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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

Doing Qualitative Research

Background
Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise‐based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.

Objectives
To assess the clinical effectiveness and cost‐effectiveness of exercise‐based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health‐related quality of life (HRQoL) in people with CHD.

Search methods
We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021.

Selection criteria
We included randomised controlled trials (RCTs) of exercise‐based interventions with at least six months’ follow‐up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease.

Data collection and analysis
We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta‐analysis by duration of follow‐up: short‐term (6 to 12 months); medium‐term (> 12 to 36 months); and long‐term ( > 3 years), and used meta‐regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow‐up time point). 

Main results
This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post‐MI and post‐revascularisation patients, with a mean age ranging from 47 to 77 years.

In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty‐one of the included trials were performed in low‐ and middle‐income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow‐up time was 12 months (range 6 months to 19 years).

At short‐term follow‐up (6 to 12 months), exercise‐based CR likely results in a slight reduction in all‐cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all‐cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials; NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise‐based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow‐up. We are uncertain about the effects of exercise‐based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all‐cause hospitalisation, but not for all other outcomes.

At medium‐term follow‐up, although there may be little to no difference in all‐cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all‐cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials).

At long‐term follow‐up, although there may be little to no difference in all‐cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise‐based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials).

Meta‐regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow‐up length, publication year, CR setting, study location, sample size or risk of bias.

There was evidence that exercise‐based CR may slightly increase HRQoL across several subscales (SF‐36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow‐up; however, these may not be clinically important differences. The eight trial‐based economic evaluation studies showed exercise‐based CR to be a potentially cost‐effective use of resources in terms of gain in quality‐adjusted life years (QALYs).

Authors' conclusions
This updated Cochrane Review supports the conclusions of the previous version, that exercise‐based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all‐cause mortality, and a large reduction in all‐cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow‐up. Over longer‐term follow‐up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well‐designed, adequately‐reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer‐term follow‐up, and assess costs and cost‐effectiveness.

/pdf/exercise-based-cardiac-rehabilitation-for-coronary-heart-ctqt9teiud.pdf

Exercise-based cardiac rehabilitation for coronary heart disease

Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis

A systematic review of clinical assessment for undergraduate nursing students

Vital signs monitoring is an important nursing assessment. Yet, nurses seem to be doing it as part of a routine and often overlooking their significance in detecting patient deterioration. An integrative literature review was conducted to explore factors surrounding ward nursing practice of vital signs monitoring in detecting and reporting deterioration. Twenty papers were included. The structural component of a Nursing Role Effectiveness Model framework, which comprises of patient, nurse and organizational variables, was used to synthesize the review. Patient variables include signs of deterioration displayed by patients which include physical cues and abnormal vital signs. Nursing variables include clinical knowledge, roles and responsibilities, and reporting of deteriorating vital signs. Organizational variables include heavy workload, technology, and observation chart design. This review has highlighted current nursing practice in vital signs monitoring. A myriad of factors were found to surround ward practice of vital signs monitoring in detecting and reporting deterioration.

Vital signs monitoring to detect patient deterioration: An integrative literature review

Objective To develop and determine the psychometrics properties of an instrument (V-scale) and to explore nurses' attitudes towards vital signs monitoring in the detection of clinical deterioration in general wards.

Design Scale development with psychometric testing and a descriptive quantitative survey.

Setting Tertiary acute care hospital.

Participants A total of 614 general ward nurses.

Findings Principal component analysis revealed a 16-item instrument in a five-factor solution (key indicators, knowledge, communication, workload and technology) that explained 56.27% of the variance. The internal consistency was sufficient with Cronbach's alpha of 0.71 and strong item subscale correlations (0.56–0.89). The test–retest reliability was adequate with an Intraclass Correlation Coefficient (ICC) of 0.85. Many nurses (56.9%) erroneously perceived blood pressure changes as the first indicator of deterioration, and 46% agreed that an altered respiratory rate was the least important indicator. Most nurses (59.8%) also reported relying on oxygen saturation to evaluate respiratory dysfunction, and 27.4% indicated that they make quick estimates of the respiratory rate. Current practices for vital signs monitoring were considered to be time consuming (21.0%) and overwhelming (35.3%). Nurses' attitudes were most significantly influenced by whether they had a degree qualification followed by whether they worked in a general ward with a specialty and had >5 years of experience.

Conclusions This exploratory study provides evidence for the psychometric properties of the V-scale. It reveals a need for continuous professional development to improve ward nurses' attitudes towards vital signs monitoring. Vital signs monitoring needs to be prioritized in workload planning.

/pdf/attitudes-towards-vital-signs-monitoring-in-the-detection-of-3u4w0idfsc.pdf

Attitudes towards vital signs monitoring in the detection of clinical deterioration: scale development and survey of ward nurses

Aim To evaluate further the psychometric properties of the Chinese version of the Hospital Anxiety and Depression Scale (HADS) as a screening instrument for anxiety and depression in Chinese patients with coronary heart disease (CHD) in Xian, China Background There is considerable evidence that anxiety and depression are common in patients with CHD and are associated with increased morbidity and mortality A valid, reliable and sensitive screening tool that can be used readily on this group of patients would be useful for assessment, intervention and outcome evaluation Design A single group, cross-sectional study Method Measurement performance was tested on 314 Chinese patients with CHD and repeated on 173 of them two weeks later Results The Chinese version of HADS (C-HADS) had acceptable internal consistency and test-retest reliability, with a Cronbach’s alpha of 085 and intraclass correlation coefficient of 090, respectively There was acceptable concurrent validity with significant (p < 005) correlations between the anxiety and depression subscales of the C-HADS and CHD patients’ perceived health status as measured by the Chinese-Mandarin version of the Short Form-36 health survey (CM:SF-36) Principal components analysis revealed a three-factor solution accounting for 53% of the total variance The three underlying sub-scale dimensions are depression, psychic anxiety and psychomotor anxiety The responsiveness of the C-HADS was also satisfactory with significant correlation between the changes in the C-HADS score and the changes in the mental health domain of the CM:SF-36 (p < 001) Finally, over one-third of the patients demonstrated psychological distress Conclusion Empirical data support the C-HADS as a reliable and valid screening instrument for the assessment of anxiety and depression in Chinese-speaking patients with CHD A tri-dimensional scoring approach should be considered as potentially clinically useful for this group of patients Relevance to clinical practice The C-HADS can guide and evaluate the delivery of psychological care for Chinese patients with CHD

Wenru Wang

Papers

A systematic review of clinical assessment for undergraduate nursing students

Vital signs monitoring to detect patient deterioration: An integrative literature review

Attitudes towards vital signs monitoring in the detection of clinical deterioration: scale development and survey of ward nurses

A psychometric evaluation of the Chinese version of the Hospital Anxiety and Depression Scale in patients with coronary heart disease

Relationship between job stress level and coping strategies used by Hong Kong nurses working in an acute surgical unit.