The perceived benefits of the chronic disease self-management program among participants with stroke: A qualitative study

Despite the expense associated with rehabilitation following stroke, dissatisfaction with psychosocial outcomes is common (Thomas & Parry, 1996). The rehabilitation system has been critiqued as lacking a theoretical base for psychosocial interventions (Goldberg, Segal, Berk, Schall, & Gershkoff, 1997). The current paper examines the possible role of the Chronic Disease Self-Management Program ([CDSMP] Lorig, 1996) in contributing to the psychosocial rehabilitation of people with stroke. This paper focuses on the analysis of incidental comments made by participants about a version of the CDSMP, tailored for people with stroke. These comments, collected over an 18-month follow-up period, provide interesting insights into the key aspects of the program. Six informative themes emerged from the more specific comments, namely (1) the importance of social contact and comparison, (2) increased awareness and knowledge about stroke, (3) motivation to pursue goals and activities, (4) a sense of achievement, (5) maintenance of gains, and (6) the paradoxical nature of social support. According to participants, the program was associated with enhanced self-efficacy. Other reported benefits (such as social support and enhanced knowledge) were indirectly associated with the program and appeared to reflect social aspects of the group and its stroke-specific focus. Maintenance of gains made by participants was seen as a crucial issue.

Asthma management by New Zealand pharmacists: a pharmaceutical care demonstration project

Background: Pharmaceutical care services became recognized in New Zealand in the mid-1990s, albeit with limited evidence of the acceptability and effectiveness of the model. An asthma-specific pharmaceutical care service was trialled in southern New Zealand, based on a 'problem-action-outcome' method, with pharmacists adopting a patient-centred, outcome-focused approach with multidisciplinary consultation. Objective: To report on the implementation and outcomes of a specialist asthma service offered by community pharmacists. Design: Pharmacists in five pharmacies, servicing predominantly rural, established clientele, received training in the asthma service and research documentation. Ten patients per pharmacy were recruited in each year (years 1 and 2) of the study. The patients were entered into the study in cohorts of five per pharmacy twice yearly, with year 2 mirroring year 1. The phase-in design minimized the impact on the pharmacists. The patients acted as their own controls. All patients received individualized care and had approximately monthly consultations with the pharmacist, with clinical and quality of life (QoL) monitoring. Results: A total of 100 patients were recruited. On average, 4.3 medication-related problems were identified per patient; two-thirds of them were compliance-related. The most common interventions were revision of patients' asthma action plans, referral and medication counselling. Clinical outcomes included reduced bronchodilator use and improved symptom control in around two-thirds of patients. Asthma-specific QoL changes were more positive and correlated well with clinical indicators. Conclusion: Further research is warranted to integrate this service into daily practice. Clinical outcomes were generally positive and supported by QoL indicators. Characteristics of New Zealand practice and this sample of pharmacies may limit the generalizability of these findings.

A review of telemedicine and asthma

The literature contains a number of reports of early work involving telemedicine and chronic disease; however, there are comparatively few studies in asthma. Most of the telemedicine studies in asthma have investigated the use of remote monitoring of patients in the home, e.g. transmitting spirometry data via a telephone modem to a central server. The primary objective of these studies was to improve management. A secondary benefit was that patient adherence to prescribed treatment is also likely to be improved. Early results are encouraging; home monitoring in a randomized controlled trial in Japan significantly reduced the number of emergency room visits by patients with poorly controlled asthma. Other studies have described the cost-benefits of a specialist asthma nurse who can manage patients by telephone contact, as well as deliver asthma education. Many web-based systems are available for the general public or healthcare professionals to improve education in asthma, although their quality is highly variable. The work on telemedicine in asthma clearly shows that the technique holds promise in a number of areas. Unfortunately - as in telemedicine generally - most of the literature in patients with asthma refers to pilot trials and feasibility studies, with short-term outcomes. Large-scale, formal research trials are required to establish the cost effectiveness of telemedicine in asthma.

Achieving better in-hospital and after-hospital care of patients with acute cardiac disease

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after hospital care, patient self-care, and hospital-community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital-community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before-after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and beta-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF. Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, beta-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P=0.06) and from 13.4% to 10.1% (P= 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P= 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.