled trial with 201 patients with poorly controlled type 2 diabetes mellitus (72% African American or Latino; 74% with incomes of ≤$15,000). Participants were randomized to an intervention package consisting of a 24-minute video behavior support intervention with a workbook and 5 sessions of telephone coaching by a trained diabetes nurse or a 20-page brochure developed by the National Diabetes Education Program. Study measures were completed at baseline, 1 month, and 6 months. Participants' review of the intervention materials was assessed at 1 month. The primary trial end point was hemoglobin A(1c) value. Secondary end points included lipid levels, blood pressure, diabetes knowledge, and self-care behaviors. Data were analyzed with repeated measures analysis of variance. Most participants in both groups (94%) reviewed the intervention provided, and 73% of participants assigned to the experimental group completed 5 sessions of telephone coaching. There was a significant overall reduction in mean (SD) hemoglobin A(1c) value from baseline (9.6% [2.0%]) to 6 months (9.1% [1.9%]) (P < .001), but differences between groups were nonsignificant. Differences on other clinical measures (lipid levels and blood pressure) and measures of diabetes knowledge and self-care behaviors were also nonsignificant. There was no significant effect of the experimental intervention compared with the control condition. The dose of intervention provided was less than in previously published studies. More intensive interventions may be necessary for the most disadvantaged patients. clinicaltrials.gov Identifier: NCT00668590.

The design of patient decision support interventions: addressing the theory–practice gap

Although an increasing number of decision support interventions for patients (including decision aids) are produced, few make explicit use of theory. We argue the importance of using theory to guide design. The aim of this work was to address this theory-practice gap and to examine how a range of selected decision-making theories could inform the design and evaluation of decision support interventions. We reviewed the decision-making literature and selected relevant theories. We assessed their key principles, theoretical pathways and predictions in order to determine how they could inform the design of two core components of decision support interventions, namely, information and deliberation components and to specify theory-based outcome measures. Eight theories were selected: (1) the expected utility theory; (2) the conflict model of decision making; (3) prospect theory; (4) fuzzy-trace theory; (5) the differentiation and consolidation theory; (6) the ecological rationality theory; (7) the rational-emotional model of decision avoidance; and finally, (8) the Attend, React, Explain, Adapt model of affective forecasting. Some theories have strong relevance to the information design (e.g. prospect theory); some are more relevant to deliberation processes (conflict theory, differentiation theory and ecological validity). None of the theories in isolation was sufficient to inform the design of all the necessary components of decision support interventions. It was also clear that most work in theory-building has focused on explaining or describing how humans think rather than on how tools could be designed to help humans make good decisions. It is not surprising therefore that a large theory-practice gap exists as we consider decision support for patients. There was no relevant theory that integrated all the necessary contributions to the task of making good decisions in collaborative interactions. Initiatives such as the International Patient Decision Aids Standards Collaboration influence standards for the design of decision support interventions. However, this analysis points to the need to undertake more work in providing theoretical foundations for these interventions.

A Review of Volunteer-Based Peer Support Interventions in Diabetes

Given the complexity of diabetes self-management activities and patients' resultant need for lifelong diabetes self-management support (DSMS), peer support has been increasingly examined as a potential model for diabetes self-management education (DSME) and ongoing DSMS.1 Dennis2 defines peer support as “the provision of emotional, appraisal, and informational assistance by a created social network member who possesses experiential knowledge of a specific behavior or stressor and similar characteristics as the target population, to address a health-related issue of a potentially or actually stressed focal person.” During the past decade, there has been a proliferation of research examining the feasibility, acceptability, and health-related impact of peer support interventions in the context of diabetes care.3–14 Based on a review of peer support interventions for patients with diabetes, Heisler15,16 identified five models of peer support, including 1 ) face-to-face group self-management programs, 2 ) peer coaches or mentors, 3 ) community health workers (CHWs), 4 ) telephone-based peer support, and 5 ) Internet or e-mail–based peer support. Face-to-face group support typically involves a peer supporter or a team of peer supporters delivering DSME or DSMS in a group-based setting such as the diabetes-specific version of the chronic disease self-management program of Lorig and Gonzales.17 Peer coaching or mentoring usually involves individuals working with patients on a less structured basis providing emotional support and serving as a role model.18 CHWs are individuals who live in the same community and share the same cultural background, values, and customs as the target patient population.19,20 CHWs provide informational, instrumental, and emotional support and often function as a bridge between community members and the health care system.19,20 In fact, some studies in a 2007 systematic review of diabetes interventions21 involving CHWs reported improvements in clinical (glycemic control, …

Investing in Deliberation: A Definition and Classification of Decision Support Interventions for People Facing Difficult Health Decisions

This article provides an analysis of 'decision aids', interventions to support patients facing tough decisions. Interest has increased since the concept of shared decision making has become widely considered to be a means of achieving desirable clinical outcomes. We consider the aims of these interventions and examine assumptions about their use. We propose three categories, interventions that are used in face-to-face encounters, those designed for use outside clinical encounters and those which are mediated, using telephone or other communication media. We propose the following definition: decision support interventions help people think about choices they face; they describe where and why choice exists; they provide information about options, including, where reasonable, the option of taking no action. These interventions help people to deliberate, independently or in collaboration with others, about options, by considering relevantattributes; they support people to forecast how they might feel about short, intermediate and long-term outcomes which have relevant consequences, in ways which help the process of constructing preferences and eventual decision making, appropriate to their individual situation. Although quality standards have been published for these interventions, we are also cautious about premature closure and consider that the need for short versions for use inside clinical encounters and long versions for external use requires further research. More work is also needed on the use of narrative formats and the translation of theory into practical designs. The interest in decision support interventions for patients heralds a transformation in clinical practice although many important areas remain unresolved.

Clinicians’ concerns about decision support interventions for patients facing breast cancer surgery options: understanding the challenge of implementing shared decision-making

There is interest in interventions that provide support for patients facing challenging decisions, such as the choice between mastectomy and breast conservation surgery for breast cancer. However, it is difficult to implement these interventions. One potential source of resistance is the attitudes of clinicians. To examine specialist breast clinicians' opinions about the provision of decision support interventions (DesIs) for patients. As part of the development of a web-based DesI (BresDex), semi-structured interviews were conducted with specialist clinicians [breast surgeons, breast care nurses (BCNs) and oncologists] from four breast units in a UK region, and speciality national opinion leaders. Interviews were recorded, transcribed and analysed using the Framework approach. A majority of the 24 clinicians interviewed did not have a working knowledge of DesIs and were ambivalent or sceptical. Many expressed conflicting opinions: they noted the potential benefits, but at the same time expressed reservations about information overlap, overload and about content that they considered inappropriate. Many wanted access to DesIs to be always under clinical supervision. In particular, they were uncertain as regards how DeSIs could be tailored to individual patients' needs and also accommodate clinical practice variation. BCNs were particularly concerned that DesIs might induce patient anxiety and replace their role. The concept of providing interventions to support patients in decision-making tasks generated concern, defensiveness and scepticism. These attitudes will be a significant barrier. Implementation efforts will need to recognize and address these issues if these interventions are to become embedded in clinical practice.

How to develop web-based decision support interventions for patients: A process map

Objective Significant advances have been made in the development of decision support interventions, also called decision aids, for patients facing difficult or uncertain decisions. However, challenges related to the definition, the theoretical underpinnings, the relative contribution of different components and how to migrate these tools to the Internet, remain unresolved. We propose a systematic process map for others to consider as they develop web-based, perhaps multimedia, decision support interventions and to examine the future challenges faced by developers. Methods Based on our experiences of developing and evaluating web-based decision support interventions, we outline a process map to illustrate the general principles of content specification followed by creative design and tailoring to the target audience. Results Content specification is fundamental and it should go beyond the traditional emphasis on scientific evidence in order to ensure patients’ perspectives on the proposed options. The creative design phase aims to develop a medium to achieve three fundamental tasks: present information; achieve accurate affective forecasting; provide a basis for preference construction. This phase should be an open to experimentation and, where empirical work may be difficult or not yet available, guided by consultation with users, using an iterative method of trial and adaptation. Conclusion There is little empirical research on how best to achieve these tasks. The guiding principle needs to be one of customising the delivery, based on close consultation with the target users and an iterative development process until the intervention is deemed accessible and useful. Practice implications The process map provides a basis for further developments and outlines areas where remaining challenges need further investigation.

The role of primary care physicians in advanced cancer care: perspectives of older patients and their oncologists.

To examine data from advanced cancer patients and their oncologists regarding patient age-related differences in patient and oncologist perspectives on involvement of primary care physicians (PCPs) in aspects of cancer management. Randomized controlled trial of a support intervention for patients with late-stage cancer treated in two teaching hospital-based cancer clinics caring for underserved populations. Three hundred fifty-seven patients who had an oncologist and PCP enrolled 2 to 3 months after an advanced cancer diagnosis. Sociodemographic data and structured interviews were used to assess patients' perceptions of PCP involvement in care discussions and decision-making and satisfaction with that involvement, oncologists' beliefs about how involved PCPs should be in these discussions and decisions, and their shared care practices. Older patients (>or=65) were more likely to have a PCP (P=.02). Patients reported a broad range of perceived PCP involvement and satisfaction with that involvement. Greater involvement was associated with greater satisfaction (P<.001). Half of oncologists reported themselves as PCP for more than 25% of their patients. Approximately half of oncologists reported that more older than younger patients had PCPs, yet only 20% reported differences in PCP involvement or in their communication with PCPs for older late-stage patients. Results support involvement of PCPs in advanced cancer care and demonstrate variable perspectives on PCP involvement. Matching patient preferences and practices may improve satisfaction. Clarification of elements in the partnership between patients, PCPs, and oncologists will inform efforts to optimally care for older patients with advanced cancer.

Managing Chronic Sorrow

The goals of this study were to describe the ways in which patients with multiple sclerosis (MS) manage chronic sorrow and to apply this information to the theoretical model of chronic sorrow. This descriptive study involved 38 participants with MS who were experiencing chronic sorrow. Using the theoretical model of chronic sorrow, we applied content analysis to participants' accounts of how they attempted to manage this sorrow. The findings showed that discomfort resulted from ineffective management of chronic sorrow, reflecting the vulnerability these patients experience and the lack of understanding of their needs and appropriate support from family, friends, and healthcare personnel. In some cases, however, the losses and emotional distress caused by MS were managed effectively, which led to increased comfort through personal growth and a greater appreciation of life, greater confidence, and hope for the future. The theoretical model was valuable in helping to describe participants' patterns of managing chronic sorrow. Healthcare personnel should acknowledge chronic sorrow as one aspect of psychological distress in MS. Knowledge of patients' experiences of chronic sorrow should be included in the education for neuroscience nurses. Furthermore, it is necessary to develop support interventions for patients with chronic sorrow and their families.

Quality of life in chronic lymphocytic leukemia: an international survey of 1482 patients

Although a diagnosis of chronic lymphocytic leukemia (CLL) can have a profound effect on the quality of life (QOL), few studies have objectively measured the QOL of CLL patients or compared it to the general population. We conducted an international, web-based survey of patients with CLL using standardized instruments with published population norms to evaluate fatigue and QOL. Co-morbid health conditions were assessed using the Charlson Co-Morbidity Index. Between June and October 2006, 1482 patients with CLL responded to the survey. The physical, social/family, functional, and overall QOL scores of CLL patients were similar to or better than published population norms. In contrast, the emotional well-being scores of CLL patients were dramatically lower than that of both the general population (P < 0.001) and patients with other types of cancer (P < 0.001). QOL scores were lower among individuals with advanced stage disease (all P < 0.05). Factors associated with lower overall QOL on multivariate analysis included older age, greater fatigue, severity of co-morbid health conditions, and current treatment. CLL has a profound impact on QOL at all disease stages. The effects of CLL on QOL appear to differ from that of other malignancies with a more marked impact on emotional QOL. Research identifying efficacious psycho-oncologic support interventions for patients with CLL is needed.

Life with a left ventricular assist device: the patient's perspective

Understanding the psychological experience of living with a life-sustaining device is necessary for developing individualized, supportive interventions for patients with a left ventricular assist device. To describe patients' experiences with left ventricular assist devices, strategies for coping with prolonged hospitalization, and suggestions for individualized nursing interventions. The phenomenology method of qualitative research was used. Data collection involved unstructured, open-ended interviews of 6 hospitalized subjects who had a pneumatic left ventricular assist device. Patients described coping strategies for prolonged hospitalization, including family support, religious convictions, and diversional activities. Data analysis suggests that critical care nurses can best support these patients by establishing trusting relationships, fostering independence, and incorporating humor into their care. Patients awaiting cardiac transplantation coped effectively with prolonged hospitalization with a life-sustaining device in place. Spirituality, humor, and strong family relationships contributed to their positive outlook.