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Fall rates in hospital rehabilitation units after individualised patient and staff education programmes: a pragmatic, stepped-wedge, cluster-randomised controlled trial
Falls are the most frequent adverse events that are reported in hospitals. We examined the effectiveness of individualised falls-prevention education for patients, supported by training and feedback for staff, delivered as a ward-level programme.
Eight rehabilitation units in general hospitals in Australia participated in this stepped-wedge, cluster-randomised study, undertaken during a 50 week period. Units were randomly assigned to intervention or control groups by use of computer-generated, random allocation sequences. We included patients admitted to the unit during the study with a Mini-Mental State Examination (MMSE) score of more than 23/30 to receive individualised education that was based on principles of changes in health behaviour from a trained health professional, in addition to usual care. We provided information about patients' goals, feedback about the ward environment, and perceived barriers to engagement in falls-prevention strategies to staff who were trained to support the uptake of strategies by patients. The coprimary outcome measures were patient rate of falls per 1000 patient-days and the proportion of patients who were fallers. All analyses were by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials registry, number ACTRN12612000877886).
Between Jan 13, and Dec 27, 2013, 3606 patients were admitted to the eight units (n=1983 control period; n=1623 intervention period). There were fewer falls (n=196, 7·80/1000 patient-days vs n=380, 13·78/1000 patient-days, adjusted rate ratio 0·60 [robust 95% CI 0·42–0·94], p=0·003), injurious falls (n=66, 2·63/1000 patient-days vs 131, 4·75/1000 patient-days, 0·65 [robust 95% CI 0·42–0·88], p=0·006), and fallers (n=136 [8·38%] vs n=248 [12·51%] adjusted odds ratio 0·55 [robust 95% CI 0·38 to 0·81], p=0·003) in the intervention compared with the control group. There was no significant difference in length of stay (intervention median 11 days [IQR 7–19], control 10 days [6–18]).
Individualised patient education programmes combined with training and feedback to staff added to usual care reduces the rates of falls and injurious falls in older patients in rehabilitation hospital-units.
State Health Research Advisory Council, Department of Health, Government of Western Australia.
Journal Article
Beyond transformative learning in African American adult education : religion, health, and permeated learning as a new model of adult learning
By exploring how the religious beliefs, scientific knowledge, and social surroundings of African-American sufferers of type 2 diabetes mellitus (T2DM) impacts their understanding of the condition, this book develops a new model of effective adult learning. Presenting the findings of rigorous qualitative research undertaken with five individuals with T2DM, this volume considers how individuals' educational background, their personal experiences, and their relationship with African-American theism have impacted on their efforts to understand and manage the disease. Identification of the social and spiritual dynamics which govern adults' acceptance of a chronic condition such as diabetes, and their ability to manage the illness according to modern medical principles, informs the development of a new theory of adult learning known as permeated learning. This model, which extends beyond transformative learning to recognize the influence of social constructs specific to African-American communities, will have broad application to adult education and the management of chronic diseases. This scholarly text will be of great interest to graduate and postgraduate students, researchers, academics, and policymakers in the field of adult education, African-American education, transformative learning, lifelong learning, and multicultural education.
Book
Patient Activation and 30-Day Post-Discharge Hospital Utilization
ABSTRACT
BACKGROUND
Patient activation is linked to better health outcomes and lower rates of health service utilization. The role of patient activation in the rate of hospital readmission within 30 days of hospital discharge has not been examined.
METHODS
A secondary analysis using data from the Project RED-LIT randomized controlled trial conducted at an urban safety net hospital. Data from 695 English-speaking general medical inpatient subjects were analyzed. We used an adapted, eight-item version of the validated Patient Activation Measure (PAM). Total scores were categorized, according to standardized methods, as one of four PAM levels of activation: Level 1 (lowest activation) through Level 4 (highest activation). The primary outcome measure was total 30-day post-discharge hospital utilization, defined as total emergency department (ED) visits plus hospital readmissions including observation stays. Poisson regression was used to control for confounding.
RESULTS
Of the 695 subjects, 67 (9.6 %) were PAM Level 1, 123 (17.7 %) were Level 2, 193 (27.8 %) were Level 3, and 312 (44.9 %) were Level 4. Compared with highly activated patients (PAM Level 4), a higher rate of 30-day post-discharge hospital utilization was observed for patients at lower levels of activation (PAM Level 1, incident rate ratio [IRR] 1.75, 95 % CI,1.18 to 2.60) and (PAM Level 2, IRR 1.50, 95 % CI 1.06 to 2.13). The rate of returning to the hospital among patients at PAM Level 3 was not statistically different than patients with PAM Level 4 (IRR 1.30, 95 % CI, 0.94 to 1.80). The rate ratio for PAM Level 1 was also higher compared with Level 4 for ED use alone (1.68(1.07 to 2.63)) and for hospital readmissions alone (1.93 [1.22 to 3.06]).
CONCLUSION
Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization.
Journal Article
Shared Treatment Decision Making Improves Adherence and Outcomes in Poorly Controlled Asthma
Abstract
Rationale
Poor adherence to asthma controller medications results in poor treatment outcomes.
Objectives
To compare controller medication adherence and clinical outcomes in 612 adults with poorly controlled asthma randomized to one of two different treatment decision-making models or to usual care.
Methods
In shared decision making (SDM), nonphysician clinicians and patients negotiated a treatment regimen that accommodated patient goals and preferences. In clinician decision making, treatment was prescribed without specifically eliciting patient goals/preferences. The otherwise identical intervention protocols both provided asthma education and involved two in-person and three brief phone encounters.
Measurements and Main Results
Refill adherence was measured using continuous medication acquisition (CMA) indices—the total days' supply acquired per year divided by 365 days. Cumulative controller medication dose was measured in beclomethasone canister equivalents. In follow-up Year 1, compared with usual care, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.46; P < 0.0001) and long-acting β-agonist adherence (CMA, 0.51 vs. 0.40; P = 0.0225); higher cumulative controller medication dose (canister equivalent, 10.9 vs. 5.2; P < 0.0001); significantly better clinical outcomes (asthma-related quality of life, health care use, rescue medication use, asthma control, and lung function). In Year 2, compared with usual care, SDM resulted in significantly lower rescue medication use, the sole clinical outcome available for that year. Compared with clinician decision making, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.59; P = 0.03) and long-acting β-agonist adherence (CMA, 0.51 vs. 0.41; P = 0.0143); higher cumulative controller dose (CMA, 10.9 vs. 9.1; P = 0.005); and quantitatively, but not significantly, better outcomes on all clinical measures.
Conclusions
Negotiating patients' treatment decisions significantly improves adherence to asthma pharmacotherapy and clinical outcomes.
Clinical trials registered with www.clinicaltrials.gov (NCT00217945 and NCT00149526).
Journal Article
Principles of counseling and psychotherapy : learning the essential domains and nonlinear thinking of master practitioners
Research has shown that the most effective way to prepare students for practice with real clients is to learn to think in a new way rather than simply learning and using a set of steps. While there is much to be learned from what master practitioners do in their sessions, there is even more knowledge to gain from learning how they think. The second edition of Principles of Counseling and Psychotherapy offers students and practitioners a way to understand the processes behind effective outcomes with a wide variety of clients. The second edition is infused with real-world clinical case examples and opportunities for readers to apply the material to the cases being presented. New \"thought-exercise\" sections are specifically designed to engage the reader's natural non-linear thinking, and transcript material both from cases and from master therapists themselves are interwoven in the text. -- !c From publisher's description.
Book
Readability of Patient Education Materials Available at the Point of Care
Background
Many patient education materials (PEMs) available on the internet are written at high school or college reading levels, rendering them inaccessible to the average US resident, who reads at or below an 8
th
grade level. Currently, electronic health record (EHR) providers partner with companies that produce PEMs, allowing clinicians to access PEMs at the point of care.
Objective
To assess the readability of PEMs provided by a popular EHR vendor as well as the National Library of Medicine (NLM).
Design
We included PEMs from Micromedex, EBSCO, and MedlinePlus. Micromedex and EBSCO supply PEMs to Meditech, a popular EHR supplier in the US. MedlinePlus supplies the NLM. These PEM databases have high market penetration and accessibility.
Measurements
Grade reading level of the PEMs was calculated using three validated indices: Simple Measure of Gobbledygook (SMOG), Gunning Fog (GFI), and Flesch–Kincaid (FKI). The percentage of documents above target readability and average readability scores from each database were calculated.
Results
We randomly sampled 100 disease-matched PEMs from three databases (n = 300 PEMs). Depending on the readability index used, 30-100% of PEMs were written above the 8
th
grade level. The average reading level for MedlinePlus, EBSCO, and Micromedex PEMs was 10.2 (1.9), 9.7 (1.3), and 8.6 (0.9), respectively (p ≤ 0.000) as estimated by the GFI. Estimates of readability using SMOG and FKI were similar.
Conclusions
The majority of PEMS available through the NLM and a popular EHR were written at reading levels considerably higher than that of the average US adult.
Journal Article
Teaching clients to use mindfulness skills : a practical guide
\"Mindfulness has become a vital skill for many people working in the fields of physical and mental health, teaching, business, leadership and sports. While plenty of books explain the uses of mindfulness, until now none has addressed the particular challenges of effectively passing these skills on to clients in a user-friendly way. This book helps professionals to take their first steps into the process of introducing mindfulness skills to clients who they think will benefit - whether in helping them to handle recurrent stress, to deal with ruminative thought or just to live in a more effective, rewarding way. Incorporating a series of practical exercises and drawing on their own professional experience, the authors clearly demonstrate the most effective methods for presenting mindfulness techniques to those with no previous experience. Topics covered include: - Orienting the client to the skill - Obtaining and using client feedback effectively - Introducing simple practises - Teaching clients to utilise mindfulness in everyday life - Case scenarios demonstrating the skills in practice This practical, structured guide is essential for professionals already teaching or planning to teach mindfulness skills, those taking courses or workshops and for anyone interested in learning more about mindfulness\"-- Provided by publisher.
Book
Encounter Decision Aid vs. Clinical Decision Support or Usual Care to Support Patient-Centered Treatment Decisions in Osteoporosis: The Osteoporosis Choice Randomized Trial II
Osteoporosis Choice, an encounter decision aid, can engage patients and clinicians in shared decision making about osteoporosis treatment. Its effectiveness compared to the routine provision to clinicians of the patient's estimated risk of fracture using the FRAX calculator is unknown.
Patient-level, randomized, three-arm trial enrolling women over 50 with osteopenia or osteoporosis eligible for treatment with bisphosphonates, where the use of Osteoporosis Choice was compared to FRAX only and to usual care to determine impact on patient knowledge, decisional conflict, involvement in the decision-making process, decision to start and adherence to bisphosphonates.
We enrolled 79 women in the three arms. Because FRAX estimation alone and usual care produced similar results, we grouped them for analysis. Compared to these, use of Osteoporosis Choice increased patient knowledge (median score 6 vs. 4, p = .01), improved understanding of fracture risk and risk reduction with bisphosphonates (p = .01 and p<.0001, respectively), had no effect on decision conflict, and increased patient engagement in the decision making process (OPTION scores 57% vs. 43%, p = .001). Encounters with the decision aid were 0.8 minutes longer (range: 33 minutes shorter to 3.0 minutes longer). There were twice as many patients receiving and filling prescriptions in the decision aid arm (83% vs. 40%, p = .07); medication adherence at 6 months was no different across arms.
Supporting both patients and clinicians during the clinical encounter with the Osteoporosis Choice decision aid efficiently improves treatment decision making when compared to usual care with or without clinical decision support with FRAX results.
clinical trials.gov NCT00949611.
Journal Article