Centre for eHealth, Centre for Care Research, Southern Norway, Department of Health and Nursing Sciences, Faculty of Health and Sport Sciences, University of Agder, Post box 422, 4604, Kristiansand, Norway. firstname.lastname@example.org.
Telemedicine is changing traditional nursing care, and entails nurses performing advanced and complex care within a new clinical environment, and monitoring patients at a distance. Telemedicine practice requires complex disease management, advocating that the nurses' reasoning and decision-making processes are supported. Computerised decision support systems are being used increasingly to assist reasoning and decision-making in different situations. However, little research has focused on the clinical reasoning of nurses using a computerised decision support system in a telemedicine setting. Therefore, the objective of the study is to explore the process of telemedicine nurses' clinical reasoning when using a computerised decision support system for the management of patients with chronic obstructive pulmonary disease. The factors influencing the reasoning and decision-making processes were investigated.
In this ethnographic study, a combination of data collection methods, including participatory observations, the think-aloud technique, and a focus group interview was employed. Collected data were analysed using qualitative content analysis.
When telemedicine nurses used a computerised decision support system for the management of patients with complex, unstable chronic obstructive pulmonary disease, two categories emerged: "the process of telemedicine nurses' reasoning to assess health change" and "the influence of the telemedicine setting on nurses' reasoning and decision-making processes". An overall theme, termed "advancing beyond the system", represented the connection between the reasoning processes and the telemedicine work and setting, where being familiar with the patient functioned as a foundation for the nurses' clinical reasoning process.
In the telemedicine setting, when supported by a computerised decision support system, nurses' reasoning was enabled by the continuous flow of digital clinical data, regular video-mediated contact and shared decision-making with the patient. These factors fostered an in-depth knowledge of the patients and acted as a foundation for the nurses' reasoning process. Nurses' reasoning frequently advanced beyond the computerised decision support system recommendations. Future studies are warranted to develop more accurate algorithms, increase system maturity, and improve the integration of the digital clinical information with clinical experiences, to support telemedicine nurses' reasoning process.
Chronic obstructive pulmonary disease (COPD) is a public health problem. Interprofessional collaboration and health promotion interventions such as exercise training, education, and behaviour change are cost effective, have a good effect on health status, and are recommended in COPD treatment guidelines. There is a gap between the guidelines and the healthcare available to people with COPD. The aim of this study was to increase the understanding of what shapes the provision of primary care services to people with COPD and what healthcare is offered to them from the perspective of healthcare professionals and managers.
The study was conducted in primary care in a Swedish county council during January to June 2015. A qualitatively driven mixed methods design was applied. Qualitative and quantitative findings were merged into a joint analysis. Interviews for the qualitative component were performed with healthcare professionals (n = 14) from two primary care centres and analysed with qualitative content analysis. Two questionnaires were used for the quantitative component; one was answered by senior managers or COPD nurses at primary care centres (n = 26) in the county council and the other was answered by healthcare professionals (n = 18) at two primary care centres. The questionnaire data were analysed with descriptive statistics.
The analysis gave rise to the overarching theme building COPD care on shaky ground. This represents professionals driven to build a supportive COPD care on 'shaky' organisational ground in a fragmented and non-compliant healthcare organisation. The shaky ground is further represented by uninformed patients with a complex disease, which is surrounded with shame. The professionals are autonomous and pragmatic, used to taking responsibility for their work, and with limited involvement of the management. They wish to provide high quality COPD care with interprofessional collaboration, but they lack competence and are hindered by inadequate routines and lack of resources.
There is a gap between COPD treatment guidelines and the healthcare that is provided in primary care. To facilitate implementation of the guidelines several actions are needed, such as further training for professionals, additional resources, and improved organisational structure for interprofessional collaboration and patient education.
Cites: Eur Respir J. 2015 Apr;45(4):879-905 PMID 25829431
Cites: COPD. 2013 Aug;10(4):425-35 PMID 23537344
Cites: Am J Respir Crit Care Med. 2005 May 1;171(9):972-7 PMID 15665324
Cites: Am J Respir Crit Care Med. 2013 Oct 15;188(8):e13-64 PMID 24127811
Cites: COPD. 2015 Apr;12(2):144-53 PMID 24984085
Cites: J Health Serv Res Policy. 2008 Apr;13(2):92-8 PMID 18416914
Cites: Cochrane Database Syst Rev. 2015 Feb 23;(2):CD003793 PMID 25705944
Cites: COPD. 2008 Apr;5(2):133-8 PMID 18415812
Cites: Qual Health Res. 2014 Jan;24(1):3-5 PMID 24448383
Cites: Health Serv Res. 2013 Dec;48(6 Pt 2):2134-56 PMID 24279835
Cites: Am J Respir Crit Care Med. 2015 Dec 1;192(11):1373-86 PMID 26623686
Chronic obstructive pulmonary disease (COPD) is a common respiratory condition and the fourth leading cause of death in Canada. Optimal COPD management requires patients to participate in their care and physician knowledge of patients' perceptions of their disease.
A prospective study in which respiratory specialist physicians completed a practice assessment questionnaire and patient assessments for 15 to 20 consecutive patients with COPD. Patients also completed a questionnaire regarding their perceptions of COPD and its management.
A total of 58 respiratory specialist physicians from across Canada completed practice assessments and 931 patient assessments. A total of 640 patients with COPD (96% with moderate, severe or very severe disease) completed questionnaires. Symptom burden was high and most patients had experienced a recent exacerbation. Potential COPD care gaps were identified with respect to appropriate medication prescription, lack of an action plan, and access to COPD educators and pulmonary rehabilitation. Perceived knowledge needs and gaps differed between physicians and patients.
Despite the dissemination of Canadian and international COPD clinical practice guidelines for more than a decade, potential care gaps remain among patients seen by respiratory specialist physicians. Differing perceptions regarding many aspects of COPD among physicians and patients may contribute to these care gaps.
Cites: Arch Intern Med. 2003 Mar 10;163(5):585-9112622605
Cites: Eur Respir J. 2004 Jun;23(6):932-4615219010
Cites: J Contin Educ Health Prof. 2004 Fall;24 Suppl 1:S31-715712775
Cites: J Contin Educ Health Prof. 2006 Winter;26(1):13-2416557505
Cites: Int J Chron Obstruct Pulmon Dis. 2012;7:201-922500120
Cites: Can Respir J. 2008 Jan-Feb;15 Suppl A:1A-8A18292855
Evaluate the feasibility of the COPD Web and its study design and study procedures and to increase the understanding of the potential effect of the tool in order to provide guidance for a future large scale trial.
Parallel-group controlled pragmatic pilot trial.
There was a total of 83 patients with COPD (mean age 70?±?8 years with a forced expiratory volume in first second percent predicted of 60?±?17%). The intervention group (n?=?43) was introduced to and had access to the COPD Web in addition to usual care, while the control group (n?=?40) received usual care alone.
The feasibility of the COPD Web (i.e., if and how the COPD Web was used) was automatically collected through the website, while outcomes on health, conceptual knowledge, and physical activity (PA) were collected through questionnaires at baseline, 3 months and 12 months.
At 3 months, 77% of the intervention group was considered users, and the majority of time spent on the site was related to PA and exercises and was spent during the first month (>80%). In addition, the intervention group reported increased PA (odds ratio [OR]?=?4.4, P?
Rurality can contribute to the vulnerability of people with chronic diseases. Qualitative research can identify a wide range of health care access issues faced by patients living in a remote or rural setting.
To systematically review and synthesize qualitative research on the advantages and disadvantages rural patients with chronic diseases face when accessing both rural and distant care.
This report synthesizes 12 primary qualitative studies on the topic of access to health care for rural patients with chronic disease. Included studies were published between 2002 and 2012 and followed adult patients in North America, Europe, Australia, and New Zealand.
Qualitative meta-synthesis was used to integrate findings across primary research studies.
Three major themes were identified: geography, availability of health care professionals, and rural culture. First, geographic distance from services poses access barriers, worsened by transportation problems or weather conditions. Community supports and rurally located services can help overcome these challenges. Second, the limited availability of health care professionals (coupled with low education or lack of peer support) increases the feeling of vulnerability. When care is available locally, patients appreciate long-term relationships with individual clinicians and care personalized by familiarity with the patient as a person. Finally, patients may feel culturally marginalized in the urban health care context, especially if health literacy is low. A culture of self-reliance and community belonging in rural areas may incline patients to do without distant care and may mitigate feelings of vulnerability.
Qualitative research findings are not intended to generalize directly to populations, although meta-synthesis across a number of qualitative studies builds an increasingly robust understanding that is more likely to be transferable. Selected studies focused on the vulnerability experiences of rural dwellers with chronic disease; findings emphasize the patient rather than the provider perspective.
This study corroborates previous knowledge and concerns about access issues in rural and remote areas, such as geographical distance and shortage of health care professionals and services. Unhealthy behaviours and reduced willingness to seek care increase patients' vulnerability. Patients' perspectives also highlight rural culture's potential to either exacerbate or mitigate access issues.
People who live in a rural area may feel more vulnerable--that is, more easily harmed by their health problems or experiences with the health care system. Qualitative research looks at these experiences from the patient's point of view. We found 3 broad concerns in the studies we looked at. The first was geography: needing to travel long distances for health care can make care hard to reach, especially if transportation is difficult or the weather is bad. The second concern was availability of health professionals: rural areas often lack health care services. Patients may also feel powerless in "referral games" between rural and urban providers. People with low education or without others to help them may find navigating care more difficult. When rural services are available, patients like seeing clinicians who have known them for a long time, and like how familiar clinicians treat them as a whole person. The third concern was rural culture: patients may feel like outsiders in city hospitals or clinics. As well, in rural communities, people may share a feeling of self-reliance and community belonging. This may make them more eager to take care of themselves and each other, and less willing to seek distant care. Each of these factors can increase or decrease patient vulnerability, depending on how health services are provided.
Cites: J Adv Nurs. 2000 Mar;31(3):715-2110718892
Cites: Prim Care Respir J. 2011 Mar;20(1):54-820871944
Cites: J Nurs Scholarsh. 2002;34(3):213-912237982
Cites: J Adv Nurs. 2002 Nov;40(4):421-3112421401
Cites: Res Nurs Health. 2003 Apr;26(2):153-7012652611
Cites: BMC Med Res Methodol. 2004 Mar 16;4:515070427
Cites: Qual Health Res. 2003 Sep;13(7):893-90414502956
Chronic obstructive pulmonary disease (COPD) affects millions of people worldwide. A complication of COPD is exacerbations that result in increased utilization of healthcare services, readmissions to the hospital, and a decline in health-related quality of life. Home telehealth has been shown both to improve health-related quality of life and to reduce admission rates. Using clinical data from a home telemonitoring group, this study sought to investigate the clinical impact of telemonitoring.
Fifty-seven subjects with COPD were included in a 4-month telemonitoring project. Differences between the clinical parameters during the first and last months of participation in the project were tested for significance, and the levels for the first month versus the difference were tested for correlation.
Significant declines were observed in prescriptions for antibiotics and steroids (p=0.03), clinical consultations (p=0.05), mean systolic blood pressure (p
This study compares continuity of care between Germany - a social health insurance country, and Norway - a national health service country with gatekeeping and patient lists for COPD patients before and after initial hospitalization. We also investigate how subsequent readmissions are affected.
Continuity of Care Index (COCI), Usual Provider Index (UPC) and Sequential Continuity Index (SECON) were calculated using insurance claims and national register data (2009-14). These indices were used in negative binomial and logistic regressions to estimate incident rate ratios (IRR) and odds ratios (OR) for comparing readmissions.
All continuity indices were significantly lower in Norway. One year readmissions were significantly higher in Germany, whereas 30-day rates were not. All indices measured one year after discharge were negatively associated with one-year readmissions for both countries. Significant associations between indices measured before hospitalization and readmissions were only observed in Norway - all indices for one-year readmissions and SECON for 30-day readmissions.
Our findings indicate higher continuity is associated with reductions in readmissions following initial COPD admission. This is observed both before and after hospitalization in a system with gatekeeping and patient lists, yet only after for a system lacking such arrangements. These results emphasize the need for policy strategies to further investigate and promote care continuity in order to reduce hospital readmission burden for COPD patients.
Chronic obstructive pulmonary disease (COPD) is a common cause of suffering and death. Evidence-based management of COPD by general practitioners (GPs) is crucial for decreasing the impact of the disease. Efficient strategies include early diagnosis, smoking cessation and multimodal treatment.
To describe knowledge about and skills for managing COPD in GPs in Sweden.
Prior to COPD education (the PRIMAIR Study), GPs at primary health care centers (PHCCs) in Stockholm replied to 13 written, patient-case based, multiple choice and free-text questions about COPD. Their knowledge and practical management skills were assessed by assigned points that were analyzed with non-parametric tests.
Overall, 250 GPs at 34 PHCCs replied (89% response rate). Total mean score was 9.9 (maximum 26). Scores were highest on 'management of smoking cessation', 'follow-up after exacerbation' and 'diagnostic procedures'. Spirometry was used frequently, although interpretation skills were suboptimal. 'Management of maintenance therapy', 'management of multimorbidity' and 'interprofessional cooperation' had mediocre scores. Scores were unrelated to whether there was a nurse-led asthma/COPD clinic at the PHCC.
Swedish GPs' knowledge of COPD and adherence to current guidelines seem insufficient. A nurse-led asthma/COPD clinic at the PHCC does not correlate with sufficient COPD skills in the GPs. The relevance of this study to participants' actual clinical practice and usefulness of easy-to-access clinical guides are interesting topics for future investigation. To identify problem areas, we suggest using questionnaires prior to educational interventions. Key Points General practitioners (GPs) play a crucial role in providing evidence-based care for patients with chronic obstructive pulmonary disease (COPD) who are treated in primary care. Swedish GPs' knowledge about COPD and adherence to current guidelines seem insufficient. Areas in greatest need of improvement are spirometry interpretation, management of maintenance therapy, management of multimorbidity in patients with COPD and interprofessional cooperation.
Cites: Scand J Prim Health Care. 2006 Jun;24(2):81-7 PMID 16690555
Cites: Int J Chron Obstruct Pulmon Dis. 2011;6:659-67 PMID 22259242
Long-term oxygen therapy (LTOT) improves survival and may reduce hospital admissions in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia, but the impact of daily duration of LTOT on hospitalization rate is unknown. We aimed to estimate the association between the daily duration of LTOT (24 vs 15 h/d) and hospital admissions in patients with LTOT due to COPD.
A population-based, cohort study included patients who started LTOT due to COPD between October 1, 2005 and June 30, 2009 in the Swedish national register for respiratory failure (Swedevox). Time to first hospitalization from all causes and from respiratory or nonrespiratory disease, using the National Patient Registry, was analyzed using Fine-Gray regression, adjusting for potential confounders.
A total of 2,249 patients with COPD (59% women) were included. LTOT 24 h/d was prescribed to 539 (24%) and LTOT 15-16 h/d to 1,231 (55%) patients. During a median follow-up of 1.1 years (interquartile range, 0.6-2.1 years), 1,702 (76%) patients were hospitalized. No patient was lost to follow-up. The adjusted rate of all-cause hospitalization was similar between LTOT 24 and 15-16 h/d (subdistribution hazard ratio [SHR] 0.96; [95% CI] 0.84-1.08), as was cause-specific hospitalizations analyzed for respiratory disease (SHR: 1.00; 95% CI: 0.86-1.17) and nonrespiratory disease (SHR: 0.92; 95% CI: 0.75-1.14).
LTOT prescribed for 24 h/d was not associated with decreased hospitalization rates compared with LTOT for 15-16 h/d in patients with oxygen-dependent COPD. The results should be validated in a randomized controlled trial.
OBJECTIVE: To study differences in readmissions to primary and secondary care hospitals for exacerbations of chronic obstructive pulmonary disease (COPD). DESIGN: A register-based study. SUBJECTS: The data were gathered from the hospital admissions register of the Finnish National Research and Development Centre for Welfare and Health. The data included all acute periods of treatment received by COPD patients aged over 44 years in 1996-2004 who had a principal or subsidiary diagnosis of COPD (ICD 10: J41-J44), respiratory infection (ICD 10: J00-J39, J85-J86) or cardiac insufficiency (ICD 10: I50), followed by an emergency readmission. Treatment had to have taken place in either a primary care hospital or a specialized ward for respiratory diseases or internal medicine in a secondary care hospital. MAIN OUTCOME MEASURES: The risk of readmission within a week of discharge, analysed by site of care. RESULTS: The risk of readmission within seven days of discharge is 1.74-fold for a patient treated in primary care compared with a patient treated in secondary care. CONCLUSIONS: COPD patients discharged from primary care hospitals have a greater risk of readmission, particularly within a week, than those discharged from secondary care. This risk may be attributed to differences in treatment procedures and arrangement of subsequent care. Thus, in the future, more attention should be paid to primary healthcare resources and staff training.