Nurse-led behavioral management of diabetes and hypertension in community practices: a randomized trial.

BACKGROUND: Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions. OBJECTIVE: To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases. DESIGN: The study was designed as a patient-level randomized controlled trial. PARTICIPANTS: Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5%) but could have well-controlled HTN. INTERVENTIONS: All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention). MAIN OUTCOMES AND MEASURES: Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point. RESULTS: Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55% female and 50% white; the mean baseline A1c was 9.1% (SD = 1%) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69% of intervention patients and 70% of control patients reached the 24-month time point. Expressing model estimated differences as (intervention--control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (-0.3, 0.5), p = 0.51] and SBP [diff = -0.9 mmHg, 95% CI (-5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points. CONCLUSIONS: In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.

Money laundering and FATF compliance by the international community

This paper examines the anti-money laundering systems of Australia, the United Arab Emirates (UAE), the United Kingdom (UK) and the United States of America (USA), the extent to which they have implemented the Financial Action Task Force (FATF) recommendations, and how compliance with these recommendations is affected by local cultural and economic factors. The paper makes use of FATF evaluation reports to compare the countries’ compliance; it examines some of the underlying cultural considerations and culture-specific ethical issues that affect the extent of compliance, and how cultural and ethical considerations may affect good governance. The findings indicate that the UK and the USA are the most advanced with regards to their compliance with the FATF recommendations and Australia and the UAE less so. The UAE is in particular found to be least compliant. We relate this finding to previous work on how a country’s legal and financial systems develop in line with its religion, culture and socio-economic situation, and examine how such local factors have affected the UAE’s financial and anti-money laundering and combating the financing of terrorism (AML/CFT) systems. This research will be of interest to policy-makers and government agencies involved in addressing money laundering and its successful detection and prosecution.

The real area of contact and compliance of rough cylinders in compression

Bearing area analysis has been used to study the real area of contact and compliance of rough turned steel cylinders in compression. Calculations show that the elastic real area of contact is very small compared to the plastic real area of contact, and that local compliance due to flattening of asperity tips is a small proportion of the total compliance obtained from experiments. The fact that increased load brings more and more new asperities under load rather than enlarging the contact spots leads to a rather simple load-compliance relation for a rough cylinder, viz., W' = Nh · K1δn, where W0 = K1δn defines the load-compliance relation of the individual asperities, and Nh represents the number of asperities bearing the load.

real area of contact and compliance of rough cylinders in compression

Bearing area analysis has been used to study the real area of contact and compliance of rough turned steel cylinders in compression. Calculations show that the elastic real area of contact is very small compared to the plastic real area of contact, and that local compliance due to flattening of asperity tips is a small proportion of the total compliance obtained from experiments. The fact that increased load brings more and more new asperities under load rather than enlarging the contact spots leads to a rather simple load-compliance relation for a rough cylinder, viz., W' = Nh · K1δn, where W0 = K1δn defines the load-compliance relation of the individual asperities, and Nh represents the number of asperities bearing the load.

Compliance of rough cylinders in compression

Compression of a rough turned cylinder between two hard, smooth, flat plates has been analysed with the aid of a mathematical model based on statistical analysis. It is assumed that the asperity peak heights follow Gaussian or normal and beta distribution functions and that the loaded asperities comply as though they are completely isolated from the neighbouring ones. Equations have been developed for the loadcompliance relation of the real surface using a simplified relation of the form W0 = K1δn for the load-compliance of a single asperity. Parameters K1 and n have considerable influence on the load-compliance curve and they depend on the material, tip angle of the asperity, standard deviation of the asperity peak height distribution and the density of the asperities.

Learning, development, and support needs of community palliative care clinical nurse specialists

Background: The palliative care clinical nurse specialist (PC-CNS) is a core member of the specialist palliative care team. According to professional policy, the role has four specific components: clinical practice, education, research, and leadership and management. Little is known about how to support staff in this role. Aim: The aim of this study was to explore what learning, development, and support PC-CNSs in one hospice need to enable them to fulfil all components of their role. Design: Using a descriptive exploratory approach, semi-structured interviews were undertaken with a purposive sample of community PC-CNSs from a hospice in Northern Ireland. Interviews were audio-recorded, transcribed verbatim, and thematically analysed. Findings: Seventeen interviews were analysed and three themes identified: influence of organisational culture, influence of the individual, and learning and development solutions. Conclusions: Participants reported that the PC-CNS role was stressful. They identified that the organisational culture and indeed individuals themselves influenced the learning and development support available to help them fulfil the four components of the role. Working relationships and stability within teams affected how supported individuals felt and had implications for managers in meeting the needs of staff while balancing the needs of the service.

Outcomes and cost effectiveness of treating type 2 diabetes with a nurse case manager following treatment algorithms versus primary care physicians

Background. Diabetes places a significant burden on the health care system. Reduction in blood glucose levels (HbA1c) reduces the risk of complications; however, little is known about the impact of disease management programs on medical costs for patients with diabetes. In 2001, economic costs associated with diabetes totaled $100 billion, and indirect costs totaled $54 billion. ^ Objective. To compare outcomes of nurse case management by treatment algorithms with conventional primary care for glycemic control and cardiovascular risk factors in type 2 diabetic patients in a low-income Mexican American community-based setting, and to compare the cost effectiveness of the two programs. Patient compliance was also assessed. ^ Research design and methods. An observational group-comparison to evaluate a treatment intervention for type 2 diabetes management was implemented at three out-patient health facilities in San Antonio, Texas. All eligible type 2 diabetic patients attending the clinics during 1994–1996 became part of the study. Data were obtained from the study database, medical records, hospital accounting, and pharmacy cost lists, and entered into a computerized database. Three groups were compared: a Community Clinic Nurse Case Manager (CC-TA) following treatment algorithms, a University Clinic Nurse Case Manager (UC-TA) following treatment algorithms, and Primary Care Physicians (PCP) following conventional care practices at a Family Practice Clinic. The algorithms provided a disease management model specifically for hyperglycemia, dyslipidemia, hypertension, and microalbuminuria that progressively moved the patient toward ideal goals through adjustments in medication, self-monitoring of blood glucose, meal planning, and reinforcement of diet and exercise. Cost effectiveness of hemoglobin AI, final endpoints was compared. ^ Results. There were 358 patients analyzed: 106 patients in CC-TA, 170 patients in UC-TA, and 82 patients in PCP groups. Change in hemoglobin A1c (HbA1c) was the primary outcome measured. HbA1c results were presented at baseline, 6 and 12 months for CC-TA (10.4%, 7.1%, 7.3%), UC-TA (10.5%, 7.1%, 7.2%), and PCP (10.0%, 8.5%, 8.7%). Mean patient compliance was 81%. Levels of cost effectiveness were significantly different between clinics. ^ Conclusion. Nurse case management with treatment algorithms significantly improved glycemic control in patients with type 2 diabetes, and was more cost effective. ^

Climate and grazing control nurse effects in an Ecuadorian dry shrubby community

Positive plant interactions have strong effects on plant diversity at several spatial scales, expanding species distribution under stressful conditions. We evaluated the joint effect of climate and grazing on the nurse effect of Croton wagneri, by monitoring several community attributes at two spatial scales: microhabitat and plant community. Two very close locations that only differed in grazing intensity were surveyed in an Ecuadorian dry scrub ecosystem. At each location, two 30 × 30-m plots were established at four altitudinal levels (1500, 2630, 1959 and 2100 m asl) and 40 microsites were surveyed in each plot. Croton wagneri acted as community hubs, increasing species richness and plant cover at both scales. Beneath nurses mean richness and cover values were 3.4 and 21.9%, and in open areas 2.3 and 4.5%, respectively. Magnitude of nurse effect was dependent on climate and grazing conditions. In ungrazed locations, cover increased and diversity reduced with altitude, while grazed locations showed the opposite trend. In ungrazed plots the interactions shifted from positive to negative with altitude, in grazed locations interactions remained positive. We conclude that the nurse effect is a key mechanism regulating community properties not only at microsite but also at the entire community scale.