Sue Kirby

Introduction: Nurse-led diabetes management has been shown to be effective in urban and regional general practice. We sought to test the feasibility of providing a nurse-led annual cycle of diabetes care in a remote location and to explore the factors that patients indicated were important in diabetes self-management. Methods: We conducted a pilot study in 3 locations: 1 town and 2 small townships in remote Australia. A chronic disease nurse (CDN) visited each patient over the course of a year. We examined patient clinical outcomes and interview data. We estimated the cost per hour of the CDN's time, including travel time, per 1% drop in glycated hemoglobin (HbA 1C). Results: A total of 21 patients participated in the pilot study. Clinical findings showed significant reductions in HbA 1C levels after the nurse-led intervention. Patients reported that they trusted the nurse and thought her advice was pitched at their level. Patients were motivated through a process that included emotional response, change identity and acceptance. The estimated cost in CDN hours per 1% drop in HbA 1C level was A$242.95 (Can$237.60). Conclusion: Nurse-led diabetes care motivated patients to manage their diabetes and resulted in a significant improvement in diabetes management in this remote setting. Introduction : En milieu urbain et en région, la prise en charge du diabète par le personnel infirmier s'est révélée efficace en médecine générale. Nous avons voulu vérifier s'il est envisageable de fournir un cycle annuel de soins infirmiers pour le diabète dans un secteur éloigné et étudier les facteurs que les patients jugent déter-minants pour assurer eux-mêmes la gestion de leur diabète. Méthodes : Nous avons réalisé une étude pilote à 3 endroits : 1 municipalité et 2 petits villages d'une région éloignée de la campagne australienne. Une infirmière spécialisée en maladies chroniques (ISMC) a rendu visite à chaque patient sur une période d'un an. Nous avons examiné les résultats cliniques des patients et les données des entrevues réalisées avec eux. Nous avons estimé le coût horaire du temps des ISMC, incluant leurs déplacements, par tranche de 1 % de réduction de l'hémoglobine glyquée (HbA 1C). Résultats : En tout, 21 patients ont participé à l'étude pilote. Les observations cliniques ont révélé des réductions significatives des taux d'HbA 1C après l'intervention en soins infirmiers. Les patients ont dit faire confiance à l'infirmière et ont trouvé ses conseils bien adaptés à leur situation. Les patients ont été motivés par le biais d'une intervention axée sur les dimensions affectives et identitaires et sur l'acceptation. Le coût horaire des ISMC par tranche de 1 % de réduction du taux d'HbA 1C a été estimé à 242,95 $A (237,60 $CA). Conclusion : Les interventions en soins infirmiers ont motivé les patients à gérer leur diabète et ont entraîné une amélioration significative de sa prise en charge dans cette région éloignée.

Chronic obstructive pulmonary disease (COPD) is a common cause of hospital readmissions worldwide. Outcomes for COPD patients improve if care is more integrated. COPD patients and their health care providers at a district hospital and community health service were interviewed about their perceptions of integration of care. Patients were confused about provider roles, had little understanding of their disease, had difficulty accessing services and did not have COPD action plans. Health care providers espoused integration of COPD care. Care was reasonably well integrated in the hospital. Integration of care was compromised in the community because COPD patients went to the emergency department when symptoms became unmanageable, while only attending their GPs for routine booked appointments. Integration could be improved if health care providers spent more time with patients, promoting understanding of the disease, supporting self-management and liaising with other providers. Patients would benefit from an action plan and additional support. Potentially preventable COPD admissions will continue without action to improve integration of community services and patients' understanding of their condition.

Background: Primary health care (PHC) clinicians have an important role to play in addressing lifestyle risk factors for chronic diseases. However they intervene only rarely, despite the opportunities that arise within their routine clinical practice. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about this for PHC clinicians working outside general practice. The aim of this study was to explore the beliefs and attitudes of PHC clinicians about incorporating lifestyle risk factor management into their routine care and to examine whether these varied according to their self reported level of risk factor management.

Many frequent readmissions due to acute exacerbations of chronic disease could be prevented if patients self-managed. This study explored factors involved in patient activation for chronic disease self-management by qualitative analysis of interview data from hospital and community-based clinicians and patients. All clinicians reported that many frequently readmitted patients did not readily take up referral to chronic disease self-management services. This reluctance was compounded by system or access barriers. Clinicians who had a defined role in chronic disease management and patient-centred and behaviour change skills reported that although some patients were more resistant than others, patients could be persuaded to adopt self-management behaviours. Hospital clinicians and GPs were more inclined to attribute blame to clinical, social and personal patient factors, such as difficulty with support at home, social circumstances and reluctance to take responsibility. Investment in extending the skills and role of hospital clinicians and GPs to take a more supportive role in patient uptake of referrals to chronic disease self-management services would reduce hospital readmissions. Improvements in access to chronic disease self-management and GP services are also needed to address failure to take up chronic disease self-management.

Understanding the factors that activate people to self-manage chronic disease is important in improving uptake levels. If the many frequent hospital users who present with acute exacerbations of chronic disease were to self-manage at home, some hospital admissions would be avoided. Patient interview and demographic, psychological, clinical and service utilisation data were compared for two groups of patients with chronic disease: those attending self-management services and those who managed by using hospital services. Data were analysed to see whether there were differences that might explain the two different approaches to managing their conditions. The two groups were similar in terms of comorbidity, age, sex, home services, home support and educational level. Self-managing patients were activated by their clinician, accepted their disease, changed their identity, confronted emotions and learnt the skills to self-manage and avoid hospital. Patients who frequently used hospital services to manage their chronic disease were often in denial about their chronic disease, hung on to their identity and expressed little emotional response. However, they reported a stronger sense of coherence and rated their health more highly than self-managing patients. This study shed light on the process of patient activation for self-management. A better understanding of the process of patient activation would encourage clinicians who come into contact with frequently readmitted chronic disease patients to be more proactive in supporting self-management.

Understanding the reasons for frequent re-attendances will assist in developing solutions to hospital overcrowding. This study aimed to identify the factors associated with frequent re-attendances in a regional hospital thereby highlighting possible solutions to the problem. A retrospective analysis was performed on emergency department data from 2008. Frequent re-attenders were defined as those with four or more presentations in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on re-presentations using multivariate analysis. RESULTS; A total of 8% of the total patients presenting to emergency re-attended four or more times in the year. Frequent re-attenders were older, presented with an unplanned returned visit and had a diagnosis of neurosis, chronic obstructive pulmonary disease (COPD), convulsions, dyspnoea or repeat prescriptions, follow-up examinations or dressings and sutures and less likely to present in summer. Frequent re-attendances were unrelated to sex, time of presentation or country of birth. Diversion of patients with minor conditions to alternative services; referral of COPD patients to follow-up respiratory services and patients with neurosis to community mental health services would reduce emergency utilisation. Improving access to and resourcing of alternative non-hospital services should be investigated to reduce emergency overcrowding.

The aim of this study was to determine the patient characteristics associated with unplanned return visits, using routinely collected hospital data, to assist in developing strategies to reduce their occurrence. Emergency department data from a regional hospital were analysed using univariate and multivariate methods to determine the influence of clinical, service usage and demographic patient characteristics on unplanned return visits. Around 80% of the 16000 patients attending emergency presented on only one occasion in a year. Five per cent of patients presented with an unplanned return visit. Older patients, those with minor and low urgency conditions and with non-psychotic mental health conditions, those presenting during winter and after hours were significantly more likely to present as unplanned return visits. Although patient characteristics associated with unplanned return visits have been identified, the reasons underpinning the unplanned return visit rate, such as patient service preference and attitudes, need to be more fully investigated.