Traditional versus telenursing outpatient management of patients with cancer with new ostomies. Functional Incidental Training: applicability and feasibility in the Veterans Affairs nursing home patient population. Peak flow based asthma self-management: a randomised controlled study in general practice. British Thoracic Society Research Committee. Can just-in-time, evidence-based "reminders" improve pain management among home health care nurses and their patients? Does an exercise and incontinence intervention save healthcare costs in a nursing home population? In-practice management versus quitline referral for enhancing smoking cessation in general practice: a cluster randomized trial.
To measure the impact of telenursing on patients discharged with ostomies resulting from cancer treatment.
                Quasi-experimental design with surveys.
                Large tertiary care center in the southwestern United States.
                28 patients with cancer in two groups: traditional home health and home health plus telenursing.
                Recorded the number of home health and telenursing contacts, dates when ostomy self-care needs were met, supplies used, and distance traveled. Patients completed a satisfaction survey and Maklebusts Ostomy Adjustment Scale.
                Type of care, costs, patient satisfaction, ostomy adjustment, and time to achieve ostomy self-care.
                Telenursing patients indicated higher satisfaction. The home health group averaged one more home health visit per patient (telenursing mean= three visits). Overall costs for both types of visits were about equal. The home health group used an average of four more pouches per patient, with increased cost of 52 dollars per patient. Telenursing patients believed that nurses had increased understanding of their problems, and they were more comfortable with what nurses told them about ostomy. Telenursing participants believed that telenursing made care more accessible; they preferred telemedicine rather than waiting for face-to-face visits but still believed that face-to-face visits were best.
                Combining traditional home health and telenursing is feasible for supporting discharged patients with new ostomies and enhances traditional home health, resulting in increased satisfaction overall.
                Oncology nurses should develop telenursing programs that include patient and family education regarding oncology issues. To examine the applicability and feasibility of an intervention directed at improving continence, endurance, and strength (Functional Incidental Training [FIT]), for older patients in Veterans Administration (VA) nursing homes.
                Data were collected during a randomized, controlled, crossover trial.
                Four VA nursing homes.
                All 528 patients in the nursing homes were screened, 178 were eligible, and 107 were randomized into the trial. A total of 64 participants completed the intervention phase of the trial.
                Trained research staff provided the FIT intervention, which included prompted voiding combined with individualized, functionally oriented endurance and strength training exercises offered four times per day, 5 days per week, for 8 weeks.
                Descriptive data were collected relevant to the translation of the FIT intervention into everyday practice, including number of patients eligible and reasons for ineligibility, attrition rates and reasons for attrition, participant adherence to and satisfaction with FIT, and the costs of FIT relative to usual care.
                One third of the 528 patients met the eligibility criteria. The major reasons for ineligibility were being continent, age under 60, and a short anticipated length of stay. Of the 146 patients enrolled in the trial, 85 (58%) dropped out during the 9- to 10-month project. Deterioration in health status, death, and discharge accounted for two thirds of the attrition. Adherence to FIT was in general high but variable. Participants completed prompted voiding plus at least one exercise in 75% of the FIT rounds offered. Of the 60 participants who completed the protocol and who could answer simple questions, 75% indicated they enjoyed FIT, but 62% indicated that the exercise was too frequent, and 28% indicated they were offered opportunities to toilet too often. Based on timed observations, the costs of FIT are about four times as high as usual continence care.
                FIT is applicable to a substantial number of patients in VA nursing homes. The FIT protocol tested in this trial can be further refined and individualized based on patient preferences and adherence to various components of FIT in order to make it more feasible, efficient, and cost-effective in practice. The costs of maintaining an intervention such as FIT in all VA nursing home patients who may benefit, however, are high and must be justified largely by potential positive effects on function and quality of life, as opposed to cost savings resulting from the intervention. Peak flow based asthma self-management plans have been strongly advocated in consensus statements, but convincing evidence for the effectiveness of this approach has been largely lacking.
                A randomised controlled trial was conducted in 25 general practices comparing an asthma self-management programme based on home peak flow monitoring and surgery review by a general practitioner or practice nurse with a programme of planned visits for surgery review only over a six month period.
                Seventy two subjects (33 in the self-management group and 39 in the planned visit group) completed the study protocol, but diary card data for at least three months were available on a total of 84 (39 in the self-management group and 45 in the planned visit group). Teaching self-management took longer than the planned visit review. In the self-management group home peak flow monitoring was felt to be useful by doctors and patients in 28 (85%) and 27 (82%) cases, respectively. There were no between group differences during the study period in terms of lung function, symptoms, quality of life, and prescribing costs. Only within the self-management group were improvements noted in disturbance of daily activities and quality of life. Possible explanations for these negative results include small numbers of subjects, the mild nature of their asthma, and inappropriate self-management strategies for such patients.
                Rigid adherence to long term daily peak flow measurement in the management of mild asthma in general practice does not appear to produce large changes in outcomes. Self-management and the use of prescribed peak flow meters need to be tailored to individual circumstances. The purpose of this randomized, controlled, home care intervention was to test the effectiveness of two nurse-targeted, e-mail-based interventions to increase home care nurses' adherence to pain assessment and management guidelines, and to improve patient outcomes. Nurses from a large urban non-profit home care organization were assigned to usual care or one of two interventions upon identification of an eligible cancer patient with pain. The basic intervention consisted of a patient-specific, one-time e-mail reminder highlighting six pain-specific clinical recommendations. The augmented intervention supplemented the initial e-mail reminder with provider prompts, patient education material, and clinical nurse specialist outreach. Over 300 nurses were randomized and outcomes of 673 of their patients were reviewed. Data collection involved clinical record abstraction of nurse care practices and patient interviews completed approximately 45 days after start of care. The intervention had limited effect on nurse-documented care practices but patient outcomes were positively influenced. Patients in the augmented group improved significantly over the control group in ratings of pain intensity at its worst, whereas patients in the basic group had better ratings of pain intensity on average. Other outcomes measures were also positively influenced but did not reach statistical significance. Our findings suggest that although reminders have some role in improving cancer pain management, a more intensive approach is needed for a generalized nursing workforce with limited recent exposure to state-of-the-art pain management practices. To determine whether an intervention that combines low-intensity exercise and incontinence care offsets some of its costs by reducing the incidence of selected health conditions in nursing home residents.
                Randomized, controlled trial with the incidence and costs of selected, acute conditions compared between a 6-month baseline and an 8-month intervention phase.
                Four nursing homes.
                One hundred ninety incontinent, long-stay nursing home residents.
                Low-intensity, functionally oriented exercise and incontinence care were provided every 2 hours from 8:00 a.m. to 4:00 p.m. for 5 days a week for 8 months.
                Predefined acute conditions hypothesized to be related to physical inactivity, incontinence, or immobility were abstracted from residents' medical records by blinded observers during a 6-month baseline period and throughout the 8-month intervention. Conditions included those in the dermatological, genitourinary, gastrointestinal, respiratory and cardiovascular systems; falls; pain; and psychiatric and nutritional disturbances. Costs were determined using Current Procedural Terminology Center and Medicare allowable cost reimbursement at a rate of 80%.
                The intervention group had significantly better functional outcomes than the control group (strength, mobility endurance, urinary and fecal incontinence) and a reduction of 10% in the incidence of the acute conditions, which was not significant. There were no significant differences between groups in the cost of assessing and treating these acute conditions between baseline and intervention.
                The intervention, which is consistent with federal and clinical practice guidelines, significantly improved functional outcomes but did not reduce the incidence and costs of selected acute health conditions. The cost of implementing these labor-intensive interventions for frail nursing home residents will have to be justified based on functional and quality-of-life outcomes and are unlikely to be offset by savings in medical care costs in this population. GPs are an important source of smoking cessation advice. This research examined whether a model encouraging GP referral of patients who smoke to a specialist service would be acceptable and effective for increased smoking cessation when compared with a model of in-practice management.
                The study design was cluster randomized controlled trial. Practices were randomized to one of two interventions, at a rate of 1:2: (i) standard in-practice GP management or (ii) referral to a quitline service. The main outcome measures were sustained abstinence of >or=1 month duration at 3-month follow-up and >or=10 months duration at 12 months, using intention to treat analysis.
                At 3-month follow-up, patients in the referral condition were twice as likely to report sustained abstinence than those in the in-practice condition [12.3% compared with 6.9%; odds ratio (OR) = 1.92 (95% confidence interval (CI) 1.17-3.13]. At 12-month follow-up, patients in the referral condition had nearly three times the odds of sustained abstinence [6.5% compared with 2.6%; OR = 2.86 (95% CI 0.94-8.71)]. The intervention effect was mediated by the amount of help received outside the practice.
                This research provided evidence that GPs referring smokers to an evidence-based quitline service results in increased cessation. The benefit is largely due to patients in the referral condition receiving more external help than patients in the in-practice condition, as they received equivalent practice-based help. Where suitable services exist, we recommend that referral become the normative strategy for management of smoking cessation in general practice to complement any practice-based help provided.
The limited evidence suggests that home management is cost effective and preferred by patients. Further large trials comparing these treatments are unlikely to occur. Therefore, home treatment is likely to become the norm; further research will be directed to resolving practical issues.