Treatment Of Chronic Conditions Research Articles

Therapeutic videoconferencing interventions for the treatment of long-term conditions

We conducted a systematic review of literature relating to videoconferencing in therapeutic interventions for chronic conditions. Two hundred articles were reviewed in detail, 35 of which were relevant to the study. Of these, eight were randomized controlled trials (RCTs) and the remainder were service evaluations, pilot studies and case studies. Two major themes emerged, relating specifically to videoconferencing: clinical outcomes and patient satisfaction. There were 14 studies which measured clinical outcomes of interventions for chronic conditions delivered by videoconferencing. A range of evidence, including four RCTs of high quality, indicates that interventions for a variety of conditions, including psychological and physical, delivered by videoconferencing produce similar outcomes to treatment delivered in-person. Evidence suggests that levels of patient satisfaction with telerehabilitation are high and that the formation of a good therapeutic alliance is possible. Several papers reported that clinical staff showed lower levels of satisfaction in using telerehabilitation than patients. It is feasible to use videoconferencing as a means of delivering therapeutic interventions for people with chronic conditions in rural communities.

Is Disease Management Right for Oncology?

The disease management (DM) model for the treatment of chronic conditions has been around for many years and has been found to be effective for diseases of high prevalence and high cost (eg, diabetes, asthma, heart disease). With an increasing number of people living with cancer and the continual escalation of treatment costs, DM vendors have begun to implement DM concepts into cancer care. However, the multitude of cancer types, treatment options, and adverse effects have all presented barriers to oncology DM, and data reflecting the effectiveness of oncology DM have remained scarce. Oncology costs, the lack of congruence between provider and patient expectations of treatment, the lack of prevention and early detection for many cancers, and, most importantly, the inability of people to adhere to healthy lifestyles are additional obstacles that must be overcome. Moreover, when designing an oncology DM program, it is imperative to look at cancers individually as the etiology, treatment, and impact of cancer can be markedly different from one patient to the next. An effective oncology DM program is one that acts to decrease fatigue, reduces nosocomial infections, deals with dehydration and pain, manages anemia, identifies and treats skin infections, recognizes and treats depression and other psychological distress, provides patients access to palliative care services, facilitates informed decision making and end-of-life transitions, and promotes communication between patients and their providers as well as between physicians. Moving forward, DM vendors and health insurance companies capable of incorporating DM with medical management will be in the best position to provide optimal cancer care.

Fabrication and Physical-Chemical Characterisation of Polyelectrolyte Microparticles: Platform for Controlled Release of Bioactives

Porous CaCO(3) microparticles were fabricated by colloidal crystallization. Two oppositely charged polyelectrolytes, poly (styrene sulfonate, PSS) and poly (allylamine hydrochloride, PAH) were adsorbed layer-by-layer on the CaCO(3) templates. Polyelectrolyte microcapsules were then obtained by removing the CaCO(3) core. Scanning electron microscopy (SEM), energy-dispersion X-ray analysis (EDX), laser diffraction particle sizing and Raman spectroscopy were employed to characterize the physico-chemical properties of the constructed microcapsules. In vitro drug release studies were conducted using the model water-soluble drug Rhodamine B. Factors such as the number of polyelectrolyte layers and pH were investigated. SEM micrographs revealed uniform CaCO(3) microparticles, nearly spherical in shape with pronounced surface roughness, and highly developed interior porous structure. The surface of polyelectrolyte coated particles became rougher than the initial CaCO(3) microparticles. The acquired SEM micrographs of the (PSS/PAH)(n) microcapsules indicated that the number of layers affected the morphology of the microcapsules. The (PSS/PAH)(3) microcapsules revealed a very porous network with many holes resembling the initial morphology of CaCO(3) microparticles. Raman spectra showed peaks at 1125 cm(-1) (S=O bond) and 1600 cm(-1) (aromatic ring stretching) which represented the PSS molecule. The thickness of each layer was about 10 to 20 nm and it can be tailored to such nanometer level by controlling the number of adsorbed layers. The in vitro release of Rhodamine B was dependent on both the number of wall bilayers as well as the pH of the release media. These systems provide an opportunity for the development of controlled release dosage forms with greater effectiveness in the treatment of chronic conditions.

Adherence To Medications In Systemic Lupus Erythematosus

Lack of adherence is a ubiquitous problem which can be a hindrance in the treatment of chronic conditions like systemic lupus erythematosus (SLE). A random sample of 63 SLE patients attending rheumatology clinics associated with University Medical Centers were surveyed to measure level of adherence to their SLE medications and to identify the risk factors that have been associated previously with nonadherence to these medications. Information on traditional SLE outcomes was obtained by face-to-face interviews and medical record review. Various patient proposed strategies were identified to improve adherence to these medications. When considering adherence estimates of > or =80% as representing sufficient adherence for achieving a therapeutic response, adherence to medications was only modestly adherent, likely limiting the effectiveness of the prescribed medication regimens. Based on pharmacy refill information 61% of the patients were sufficiently adherent to prednisone, 49% to hydroxychloroquine, and 57% to other immunosuppressant medications. Significant risk factors of insufficient adherence included being single, low educational level, presence of other comorbidities, limited comprehension of physician explanations and instructions, and having to take the medication more than one daily. Based on subject reports, busy life styles were among the most important barriers to adherence whereas pillboxes were considered most helpful for helping with medication adherence. Although lack of sufficient adherence to medications appears to be a multifactorial problem, improved communication between the healthcare provider and the patient, and less complicated medication regimens, may be especially suitable interventions to improve adherence to medications.

Overcoming Legal Obstacles Involving the Voluntary Care of Children Who Are Separated From Their Legal Guardians During a Disaster

A large-scale disaster may separate children from their parents or guardians and may strand many children in the care of temporary caregivers, including physicians and nurses. In general, unless a physician or nurse is a member of a public sector emergency response program (a "VHP"), parental consent is required for the treatment of minors outside of an emergency department unless the minor is suffering from an imminently life-threatening condition. Physicians or nurses who are not VHP's may be held liable (civilly, criminally and administratively) if they provide care without parental consent outside of an emergency room to a child who is not suffering from an imminently life-threatening condition. The existing rules regarding parental consent would, in many cases, limit (or at least discourage) the provision of optimal health care to children in a large-scale disaster by restricting care aimed to alleviate pain, the treatment of chronic conditions as well as the treatment of conditions, or potential conditions, that could worsen or develop in the absence of treatment.Additionally, "Good Samaritan" laws that generally limit the liability of health care providers who voluntarily provide care in an emergency may not apply when care is provided in a crude or makeshift clinic or when care is not provided at the scene of the emergency. Thus, benevolent physicians and nurses who voluntarily provide care during a large-scale disaster unjustly risk liability. The prospect of such liability may substantially deter the provision of optimal medical care to children in a disaster. This article discusses the shortcomings of current laws and proposes revisions to existing state laws. These revisions would create reasonable and appropriate liability rules for physicians and nurses providing gratuitous care in emergencies and thus would create reasonable incentives for health care providers to deliver such care. ("Gratuitous care" is the legal term for care provided voluntarily and without expectation of payment.).

Daniel Callahan and Angela A Wasunna, Medicine and the market: equity v. choice, Baltimore, MD, Johns Hopkins University Press, 2006, pp. x, 320, £23.50, $35.00 (hardback 0-8018-8339-3).

Daniel Callahan and Angela A Wasunna, Medicine and the market: equity v. choice, Baltimore, MD, Johns Hopkins University Press, 2006, pp. x, 320, £23.50, $35.00 (hardback 0-8018-8339-3). - Volume 51 Issue 2

Patient reported outcomes: general principles of development and interpretability

Direct measurement of how people are feeling and the extent to which they are functioning in daily activities (generally as patient reported outcomes) is critical to judging the benefit of health interventions in chronic conditions. Selection of an appropriate instrument will reflect a comprehensive understanding of the condition of interest and a thorough knowledge of the expected benefits and harms of the proposed intervention. We provide a brief discussion about different ways that health and health measurement have been defined, including the International Classification of Function, Disability and Health (ICF), Health Related Quality of Life (HRQOL) and cost-to-benefit analyses. We outline important properties (reliability, validity, and responsiveness) that a measurement instrument must demonstrate depending on the purpose of measurement, and provide insight as to how to interpret the results of studies that report patient reported outcomes.

Rheumatology in Singapore – Moving Forward

The practice of Rheumatology and Clinical Immunology has made big strides in the last decade. The availability of immune modifiers, e.g. anti-cytokine agents, has changed the therapeutic landscape of arthritis treatment. What is refractory arthritis previously had now become controllable disease. Fan and Leong1 had in this issue reviewed the use of biological agents in the treatment of rheumatoid arthritis and given us an overview of the evolving treatment regimens over the years. This experience is indeed repeated for other arthritis seen by rheumatologist in their clinics. The advent of biologics agents however do not exclude the need for better understanding of the epidemiology of rheumatological conditions. Howe et al2 in their article reviewed seronegative spondyloarthropathy studies from the Asia-pacific region, bringing to the fore the collaborative research efforts among Asia-pacific rheumatologists. Thumboo and Strand3 touched on another important subject for rheumatologists who deal with chronic diseases daily. Treatment of chronic conditions have reached a level in which the question being asked is not “what is the mortality or survival rate” but “what is the effect on quality of life”. The importance of using health-related quality of life instruments to measure disease outcomes is paramount. The article dealt with systemic lupus erythematosus but the underlying principles are the same for other chronic rheumatic diseases. Today, information technology is widely harnessed for research and service, and transcends all disciplines. Immunology is no exception. The article by Chan and Kepler4 on computational immunology gives a snapshot of what’s possible and on the horizon. It promises to enhance the pace of immunology research as well as provides directions for new research areas. It is without doubt going to play an increasingly significant role in immunology research. Apart from the review articles, there is a good mix of letters, case reports and original articles dealing with research from the bedside to the bench. Clinical case reports and letters provide insights into particular aspects of rheumatic diseases. Hepatitis B infections are prevalent in Singapore and Thong et al5 reported the outcomes of chronic hepatitis B infection in local rheumatic diseases patients. It is of particular interest as corticosteroids and immunosuppressives therapy are used commonly in the treatment of rheumatic diseases, and rightly feared to be a factor in causing hepatitis B infection flares. Xu et al6 reported on their study of cytokines gene polymorphisms in systemic lupus erythematosus (SLE) and Suppiah et al7 on cytokines levels in rheumatoid arthritis (RA). IL-18 promoter gene polymorphism (CC genotype) is found to be associated with SLE, while IL-1beta, IL-6, TNF-alpha and IL-18 proteins concentrations are elevated in RA patients. Conversely, TGF-beta levels are reduced in RA patients when compared to normal controls. The articles by Lim et al8 and Chong et al9 on patient satisfaction and value of joint aspiration respectively reveal important aspects of clinical management. They provide good insights into simple but important clinical research. The wide spectrum of rheumatic conditions studied as well as the various aspects of pathogenetic factors and clinical management published in this issue makes it a worthwhile effort, and highlights the active rheumatology and immunology research scene in Singapore.

Challenges for the 21st Century: The Future of Electrical Neuromodulation

After a checkered past, the modern era of therapeutic neuromodulation began in the 1960s, since when many targets and applications have been developed. Some have come and gone. To compete successfully for limited resources, good-quality evidence of efficacy is increasingly demanded. This was previously lacking, as was a full appreciation of the implications of neuromodulation being a long-term treatment for chronic conditions. Its future will involve a complex interaction of improved understanding of the indications and mechanisms of action, exciting new indications, more mature assessment of outcomes, socioeconomic considerations, and fundamental technological developments. A shift away from a medication-dominated mindset should help physical treatments like neuromodulation to fulfill their enormous potential in future years. Earlier application may even modify the course of some conditions.

Cost‐effectiveness of asthma control: an economic appraisal of the GOAL study

The Gaining Optimal Asthma ControL (GOAL) study has shown the superiority of a combination of salmeterol/fluticasone propionate (SFC) compared with fluticasone propionate alone (FP) in terms of improving guideline defined asthma control. Clinical and economic data were taken from the GOAL study, supplemented with data on health related quality of life, in order to estimate the cost per quality adjusted life year (QALY) results for each of three strata (previously corticosteroid-free, low- and moderate-dose corticosteroid users). A series of statistical models of trial outcomes was used to construct cost effectiveness estimates across the strata of the multinational GOAL study including adjustment to the UK experience. Uncertainty was handled using the non-parametric bootstrap. Cost-effectiveness was compared with other treatments for chronic conditions. Salmeterol/fluticasone propionate improved the proportion of patients achieving totally and well-controlled weeks resulting in a similar QALY gain across the three strata of GOAL. Additional costs of treatment were greatest in stratum 1 and least in stratum 3, with some of the costs offset by reduced health care resource use. Cost-effectiveness by stratum was 7600 pound (95% CI: 4800-10,700 pound) per QALY gained for stratum 3; 11,000 pound (8600-14,600 pound) per QALY gained for stratum 2; and 13,700 pound (11,000-18,300 pound) per QALY gained for stratum 1. The GOAL study previously demonstrated the improvement in total control associated with the use of SFC compared with FP alone. This study suggests that this improvement in control is associated with cost-per-QALY figures that compare favourably with other uses of scarce health care resources.

Adapting the randomized consent (Zelen) design for trials of behavioural interventions for chronic disease: feasibility study

Standard randomized controlled trials of interventions for chronic conditions that involve behavioural change, or that are highly desired by participants, are difficult to undertake because of problems with recruitment and contamination. Alternatives include cluster-randomized trials or pre-randomization designs such as the Zelen design. The aim here was to develop a pre-randomization design that would overcome ethical and methodological problems associated with the conventional Zelen design, and permit the rigorous evaluation of a complex package of care, involving physical therapy and behavioural changes, for patients with painful patello-femoral osteoarthritis of the knee joint. Eligible patients were first consented to a one-year observational study of their arthritis. They were subsequently randomized into intervention and control arms. Those in the intervention arm were then asked if they were willing to participate in a further study involving regular sessions with a physiotherapist. Those in the control arm were not told about this, but were followed up as agreed. Eighty-seven patients consented to the observational study, 43 of whom were subsequently randomized to the intervention arm. All 43 consented to the intervention, although five of these did not receive the full package of care. Assessments were carried out at five months and one year on 82 patients, and concealment was satisfactorily maintained in the majority. We conclude that this study design could potentially offer an acceptable compromise between the need for scientific rigour and the ethical imperative of fully informed consent in trials that involve behavioural change or interventions that patients might want to obtain.

CORM‐A1: a new pharmacologically active carbon monoxide‐releasing molecule

Carbon monoxide (CO) is emerging as an important and versatile mediator of physiological processes to the extent that treatment of animals with exogenous CO gas has beneficial effects in a range of vascular- and inflammatory-related disease models. The recent discovery that certain transition metal carbonyls function as CO-releasing molecules (CO-RMs) in biological systems highlighted the potential of exploiting this and similar classes of compounds as a stratagem to deliver CO for therapeutic purposes. Here we describe the biochemical features and pharmacological actions of a newly identified water-soluble CO releaser (CORM-A1) that, unlike the first prototypic molecule recently described (CORM-3), does not contain a transition metal and liberates CO at a much slower rate under physiological conditions. Using a myoglobin assay and an amperometric CO electrode, we demonstrated that the release of CO from CORM-A1 is both pH- and temperature-dependent with a half-life of approximately 21 min at 37 degrees C and pH 7.4. In isolated aortic rings, CORM-A1 promoted a gradual but profound concentration-dependent vasorelaxation over time, which was highly amplified by YC-1 (1 microM) and attenuated by ODQ, a stimulator and inhibitor of guanylate cyclase, respectively. Similarly, administration of CORM-A1 (30 micromol/kg i.v.) in vivo produced a mild decrease in mean arterial pressure, which was markedly potentiated by pretreatment with YC-1 (1.2 micromol/kg i.v.). Interestingly, an inactive form of CORM-A1 that is incapable of releasing CO failed to promote both vasorelaxation and hypotension, thus directly implicating CO as the mediator of the observed pharmacological effects. Our results reveal that the bioactivities exerted by CORM-A1 reflect its intrinsic biochemical behavior of a slow CO releaser, which may be advantageous in the treatment of chronic conditions that require CO to be delivered in a carefully controlled manner.

Alternative and Complementary Modalities for Managing Stress and Anxiety

is director of Holistic Nursing Consultants in Temple, Tex, and Port Angeles, Wash, and editor of Holistic Nursing Update. She has written 9 books and numerous journal publications and serves on the boards of several nursing organizations. frequently used therapies mentioned in the survey were relaxation techniques, chiropractic, massage therapy, imagery, spiritual healing, lifestyle diets, herbal medicine, megavitamin therapy, self-help groups, energy healing, biofeedback, hypnosis, homeopathy, acupuncture, folk remedies, exercise, and prayer. A 1997 follow-up national survey by the same team found that use of at least 1 of 16 alternative therapies during the preceding year increased from 33.8% in 1990 to 42.1% in 1997. Overall, use of alternative therapies increased by 25%, total visits to alternative medicine practitioners increased by 47%, and expenditures for alternative goods and services increased by 45% (exclusive of inflation). Results from the follow-up study also indicated that ailing persons most often seek nonmainstream treatments for chronic conditions, such as back problems, anxiety, depression, and headaches. In 1990, an estimated 3 in 10 Americans used at least one alternative therapy; in always adverse, however; managed correctly, the problems caused by stress can be minimized. Realistically, stress is a normal aspect of life that must be endured at some level. Additionally, a stress response can be helpful in many ways, motivating persons to work or study or increasing their alertness while taking a test or giving a talk. The problem occurs when stress exceeds a productive level and interferes with the ability to think, remember, and focus on tasks. Stress that is ineffectively managed and remains too high for too long can contribute to multiple illnesses. Americans are using alternative and complementary therapies, often for stress-related complaints. The results of a nationwide survey of 1539 adults published in the New England Journal of Medicine indicated that 1 in 3 Americans uses therapies considered unconventional. This study was the landmark investigation that opened the floodgates to exploring and understanding these new therapies and how they work. The most ProtocolsforPractice

Use of chronic medications among a large, commercially-insured US population.

To examine use of chronic therapies by females and males of all ages. Participants were 1,295,948 members of a large US pharmacy benefit manager. The use of chronic medications by males and females during 1999 was examined overall and within 16 commonly-used chronic drug groups. Dependent variables were use of a drug group, number of drug groups used, number of prescriptions filled and sum of costs, both within each drug group and overall. Combination therapy was defined as using at least two of the 16 chronic therapy groups during 1999. Females were more likely than males to use chronic medications during the study year (36.5 vs. 22.4%, p < 0.001). Generally, the likelihood of using a chronic medication increased with age for both sexes. Commonly-used chronic medications accounted for 54 and 50% of prescriptions for females and males respectively, and for 53% of total drug costs for both sexes. There were few meaningful sex differences in the likelihood of using particular drug groups. Of those who took chronic drugs 14% used combination chronic therapy. This study provides demographic information regarding treatment of chronic conditions that can be used to aid policy decisions and to provide an impetus for future research.

DG2: THE INCREMENTAL COST OF DIABETES IN CHRONIC ILLNESS CO-OCCURRENCES

OBJECTIVES: The cost and management of patients with multiple chronic conditions present unique challenges to the health care system. Major chronic conditions such as diabetes often co-occur with other chronic illnesses. The objective of this study is to report the incremental cost of diabetes mellitus when it co-occurs with cardiovascular conditions, depression, hypertension, psychosis, respiratory/asthma, or acid peptic disease. METHODS: A one-year retrospective database analysis using an integrated Medicaid dataset from the State of Oklahoma. Disease states were identified by ICD-9-CM codes and a validated drug-based classification. Patients included in the study had the chronic condition identified by both drug and diagnosis information. The incremental costs of diabetes when co-occurring with other chronic conditions was determined by subtracting the cost of the non-diabetes single condition from the co-occurring disease group. RESULTS: Seven groups of patients consisted of; diabetes only (n = 1038), diabetes co-occurring with hypertension (n = 313), respiratory illness/asthma (n = 62), depression (n = 48), cardiovascular illness (n = 35), psychosis (n = 35), and acid peptic disease (n = 30). Diabetes as a single chronic illness had an annual cost of $818 over patients with no evidence of chronic illness. The incremental cost of diabetes when co-occurring with psychosis was $7,211, respiratory illness/asthma $3,161, hypertension $1,595, depression $1,319, acid peptic disease $977, and cardiovascular illness $−35. The incremental cost of diabetes co-occurring with psychosis was significantly higher than all other disease co-occurrences. Differences in the incremental cost of diabetes were not statistically significant between the other disease combinations. ANCOVA was performed with longevity in the program as a covariate to adjust for differential enrollment time. CONCLUSION: The cost and management of chronic conditions such as diabetes may be highly influenced by other chronic conditions the patient may have. Disease management programs may incorporate co-morbidity research and models when evaluating the cost and treatment of chronic conditions.

Measuring Quality of Life in Epilepsy Surgery Patients

Treatment of chronic conditions often entails trade-offs between benefits and risks or side effects. This is of particular importance in epilepsy. Consequently, assessment of effectiveness must incorporate this trade-off as perceived by the recipient of the intervention, ie., the patient. Measurement of health related quality of life (HRQOL) aims at capturing such patient-centred effects of therapy. Conceptual aspects of HRQOL are described and issues relevant to outcomes of epilepsy surgery are addressed. Finally, practical aspects of measurement in the context of epilepsy surgery are discussed.

Quality of life assessment.

Quality of Life (QOL) is a generic term covering a wide variety of end points. It generally refers to a multitude of subjective experiences important to people's lives. Four domains contribute to this overall effect: physical and occupational function, psychological state, social interaction, and economic status/factors. Quality of life has emerged as an important outcome measure of optimal medical care, particularly for the treatment of chronic conditions. Four types of clinical trials in which QOL should be evaluated are: (1) the intervention has an effect on symptoms but not mortality or complication rates; (2) the intervention causes a high frequency of side effects; (3) prevention trials, and (4) trials designed to lower cost or rate of adverse effects. Standards for such trials are currently being developed. The one area of current agreement is the need for the use of validated scales of measurement. The use of both a general scale and a disease- (or age group) specific scale may provide the best assessment of overall QOL.

Discontinuations of antihyperlipidemic drug therapy: assessment by means of automated databases.

Discontinuations of drugs used in the treatment of chronic conditions such as hyperlipidemia often signal adverse drug effects or therapeutic ineffectiveness. Discontinuations of antihyperlipidemic drug therapy among 2369 patients were evaluated using the computerized files and written medical records of two health maintenance organizations (HMOs) in Massachusetts for the period 1988 to 1990. Three methods were assessed for the identification of potential discontinuations of drug therapy using the automated databases. Overall, 75% of discontinuations flagged by the automated databases were confirmed in the medical charts. (1) In new users, 618 of the 635 (97%) drugs identified as drug switches by the computerized HMO pharmacy files were confirmed as discontinuations by the medical charts. (2) Of 620 eligible HMO members 332 (54%) identified with greater than 6 months between the last refill for an antihyperlipidemic drug and the end of the study stopped the drug therapy according to the medical chart. (3) Of 219 eligible drug therapies flagged with an 'inactive' or with an 'omit' status in the clinical encounter files 198 (90%) were discontinued according to the medical chart. This study demonstrates the utility of clinical automated databases to facilitate the study of drug discontinuations in primary care settings, reducing the cost and the amount of time required for the evaluation.