자연주의적 탐구조사(Naturalistic Inquiry)

XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

SOURCES AND EFFECTS OF IONIZING RADIATION : United Nations Scientific Committee on the Effects of Atomic Radiation UNSCEAR 2000 Report to the General Assembly, with Scientific Annexes

The purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults." The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.

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Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise

The full benefit of many effective medications will be achieved only if patients adhere to prescribed treatment regimens. Unfortunately, applying terms such as “noncompliant” and “nonadherent” to patients who do not consume every pill at the desired time can stigmatize them in their future relationships with health care providers. This article on medication adherence (or compliance) reviews strategies to assess and enhance this important aspect of patient care.

/pdf/adherence-to-medication-1h7gc1z12g.pdf

Adherence to Medication

Results Compared with the BRFSS and the PACE, the RAPA was more positively correlated with the CHAMPS moderate caloric expenditure (r = 0.54 for RAPA, r = 0.40 for BRFSS, and r = 0.44 for PACE) and showed as good or better sensitivity (81%), positive predictive value (77%), and negative predictive value (75%) as the other tools. Specificity, sensitivity, and positive predictive value of the questions on flexibility and strength training were in the 80% range, except for specificity of flexibility questions (62%). Mean caloric expenditure per week calculated from the CHAMPS was compared between those who did and those who did not meet minimum recommendations for moderate or vigorous physical activity based on these selfreport questionnaires. The RAPA outperformed the PACE and the BRFSS. Conclusion

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The Rapid Assessment of Physical Activity (RAPA) among older adults.

Explorations in Quality Assessment and Monitoring. Volume I: The Definitions of Quality and Approaches to its Assessment

ContextOlder adults with social isolation, medical comorbidity, and physical
impairment are more likely to be depressed but may be less able to seek appropriate
care for depression compared with older adults without these characteristics.ObjectiveTo determine the effectiveness of a home-based program of detecting
and managing minor depression or dysthymia among older aldults.Design and SettingRandomized controlled trial with recruitment through community senior
service agencies in metropolitan Seattle, Wash, from January 2000 to May 2003.PatientsOne hundred thirty-eight patients aged 60 years or older with minor
depression (51.4%) or dysthymia (48.6%). Patients had a mean of 4.6 (SD, 2.1)
chronic medical conditions; 42% of the sample belonged to a racial/ethnic
minority, 72% lived alone, 58% had an annual income of less than $10 000,
and 69% received a form of home assistance.InterventionsPatients were randomly assigned to the Program to Encourage Active,
Rewarding Lives for Seniors (PEARLS) intervention (n = 72) or usual care (n
= 66). The PEARLS intervention consisted of problem-solving treatment, social
and physical activation, and potential recommendations to patients' physicians
regarding antidepressant medications.Main Outcome MeasuresAssessments of depression and quality of life at 12 months compared
with baseline.ResultsAt 12 months, compared with the usual care group, patients receiving
the PEARLS intervention were more likely to have at least a 50% reduction
in depressive symptoms (43% vs 15%; odds ratio [OR], 5.21; 95% confidence
interval [CI], 2.01-13.49), to achieve complete remission from depression
(36% vs 12%; OR, 4.96; 95% CI, 1.79-13.72), and to have greater health-related
quality-of-life improvements in functional well-being (P = .001) and emotional well-being (P = .048).ConclusionsThe PEARLS program, a community-integrated, home-based treatment for
depression, significantly reduced depressive symptoms and improved health
status in chronically medically ill older adults with minor depression and
dysthymia.

https://jamanetwork.com/journals/jama/articlepdf/198486/JOC32323.pdf

Community-integrated home-based depression treatment in older adults: a randomized controlled trial.

Introduction Increasing physical activity is a goal of Healthy People 2010. Although the health benefits of physical activity are documented, older adults are less physically active than any other age group. The purpose of this study was to examine barriers and facilitators to physical activity and exercise among underserved, ethnically diverse older adults. Methods Seventy-one older adults were recruited through community agencies to participate in seven ethnic-specific focus groups: American Indian/Alaska Native, African American, Filipino, Chinese, Latino, Korean, and Vietnamese. Groups were conducted in the participants' primary language and ranged in size from 7-13 participants. Mean age was 71.6 years (range from 52 to 85 years; SD +/- 7.39). Professional translators transcribed audiotapes into the language of the group and then translated the transcript into English. Transcripts were systematically reviewed using content analysis. Results Suggested features of physical activity programs to enhance participation among ethnically diverse minority older adults included fostering relationships among participants; providing culture-specific exercise; offering programs at residential sites; partnering with and offering classes prior to or after social service programs; educating families about the importance of physical activity for older adults and ways they could help; offering low- or no-cost classes; and involving older adults in program development. Walking was the exercise of choice across all ethnic groups. Health served as both a motivator and a barrier to physical activity. Other factors influencing physical activity were weather, transportation, and personal safety. Conclusion Findings from this study suggest strategies for culture-specific programming of community-based physical activity programs.

Older adult perspectives on physical activity and exercise: voices from multiple cultures.

Objective. —To assess the feasibility and measurement characteristics of ratings completed by professional associates to evaluate the performance of practicing physicians. Design. —The clinical performance of physicians was evaluated using written questionnaires mailed to professional associates (physicians and nurses). Physician-associates were randomly selected from lists provided by both the subjects and medical supervisors, and detailed information was collected concerning the professional and social relationships between the associate and the subject. Responses were analyzed to determine factors that affect ratings and measurement characteristics of peer ratings. Setting and Participants. —Physician-subjects were selected from among practicing internists in New York, New Jersey, and Pennsylvania who received American Board of Internal Medicine certification 5 to 15 years previously. Main Outcome Measure. —Physician performance as assessed by peers. Results. —Peer ratings are not biased substantially by the method of selection of the peers or the relationship between the rater and the subject. Factor analyses suggest a two-dimensional conceptualization of clinical skills: one factor represents cognitive and clinical management skills and the other factor represents humanistic qualities and management of psychosocial aspects of illness. Ratings from 11 peer physicians are needed to provide a reliable assessment in these two areas. Conclusions. —These findings suggest that it is feasible to obtain assessments from professional associates of practicing physicians in areas such as clinical skills, humanistic qualities, and communication skills. Using a shorter version of the questionnaire used in this study, peer ratings provide a practical method to assess clinical performance in areas such as humanistic qualities and communication skills that are difficult to assess with other measures. ( JAMA . 1993;269:1655-1660)

https://jamanetwork.com/journals/jama/articlepdf/405098/jama_269_13_034.pdf

James P. LoGerfo

Papers

The Rapid Assessment of Physical Activity (RAPA) among older adults.

Explorations in Quality Assessment and Monitoring. Volume I: The Definitions of Quality and Approaches to its Assessment

Community-integrated home-based depression treatment in older adults: a randomized controlled trial.

Older adult perspectives on physical activity and exercise: voices from multiple cultures.

Use of Peer Ratings to Evaluate Physician Performance