Verifying intervention fidelity procedures for a palliative home care intervention with pilot study results

Fidelity (consistency of intervention implementation) is essential to rigorous research. Intervention fidelity maintains study internal validity, intervention reproducibility, and transparency in the research conduct. The purpose of this manuscript is to describe intervention fidelity strategies/procedures developed for a pilot study testing a new palliative care nursing intervention (FamPALcare) for families managing advanced lung disease. The procedures described herein are based on the fidelity best practices recommendations from the NIH Consortium. An evidence-based checklist guided observational ratings of the fidelity procedures used and the intervention content implemented in each intervention session. Descriptive data on how participants understood (received), enacted, or used the intervention information were summarized. The fidelity checklist observational scores found ≥93% of the planned intervention content was implemented, and the fidelity strategies were adhered to consistently during each intervention session. The small variation (7%) in implementation was expected and related to participants' varying experiences, input, and/or questions. The helpfulness scale items include participants' ability to use home care resources, to anticipate and manage end-of-life symptoms, and to use Advance Directive forms. The high ratings (M = 4.4) on the 1-5 (very helpful) Likert Helpfulness Scale verified participants utilized the information from the intervention. Furthermore, there was an improvement in patients' breathlessness scores and completion of Advance Directive forms at 3 months after baseline. It is essential to plan intervention fidelity strategies to use throughout a study and to report fidelity results.

Impact of Sleep Apnea, Daytime Sleepiness, Comorbidities, and Depression on Patients' Heart Failure Health Status

There is a gap in current research on common factors that impact patients with advanced heart failure (HF). The purpose of this secondary data analysis was to explore associations of those factors with three empirically verified measures of HF-related clinical, physical, and mental health status. Baseline data of 198 advanced systolic HF (EF < 40%) patients were analyzed. Patients were 61.6% male, with a mean age of 62.3 (SD = 13.2) years. The multivariable general linear modeling results indicated that patients who had poorer scores on HF-related clinical status were those who had sleep apnea (β = -6.6, p < .05), daytime sleepiness (β = -9.4, p < .01), four or more comorbidities (β = -11.8, p < .001), and depression (β = -18.7, p < .001). Depression was associated with all three measures of HF-related health status. These findings alert nurses to assess for sleep apnea and to use known screening measures for daytime sleepiness, depression, and comorbidities.

Palliative care for rare advanced lung diseases in underserved Appalachia: Study protocol for a randomized controlled trial

AIM

To pilot test a home end-of-life and palliative care intervention for family caregivers and patients with rare advanced lung diseases and to estimate effect-size for the power analysis in a future clinical trial.

DESIGN

This study uses a parallel randomized control trial. Families are randomly assigned to the intervention group or the control group in a 1:1 fashion.

METHODS

The study population includes patients with rare advanced lung diseases and their family caregivers who are involved in patients' home care. The control group receives standard care through their hospital or outpatient clinics. The intervention group receives standard care plus 2-weekly home end-of-life and palliative care coaching by experienced community nurses. Primary outcome is breathlessness measured by shortness of breath scale. Secondary outcomes are: (a) caregivers' anxiety and depression measures; (b) the presence of patient's signed advance directives in the medical record or not; and (c) Helpfulness of intervention measured by self-report Helpfulness scale. The study was funded in October 2018 and received ethical Institutional Review Board approval in February 2019.

DISCUSSION

West Virginia has one of the highest incidence rates of lung disease deaths in the nation. However, there is inadequate home end-of-life and palliative care for this underserved population. This is an initial interventional study of nurse-led coaching home-based palliative care for rare advanced lung diseases in rural Appalachia. Developing research collaboration with clinicians is essential for enrolment. Enrolment was successful due to regular meetings with pulmonologists who screened patients per the study inclusion criteria in their specialty clinic and made direct referrals to the research assistants. Results of this study will be used in the future trial.

IMPACT

The findings will contribute to the evidence-based home nursing care, planning for family/patient preferences and supportive end-of-life palliative care for managing advanced lung diseases at home.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03813667; registered January 23, 2019. https://clinicaltrials.gov/ct2/show/NCT03813667.

Study protocol of coaching end-of-life palliative care for advanced heart failure patients and their family caregivers in rural appalachia: a randomized controlled trial

BACKGROUND

Heart failure (HF) afflicts 6.5 million Americans with devastating consequences to patients and their family caregivers. Families are rarely prepared for worsening HF and are not informed about end-of-life and palliative care (EOLPC) conservative comfort options especially during the end stage. West Virginia (WV) has the highest rate of HF deaths in the U.S. where 14% of the population over 65 years have HF. Thus, there is a need to investigate a new family EOLPC intervention (FamPALcare), where nurses coach family-managed advanced HF care at home.

METHODS

This study uses a randomized controlled trial (RCT) design stratified by gender to determine any differences in the FamPALcare HF patients and their family caregiver outcomes versus standard care group outcomes (N = 72). Aim 1 is to test the FamPALcare nursing care intervention with patients and family members managing home supportive EOLPC for advanced HF. Aim 2 is to assess implementation of the FamPALcare intervention and research procedures for subsequent clinical trials. Intervention group will receive routine standard care, plus 5-weekly FamPALcare intervention delivered by community-based nurses. The intervention sessions involve coaching patients and family caregivers in advanced HF home care and supporting EOLPC discussions based on patients' preferences. Data are collected at baseline, 3, and 6 months. Recruitment is from sites affiliated with a large regional hospital in WV and community centers across the state.

DISCUSSION

The outcomes of this clinical trial will result in new knowledge on coaching techniques for EOLPC and approaches to palliative and end-of-life rural home care. The HF population in WV will benefit from a reduction in suffering from the most common advanced HF symptoms, selecting their preferred EOLPC care options, determining their advance directives, and increasing skills and resources for advanced HF home care. The study will provide a long-term collaboration with rural community leaders, and collection of data on the implementation and research procedures for a subsequent large multi-site clinical trial of the FamPALcare intervention. Multidisciplinary students have opportunity to engage in the research process.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04153890, Registered on 4 November 2019.

Cultural and Environmental Enablers and Barriers to Participation and Retention in Clinical Trials for Cancer Research

BACKGROUND

West Virginia (WV) residents have often rejected participation in community-based cancer research studies. Nationally, 49% of eligible patients participate in clinical trials but less than 10% of patients in WV participate.

OBJECTIVE

To understand issues related to recruitment and retention of patients for cancer research in Appalachian WV.

METHODS

Data were obtained from 3 focus groups including: (1) 9 patients who participated in clinical cancer trials, (2) 8 cancer research nurse coordinators, and (3) 10 physicians involved in cancer research. Groups were audio-taped and transcriptions were analyzed using MAXQDA and results were verified by two co-investigators.

RESULTS

Most enablers and barriers identified were cultural as indicated by 72% of patients; 68% nurse coordinators; and 55% physicians. Patients identified personal emotional strength as an enabler, and negative health behaviors and fears as barriers. Enablers that nurses identified were positive patient characteristics and barriers included fear of trials, randomization, and death. Physicians identified enablers as a patient's understanding of the clinical trial and motivation to help others and the inverse of these two enablers as barriers.

CONCLUSION

A foundation for improving recruitment and retention of participants in cancer research in Appalachia was identified. The next step will involve cancer community organizations and patients in developing a plan to enhance enablers and overcome barriers to patient recruitment in cancer studies.

IMPLICATIONS FOR PRACTICE

Cultural influences must be considered when recruiting for clinical trials. Community organizations educating the public about cancer research may be the key to enhancing patient enrollment.

The Use of Video Conferencing for Persons with Chronic Conditions: A Systematic Review

The purpose of this paper is to present a systematic review of studies that used Video Conferencing (VC) intervention for common chronic conditions. Chronic conditions account for the majority of poor health, disability, and death, and for a major portion of health-care expenditures in the United States. Innovative methods and interventions are needed to enhance care and management, improve access to care, improve patient outcomes, narrow health disparities and reduce health-care costs. Video Conferencing could be particularly relevant in improving health, care management, access and cost in the care of chronic illnesses. A comprehensive literature search process guided by the PRISMA statement led to the inclusion of 27 articles measuring video conferencing, at least one chronic illness, and patient outcomes for adults living in a community setting. While VC has been found to be feasible and effective, a low number of randomized controlled trials limit evidence. In addition, studies in this review were not designed to address the question of whether access to care in rural areas is improved through VC. Hence, more research is needed.

A Systematic Review of Loneliness and Common Chronic Physical Conditions in Adults

Loneliness is a prevalent and global problem for adult populations and has been linked to multiple chronic conditions in quantitative studies. This paper presents a systematic review of quantitative studies that examined the links between loneliness and common chronic conditions including: heart disease, hypertension, stroke, lung disease, and metabolic disorders. A comprehensive literature search process guided by the PRISMA statement led to the inclusion of 33 articles that measure loneliness in chronic illness populations. Loneliness is a significant biopsychosocial stressor that is prevalent in adults with heart disease, hypertension, stroke, and lung disease. The relationships among loneliness, obesity, and metabolic disorders are understudied but current research indicates that loneliness is associated with obesity and with psychological stress in obese persons. Limited interventions have demonstrated long-term effectiveness for reducing loneliness in adults with these same chronic conditions. Future longitudinal randomized trials that enhance knowledge of how diminishing loneliness can lead to improved health outcomes in persons with common chronic conditions would continue to build evidence to support the translation of findings to recommendations for clinical care.

Electronic patient registries improve diabetes care and clinical outcomes in rural community health centers

CONTEXT

Diabetes care is challenging in rural areas. Research has shown that the utilization of electronic patient registries improves care; however, improvements generally have been described in combination with other ongoing interventions. The level of basic registry utilization sufficient for positive change is unknown.

PURPOSE

The goal of the current study was to examine differential effects of basic registry utilization on diabetes care processes and clinical outcomes according to level of registry use in a rural setting.

METHODS

Patients with diabetes (N = 661) from 6 Federally Qualified Health Centers in rural West Virginia were entered into an electronic patient registry. Data from pre- and post-registry were compared among 3 treatment and control groups that had different levels of registry utilization: low, medium, or high (for example, variations in the use of registry-generated progress notes examined at the point-of-care and in the accuracy of registry-generated summary reports to track patients' care). Data included care processes (annual exams, screens to promote wellness, education, and self-management goal-setting) and clinical outcomes (HbA1c, LDL, HDL, cholesterol, triglycerides, blood pressure).

FINDINGS

The registry assisted in significantly improving 12 of 13 care processes and 3 of 6 clinical outcomes (HbA1c, LDL, cholesterol) for patients exposed to at least medium levels of registry utilization, but not for the controls. For example, the percent of patients who had received an annual eye exam at follow-up was 11%, 34%, and 38% for the low, medium, and high utilization groups, respectively; only the latter groups improved.

CONCLUSIONS

As an initial step to achieving control of diabetes, basic registry utilization may be sufficient to drive improvements in provider-patient care processes and in patient outcomes in rural clinics with few resources.

Transparent film dressing vs pressure dressing after percutaneous transluminal coronary angiography

BACKGROUND

Pressure dressings have been used as the standard following sheath removal after percutaneous transluminal angioplasty in many institutions. Patients complain about discomfort while the dressing is in place, pain when the dressing is removed after discharge, and skin complications afterward. Many patients have experienced skin irritation where tape has been applied. Nurses have also described difficulty assessing the sheath insertion site in the groin when a pressure dressing is in place.

OBJECTIVES

To compare 3 different dressings with respect to effect on bleeding, discomfort voiced by patients, and ease of groin assessment in patients after percutaneous transluminal coronary angiography.

METHODS

A total of 100 patients were randomly assigned to 1 of 3 groups: pressure dressing, transparent film dressing, or adhesive bandage. Outcome variables were bleeding, patient discomfort, and nurse-reported ease of observation of the groin site.

RESULTS

No bleeding occurred in patients with transparent film dressings or adhesive bandages. Patients rated these dressings significantly higher than they rated the pressure dressing. Because two-thirds of the sample had previously undergone percutaneous transluminal coronary angiography, they could compare their experience with the new dressing with previous experiences with pressure dressings. Nurses rated the ease of assessing the groin significantly higher for the transparent film and adhesive bandage dressings than for pressure dressings.

CONCLUSIONS

As a result of this study, a practice change was made hospital-wide: rather than a standard opaque pressure dressing, a transparent film dressing is used for all patients after removal of a femoral sheath.