Poor mental health places a burden on individuals and populations. Resilient persons are able to adapt to life's challenges and maintain high quality of life and function. Finding effective ...strategies to bolster resilience in individuals and populations is of interest to many stakeholders.
To synthesize the evidence for resiliency training programs in improving mental health and capacity in 1) diverse adult populations and 2) persons with chronic diseases.
Electronic databases, clinical trial registries, and bibliographies. We also contacted study authors and field experts.
Randomized trials assessing the efficacy of any program intended to enhance resilience in adults and published after 1990. No restrictions were made based on outcome measured or comparator used.
Reviewers worked independently and in duplicate to extract study characteristics and data. These were confirmed with authors. We conducted a random effects meta-analysis on available data and tested for interaction in planned subgroups.
The standardized mean difference (SMD) effect of resiliency training programs on 1) resilience/hardiness, 2) quality of life/well-being, 3) self-efficacy/activation, 4) depression, 5) stress, and 6) anxiety.
We found 25 small trials at moderate to high risk of bias. Interventions varied in format and theoretical approach. Random effects meta-analysis showed a moderate effect of generalized stress-directed programs on enhancing resilience pooled SMD 0.37 (95% CI 0.18, 0.57) p = .0002; I2 = 41% within 3 months of follow up. Improvement in other outcomes was favorable to the interventions and reached statistical significance after removing two studies at high risk of bias. Trauma-induced stress-directed programs significantly improved stress -0.53 (-1.04, -0.03) p = .03; I2 = 73% and depression -0.51 (-0.92, -0.10) p = .04; I2 = 61%.
We found evidence warranting low confidence that resiliency training programs have a small to moderate effect at improving resilience and other mental health outcomes. Further study is needed to better define the resilience construct and to design interventions specific to it.
PROSPERO #CRD42014007185.
Background
Eliciting patient concerns and listening carefully to them contributes to patient-centered care. Yet, clinicians often fail to elicit the patient’s agenda and, when they do, they interrupt ...the patient’s discourse.
Objective
We aimed to describe the extent to which patients’ concerns are elicited across different clinical settings and how shared decision-making tools impact agenda elicitation.
Design and Participants
We performed a secondary analysis of a random sample of 112 clinical encounters recorded during trials testing the efficacy of shared decision-making tools.
Main Measures
Two reviewers, working independently, characterized the elicitation of the patient agenda and the time to interruption or to complete statement; we analyzed the distribution of agenda elicitation according to setting and use of shared decision-making tools.
Key Results
Clinicians elicited the patient’s agenda in 40 of 112 (36%) encounters. Agendas were elicited more often in primary care (30/61 encounters, 49%) than in specialty care (10/51 encounters, 20%);
p
= .058. Shared decision-making tools did not affect the likelihood of eliciting the patient’s agenda (34 vs. 37% in encounters with and without these tools;
p
= .09). In 27 of the 40 (67%) encounters in which clinicians elicited patient concerns, the clinician interrupted the patient after a median of 11 seconds (interquartile range 7–22; range 3 to 234 s). Uninterrupted patients took a median of 6 s (interquartile range 3–19; range 2 to 108 s) to state their concern.
Conclusions
Clinicians seldom elicit the patient’s agenda; when they do, they interrupt patients sooner than previously reported. Physicians in specialty care elicited the patient’s agenda less often compared to physicians in primary care. Failure to elicit the patient’s agenda reduces the chance that clinicians will orient the priorities of a clinical encounter toward specific aspects that matter to each patient.
Context:
Significant uncertainty remains surrounding the diagnostic accuracy of sonographic features used to predict the malignant potential of thyroid nodules.
Objective:
The objective of the study ...was to summarize the available literature related to the accuracy of thyroid nodule ultrasound (US) in the prediction of thyroid cancer.
Methods:
We searched multiple databases and reference lists for cohort studies that enrolled adults with thyroid nodules with reported diagnostic measures of sonography. A total of 14 relevant US features were analyzed.
Results:
We included 31 studies between 1985 and 2012 (number of nodules studied 18 288; average size 15 mm). The frequency of thyroid cancer was 20%. The most common type of cancer was papillary thyroid cancer (84%). The US nodule features with the highest diagnostic odds ratio for malignancy was being taller than wider 11.14 (95% confidence interval 6.6–18.9). Conversely, the US nodule features with the highest diagnostic odds ratio for benign nodules was spongiform appearance 12 (95% confidence interval 0.61–234.3). Heterogeneity across studies was substantial. Estimates of accuracy depended on the experience of the physician interpreting the US, the type of cancer and nodule (indeterminate), and type of reference standard. In a threshold model, spongiform appearance and cystic nodules were the only two features that, if present, could have avoided the use of fine-needle aspiration biopsy.
Conclusions:
Low- to moderate-quality evidence suggests that individual ultrasound features are not accurate predictors of thyroid cancer. Two features, cystic content and spongiform appearance, however, might predict benign nodules, but this has limited applicability to clinical practice due to their infrequent occurrence.
The impact of subclinical hypothyroidism (SCH) and of levothyroxine replacement in pregnant women with SCH is unclear. The aims of this study were to assess (i) the impact of SCH during pregnancy on ...maternal and neonatal outcomes, and (ii) the effect of levothyroxine replacement therapy in these patients.
Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, the Cochrane Controlled Trials Register, Ovid EMBASE, Web of Science, and Scopus were searched from inception to January 2015. Randomized trials and cohort studies of pregnant women with SCH that examined adverse pregnancy and neonatal outcomes were included. Reviewers extracted data and assessed methodological quality in duplicate. Eighteen cohort studies at low-to-moderate risk of bias were included. Compared with euthyroid pregnant women, pregnant women with SCH were at higher risk for pregnancy loss (relative risk RR 2.01 confidence interval (CI) 1.66-2.44), placental abruption (RR 2.14 CI 1.23-3.70), premature rupture of membranes (RR 1.43 CI 1.04-1.95), and neonatal death (RR 2.58 CI 1.41-4.73). One study at high risk of bias compared pregnant women with SCH who received levothyroxine to those who did not and found no significant decrease in the rate of pregnancy loss, preterm delivery, gestational hypertension, low birth weight, or low Apgar score.
SCH during pregnancy is associated with multiple adverse maternal and neonatal outcomes. The value of levothyroxine therapy in preventing these adverse outcomes remains uncertain.
The Chronic Care Model (CCM) emerged in the 1990s as an approach to re-organize primary care and implement critical elements that enable it to proactively attend to patients with chronic conditions. ...The chronic care landscape has evolved further, as most patients now present with multiple chronic conditions and increasing psychosocial complexity. These patients face accumulating and overwhelming complexity resulting from the sum of uncoordinated responses to each of their problems. Minimally Disruptive Medicine (MDM) was proposed to respond to this challenge, aiming at improving outcomes that matter to patients with the smallest burden of treatment. We sought to critically appraise the extent to which MDM constructs (e.g., reducing patient work, improving patients' capacity) have been adopted within CCM implementations.
We conducted a systematic review and qualitative thematic synthesis of reports of CCM implementations published from 2011-2016.
CCM implementations were mostly aligned with the healthcare system's goals, condition-specific, and targeted disease-specific outcomes or healthcare utilization. No CCM implementation addressed patient work. Few reduced treatment workload without adding additional tasks. Implementations supported patient capacity by offering information, but rarely offered practical resources (e.g., financial assistance, transportation), helped patients reframe their biography with chronic illness, or assisted them in engaging with a supportive social network. Few implementations aimed at improving functional status or quality of life, and only one-third of studies were targeted for patients of low socioeconomic status.
MDM provides a lens to operationalize how to care for patients with multiple chronic conditions, but its constructs remain mostly absent from how implementations of the CCM are currently reported. Improvements to the primary care of patients with multimorbidity may benefit from the application of MDM, and the current CCM implementations that do apply MDM constructs should be considered exemplars for future implementation work.
To understand the extent to which behaviors consistent with high quality medication reconciliation occurred in primary care settings and explore barriers to high quality medication reconciliation.
...Fully mixed sequential equal status design including ethnographic observations, semi-structured interviews, and surveys.
Primary care practices within an integrated healthcare delivery system in the United States.
We conducted 170 observations of patient encounters across 15 primary care clinics, 48 semi-structured interviews with staff, and 10 semi-structured interviews with patients. We also sent out surveys to 2,541 eligible staff with 616 responses (24% response rate) and to 5,132 eligible patients with 577 responses (11% response rate).
Inconsistency emerged as a major barrier to effective medication reconciliation. This inconsistency was present across a variety of factors such as the lack of standardized workflows for conducting medication reconciliation, a lack of knowledge about medication and the process of medication reconciliation, varying levels of importance ascribed to medication reconciliation, and inadequate integration of medication reconciliation into clinical workflows. Findings were generally consistent across all data collection methods.
We have identified several barriers which impact the process of medication reconciliation in primary care settings. Our key finding is that the process of medication reconciliation is plagued by inconsistencies which contribute to inaccurate medication lists. These inconsistencies can be broken down into several categories (standardization, knowledge, importance, and inadequate integration) which can be targets for future studies and interventions.
Emergency hospital admissions are common, with several interventions having been developed to reduce their rates. Bobrovitz et al. summarized the available body of evidence regarding pharmacologic ...therapies aimed at reducing emergency hospital admissions, and identified 28 medications for which high- or moderate-quality evidence supports their use, 11 of which were identified as being supported by current guideline recommendations. Additionally, the authors identified 28 medications supported by low- or very low-quality evidence, which can serve as targets for future research. The article by Bobrovitz et al. presents a good summary of the evidence, albeit with limitations in the search strategy that cannot guarantee the review as comprehensive. Despite this, the review has important implications for policymakers, guideline panels, researchers, clinicians, and funders since the identified medications can either be targets for quality improvement initiatives or for future research. Bobrovitz et al.'s review highlights the challenge that systematic reviewers face when balancing feasibility and comprehensiveness.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1104-9.
Reducing early (<30 days) hospital readmissions is a policy priority aimed at improving health care quality. The cumulative complexity model conceptualizes patient context. It predicts that highly ...supportive discharge interventions will enhance patient capacity to enact burdensome self-care and avoid readmissions.
To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features--including their impact on treatment burden and on patients' capacity to enact postdischarge self-care--that might explain their varying effects.
We searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies.
Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients hospitalized for a medical or surgical cause for more than 24 hours and discharged to home.
Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the cumulative complexity model.
Relative risk of all-cause or unplanned readmission with or without out-of-hospital deaths at 30 days postdischarge.
In 42 trials, the tested interventions prevented early readmissions (pooled random-effects relative risk, 0.82 95% CI, 0.73-0.91; P < .001; I² = 31%), a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (interaction P = .01). In exploratory subgroup analyses, interventions with many components (interaction P = .001), involving more individuals in care delivery (interaction P = .05), and supporting patient capacity for self-care (interaction P = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions, respectively. A post hoc regression model showed incremental value in providing comprehensive, postdischarge support to patients and caregivers.
Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective.
Sleep complaints are reported by 40–60 % of menopausal women. Poor sleep is a risk factor for cardiovascular disease, diabetes, and obesity. The effect of menopausal hormone therapy on sleep quality ...is unclear. A systematic review and meta-analysis were conducted to summarize the efficacy of menopausal hormone therapy on self-reported sleep quality. Electronic databases (PubMed, Scopus, Ovid MEDLINE, EMBASE, EBM Reviews CENTRAL, and PsycInfo) were searched from 2002 to October 2015. Randomized trials assessing the effect of menopausal hormone therapy with a minimum follow up of 8 weeks were included. Titles, abstracts, and full texts were screened independently and in duplicate. Primary outcome included sleep items within a questionnaire, scale or diary. Standardized mean differences across trials were pooled using random-effects models. The search identified 424 articles, from which 42 trials were included. Seven trials at a moderate to high risk of bias enrolling 15,468 women were pooled in meta-analysis. Menopausal hormone therapy improved sleep quality in women who had vasomotor symptoms at baseline standardized mean difference –0.54 (−0.91 to −0.18), moderate quality evidence. No difference was noted when women without such symptoms were analyzed separately or combined. Across 31 sleep quality questionnaires, daytime dysfunction was the most evaluated sleep domain. Menopausal hormone therapy improves sleep in women with concomitant vasomotor symptoms. Heterogeneity of trials regarding study population, formulations, and sleep scales; limit overall certainty in the evidence. Future menopausal hormone therapy trials should include assessment of self-reported sleep quality using standardized scales and adhere to reporting guidelines.
Confidence is a judgment and is subjective and sensitive to the needs of the individual evaluating the body of evidence. ...the rating of the overall body of evidence may differ depending on who is ...evaluating the body of evidence and for what purpose.
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