UWOMJ Volume 77, No. 2, 2008

Schulich School of Medicine & Dentistryhttps://ir.lib.uwo.ca/uwomj/1081/thumbnail.jp

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

Understanding research impact

Across the globe, numerous kid-ney transplant candidates and donors are linking up in often complicated ways to facilitate more transplants through exchange pro-grams, or swaps. The largest swap so far, which was orchestrated by the National Kidney Registry (NKR) and involved 60 lives and 30 kid-neys, was described recently in The New York Time

Erectile dysfunction: is it really that difficult to talk about? An interpretative phenomenological exploration

Background This thesis explores the disclosure of erectile dysfunction to healthcare professionals by asking men with erectile dysfunction, their partners and healthcare professionals to recall their experiences of such conversations. Erectile dysfunction can be a difficult subject to broach or disclose, and as a result, it is considered that the condition is under reported and therefore under diagnosed. In the light of erectile dysfunction being considered a possible marker of cardiovascular risk this thesis seeks to highlight the issues around disclosing the condition with a view to improving disclosure rates and therefore informing subsequent cardiovascular risk assessment. Literature There is a body of literature which demonstrates that erectile dysfunction is a common issue which is correlated with many physical and mental health conditions. Specifically within populations of men with known cardiovascular disease prevalence rates of erectile dysfunction can be as high as 70%. Literature which explores the experience of having erectile dysfunction and disclosing it to a healthcare professional demonstrates that this is a conversation which is complex and is often avoided by both men with erectile dysfunction and healthcare professionals alike. In light of literature which demonstrates that ED and cardiovascular disease are linked, and that which demonstrates that disclosing ED is difficult there is a gap in the literature which specifically explores the disclosing of ED when it is a known marker of cardiovascular disease risk. Research Process Following a cardiac event, men who identified themselves as having erectile dysfunction, their partners and healthcare professionals to whom a disclosure may be given, were approached and asked to describe their experiences. The study was designed using a phenomenological perspective so as to allow the thoughts and experiences of the participants’ and researcher to be used to provide an illustration of the disclosure of erectile dysfunction, particularly when considered as a precursor and marker of cardiovascular risk. The initial analysis used a thematic approach but this was found to be problematic in relation to the depth of the data that was captured and therefore a second analysis was undertaken, the results of which are presented as the findings of this study. The second analysis of data used a staged approach favoured in interpretative phenomenological analysis (Smith et al. 2009), which facilitated an analysis of the interview transcripts descriptively, interpretatively and linguistically. This latter analysis provided a unique perspective in relation to the topic which is acknowledged as difficult to discuss, and resulted in the linguistic tools which were used by the participants being identified as evidence for the embarrassment; this was identified as one of the themes which emerged from the descriptive analysis. Analysis and Findings Analysis of the interview data with men and their partners identified the themes of: the impact that erectile dysfunction has had on their lives, disclosure (or not) of erectile dysfunction and erectile dysfunction in contemporary society. The interviews with healthcare professionals generated themes which resonated with those from the men as well as focusing on professional issues of ownership in relation to ED disclosure, anxieties in relation to such discussions and experience of receiving disclosures. All of the themes have been extensively written about in relation to other health related issues but they have not been explored explicitly in relation to the disclosure of erectile dysfunction and therefore a unique position of the findings in relation to the existing literature is evidenced within Chapter Nine. The discussion located the findings specifically within existing literature related to embarrassment, stigma and medicalisation. The discussion of the analysed data within the context of the existing literature is then extrapolated to the current clinical environment and changes to clinical practice are suggested by linking the findings to practice. Suggested adaptations to clinical practice focus on improving the confidence of all involved in the disclosure of erectile dysfunction in having such conversations, by increasing the opportunities for them to occur and improving the confidence of all involved in managing such situations

From persuasion to negotiation in health promoting technology

Over recent years, designing technologies to promote health-related behavioural change has been an area of growing interest in HCI. Given the prevalence of self-monitoring and social facilitation in emerging designs, the assumption appears to be that increasing an individual’s awareness of his or her behaviour and the behaviour of others will promote behavioural change. This thesis argues that while this is true to some extent, this represents a somewhat naive view of how individuals come to make decisions regarding their health-related behaviours. Three qualitative studies within distinct health domains illustrate the complex nature of health-related behavioural change. Weight Management was an inherently social activity, albeit subject to selective disclosure and incremental participation. Individuals were generally motivated by appearance rather than health, implementing change based on exposure and orientation to alternative strategies. In Families at Risk, caregivers were highly motivated by a desire to safeguard the health of their children but were restricted by a lack of financial and strategic resources. Lack of trust and a transient community contributed to social isolation, thus inhibiting opportunities for collaboration. In Cardiac Rehabilitation, behavioural change efforts were prompted by an acute health crisis and guided by health professionals. However, behavioural change efforts were sometimes restricted by a desire to return to normal, tensions arising when what was considered normal was composed of risk behaviours. Family involvement varied greatly, ranging from disregard to facilitating change, and a desire for independence and ownership of the rehabilitation sometimes restricted the active involvement of peers. Informed by the findings of these studies this thesis highlights the strengths and limitations of current technological approaches to promoting behavioural change, provides implications for design, and supported by the sociomedical literature, identifies alternative avenues of technological innovation. The thesis reflects on technology’s role in health-related behavioural change and considers associated ethical implications. Overall, the main contribution of this thesis is a reframing of the problem of promoting health-related behavioural change as more than a matter of behavioural awareness and personal motivation. While it is understandable that technologists would look to the clinical domain to inform initial investigations in this area, this thesis argues that technologists should be cautious about blindly adopting its prescriptive paradigm. As an alternative to persuasion, this thesis offers negotiation as a potential model for future innovations in this area

The role of the nurse in a cardiovascular risk management programme

Increasingly, the emphasis in health care is on wellness and prevention, and efforts are focused on keeping patients out of costly healthcare centres. High-risk cardiovascular patients are identified and incorporated into risk reduction and management programmes. The aim of this study was to explore the role of the nurse in such a programme and make recommendations about the expansion of this role. By conducting a literature study, the ideal role of the nurse in a risk reduction and management programme was analysed, thereby reaching the study’s first objective. The second objective was met by conducting qualitative research on the current role of the nurse in cardiovascular health risk management in South Africa. The researcher then compared the empirical data to the ideal role as it emerged from the literature. The findings were presented as areas for expansion of the role of the nurse in a cardiovascular risk management programme.Dissertation (MCur (Clinical))--University of Pretoria, 2008.Nursing Scienceunrestricte

Smoking cessation : a report of the Surgeon General

Tobacco smoking is the leading cause of preventable disease, disability, and death in the United States (U.S. Department of Health and Human Services [USDHHS] 2014). Smoking harms nearly every organ in the body and costs the United States billions of dollars in direct medical costs each year (USDHHS 2014). Although considerable progress has been made in reducing cigarette smoking since the first U.S. Surgeon General\u2019s report was released in 1964 (USDHHS 2014), in 2018, 13.7% of U.S. adults (34.2 million people) were still current cigarette smokers (Creamer et al. 2019). One of the main reasons smokers keep smoking is nicotine (USDHHS 1988). Nicotine, a drug found naturally in the tobacco plant, is highly addictive, as with such drugs as cocaine and heroin; acti- vates the brain\u2019s reward circuits; and reinforces repeated nicotine exposure (USDHHS 1988, 2010, 2014; National Institute on Drug Abuse [NIDA] 2018).The majority of cigarette smokers (68%) want to quit smoking completely (Babb et al. 2017). The 1990 Surgeon General\u2019s report, The Health Benefits of Smoking Cessation, was the last Surgeon General\u2019s report to focus on cur- rent research on smoking cessation and to predominantly review the health benefits of quitting smoking (USDHHS 1990). Because of limited data at that time, the 1990 report did not review the determinants, processes, or outcomes of attempts at smoking cessation. Pharmacotherapy for smoking cessation was not introduced until the 1980s. Additionally, behavioral and other counseling approaches were slow to develop and not widely available at the time of the 1990 report because few were covered under health insurance, and programs such as group counseling ses- sions were hard for smokers to access, even by those who were motivated to quit (Fiore et al. 1990).The purpose of this report is to update and expand the 1990 Surgeon General\u2019s report based on new scien- tific evidence about smoking cessation. Since 1990, the scientific literature has expanded greatly on the deter- minants and processes of smoking cessation, informing the development of interventions that promote cessa- tion and help smokers quit (Fiore et al. 2008; Schlam and Baker 2013). This knowledge and other major develop- ments have transformed the landscape of smoking ces- sation in the United States. This report summarizes this enhanced knowledge and specifically reviews patterns and trends of smoking cessation; biologic mechanisms; various health benefits; overall morbidity, mortality, and economic benefits; interventions; and strategies that pro- mote smoking cessation.Suggested citation: U.S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020.2020-cessation-sgr-full-report.pdf2020713

REGULATION AND GOVERNANCE OF ACCESS TO UNPROVEN MEDICAL INTERVENTIONS IN CANADA; A CASE STUDY ANALYSIS

This research used case studies to identify and explore lessons from past regulation and governance of access to unproven medical interventions provided by physicians in Canada, with the goal of informing and strengthening future strategies. The examples selected were chelation therapy for applications other than treating heavy metal toxicity, liberation therapy for multiple sclerosis, and unproven stem cell interventions. For each case study, a systematic data collection strategy was used that included academic literature from relevant disciplines, legislation, government documents, records of legislative and parliamentary debates, jurisprudence, professional regulatory decisions and guidance, news media, and patient advocacy activity. The role of law helped set boundaries for the data collection and analysis, which focused primarily on regulatory and governance tools and strategies that use or are empowered or constrained by law. A second objective of this research was to develop theoretical insights regarding the use of regulation and governance as frameworks for understanding complex policy issues. Drawing on the fields of regulation and governance, a conceptual framework was developed to guide the case study analyses. This conceptual framework was revised iteratively throughout the work. The key features of regulation and governance that were identified and explored through each case study were actors, instruments, purposes, legitimacy, and responsiveness and adaptability. Following the individual case study analyses, which developed a deep understanding of each case, a cross-case analysis was conducted to identify features of the Canadian context that future regulation and governance of access to unproven medical interventions will likely need to account for to be successful. These features include our decentralized healthcare system, the importance of medical professional regulation, and our independent judicial processes. There are also several areas of focus that the findings from this research suggest may strengthen future regulation and governance of access to unproven medical interventions provided by physicians in Canada. These priorities include maximizing the potential of collaborative distributed governance, emphasizing protection of the public interest in renewal of medical professional regulation, prioritizing fairness and transparency in stakeholder engagement practices, promoting the need for clarity and nuance in discussions about evidence, and supporting strong science and health communication practices. The conceptual framework developed in this work provided a systematic approach for identifying and analyzing the field of influence over the complex issues at the heart of this research and it may prove useful for future study in other fields. Bridging the fields of regulation and governance in this way also added richness and nuance to key concepts in each domain. In so doing, this research responded to calls for work that uses regulation and governance theory to inform and strengthen practice, and vice versa