Effect of hospital on variation in visual acuity and vision‐specific quality of life after cataract surgery

Objective To evaluate the contribution of hospital‐to‐hospital variability in changes in clinical and health‐related quality of life outcomes among patients undergoing cataract extraction by phacoemulsification. Methods Prospective observational study of 14 public hospitals. We recruited consecutive patients on waiting lists for cataract extraction. Clinical data were collected prior to the intervention and 6 weeks afterward. Subjects completed the visual function index (VF‐14) prior to the procedure and 3 months afterward. Univariate and multivariate analysis were performed for visual acuity and VF‐14 scores. Results Substantial differences were observed across the 14 hospitals. At baseline, mean visual acuity ranged from 0.16 to 0.34, and mean VF‐14 scores ranged from 48.06 to 75.89. Following cataract extraction, the mean improvement in visual acuity ranged from 0.35 to 0.57 and in VF‐14 scores from 10.94 to 41.70. The ranges were even more pronounced among patients with low visual acuity or low VF‐14 scores prior to the intervention. Significant differences remained in multivariate analysis. Within the multivariate analysis, the variable ‘hospitals’ had an R² of 0.069 for the visual acuity model and of 0.073 for the VF‐14 model, 20% and 13%, respectively, of the total variability explained. Variation was also observed within geographic regions. Conclusions Outcomes of patients undergoing cataract extractions vary widely from hospital to hospital, even within the same geographic region, explaining an important part of the results. Quality improvement efforts should concentrate on patients with low pre‐intervention visual acuity or vision‐related disability to reduce this variability in outcomes.     

Exploring the quality of dying of patients with chronic obstructive pulmonary disease in the intensive care unit: a mixed methods study

Rationale for the study:  Improving the quality of end-of-life (EOL) care in critical care settings is a high priority. Patients with advanced chronic obstructive pulmonary disease (COPD) are frequently admitted to and die in critical care units. To date, there has been little research examining the quality of EOL care for this unique subpopulation of critical care patients.
Aims:  The aims of this study were (a) to examine critical care clinician perspectives on the quality of dying of patients with COPD and (b) to compare nurse ratings of the quality of dying and death between patients with COPD with those who died from other illnesses in critical care settings.
Design and sample:  A sequential mixed method design was used. Three focus groups provided data describing the EOL care provided to patients with COPD dying in the intensive care unit (ICU). Nurses caring for patients who died in the ICU completed a previously validated, cross-sectional survey (Quality of Dying and Death) rating the quality of dying for 103 patients.
Data analysis:  Thematic analysis was used to analyse the focus group data. Total and item scores for 34 patients who had died in the ICU with COPD were compared with those for 69 patients who died from other causes.
Results:  Three primary themes emerged from the qualitative data are as follows: managing difficult symptoms, questioning the appropriateness of care and establishing care priorities. Ratings for the quality of dying were significantly lower for patients with COPD than for those who died from other causes on several survey items, including dyspnoea, anxiety and the belief that the patient had been kept alive too long. The qualitative data allowed for in-depth explication of the survey results.
Conclusions:  Attention to the management of dyspnoea, anxiety and treatment decision-making are priority concerns when providing EOL care in the ICU to patients with COPD.     

A multi-intervention approach on drug therapy can lead to a more appropriate drug use in the elderly. LIMM-Landskrona Integrated Medicines Management

Rationale, aims and objectives  To evaluate if an integrated medicines management can lead to a more appropriate drug use in elderly inpatients.
Method  The study was an intervention study at a department of internal medicine in southern Sweden. During the intervention period pharmacists took part in the daily work at the wards. Systematic interventions aiming to identify, solve and prevent drug-related problems (DRPs) were performed during the patient's hospital stay by multidisciplinary teams consisting of physicians, nurses and pharmacists. DRPs identified by the pharmacist were put forward to the care team and discussed. Medication Appropriateness Index (MAI) was used to evaluate the appropriateness in the patients' drug treatment at admission, discharge and 2 weeks after discharge. In total 43 patients were included, 28 patients in the intervention group and 25 patients in the group which was used as control.
Results  For the intervention group there was a significant decrease in the number of inappropriate drugs compared with the control group ( P  = 0.049). Indication, duration and expenses were the MAI-dimensions with most inappropriate ratings, and the drugs with most inappropriate ratings were anxiolytics, hypnotics and sedatives.
Conclusion  This kind of systematic approach on drug therapy can result in a more appropriate drug use in the elderly.     

Coronary artery bypass graft (CABG) surgery patients in a clinical pathway gained less in health-related quality of life as compared with patients who undergo CABG in a conventional-care plan

Aims and objectives  The aim of this study is to determine the difference between clinical pathway (CP) and conventional care in terms of health-related quality of life (HRQoL) domains, depression and anxiety, as well as to determine the relative contribution of CP towards an improved HRQoL after coronary artery bypass graft (CABG).
Method  A longitudinal quasi-experimental pre-test/post-test design was used to study and compare clinical outcome, HRQoL depression and anxiety for CP versus conventional-care patients after CABG. HRQoL was measured by using Sf-36, while depression and anxiety were measured by using hospital anxiety and depression scale. Length of stay and patient complications were derived from the hospital database.
Results  We found that implementing a CP decreased hospital delay from 2.50 (±7.19) to 1.80 (±1.60), which was statistically significant P  = 0.002. We also found that patients in the conventional-care plan improved more than patients in the CP in HRQoL. Outcomes in favour of patients in the conventional-care trajectory were based on the difference between small effect sizes (ES) (≥0.20 <0.50) for pathway patients and moderate ES (≥0.50 <0.80) for conventional-care patients, except for the domain of physical functioning and physical component summary, where the ES for conventional care was large (>0.80).
Conclusion  The aim of designing and implementing pathways is to decrease length of stay and costs, while maintaining quality of care and improving patient outcomes. Our findings suggest that these aims were not fulfilled in this CABG pathway. We recommend that when designing a CP, all patient-related characteristics, risk indicators, along with physiological status, be taken into consideration.     

Poor health-related quality of life of patients with indication for chronic cardiac pacemaker therapy

Background: Studies on health-related quality of life (HRQoL) of patients awaiting pacemaker (PM) implantation are scarce, or executed in specific patient subgroups (regarding age or specific cardiac rhythm disorders). The purpose of this study was to systematically assess the HRQoL in a large unselected cohort of patients with a conventional indication for PM therapy.
Methods: Pre-PM implantation HRQoL (measured with the SF-36 questionnaire, completed at hospital admission) of 818 consecutive Dutch patients included in the FOLLOWPACE study was compared with the HRQoL in a sample of the general Dutch population, and with several cohorts of patients with other conditions. Linear regression analysis was performed to analyze determinants of this HRQoL.
Results: Almost all SF-36 subscale scores were substantially and significantly lower in the PM patients compared to the general population, with P-values < 0.001 in all SF-36 subscales except for "pain" and "general health perception." In the PM patients, presence of comorbidities, gender, and age were significantly associated with the overall physical component summary score (mean 38.8 ± 27 standard deviation) whereas the overall mental component summary score (46.8 ± 27.0) was associated with gender and age.
Conclusion: The HRQoL of patients before first PM implantation is significantly lower than that of a general population and also various other patient populations. Physicians should be aware of this unfavorable condition and keep the time interval between the diagnosis of a cardiac rhythm disorder requiring PM implantation and the implantation procedure as short as possible.     

The use of D-dimer testing and Wells score in patients with high probability for acute pulmonary embolism

Rationale, aims and objective  To investigate if a combination of Wells pre-test probability score and D-dimer testing could be used as a safe base for making clinical decisions on further investigations for patients with intermediate to high risks of pulmonary embolism (PE).
Methods  One hundred and twenty patients with signs or symptoms of acute PE were investigated with pulmonary angiography (PA) or contrast enhanced computed tomography of the pulmonary arteries (CTPA), D-dimer testing (Tinaquant^®) and clinical scoring using the Wells pre-test probability score during their first 48 hours at the hospital. Patients were recruited consecutively from emergency departments at two teaching hospitals.
Results  The cut-off value of 0.5 mg L⁻¹ in D-dimer analysis is proved adequate with a negative predictive value (NPV) of 92% in this group of patients with intermediate to high risks. The combination of D-dimer testing and Wells score increases the NPV to 94%. The specificities of both tests were low.
Conclusion  D-dimer and Wells pre-test probability scores are safe to rule out acute PE even in patients with at least an intermediate risk of PE, but the specificity is low. D-dimer testing had a higher NPV than Wells score and the combination improved the algorithm further. The cut-off level for a high risk of PE measured with the Wells score was four and it seems reasonable to use that cut-off level in future algorithms. In addition, both PA and CTPA can present false positive and negative results difficult to interpret.     

Comparison of Short Form-36 Health Survey and Nottingham Health Profile in moderate to severe patients with COPD

Objective  To compare the health-related quality of life (HRQoL) assessed by Short Form-36 Health Survey (SF-36) and Nottingham Health Profile (NHP) on the basis of lung function and exercise capacity parameters in patients with moderate to severe chronic obstructive pulmonary disease (COPD).
Methods and materials  The investigation was a prospective, quality-of-life survey and cross-sectional study of 130 consecutive COPD patients. The NHP and SF-36 as generic HRQoL instruments, the Chronic Respiratory Disease questionnaire (CRQ) as a disease-specific HRQoL instrument and 6-minute walking test, severity of dyspnea, leg fatigue and lung function, were the measurements and instruments used in the study.
Results  It was determined that the subscales of both questionnaires were generally related with the FEV₁, walking distance, CRQ, severity of dyspnea and leg fatigue values ( P  < 0.05). The much higher correlation coefficient was determined between these parameters and NHP compared with the SF-36. Only NHP was found to be correlated with the age, body mass index and smoking consumption ( P  < 0.05).
Conclusions  The stronger relation of NHP with the clinical and physical parameters of the patients compared with that of SF-36 may be associated with the increased sensitivity of NHP to the clinical state owing to the increasing respiratory symptoms of our old patients with moderate to severe obstruction and/or the more intelligible and easy-to-respond nature of NHP compared with SF-36.     

Motivational interviewing-based health coaching as a chronic care intervention

Objective  To evaluate the impact of motivational interviewing-based health coaching on a chronically ill group of participants compared with non-participants. Specifically, measures that could be directly attributed to a health coaching intervention on chronic illness were assessed.
Design  Quasi-experimental study design.
Setting  A large medical university in the north-west United States.
Methods  One hundred and six chronically ill programme participants completed a health risk survey instrument prior to enrolment and again at approximately 8 months. Outcomes were compared with 230 chronically ill non-participants who completed the survey twice over a similar time frame. Inverse probability of treatment weights were used in conjunction with the propensity score to correct for selection bias.
Results  Compared with non-participants, programme participants improved their self-efficacy ( P  = 0.01), patient activation ( P  = 0.02), lifestyle change score ( P  = 0.01) and perceived health status ( P  = 0.03). Fewer participants increased their stages of change risk over time than non-participants ( P  < 0.01), and more participants decreased their stages of change risk over time than non-participants ( P  = 0.03).
Conclusion  These results support motivational interviewing-based health coaching as an effective chronic care management intervention in impacting outcome measures that could also serve well as a proxy in the absence of other clinical or cost indices.     

A Pilot Study to Validate the Priority Nursing Interventions Classification Interventions and Nursing Outcomes Classification Outcomes for the Nursing Diagnosis "Excess Fluid Volume" in Cardiac Patients

PURPOSE.  To validate the content of the priority Nursing Interventions Classification (NIC) interventions and Nursing Outcomes Classification (NOC)-suggested outcomes for cardiac patients with the nursing diagnosis excess fluid volume in the Brazilian context.
METHODS.  The content of the interventions and outcomes was scored by seven expert nurses using a Likert scale, using the Fehring model.
FINDINGS.  From the 83 activities of the priority NIC interventions, nine had scores lower than 0.5 (nonuseful) and 50 had scores higher than 0.8 (major); from the 53 indicators of the suggested NOC outcomes, eight scored lower than 0.5 and 26 had scores higher than 0.8.
CONCLUSIONS.  The majority of the NIC interventions and NOC outcomes were considered useful by the Brazilian Cardiology expert nurses.
IMPLICATIONS FOR PRACTICE.  Clinical studies are an important strategy for validation of the usefulness of North American Nursing Diagnosis Association, NIC, and NOC language in clinical protocols. Additional studies are necessary to confirm the findings of this pilot study.     

Change of subjective visual function in first-eye cataract patients when the rate of surgery increases in a population

BACKGROUND: The increasing demand for cataract surgery has stimulated interest in outcome research and the potential public health impact of the intervention. OBJECTIVE: To determine the impact of an increased rate of first-eye cataract surgery on visual acuity (VA) and subjective visual ability/disability, before and after surgery, in a geographically defined population. RESEARCH DESIGN: A prospective, observational study. SUBJECTS: All patients who had first-eye cataract extraction at one clinic during two separate 1-year periods. Five hundred seventy-six patients had surgery in 1997, and 353 had surgery in 1992 (17.2 and 10.6 per 1000 population 65 and older, respectively). MEASURES: Best-corrected VAs were measured, and the patients answered self-administered questionnaires, before and after surgery. The questionnaires focused on the patients' subjective difficulties performing some common vision-dependent activities, such as reading, television-viewing, orientation, etc. RESULTS: In 1997 compared with 1992 the VA of the eye to be operated was on average better (chi2 for trend; P<0.0001), and the subjective visual disability was less before surgery (mean disability index 6.9 vs. 7.5; P<0.0001). There was also a smaller percentage of mature cataracts (15% vs. 23%; P<0.0001). After surgery the VA of the operated eye was better in 1997 (chi2 for trend; P<0.001), but there was no difference in improvement of subjective visual ability, nor change in subjective visual disability, compared with 1992. The patients' expectations and actual postoperative improvement of their ability to cope with daily life were higher in 1997 (chi2 for trend; P<0.0001 and P<0.001). CONCLUSIONS: A higher frequency of first-eye cataract surgery in a population was before surgery associated with an on average better VA of the eye to be operated, a less perceived visual disability regarding some common vision-dependent activities, a lower percentage of mature cataracts and thus earlier surgery. Consequently, a higher rate of surgery would likely be associated with a lesser amount of visual impairment because of cataract in the population.     

Dietary and fluid compliance: an educational intervention for patients having haemodialysis

Title.  Dietary and fluid compliance: an educational intervention for patients havinghaemodialysis.
Aim.  This paper is a report of a study conducted to determine the effect of an educational intervention on dietary and fluid compliance in patients having haemodialysis.
Background.  Many of the clinical problems experienced by patients having haemodialysis are related to their failure to eat appropriate foods and restrict their fluid intake. Educational intervention in patients having haemodialysis to improve their compliance with dietary and fluid restrictions appears to be effective.
Methods.  Sixty-three patients having haemodialysis in three general hospitals in Tehran, Iran, were allocated into two groups at random for oral and/or video education. They were asked to give demographic and medical data. Bimonthly average values of serum potassium, sodium, calcium, phosphate, albumin, creatinine, uric acid, and blood urea nitrogen and interdialytic weight gain were measured before and after the teaching programmes. The data were collected in 2007.
Findings.  Compliance in terms of biochemical parameters and interdialytic weight gain was observed in 63·5% and 76·2% of patients in the oral and video teaching groups respectively. Statistically significant correlations were observed between demographic variables (age, educational level and occupation) and dietary and fluid compliances ( P  < 0·001). There was no difference between the effectiveness of two educational interventions.
Conclusion.  Nurses should emphasize sodium compliance in patients having haemodialysis and explain its adverse effects, such as excessive weight gain, hypertension, and peripheral oedema.     

A communication intervention for nursing staff in chronic care

Title.  A communication intervention for nursing staff in chronic care.
Aim.  The paper is a report of a study conducted to evaluate the effect of a brief, focused educational intervention on the quality of verbal interactions between nursing staff and patients in a chronic care facility.
Background.  Positive nurse–patient communication in chronic care is crucial to the quality of life and well-being of patients. Despite this, patients are dissatisfied with these interactions and nursing staff indicate the need for additional training.
Method.  A repeated-measures design was used to collect data between April 2003 and February 2004, by audiotaping verbal interactions between nursing staff and patients during morning care. Baseline data were analysed and an educational intervention was developed based on the results of the pretest. Five months after the educational intervention, interactions between the same nursing staff and patients were audiotaped. Twenty-seven randomly chosen patients and selected nursing staff participated in the study. Data were analysed using a qualitative comparative method, and a quantification technique was developed to compare the quality of the interactions before and after the intervention.
Findings.  Preintervention interactions were task-oriented, superficial and dominated by nursing staff. Results statistically significantly improved after the intervention was implemented. Nursing staff were less authoritative, used more solution-focused communication and interactions had a statistically significantly higher positive ratio.
Conclusion.  Brief interventions can change nursing staff's communication practice and they realized the importance of effective communication as a fundamental component to deliver patient-focused care.     

Nursing intervention by telephone interviews of patients aged over 65 years after total hip replacement improves health status: a randomised clinical trial

Scand J Caring Sci; 2010; 24; 94–100
Nursing intervention by telephone interviews of patients aged over 65 years after total hip replacement improves health status: a randomised clinical trial
Objective:  We hypothesised that all areas of health status after total hip replacement could be improved in patients aged over 65 years and over by using telephone support and counselling 2 and 10 weeks after surgery compared with a control group receiving conventional care and treatment.
Design:  A randomised clinical trial focusing on patients' health status by using short-form 36 at 4 weeks preoperatively and 3 and 9 months postoperatively was carried out. Sample: 180 patients aged 65 years and over were randomised 4 weeks preoperatively to either control or intervention groups. Measurements: both groups received conventional surgical treatment, but the intervention group was interviewed by telephone 2 and 10 weeks after surgery. Patients were given counselling within eight main dimensions with reference to their postoperative situation.
Results:  All patients experienced improvement in health status. The intervention significantly reduced the time patients needed to reach their habitual levels in three of eight areas of their health status: the intervention patients reached their habitual levels at 3 months whereas the control patients reached theirs after 9 months.
Conclusion:  Intervention by telephone support and counselling in the postoperative phase seems to benefit patients' improvement in health status.     

Effect of a regular family visiting program as an affective, auditory, and tactile stimulation on the consciousness level of comatose patients with a head injury

Aim:  The purpose of this study was to determine the effect of a regular family visiting program, as an auditory, affective, and tactile stimulation, on the consciousness level of comatose head injury patients.
Method:  A randomized controlled trial design was used. Fifty comatose head injury patients were randomly allocated into a control group or an intervention group. The consciousness level of the patients in both groups was evaluated and recorded by the Glasgow Coma Scale, before and 30 min after the visiting program.
Results:  The independent t -test results demonstrated that the means of the consciousness level at the first day before intervention had no significant difference in both groups. The repeated measured ANOVA results demonstrated that the consciousness level alterations were significant between the two groups over the 6 days of intervention.
Conclusion:  The results of the present study provided evidence to support that a regular family visiting program could induce the stimulation of comatose patients. Therefore, it can be considered as a potential nursing intervention.     

Glutathione, vitamin E and oxidative stress in coronary artery disease: relevance of age and gender

Background  Observational studies suggest that low levels of antioxidants are associated with high risk for coronary artery disease (CAD). We investigated whether the biomarkers of oxidative balance undergo the same modifications in all CAD patient groups, regardless of gender and age.
Materials and methods  One hundred sixty-eight CAD patients and 107 healthy controls were assayed for plasma levels of reduced glutathione (GSH), α- and γ-tocopherol (α- and γ-T) as endogenous antioxidants. A damage score (DS), representative of oxidative stress status, was calculated. ancova models were used to test the association between antioxidants, DS and CAD and its modulation by age and gender.
Results  The DS was higher in CAD than in controls. GSH levels, were lower in CAD patients (mean ± SEM: 57·61 ± 1·87 μmol 10 g⁻¹ haemoglobin vs. 68·55 ± 2·23 in controls, P  < 0·0006) in males and in older subjects. Levels of other antioxidants exhibited a complex pattern. Overall, no difference was found in α- and γ-T contents between CAD and controls, but lower α-T values were observed in CAD females. A significant interaction between CAD status and gender was observed ( P  = 0·003).
Conclusions  Our study shows that the involvement of antioxidants in CAD is related to patients' characteristics. These findings may be relevant in planning antioxidant therapies.     

Maintaining instrument quality while reducing items: application of Rasch analysis to a self-report of visual function

While efficiency has been of concern in the measurement of health care outcomes, little attention has been devoted to methods that achieve efficient, shortened instruments that have good psychometric properties. The purpose of this study was to show how Rasch analysis could be used to reduce the number of items in an instrument while maintaining credible psychometric properties. This approach was applied to the Visual Function-14 (VF-14), a self-report of 14 vision-dependent activities, designed to measure the need for and outcomes of cataract surgery. An instrument which contained the VF-14 plus an additional 10 items that were developed for the study (VF-24) was administered to sixty-one patients (73.7+/-9.5 years) about to undergo extracapsular cataract removal at one of two surgical centers. Rasch analysis (BIGSTEPS) of the VF-14 showed a number of limitations to the original instrument, including: 1) unequal use of the five rating categories, 2) ceiling effect, 3) several other gaps where patient abilities did not match with item difficulties, and 4) sets of items that appeared redundant, (i.e., having the same calibration level). To resolve the first three of these problems, the rating scale was converted to a three-point scale and BIGSTEPS was run with all 24 items. (10 additional items added to the VF-14 designed to "fill in" the gaps). The conversion to a three-point scale and the increase in items resulted in some improvement in the matching of item difficulty to patient ability, as evidenced by a slight decrease in gaps. The addition of items resulted in improvements in person separation (2.55 to 2.99) and Cronbach's alpha (.83 to .91) but did not substantially reduce the ceiling effect and furthermore resulted in an increase in item redundancy. The final practical improvement undertaken was to reduce the number of items while attempting to maintain the psychometric qualities of the instrument as a whole. Three criteria were used in deciding to remove items: 1) high mean square, 2) low mean square and 3) items having similar calibrations. In addition, if an analysis showed that the removal of an item substantially decrease person separation, that item was retained for further analyses. Relative to the original VF-14, the resulting VF-10 showed less redundancy of items while person separation (2.20) and Cronbach's alpha (.89) remained relatively intact. The study demonstrates that Rasch analysis, while effective in elucidating the metrics of an original instrument, can also be useful in designing modifications of instruments that are both efficient and psychometrically sound.     

Earplugs improve patients' subjective experience of sleep in critical care

Aims:  This study aimed to determine the effects of earplug use on the subjective experience of sleep for patients in critical care.
Background:  The negative effects of noise in critical care include sleep disturbances, increased stress response, and reduced patient satisfaction. The nature of critical care often precludes quiet time protocols. Previous studies indicated that earplugs can improve REM sleep and sleep efficiency. This study examined the effects of earplugs as a non-invasive method for improving the subjective sleep experience and increasing patient satisfaction.
Design:  Quasi-experimental intervention study with random assignment of subjects.
Method:  Subjects were non-ventilated, non-sedated adults admitted to critical care. The intervention group used earplugs during nighttime sleep hours allowing short term removal during patient care. Participants completed the Verran-Snyder-Halpern Sleep Scale, an 8-question visual analogue scale, to describe their subjective response to sleep. Two sample T-tests were used to detect differences between the group scores.
Results:  88 participants (49 intervention/39 control) completed the study. Mean age 63, 56% males, 93% Caucasian. Total sleep satisfaction scores were significantly better for the intervention group (p = .002). Seven of the subjective categories were independently significant (p = .005-.044). One category, satisfaction with the amount of time needed to fall asleep, was not significant (p = .111).
Conclusions:  Earplug use improved the subjective experience of sleep for un-medicated critical care patients without interfering with care delivery.
Relevance to Practice:  The negligible cost and low level of invasiveness of earplugs makes this preferable as a primary intervention to promote sleep while avoiding unnecessary sedating medications.