Faculty Bibliography

REVIEW QUESTION/OBJECTIVE/UNASSIGNED:The objective of this systematic review is to synthesize the best available evidence on the effects of motivational interviewing (MI) interventions (including adaptions of motivational interviewing [AMIs]) on the improvement of glycemic control in adults with type 2 diabetes. BACKGROUND:Worldwide, 346 million people have diabetes. With the growing prevalence of diabetes, controlling modifiable risk factors is essential to preventing complications and disease progression. The prevalence of type 2 diabetes is estimated to be double the present rate and by the year 2034 nearly 44 million Americans will have this preventable disease. In the United States (US), nearly 13 percent of adults aged 20 years and older have diabetes; this includes 25.8 million people, adults and children . Type 2 diabetes is more common in ethnic groups inclusive of African Americans, Latinos, Native Americans, and Asian Americans, Native Hawaiians and other Pacific Islanders. Diabetes is especially common in the elderly, 10.9 million or 26.9% of those aged 65 years and older have the disease. The US Centers for Disease Control and Prevention (CDC) estimates that 26% of US adults have impaired fasting glucose (IFG) of 100-125mg/dl and that 34% of adults meet the criteria for metabolic syndrome. An additional 35 % of adults have pre-diabetes, a condition marked by elevated blood sugar that is not yet in the diabetic range.Type 2 diabetes occurs when people have insulin resistance and insulin cannot be appropriately utilized for blood sugar regulation. Type 2 diabetes is characterised by impaired glucose tolerance. It can be defined by the criteria derived from the World Health Organization [WHO] that uses a single fasting glucose value of ≥ 126mg/dl or a single two hour glucose value of ≥ 200mg/dl. A laboratory blood test examining levels of glycosylated haemoglobin (HgbA1c) provides an estimated average blood glucose level over the past two-three months. An HbA1C level of 6.5% or higher can indicate diabetes.Serious complications and premature death can ensue if type 2 diabetes is not treated. Collaboratively, the health care team and people with type 2 diabetes aim to manage this disease process, and lessen the risk of complications to the heart, blood vessels, nerves, eyes and kidneys. Comprehensive support, knowledge, multidisciplinary therapy and treatment modalities will enhance health outcomes and slow disease progression.The Healthy People 2020 initiative outlines several objectives to achieve these changes and cover a comprehensive assortment of disease specific management accountabilities including regular medical care and self-management education/training. Many behaviour change techniques and strategies are known to be successful, yet are seldom implemented in today's health care arena. Dieticians, diabetes educators, and nurse practitioners are in an excellent position to serve as change agents to assist patients with diabetes in making necessary lifestyle changes.Motivational interviewing (MI) is a well-known, scientifically tested method of counseling clients first described by Miller and further developed by Miller and Rollnick. Motivational interviewing is a useful intervention strategy in the treatment of lifestyle problems and diseases such as diabetes . MI is a client-oriented, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The four guiding principles of MI are: express empathy, develop discrepancies, roll with resistance, and support self-efficacy. Adaptation of motivational interviewing (AMI) utilises the basic elements of motivational interviewing and also includes a feedback component. In clinical research, most empirical studies have dealt with the efficacy of AMIs and no studies have addressed the efficacy of MI in its relatively pure form.In clinical practice, health care providers utilise AMIs solely or in combination with other approaches such as the transtheoretical model (TTM) to promote behavioural change. These techniques are often used in brief sessions to maximise time, cost and efficiency.Motivational interviewing has been shown to be effective in counseling patients towards behaviour change in smoking cessation , increasing exercise, and reducing alcohol consumption. While combined effect estimates including body mass index (BMI) show a significant effect for MI, combined effect estimates for cigarettes per day and glycosylated haemoglobin (HA1c) were not significant . Isolated effects of MI on BMI and/or HbA1c have not been identified. Strong clinical evidence suggests that patients with diabetes should achieve certain clinical goals such as lowering HbA1c to reduce morbidity and mortality. Motivational interviewing is a technique that is effective in behaviour change and could potentially be effective with achieving these goals. MI may lead to improved quality of life, health status and clinical outcomes for persons with type 2 diabetes through empowerment and supporting informed decision-making, self-care behaviors, and problem-solving, with active participation and collaboration with the interdisciplinary health care team.A search of the MEDLINE, DARE, CINHAHL, PROSPERO, Joanna Briggs and Cochrane Libraries of Systematic Reviews failed to locate a review conducted on this topic.

BACKGROUND:Readmission rates for patients with heart failure are a major concern for hospitals worldwide. The importance of patient education and a structured care plan to ease the transition from hospital to home has been the focus of many intervention strategies to reduce readmission rates. The use of transitioning of care plans is believed to improve medication reconciliation, communication, patient education, and follow-up. To date, the evidence has not been systematically evaluated to support the effectiveness of a nurse coordinated transitioning of care for patients with heart failure in reducing readmission rates. OBJECTIVE:The objective of the systematic review was to identify the best available evidence on the effectiveness of nurse coordinated transitioning of care between hospital and home on hospital readmission rates for all causes in adult patients hospitalised with heart failure. SEARCH STRATEGY/METHODS:The search strategy aimed to find both published and unpublished studies in the English language from January 1975 through July 2010. A search of MEDLINE, CINAHL, PsycINFO, Healthsource Nursing/academic edition, EMBASE, the Cochrane Library, and the Joanna Briggs Institute Library of Systematic Reviews was conducted followed by a reference search of relevant studies. The initial key words searched were: heart failure, readmission, and transitional care. INCLUSION CRITERIA/METHODS:Randomised controlled trials that evaluated the effect of nurse coordinated transitioning of care from hospital to home in adult patients with heart failure on readmission rates were selected. The outcome was defined as hospital readmissions for all causes following an initial admission for heart failure. DATA COLLECTION AND ANALYSIS/METHODS:Studies selected for retrieval were critically evaluated by two independent reviewers for methodological validity using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data were extracted and analysed using the JBI-MAStARI program. RESULTS:A total of 16 randomised controlled studies were included. Ten of the 16 studies included in the review show that a nurse led transitioning of care intervention can reduce the rate of readmission for patients with heart failure. Interventions utilising home visits, or home visits coupled with telephone follow-up, show a more favourable reduction in readmission rates. CONCLUSIONS:Reduced readmissions occur when transitioning of care interventions are carried out by a heart failure trained nurse who conducts at least one home visit and follows the patient at least weekly for a minimum of 30 days post discharge with either additional home visits or telephone contact. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:This review supports the development of a nurse coordinated transitioning of care plan which will require improvements in communication, in addition to changes in health policy and payment systems that align incentives and performance measures in caring for patients with heart failure. IMPLICATIONS FOR RESEARCH/CONCLUSIONS:Future research should evaluate the effect of the intensity and duration of the transitioning of care intervention on readmission rates in a large randomised control trial on an adult population with heart failure to determine the ideal frequency and duration of the post discharge interventions.