Modeling payback from research into the efficacy of left-ventricular assist devices as destination therapy

Objectives: Ongoing developments in design have improved the outlook for left-ventricular assist device (LVAD) implantation as a therapy in end-stage heart failure. Nevertheless, early cost-effectiveness assessments, based on first-generation devices, have not been encouraging. Against this background, we set out (i) to examine the survival benefit that LVADs would need to generate before they could be deemed cost-effective; (ii) to provide insight into the likelihood that this benefit will be achieved; and (iii) from the perspective of a healthcare provider, to assess the value of discovering the actual size of this benefit by means of a Bayesian value of information analysis. Methods: Cost-effectiveness assessments are made from the perspective of the healthcare provider, using current UK norms for the value of a quality-adjusted life-year (QALY). The treatment model is grounded in published analyses of the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial of first-generation LVADs, translated into a UK cost setting. The prospects for patient survival with second-generation devices is assessed using Bayesian prior distributions, elicited from a group of leading clinicians in the field. Results: Using established thresholds, cost-effectiveness probabilities under these priors are found to be low (.2 percent) for devices costing as much as £60,000. Sensitivity of the conclusions to both device cost and QALY valuation is examined. Conclusions: In the event that the price of the device in use would reduce to £40,000, the value of the survival information can readily justify investment in further trials

How do the attitudes and beliefs of healthcare professionals and older people impact on the appropriate use of multi-compartment compliance aids by older people living at home

Compliance with medication regimes is a widely researched topic within the field of healthcare. Older people are considered to be a greater risk of non-compliance due to multiple morbidities. Multi-compartment compliance aids are frequently issued to older people in an attempt to improve their medicines management. This thesis aims to determine whether the attitudes and beliefs of both the older people who use MCAs and the healthcare professionals who request their use, influence the use of such devices by older people living in the community. A preliminary study which investigated the use of MCAs in primary care is described. The findings suggested that over 100,00 people in the UK may be issued with a MCA despite little evidence for their efficacy. The literature review undertaken for this thesis concludes that very few studies have been undertaken in this area and those which have are mainly of poor quality. The results from these studies failed to conclusively support the use of these devices and further rigorous conducted studies are needed. The main study comprises qualitative, in-depth semi-structured interviews with older people, who are using a MCA and healthcare professionals. The interviews were analysed using a grounded theory approach. The study revealed that older people find MCAs easy to use and convenient although a minority of the participants did experience difficulties using the device. Maintaining independence and remaining in control was important for all the older people and this influenced their attitudes towards using their MCA. The healthcare professionals concurred with the observation that MCAs were convenient to use and despite a minority stating that MCAs assisted older people to remember to take their medication, the majority acknowledged that this was not the case. The healthcare professionals agreed that the decision to issue a MCA could be seen as paternalistic however there remained a belief that the issue of a MCA would assist the older person take their medication correctly. The thesis concludes by providing details of a proposed method for undertaking a holistic, patient-centred, multi-disciplinary assessment of older people's medicines management abilities

A Qualitative Study of How Children Experience and Live with Long QT Syndrome

Long QT syndrome (LQTS) is an inherited and potentially fatal disorder affecting approximately 1 in 2,000 people. Children often experience anxiety and a sense of loss of control as they try to manage the medical, social, and psychological stress that accompanies being diagnosed with LQTS. The present study utilized a qualitative research design to examine how children experience and live with long QT syndrome. Semistructured interviews were conducted with eight children between the ages of 7 to 12 who were diagnosed with LQTS. This period in a child’s life is very important for developing social skills and self-esteem as peers and teachers become more important to the child. Themes that emerged involved treatment, relationships, and social connectedness. Children communicated aspects of treatment that were important to them, such as the doctor-patient relationship, stress test, medication, going to the hospital, and lifestyle restrictions. Parental and peer relationships were also explored with regard to how much information should be known by the child, perceptions of worry, confiding in friends or keeping it private, and values of importance in a peer relationship. The children voiced fears about not being accepted and being treated differently and more specific fears, including people knowing about the diagnosis, having to answer questions about the heart monitor, and experiencing feelings of sadness and loneliness. The “Five Pillars of Adaptation for Long QT Syndrome” born from this research are developmental level and self-esteem, peer and social relationships, parental support, social problem-solving, and treatment and resources. They provide the fundamental elements though which we can learn how a child lives with long QT syndrome

Advances in Teaching & Learning Day Abstracts 2004

Proceedings of the Advances in Teaching & Learning Day Regional Conference held at The University of Texas Health Science Center at Houston in 2004

A Conceptual Definition of Quality of Life for People Living with an Implanted, Destination Therapy Left Ventricular Assist Device

BACKGROUND: People with advanced heart failure experience persistently severe symptoms with increasingly impaired capacity and quality of life. Treatment options beyond palliative care are limited to heart transplantation or implantation with a mechanical pump that replaces the weakened heart’s function. The left ventricular assist device (LVAD) serves as a temporary bridge to transplant or bridge to recovery, or a permanent replacement as destination therapy (DT). While DT-LVAD recipients initially accept the device to extend life, there is a gap in understanding how DT-LVAD recipients define a life worth living, and how nursing and the health care team can help reach that goal. PURPOSE: This study’s purpose is to determine the conceptual definition of “quality of life” in people with a DT-LVAD. METHODS: A grounded theory study was conducted using a theoretical sample and open, selected and theoretical coding processes within the constant comparison method. Theoretical saturation was reached with 11 participants (age 32-79 years). RESULTS: Normalizing emerged as the basic social process. Participants reported that a life supported by battery-powered equipment is still a normal, human experience. A process of acceptance and adjustment occurred to Normalize a machine-dependent life. Although extending life was the original LVAD objective, recipient goals and needs evolved over time. Dependence on a machine to extend life did not replace the need for a life worth living. The conceptual definition of quality of life when living with a DT-LVAD emerged as: I am able to live my life and do what I want, with some adjustments. CONCLUSION: This conceptual definition of quality of life from the DT-LVAD recipient perspective enhances the health care team’s understanding and ability to improve DT-LVAD recipient lives. Life with an LVAD is not simply about survival; it is survival of quality that makes a difference and defines success

The Theory of Compromised Eating Behavior

The purpose of this inquiry was to develop substantive theory that describes the social process that influences the eating behavior of hospitalized older adults. Undernutrition or the inadequate intake of dietary nutrients necessary to maintain health, contributes to negative health outcomes such as increased morbidity and mortality in hospitalized older adults. Inadequate dietary intake is a risk factor for undernutrition. Despite the availability of vast resources within the hospital environment, hospitalized older adults have inadequate dietary intake. Undernutrition has been studied from a dietary intake perspective; however, why dietary intake remains inadequate is unknown. Inquiry of eating behavior and the social process that influences eating behavior will provide insight into why dietary intake remains inadequate. The Quality Health Outcomes Model was the conceptual framework that guided this inquiry. A qualitative, grounded theory methodology was used to investigate this phenomenon. Participants included acutely ill, hospitalized older adults and their healthcare providers. Field work included observation, interview, and document review to better understand the actions, interactions and perceptions of participants as to the process that influenced hospitalized older adult eating behavior. Datum was compared, coded, and analyzed using the constant comparative method. The Theory of Compromised Eating Behavior was developed and describes the process of compromise older adults experience related to eating behavior while hospitalized. The Theory has four stages: self-indication, joint-action, negotiation, and action. Hospitalized older adults choose to compromise their health should they eat inadequately or alternatively compromise their acculturated foodways should they eat adequately. Additionally, healthcare providers compromise their beliefs when older adult patients do not eat adequately. Older adults are at risk for negative health outcomes due to inadequate dietary intake while hospitalized. The meaning of hospital food and mealtimes differs from traditional food and mealtimes for the older adult, resulting in compromise. Intervention which enhances the meaning of food and mealtimes for the older adult during hospitalization may improve dietary intake and nutritional outcomes

An Exploratory Study of Patient Falls

Debate continues between the contribution of education level and clinical expertise in the nursing practice environment. Research suggests a link between Baccalaureate of Science in Nursing (BSN) nurses and positive patient outcomes such as lower mortality, decreased falls, and fewer medication errors. Purpose: To examine if there a negative correlation between patient falls and the level of nurse education at an urban hospital located in Midwest Illinois during the years 2010-2014? Methods: A retrospective crosssectional cohort analysis was conducted using data from the National Database of Nursing Quality Indicators (NDNQI) from the years 2010-2014. Sample: Inpatients aged ≥ 18 years who experienced a unintentional sudden descent, with or without injury that resulted in the patient striking the floor or object and occurred on inpatient nursing units. Results: The regression model was constructed with annual patient falls as the dependent variable and formal education and a log transformed variable for percentage of certified nurses as the independent variables. The model overall is a good fit, F (2,22) = 9.014, p = .001, adj. R2 = .40. Conclusion: Annual patient falls will decrease by increasing the number of nurses with baccalaureate degrees and/or certifications from a professional nursing board-governing body

A systematic and evidence-based approach to assessment of NHS organisational readiness to commence haemodynamic remote monitoring through cardiovascular implantable electronic devices (CIEDs) in routine heart failure care. (SEARCH-HF)

Background & Aims It is hypothesised that successful remote monitoring (RM) of patients with heart failure (HF) using cardiovascular implantable electronic devices (CIEDs) is related to the context within which the technology is used and integrated into decision-making. There is currently little guidance on how a UK clinic should perform high quality RM. The aim of this project was to provide an evidence-based approach to RM of HF patients by 1) identifying necessary pre-requisite competence to facilitate successful introduction of RM; 2) mapping a care pathway in an NHS setting for CIED-based RM of patients with HF; and 3) developing an assessment matrix of key requirements for optimal CIED-based RM. Methods A mixed-methods study was undertaken incorporating both quantitative and qualitative data from the process of CIED-based RM. Quantitative data were gained from a systematic review of literature on facilitators of, and barriers to, high quality RM. A process mapping workshop was undertaken at the Royal Brompton Hospital to identify the intricacies of the clinical pathway at an experienced RM centre. These data were supplemented by semi-structured interviews with patients and healthcare professionals to develop important themes on RM of HF patients to give a coherent interpretation of the RM process studied. Results After identifying 64 relevant publications and undertaking a process-mapping exercise on initiation of RM and responding to an alert, interviews with 12 patients and seven healthcare professionals were undertaken. The key themes emerging from these data were incorporated into a model RM pathway and pathway-anchored assessment framework. Conclusions This is the first study to investigate barriers to, and facilitators of, high quality CIED-based RM in a UK HF clinic. The tools generated from this study will allow other NHS centres to assess the key organisational, educational and data processing requirements to ensure high quality RM.Open Acces