Nurse case management to improve risk reduction outcomes in a stroke prevention clinic

McMaster University, Hamilton General Site, Hamilton Health Sciences, ON.
Canadian journal of neuroscience nursing 01/2010; 32(4):7-13.
Source: PubMed


Stroke prevention clinic health care professionals are mandated to provide early access to neurological consultation and treatment, diagnostic testing, and behavioural risk factor management for clients with transient ischemic attack or mild non-disabling stroke. Clinic nurses collaborate with clients and interprofessional teams to support risk factor reduction to prevent recurrent stroke events. Although hypertension is the most important modifiable risk factor for stroke, broader evidence indicates that adherence to prescribed medications may be less than 50%. One clinic identified a need to improve risk factor outcomes through identifying clients with uncontrolled hypertension, cognitive, self-eficacy and/or adherence characteristics predictive of non-achievement of blood pressure targets. To address this need, an expanded nurse case management care delivery model was pilot tested for feasibility in a participant sample of 20 clients. Motivational interviewing and self-management approaches were combined with interventions designed to improve adherence:facilitation of the simplification of medication routines, providing memory cues and home self-monitoring equipment, counselling, and six-month nursing follow-up. Results demonstrated that an expanded nurse case management model of care delivery is feasible with only a modest impact on clinic resources. At six months, there were significant reductions in blood pressure and increases in medication self-efficacy and adherence for selected clients identified with high risk for stroke and non-achievement of treatment outcomes.

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Available from: Linda Gould, Apr 30, 2014
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    • "Although educational interventions were not promising in primary prevention,13 they were incorporated into all secondary prevention trials as information and advice on stroke and preventive drug treatments. Yet simplification of the overall drug regimen was not used despite being the most promising strategy to improve adherence to antihypertensive medications in primary prevention trials,11 with a study suggesting feasibility in patients with stroke.49 Future interventions may use the BCT taxonomy14 to aid precise specification of the behavior change techniques used and the criteria defined by the CONSORT statement and Davidson et al50 to describe other important intervention components (eg, mode of delivery, fidelity). "
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    ABSTRACT: The purpose of this study was to determine whether interventions including components to improve adherence to antihypertensive medications in patients after stroke/transient ischemic attack (TIA) improve adherence and blood pressure control. We searched MEDLINE, EMBASE, CINAHL, BNI, PsycINFO, and article reference lists to October 2012. Search terms included stroke/TIA, adherence/prevention, hypertension, and randomized controlled trial (RCT). Inclusion criteria were participants with stroke/TIA; interventions including a component to improve adherence to antihypertensive medications; and outcomes including blood pressure, antihypertensive adherence, or both. Two reviewers independently assessed studies to determine eligibility, validity, and quality. Seven RCTs were eligible (n=1591). Methodological quality varied. All trials tested multifactorial interventions. None targeted medication adherence alone. Six trials measured blood pressure and 3 adherence. Meta-analysis of 6 trials showed that multifactorial programs were associated with improved blood pressure control. The difference between intervention versus control in mean improvement in systolic blood pressure was -5.3 mm Hg (95% CI, -10.2 to -0.4 mm Hg, P=0.035; I(2)=67% [21% to 86%]) and in diastolic blood pressure was -2.5 mm Hg (-5.0 to -0.1 mm Hg, P=0.046; I(2)=47% [0% to 79%]). There was no effect on medication adherence where measured. Multifactorial interventions including a component to improve medication adherence can lower blood pressure after stroke/TIA. However, it is not possible to say whether or not this is achieved through better medication adherence. Trials are needed of well-characterized interventions to improve medication adherence and clinical outcomes with measurement along the hypothesized causal pathway.
    Full-text · Article · Jul 2013 · Journal of the American Heart Association
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    • "Several studies have examined the effect of medical case managers in helping vulnerable people to find and remain in care (12–16). Having a medical case manager is associated with a decrease in the number of unmet needs for supportive services, improvement in clinical outcomes (9,10,12–17), and an increase in adherence to medications (16,17). We identified 3 studies on DCMs, 1 focused on a Medicaid population (18) and 2 focused on PLWHA (19,20). "
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    ABSTRACT: The American Dental Association has identified several barriers to adequate dental care for vulnerable populations, including appropriate case management. The objective of this study was to examine the perceptions, attitudes, and beliefs of dental patients living with HIV/AIDS on the role and value of the dental case manager (DCM) and the effect of DCM services on their oral or overall health. We used a qualitative descriptive study design and focus groups. Twenty-five people who had received DCM services on Cape Cod, Massachusetts, attended 1 of 5 focus groups in 2009 and 2010. Digital recordings of the groups were transcribed verbatim. Textual data were categorized using directed qualitative content analysis techniques. We identified major themes and representative quotes. The following themes emerged from discussions on the DCM's role: being available, knowledgeable about clients and insurance, and empathetic; increasing access; and providing comfort. Most participants credited their oral and overall health improvements to the DCM. All participants believed that the DCM was a valuable addition to the clinic and noted that other at-risk populations, including the elderly and developmentally disabled, likely would benefit from working with a DCM. The addition of a DCM facilitated access to dental care among this sample of people living with HIV/AIDS, providing them with an advocate and resulting in self-reported improvements to oral and overall health.
    Full-text · Article · Oct 2012 · Preventing chronic disease
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    ABSTRACT: Cognitive impairment challenges the ability to adhere to the complex medication regimens needed to treat multiple medical problems in older adults. Our aim was to conduct a systematic evidence-based review to identify barriers to medication adherence in cognitively impaired older adults and interventions aimed at improving medication adherence. A search of MEDLINE, EMBASE, PsycINFO, GoogleDocs, and CINAHL for articles published between 1966 and February 29, 2012 was performed. Studies included older adults with a diagnosis of cognitive impairment of any degree (mild cognitive impairment or mild, moderate, or severe dementia). To identify barriers to adherence, we reviewed observational studies. To identify relevant interventions, we reviewed clinical trials targeting medication adherence in cognitively impaired older adults. We excluded studies lacking a measure of medication adherence or lacking an assessment of cognitive function, case reports or series, reviews, and those focusing on psychiatric disorders or infectious diseases. Population demographics, baseline cognitive function, medication adherence methods, barriers to adherence, and prospective intervention methodologies were extracted. The initial search identified 594 articles. Ten studies met inclusion criteria for barriers to adherence and three met inclusion criteria for interventional studies. Unique barriers to adherence included understanding new directions, living alone, scheduling medication administration into the daily routine, using potentially inappropriate medications, and uncooperative patients. Two studies evaluated reminder systems and showed no benefit in a small group of participants. One study improved adherence through telephone and televideo reminders at each dosing interval. The results of the review are limited by reviewing only published articles, missing barriers or interventions due to lack of subgroup analysis, study selection and extraction completed by 1 reviewer, and articles with at least an abstract published in English. The few studies identified limit the assessment of barriers to medication adherence in the cognitively impaired population. Successful interventions suggest that frequent human communication as reminder systems are more likely to improve adherence than nonhuman reminders.
    No preview · Article · Jun 2012
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