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PubMed2002

Asthma management, Part II: Pharmacologic management.

Part I of this two-part series described the pathophysiology, types, and risk factors associated with asthma. The role of the school nurse in the development, implementation, and evaluation of a comprehensive asthma management plan was outlined, as was the role of the school nurse in controlling factors that precipitate asthma symptoms or exacerbations. Part II reviews specific school nursing responsibilities associated with current pharmacologic therapy for the child with asthma. Issues related to nutritional supplements as well as complementary and alternative treatments used in asthma management are covered. Other topics discussed include issues related to access of asthma medication in the school setting by the student, involvement of the school team in the care of the child with asthma, and health education strategies for children with asthma and their families.

Adolescent↗
PubMed1995

Pharmacist-managed, physician-directed asthma management program reduces emergency department visits.

OBJECTIVE: To determine whether the number of emergency department (ED) visits for acute asthma exacerbations could be decreased by providing patients with a comprehensive program of asthma management delivered by a pharmacist and a physician. DESIGN: Patients were selected from the ED and asked to attend a special asthma clinic that provided education about asthma and proper use of asthma medications, regular telephone contact between the pharmacist and patient, and an open-door clinic policy. SETTING: A university-affiliated urban teaching hospital. PARTICIPANTS: The study population consisted of 25 asthmatic patients who were at least 18 years of age and who were seen in the ED a minimum of 3 times in a 12-month period. MAIN OUTCOME MEASURES: The number of visits to the ED for acute exacerbations of asthma was measured. Patients served as their own controls. The number of ED visits for asthma during the 6-month study period was compared with two 6-month periods prior to the study period for each patient. RESULTS: The total number of ED visits for the 25 enrolled patients six months prior to their enrollment into the study was 92; the number of ED visits during the same months of the study in the prior year was 47. During the study period, there were only 6 ED visits for asthma exacerbations. CONCLUSIONS: The comprehensive asthma management program reduced the number of ED visits for acute exacerbations of asthma.

Acute Disease↗
PubMed2006

Clinical characteristics and initial management of patients with tuberculous pericarditis in the HIV era: the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry.

BACKGROUND: The incidence of tuberculous pericarditis has increased in Africa as a result of the human immunodeficiency virus (HIV) epidemic. However, the effect of HIV co-infection on clinical features and prognosis in tuberculous pericarditis is not well characterised. We have used baseline data of the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry to assess the impact of HIV co-infection on clinical presentation, diagnostic evaluation, and treatment of patients with suspected tuberculous pericarditis in sub-Saharan Africa. METHODS: Consecutive adult patients in 15 hospitals in three countries in sub-Saharan Africa were recruited on commencement of treatment for tuberculous pericarditis, following informed consent. We recorded demographic, clinical, diagnostic and therapeutic information at baseline, and have used the chi-square test and analysis of variance to assess probabilities of significant differences (in these variables) between groups defined by HIV status. RESULTS: A total of 185 patients were enrolled from 01 March 2004 to 31 October 2004, 147 (79.5%) of whom had effusive, 28 (15.1%) effusive-constrictive, and 10 (5.4%) constrictive or acute dry pericarditis. Seventy-four (40%) had clinical features of HIV infection. Patients with clinical HIV disease were more likely to present with dyspnoea (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.4 to 7.4, P = 0.005) and electrocardiographic features of myopericarditis (OR 2.8, 95% CI 1.1 to 6.9, P = 0.03). In addition to electrocardiographic features of myopericarditis, a positive HIV serological status was associated with greater cardiomegaly (OR 3.89, 95% CI 1.34 to 11.32, P = 0.01) and haemodynamic instability (OR 9.68, 95% CI 2.09 to 44.80, P = 0.0008). However, stage of pericardial disease at diagnosis and use of diagnostic tests were not related to clinical HIV status. Similar results were obtained for serological HIV status. Most patients were treated on clinical grounds, with microbiological evidence of tuberculosis obtained in only 13 (7.0%) patients. Adjunctive corticosteroids were used in 109 (58.9%) patients, with patients having clinical HIV disease less likely to be put on them (OR 0.37, 95% CI 0.20 to 0.68). Seven patients were on antiretroviral drugs. CONCLUSION: Patients with suspected tuberculous pericarditis and HIV infection in Africa have greater evidence of myopericarditis, dyspnoea, and haemodynamic instability. These findings, if confirmed in other studies, may suggest more intensive management of the cardiac disease is warranted in patients with HIV-associated pericardial disease.

Adolescent↗
PubMed2006

Implementing and managing self-management skills training within primary care organisations: a national survey of the expert patients programme within its pilot phase.

A key element of the United Kingdom (UK) health policy reform in relation to chronic disease management is the introduction of a national programme seeking to promote self-care from within the National Health Service (NHS). The mainstay of the Expert Patients Programme (EPP) is a six-week training course that provides the opportunity for anyone with a long-term condition to develop new skills to manage their condition better on a day-to-day basis. The course forms part of the NHS self-care support programme, is administered by Primary Care Trusts (PCTs) and delivered by people who have personal experience of living with a long-term condition. The NHS' official Expert Patients Programme website presently states that, "Pilot EPP courses began at 26 NHS PCT sites across England in May 2002, and by May 2004 approximately 300 PCTs had either actively implemented pilot courses or had committed to joining. The majority of PCTs are now coming to the end of the pilot phase, with many implementing plans to make EPP sustainable for the long-term." The NHS website heralds the pilot "a success."A national, postal survey of PCT EPP Leads was undertaken in order to examine both the evolvement of EPP during its pilot stage and future plans for the programme. A questionnaire was sent out to the 299 PCTs known to have committed to the EPP pilot, and an excellent 100% response rate was obtained over a 3-month period (April-July 2005). One marker of success of the Expert Patients Programme implementation is the actual running of courses by the Primary Care Trusts. This paper explores the extent to which the implementation of the pilot can indeed be viewed as a "success," primarily in terms of the number of courses run, and considers the extent to which PCTs have carried out all that they were committed to do. Findings suggest that the more time an EPP Lead dedicates to the Programme, the more likely it is that EPP has run successfully in the past, and the more likely it is that it will continue to run successfully in the future. Other factors indicating future EPP success include collaborating across PCTs to share co-ordinators, tutors, and funding.

Journal Article↗
PubMed1991

A comparison of nutritional management with stress management in the treatment of bulimia nervosa.

In a comparison of nutritional management (NM) and stress management (SM) for treatment of bulimia nervosa, 55 female patients were randomly assigned to either treatment. Therapy consisted of 15 sessions in a group over three months, by the end of which, patients under both treatment conditions showed a significant reduction in the frequency of binge eating and vomiting and a significant improvement in various psychopathological features such as body dissatisfaction and depression. All improvements were maintained over 12-month follow-up NM produced a more rapid improvement in general eating behaviour, a faster reduction in binge frequency and a higher abstinence rate from binge eating. SM led to greater positive changes in certain psychopathological features such as feelings of ineffectiveness, interpersonal distrust and anxiety. NM should be regarded as a necessary first intervention in all bulimic patients. Further psychological therapy, such as SM, is indicated as well for some patients, depending on their specific psychological difficulties.

Adaptation, Psychological↗
PubMed1996

Differential influences on asthma self-management knowledge and self-management behavior in acute severe asthma.

AIM: While asthma education increases knowledge, it is less clear whether education influences actual patient behavior. To determine whether there are differences between asthma self-management knowledge and the actual behavior of patients during an acute severe asthma attack and to determine which clinical and psychosocial factors are associated with knowledge and behavior. METHODS: Validated hypothetical scenarios describing the development of life-threatening asthma and patients' reported actual behavior were scored (out of 25) using a system based on Thoracic Society of Australia and New Zealand and British Thoracic Society criteria. RESULTS: In 137 patients admitted to the hospital with severe asthma, the pattern of the index attack was slow onset (> or = 6 h) in 96%. The score for the hypothetical attack (knowledge) was 13.8 +/- 4.6, while that for the timeline (behavior) was 10.2 +/- 3.9 (p < 0.001) with 56% and 84%, respectively, having a score of less than 15 (regarded as inadequate). Certain components showed marked discrepancy (eg, appropriately seeking medical help 82% vs 52% (p < 0.001) and calling ambulance 61% vs 23% (p < 0.001). Factors such as physician-patient relationship, previous asthma morbidity, availability of peak flowmeter, action plan, and oral steroids correlated positively with both measures. Knowledge was negatively associated with being non-European, with anxiety, pessimism, and stigmatization. Behavior (but not knowledge) was negatively associated with lack of knowledge of what to do in the index attack, previous emotional counseling, and business failure. Those factors associated with the difference between knowledge and behavior scores (knowledge-behavior gap) were being non-European, anxiety, pessimism, and stigmatization, concerns about medical costs, and the only income for the household being a Social Security benefit. CONCLUSION: There are marked differences between patients' self-management knowledge and their actual behavior, particularly in terms of potentially life-saving actions. Psychological, health-care, and socioeconomic factors have a powerful and differential influence on knowledge and behavior. Improved understanding of the discrepancies between knowledge and behavior and which factors influence them may lead to more effective asthma educational interventions.

Acute Disease↗
PubMed2004

Multiple management modalities in esophageal cancer: combined modality management approaches.

The overall success rate nationally in treating esophageal carcinomas remains poor, with over 90% of patients succumbing to the disease. In part I of this two-part series, we explored epidemiology, presentation and progression, work-up, and surgical approaches. In part II, we explore the promising suggestions of integrating chemotherapy and radiation therapy into the multimodal management of esophageal cancers. Alternative approaches to resection alone have been sought because of the overall poor survival rates of esophageal cancer patients, with failures occurring both local-regionally and distantly. Concomitant chemotherapy and radiation therapy (XRT) have been shown, by randomized trial, to be more effective than XRT alone in treating unresectable esophageal cancers and also have shown promise as a neoadjuvant treatment when combined with surgery in the multimodal treatment of this disease. Various studies have also addressed issues such as preoperative chemotherapy, radiation dose escalation, chemotherapy/XRT as a definitive treatment versus use as a surgical adjuvant, and alternative chemotherapy regimens. There are suggestions of some progress, but this remains a difficult problem area in which management is continuing to evolve.

Antineoplastic Agents↗
PubMedDate not supplied

Managing farming systems for nitrate control: a research review from management systems evaluation areas.

The U.S. Department of Agriculture funded the Management Systems Evaluation Area (MSEA) research project in 1990 to evaluate effectiveness of present farming systems in controlling nitrate N in water resources and to develop improved technologies for farming systems. This paper summarizes published research results of a five-year effort. Most research is focused on evaluating the effectiveness of farming system components (fertilizer, tillage, water control, cropping systems, and soil and weather variability). The research results show that current soil nitrate tests reliably predict fertilizer N needed to control environmental and economic risks for crop production. A corn (Zea mays L.)-soybean [Glycine max (L.) Merr.] rotation usually controls risk better than continuous corn, but both may result in unacceptable nitrate leaching. Reduced tillage, especially ridge-till, is better than clean tillage in reducing risk. Tile drainage controls nitrate in ground water, but discharge may increase nitrate in surface waters. Sprinkler irrigation systems provide better water control than furrow irrigation because quantity and spatial variability of applied water is reduced. Present farming systems have two major deficiencies: (i) entire fields are managed uniformly, ignoring inherent soil variability within a field; and (ii) N fertilizer rates and many field practices are selected assuming normal weather for the coming season. Both deficiencies can contribute to nitrate leaching in parts of most fields.

Agriculture↗
PubMed1999

Managing pharmaceutical expenditure while increasing access. The pharmaceutical management agency (PHARMAC) experience.

The role of the Pharmaceutical Management Agency (PHARMAC) is to manage pharmaceutical subsidy expenditure in New Zealand. PHARMAC has adopted a proactive approach. It selects the drugs that are to be subsidized and declines to subsidize others. It has established reference pricing across many drug groups, has entered into a range of innovative commercial contracts with pharmaceutical companies, and has encouraged greater price competition among pharmaceutical companies in order to lower prices and control expenditure risk. These initiatives have all been part of an overarching strategy to improve the value of the government's expenditure on pharmaceuticals. PHARMAC has also developed techniques of cost-utility analysis to assess the value of expenditure. PHARMAC has slowed pharmaceutical expenditure growth, culminating in a fall in expenditure in the 1998/1999 year. At the same time, patient access has continued to expand, with more prescriptions being written and new drugs being subsidized. Therefore, PHARMAC has made dramatic strides to improve the value of the government's expenditure on pharmaceutical subsidies and its actions have meant that more funds have been available for investment in other health services, than would have occurred if previous policies had remained unchanged.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1998

Use of services by diabetes patients in managed care organizations. Development of a diabetes surveillance system. CDC Diabetes in Managed Care Work Group.

OBJECTIVE: To develop a diabetes surveillance system that estimates the prevalence of diabetes and characterizes service use in diverse managed care organizations (MCOs). RESEARCH DESIGN AND METHODS: Computerized inpatient, pharmacy, outpatient, and laboratory records were used to develop an algorithm to identify diabetes patients and to develop surveillance indicators common to the three participating MCOs. Using 1993 data, the availability, specifications, and limitations of various surveillance indicators were determined. RESULTS: An extensive set of diabetes surveillance indicators was identified from the four sources of data. Consistent data specifications across MCOs needed to consider variation in the type of data collected, a lack of documentation on level of coverage, differences in coding data, and different models of health care delivery. A total of 16,363 diabetes patients were identified. The age-adjusted prevalence of diabetes ranged from 24 to 29 per 1,000 enrollees. Approximately one-third of patients with diabetes (32-34%) were taking insulin. The majority had one or more visits to a primary care physician during the year (72-94%). Visits to specialists were less frequent. Ophthalmologists and optometrists were the most commonly used specialists: 29-60% of the patients with diabetes at the three MCOs had visited an ophthalmologist or optometrist. About one-fifth had an overnight hospital stay during the year. CONCLUSIONS: This diabetes surveillance system is a useful tool for MCOs to track trends in prevalence of diabetes, use of health services, and delivery of preventive care to individuals with diabetes. This system may also be useful for health care planning and for assessing use changes after new developments in diabetes care or new quality management initiatives.

Adolescent↗
PubMedDate not supplied

Focus on Trent: management. Developing nurse management skills.

Within a climate of change in the National Health Service and in recognition of the management function of nurses, Trent Region introduced a 'fast-track' development initiative to prepare nurses to fulfil new managerial roles. Two self-managed action learning programmes were conducted: one for nurses who would be functioning at clinical directorate or equivalent level, and another for those at executive board level. The author argues that the programme has proved itself as an enabling process for all of the participants.

Education, Nursing, Continuing↗
PubMedDate not supplied

Management ... working day of a health services manager.

The estates function has developed from a mainly operational job to one with considerable strategic importance. John Baker, Estates Manager, Bedford Hospital NHS Trust, outlines the challenges of managing the NHS estate today.

Hospital Administrators↗
PubMed1995

Models of case management in long term home health care. The evolution of for-profit geriatric care management.

Professional geriatric care management has the potential to provide an emotionally satisfying, lucrative career for the social worker or nurse who is self-educated or who has formal continuing professional education in assessment, care options, and care coordination. Yet GCM as an organized profession, or as a career choice for the individual, requires institutional supports to grow and flourish. The GCM profession requires recognition by the states (including certification and credentialing). A network must be developed so that young persons can receive a first professional degree, or at least a concentration within nursing or social work, in the legal and financial implications of elder care as well as the biology of aging and the techniques of hands-on physical care of the elderly. Structures must be created for continuing professional education of the GCM practitioner. The various Medicaid programs that offer home care to the elderly and disabled rely heavily on assessment and case management; so does the entire Medicare system. However, the federal statutes and regulations do not explicitly authorize GCM participation in care planning. More to the point, they do not clearly authorize reimbursement of GCMs as independent professionals or as Medicare/Medicaid service providers. As private long-term care insurance evolves, GCM services should be recognized as proper components of the planning process (and therefore as services that can be reimbursed by the policy). Once this is done, the challenge for GCM professionals is to retain their focus on the needs of the elder and family, rather than to perceive themselves as gatekeepers who function to cut the cost of services instead of optimizing their variety and quality.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMedDate not supplied

Marketing skills for hospital-based laboratory managers in a managed care environment.

Managers of hospital-based laboratories have begun to realize the importance of a successful outreach program in protecting against declining inpatient activity. Succeeding in the highly competitive field of outpatient testing requires some new skills and techniques that may not have been apparent when addressing normal inpatient requirements. This article provides an overview of some very basic marketing concepts and attempts to show how they can assist the hospital-based laboratory manager in developing a successful outreach program.

Capitation Fee↗
PubMed1997

Hypertension management in managed care: the role of home blood pressure monitoring.

The interest in home blood pressure monitoring (HBPM) has grown with the widespread availability of blood pressure measurement devices, greater patient involvement in self care, and recognition of the limitations of office blood pressure monitoring (OBPM), and the expense and inconvenience of ambulatory blood pressure monitoring. HBPM is inexpensive, reproducible, and easy to learn. It can be helpful in identifying white-coat hypertension and midiagnosis, both of which may result in patients who do not have the disease being treated for hypertension and failure to maintain 24 h control of blood pressure. White-coat hypertension has been reported for about 25% and misdiagnosis for 18% of patients diagnosed with hypertension. In limited research, HBPM has been shown to reduce the number of clinic visits, the number of switches of medication, and the number of antihypertensives prescribed, and to improve control of blood pressure. Moreover, results from one large study suggest that measurements obtained via HBPM are correlated to overall mortality better than are those from OBPM. Although normal limits for blood pressure have been defined for OBPM, they have not yet been defined for HBPM. Research is now under way to confirm the clinical and economic impact of HBPM in the managed-care setting. If current data suggesting the benefit of HBPM are confirmed, the widespread adoption of this technique could improve patient care and reduce the costs of managing hypertension.

Journal Article↗