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To evaluate the effect of a disease management programme in Kazakhstan on quality indicators for patients with hypertension, diabetes and chronic heart failure.A supportive, interdisciplinary, quality improvement programme was implemented between November 2014 and November 2015 at seven polyclinics in Pavlodar and Petropavlovsk. Quality improvement teams were established at each clinic and quality improvement tools were introduced, including patient flowsheets, decision support tools, patient registries, a patient recall process, support for patient self-management and patient follow-up with intensity adjusted for level of disease control. Clinic teams met for four 3-day interactive learning sessions within 1 year, with additional coaching visits. Implementation was managed by five local coordinators and consultants trained by international consultants. National and regional steering committees monitored progress.Between July and October 2015, the proportion of hypertensive patients with the recommended blood pressure increased from 24% (101/424) to 56% (228/409). Among patients with diabetes, the proportion who recently underwent eye examinations increased from 26% (101/391) to 71% (308/433); the proportion who had their low-density lipoprotein cholesterol measured increased from 57% (221/391) to 85% (369/433); and the proportion who had their albumin : creatinine ratio measured increased from 11% (44/391) to 49% (212/433). The proportion of chronic heart failure patients who underwent echocardiography rose from 91% (128/140) to 99% (157/158). All patients set themselves self-management goals.This intensive, supportive, multifaceted programme was associated with significant improvements in quality of care for patients with chronic disease. Further investment in coaching capacity is needed to extend the programme nationally.Évaluer l'impact d'un programme de gestion des maladies au Kazakhstan sur des indicateurs de qualité chez des patients souffrant d'hypertension, de diabète et d'insuffisance cardiaque chronique.Un programme de soutien interdisciplinaire pour l'amélioration de la qualité a été mis en œuvre entre novembre 2014 et novembre 2015 dans sept polycliniques à Pavlodar et Petropavlovsk. Des équipes spécialisées ont été créées dans chaque établissement et des outils d'amélioration de la qualité ont été instaurés, parmi lesquels des diagrammes de flux de patients, des dispositifs d'aide à la prise de décision, des registres de patients, un processus de rappel des patients, ainsi qu'une assistance pour l'autogestion et le suivi des patients dont l'intensité est ajustée en fonction du degré de contrôle requis. Les équipes cliniques se sont rencontrées à quatre reprises durant l'année pour participer à des sessions d'apprentissage de trois jours chacune, agrémentées de visites d'encadrement complémentaires. La mise en œuvre a été effectuée par cinq coordinateurs et consultants locaux formés par des consultants internationaux. Des comités directeurs nationaux et régionaux se sont chargés de suivre les progrès accomplis.Entre juillet et octobre 2015, la part de patients hypertendus affichant le niveau de tension artérielle recommandé est passée de 24 % (101/424) à 56 % (228/409). Pour les patients souffrant de diabète, la proportion de patients testés pour un taux de cholestérol lié au lipoprotéines de basse densité est passé de 57% (221/391) à 85% (369/433); la proportion de patients testés pour le ratio albumine-créatinine est passé de 11% (44/391) à 49% (212/433); et la part des patients qui ont récemment subi un examen ophtalmologique a augmenté de 26% (101/391) à 71% (308/433). La proportion de patients souffrant d’insuffisance cardiaque chronique qui se sont soumis à une échocardiographie auparavant a augmenté, passant de 91% (128/140) à 99% (157/158). Tous les patients se sont fixé des objectifs d'autogestion.Ce programme multiforme de soutien intensif a entraîné une nette amélioration de la qualité des soins aux patients souffrant de maladies chroniques. Des investissements supplémentaires dans les capacités d'encadrement sont nécessaires pour déployer le programme à l'échelle nationale.Evaluar el efecto de un programa de gestión de enfermedades en Kazajstán sobre los indicadores de calidad de los pacientes con hipertensión, diabetes e insuficiencia cardíaca crónica.Entre noviembre de 2014 y noviembre de 2015 se llevó a cabo un programa de apoyo, interdisciplinario y de mejora de la calidad en siete policlínicos de Pavlodar y Petropavlovsk. Se establecieron equipos de mejora de la calidad en cada clínica y se incorporaron instrumentos de mejora de la calidad, como hojas de evolución de pacientes, instrumentos de apoyo a la toma de decisiones, registros de pacientes, un proceso de llamadas para recordar citas a los pacientes, apoyo a la autogestión de los pacientes y seguimiento de los pacientes con una intensidad ajustada al nivel de control de la enfermedad. Los equipos clínicos se reunieron en cuatro sesiones de aprendizaje interactivo de tres días en el plazo de un año, con visitas adicionales de entrenamiento. Cinco coordinadores y consultores locales, formados por consultores internacionales, gestionaron la implementación. Los comités directivos nacionales y regionales supervisaron los progresos realizados.Entre julio y octubre de 2015, el porcentaje de pacientes hipertensos con la presión arterial recomendada aumentó del 24 % (101/424) al 56 % (228/409). Entre los pacientes con diabetes, el porcentaje que se sometió recientemente a exámenes oculares aumentó del 26 % (101/391) al 71 % (308/433); el porcentaje a los que se les midió el colesterol de lipoproteína de baja densidad aumentó del 57 % (221/391) al 85 % (369/433); y el porcentaje a los que se les midió la proporción albúmina/creatinina aumentó del 11 % (44/391) al 49 % (212/433). El porcentaje de pacientes con insuficiencia cardíaca crónica que se sometieron a una ecocardiografía aumentó del 91 % (128/140) al 99 % (157/158). Todos los pacientes se fijaron objetivos de autogestión.Este programa intensivo, de apoyo y multifacético se asoció con mejoras significativas en la calidad de la atención de los pacientes con enfermedades crónicas. Se necesita una inversión adicional en la capacidad de entrenamiento para ampliar el programa a nivel nacional.تقييم تأثير برنامج إدارة الأمراض في كازاخستان على مؤشرات الجودة للمرضى الذين يعانون من ارتفاع ضغط الدم والسكري وقصور القلب المزمن. الطريقة تم تنفيذ برنامج داعم متعدد التخصصات لتحسين الجودة بين نوفمبر/تشرين ثان 2014، ونوفمبر/تشرين ثان 2015، في سبع عيادات شاملة في بافلودار وبتروبافلوفسك. تم إنشاء فرق لتحسين الجودة في كل عيادة، كما تم إدخال أدوات لتحسين الجودة، بما في ذلك مستندات تدفق المرضى، وأدوات دعم القرار، وسجلات المرضى، وعملية استدعاء المريض، ودعم الإدارة الذاتية للمريض ومتابعة المريض، مع ضبط الكثافة على مستوى السيطرة على الأمراض. اجتمعت فرق العيادات في أربع جلسات تعلم تفاعلية لمدة 3 أيام خلال عام واحد، مع زيارات تدريب إضافية. تمت أدارة التنفيذ بواسطة خمس منسقين واستشاريين محليين تم تدريبهم بواسطة استشاريين دوليين. وقامت اللجان التنظيمية الوطنية والإقليمية بمراقبة التقدم. النتائج بين شهري يوليو/تموز وأكتوبر/تشرين أول لعام 2015، فإن نسبة المرضى الذين يعانون من ارتفاع ضغط الدم، ولديهم ضغط الدم الموصى به، قد ارتفعت من 24% (101/424) إلى 56% (228/409). وبين مرضى السكري، فإن النسبة التي خضعت مؤخراً لفحوصات العين قد زادت من 26% (101/391) إلى 71% (308/433)؛ كذلك فإن نسبة الذين يقومون بقياس كوليستيرول البروتين الدهني منخفض الكثافة لديهم، قد زادت من 57% (221/391) إلى 85% (369/433)؛ ونسبة الذين يقومون بقياس نسبة الزلال إلى الكرياتينين لديهم، قد زادت من 11% (44/391) إلى 49% (212/433). ارتفعت نسبة مرضى قصور القلب المزمن الذين خضعوا لتخطيط صدى القلب من 91% (128/140) إلى 99% (157/158). وضع جميع المرضى أنفسهم كأهداف للإدارة الذاتية. الاستنتاج ارتبط هذا البرنامج المكثف الداعم متعدد الأوجه بتحسينات ملموسة في جودة الرعاية للمرضى الذين يعانون من مرض مزمن. هناك حاجة إلى مزيد من الاستثمار في قدرة التدريب لتوسيع البرنامج على المستوى الوطني.旨在评估哈萨克斯坦疾病管理项目对高血压、糖尿病和慢性心力衰竭患者护理质量指标的影响。.2014 年 11 月至 2015 年 11 月期间，在巴甫洛达尔和彼得罗巴甫洛夫斯克的七家综合诊所实施了支持性、跨学科的质量改进项目。在每个诊所中都成立了质量改进团队并引入了质量改进工具，包括患者流程图、决策支持工具、患者登记表、患者复诊提醒流程、对患者自我管理以及患者随诊的支持，并根据疾病控制程度来调整强度。诊所团队在一年内举行了四次为期 3 天的互动式学习会议，并进行了额外的指导考察。实施工作由五名当地协调员和经过国际顾问培训的顾问管理。国家和地区指导委员会监测进展。.2015 年 7 月至 10 月期间，血压达到推荐标准的高血压患者的比例从 24% (101/424) 增至 56% (228/409)。在糖尿病患者中，近期接受眼科检查的患者比例从 26% (101/391) 增至 71% (308/433)；接受低密度脂蛋白胆固醇测定的患者比例从 57% (221/391) 增至 85% (369/433)；接受白蛋白/肌酐比值测定的患者比例从 11% (44/391) 增至 49% (212/433)。接受超声心动图检查的慢性心力衰竭患者比例从 91% (128/140) 增至 99% (157/158)。所有患者都为自己设定了自我管理目标。.这个强化支持性多维项目促使慢性病患者的护理质量显著改进。需要进一步加大投资，提高指导能力，在全国范围内推广该项目。.Оценить влияние программы управления заболеваний, действующей в Казахстане, на показатели качества медицинской помощи, предлагаемой пациентам с гипертензией, диабетом и хронической сердечной недостаточностью.Комплексная междисциплинарная программа, направленная на улучшение качества медицинской помощи, проводилась в семи поликлиниках Павлодара и Петропавловска в период с ноября 2014 года по ноябрь 2015 года. В каждой поликлинике были созданы группы по повышению качества медицинского обслуживания, использовавшие соответствующие технические средства, включая графики приема пациентов, средства поддержки принятия решений, реестры пациентов, процесс повторного вызова пациентов, обучение пациентов методам самопомощи и последующее наблюдение пациентов с частотой, зависящей от уровня контроля заболевания. В течение года группы специалистов поликлиники четырежды собирались для проведения 3-дневных курсов интерактивного обучения и получали дополнительное индивидуальное обучение. Внедрением программы занимались пять местных координаторов и консультантов, прошедших международное обучение. За ходом выполнения программы следили национальный и региональный руководящие комитеты.В период между июлем и октябрем 2015 года доля пациентов, страдающих гипертензией, у которых отмечалось рекомендованное кровяное давление, выросла с 24% (101 из 424) до 56% (228 из 409). Среди пациентов с диабетом доля лиц, недавно прошедших обследование у окулиста, возросла с 26% (101 из 391) до 71% (308 из 433); доля тех, кому определяли уровень холестерина липопротеинов низкой плотности, увеличилась с 57% (221 из 391) до 85% (369 из 433); а доля тех, кому измеряли соотношение альбумина к креатинину, возросла с 11% (44 из 391) до 49% (212 из 433). Среди пациентов с хронической сердечной недостаточностью доля пациентов, прошедших эхокардиографию, увеличилась с 91% (128 из 140) до 99% (157 из 158). Все пациенты поставили себе цели по изучению методов самопомощи.Интенсивная, комплексная, разноплановая программа была связана со значительным улучшением качества медицинской помощи пациентам с хроническими заболеваниями. Для распространения программы в национальном масштабе нужны дальнейшие инвестиции в обучающую деятельность.

Background: Clinical practice guidelines generally recommend clinicians use self-management support (SMS) when managing patients with spine pain. However, even within the educational setting, the implementation of SMS remains suboptimal. The objectives of this study were to 1) estimate the organizational readiness for change toward using SMS at the Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario from the perspective of directors and deans, 2) estimate the attitudes and self-reported behaviours towards using evidence-based practice (EBP), and beliefs about pain management among supervisory clinicians and chiropractic interns, 3) identify potential barriers and enablers to using SMS, and 4) design a theory-based tailored Knowledge Translation (KT) intervention to increase the use of SMS. Methods: Mixed method design. We administered three self-administered questionnaires to assess clinicians’ and interns’ attitudes and behaviours toward EBP, beliefs about pain management, and practice style. In addition, we conducted 3 focus groups with clinicians and interns based on the Theoretical Domain Framework (TDF) to explore their beliefs about using SMS for patients with spine pain. Data were analysed using deductive thematic analysis by 2 independent assessors. A panel of 7 experts mapped behaviour change techniques to key barriers identified informing the design of a KT intervention. Results: Participants showed high level of EBP knowledge, positive attitude of EBP, and moderate frequency of EBP use. A number of barrier factors were identified from clinicians (N = 6) and interns (N = 16) corresponding to 7 TDF domains: Knowledge; Skills; Environmental context and resources; Emotion; Beliefs about Capabilities; Memory, attention & decision making; and Social Influence. To address these barriers, the expert panel proposed a multifaceted KT intervention composed of a webinar and online educational module on a SMS guided by the Brief Action Planning, clinical vignettes, training workshop, and opinion leader support. Conclusion: SMS strategies can help maximizing the health care services for patients with spine pain. This may in turn optimize patients’ health. The proposed theory-based KT intervention may facilitate the implementation of SMS among clinicians and interns.

The present study tested the feasibility of training peers with spinal cord injury (SCI) to learn brief action planning (BAP), an application of motivational interviewing principles, to promote physical activity to mentees with SCI.Thirteen peers with SCI attended a half-day BAP workshop. Using a one-arm, pre-, post-test design, feasibility to learn BAP was assessed in terms of peers' (1) BAP and motivational interviewing spirit competence; (2) training satisfaction; and (3) motivations to use BAP as assessed by measures of the theory of planned behavior constructs. Measures were taken at baseline, immediately post-training, and 1 month follow up.Following the training, participants' BAP and motivational interviewing competence significantly increased (P's0.05, d's2.27). Training satisfaction was very positive with all means falling above the scale midpoint. Participants' perceived behavioral control to use BAP increased from baseline to post (P0.05, d = 0.91) but was not maintained at follow up (P0.05).Training peers with a SCI to learn to use BAP is feasible.BAP is a tool that can be feasibly learned by peers to promote physical activity to their mentees.

Article-at-a-Glance Background Recommendations to improve self-management support and health outcomes for people with chronic conditions in primary care settings are provided on the basis of expert opinion supported by evidence for practices and processes. Practices and processes that could improve self-management support in primary care were identified through a nominal group process. In a targeted search strategy, reviews and meta-analyses were then identifed using terms from a wide range of chronic conditions and behavioral risk factors in combination with Self-Care, Self-Management, and Primary Care. On the basis of these reviews, evidence-based principles for self-management support were developed. Findings The evidence is organized within the framework of the Chronic Care Model. Evidence-based principles in 12 areas were associated with improved patient self-management and/or health outcomes: (1) brief targeted assessment, (2) evidence-based information to guide shared decision-making, (3) use of a nonjudgmental approach, (4) collaborative priority and goal setting, (5) collaborative problem solving, (6) self-management support by diverse providers, (7) self-management interventions delivered by diverse formats, (8) patient self-efficacy, (9) active follow-up, (10) guideline-based case management for selected patients, (11) linkages to evidence-based community programs, and (12) multifaceted interventions. A framework is provided for implementing these principles in three phases of the primary care visit: enhanced previsit assessment, a focused clinical encounter, and expanded postvisit options. Conclusions There is a growing evidence base for how self-management support for chronic conditions can be integrated into routine health care.

OBJECTIVES: To pilot test a new behavioral intervention to increase walking in sedentary older adults. DESIGN: Pre-post community-based pilot study. SETTING: Three senior centers in greater Los Angeles. PARTICIPANTS: Forty-six sedentary adults aged 65 and older. INTERVENTION: At four weekly 1-hour group sessions held at the senior centers, a trained health educator applied a theoretically grounded, standardized attribution retraining curriculum developed by a multidisciplinary team of investigators. Participants were taught that becoming sedentary is not inevitable with aging and that older adults should attribute being sedentary to modifiable attributes rather than to old age. A 1-hour exercise class including strength, endurance, and flexibility training followed each weekly attribution retraining session. MEASUREMENTS: Change from baseline in steps per week recorded using a digital pedometer was measured after 7 weeks. Age expectations (measured using the Expectations Regarding Aging-38 survey, a previously tested instrument on which higher scores indicate that the participant expects high functioning with aging and lower scores indicate that the participant expects physical and mental decline) and health-related quality of life were measured using in-person interviews. RESULTS: Mean steps per week increased from 24,749 to 30,707, a 24% increase-equivalent to 2.5 miles (2-sided t-test P=.002). Age expectation scores increased 30% (P

Assisting patients to improve health-related behaviors is an important responsibility of caregivers, including physicians, nurses, health educators, and counselors. From 1992 to 2000, diet and physical activity counseling took place in < 45 and 30%, respectively, of primary care physician visits by adults with coronary heart disease risk factors. 1 Physicians in primary care seldom have time to engage in such discussions and may be unsure how to discuss behavior change with their patients; 1-3

In Brief Usual medical care is not organized to make for effective and productive interaction between medical providers and their patients. This article highlights this problem by describing a typical office visit from the perspectives of a patient and a primary care physician. It then describes the development of the Chronic Care Model, which provides practical suggestions for how to change several aspects of the organization and delivery of health care to improve this situation.

Two individual teams, one from a small, rural clinic and one from a larger urban health system, were able to introduce innovations in care and realize improvement in patient outcomes.

Article-at-a-Glance Background Breakthrough Series Collaboratives addressing chronic conditions have been conducted at the national level and in single health care delivery systems but not at the state level. Two state-level collaboratives were conducted: Diabetes Collaborative I (October 1999–November 2000) included 17 clinic teams from across the state, and Diabetes Collaborative II (February 2001–March 2002) included 30 teams and 6 health plans. Methods Both collaboratives took place in Washington State, where a diverse group of primary care practices participated, and health insurance plans partnered with the clinic teams. Teams individually tested and implement changes in their systems of care to address all components of the Chronic Care Model. Results All 47 teams completed the collaboratives, and all but one maintained a registry throughout the 13 months. Most teams demonstrated some amount of improvement on process and outcome measures that addressed blood sugar testing and control, blood pressure control, lipid testing and control, foot exams, dilated eye exams, and self-management goals. Conclusion The benefits of holding collaboratives more locally include increased technical support and increased participation, translating into wider implementation of prevention-focused, patient-centered care.

Article-at-a-Glance Background Self-management support (SMS) is the area of disease management least often implemented and most challenging to integrate into usual care. This article outlines a model of SMS applicable across different chronic illnesses and health care systems, presents recommendations for assisting health care professionals and practice teams to make changes, and provides tips and lessons learned. Strategies can be applied across a wide range of conditions and settings by health educators, care managers, quality improvement specialists, researchers, program evaluators, and clinician leaders. Successful SMS programs involve changes at multiple levels: patient–clinician interactions; office environment changes; and health system, policy, and environmental supports. Patient–Clinician Interaction Level Self-management by patients is not optional but inevitable because clinicians are present for only a fraction of the patient's life, and nearly all outcomes are mediated through patient behavior. Clinicians who believe they are in control or responsible for a patient's well-being are less able to adopt an approach that acknowledges the central role of the patient in his or her care. Summary and Conclusions Self-management should be an integral part of primary care, an ongoing iterative process, and patient centered; use collaborative goal setting and decision making; and include problem solving, outreach, and systematic follow-up.

Self-management is an essential but frequently neglected component of chronic illness management that is challenging to implement. Available effectiveness data regarding self-management interventions tend to be from stand-alone programs rather than from efforts to integrate self-management into routine medical care. This article describes efforts to integrate self-management support into broader health care systems change to improve the quality of patient care in the Chronic Illness Care Breakthrough Series. We describe the general approach to system change (the Chronic Care Model) and the more specific self-management training model used. The process used in training organizations in self-management is discussed, and data are presented on teams from 21 health care systems participating in a 13-month-long Breakthrough Series to address diabetes and heart failure care. Available system-level data suggest that teams from a variety of health care organizations made improvements in support provided for self-management. Improvements were found for both diabetes and heart failure teams, suggesting that this improvement process may be broadly applicable. Lessons learned, keys to success, and directions for future research and practice are discussed.

We evaluated the accuracy of administrative data for identifying complications and comorbidities of diabetes using International Classification of Diseases, 9th edition, Clinical Modification and Current Procedural Terminology codes. The records of 471 randomly selected diabetic patients were reviewed for complications from January 1, 1993 to December 31, 1995; chart data served to validate automated data. The complications with the highest sensitivity determined by a diagnosis in the medical records identified within ±60 days of the database date were myocardial infarction (95.2%); amputation (94.4%); ischemic heart disease (90.3%); stroke (91.2%); osteomyelitis (79.2%); and retinal detachment, vitreous hemorrhage, and vitrectomy (73.5%). With the exception of amputation (82.9%), positive predictive value was low when based on a diagnosis identified within ±60 days of the database date but increased with relaxation of the time constraints to include confirmation of the condition at any time during 1993–1995: ulcers (88.5%); amputation (85.4%); and retinal detachment, vitreous hemorrhage and vitrectomy (79.8%). Automated data are useful for ascertaining potential cases of some diabetic complications but require confirmatory evidence when they are to be used for research purposes.

1. Volunteers for health promotion programs tend to be younger and healthier than program participants. 2. Volunteers in a health promotion program reported improved health and function. 3. Nurses involved in health promotion programs can extend their efforts by using trained volunteers.

BACKGROUND: Effective new strategies that complement primary care are needed to reduce disability risks and improve self-management of chronic illness in frail older people living in the community. OBJECTIVE: To evaluate the impact of a 1-year, senior center-based chronic illness self-management and disability prevention program on health, functioning, and healthcare utilization in frail older adults. DESIGN: A randomized controlled trial. SETTING: A large senior center located in a northeast Seattle suburb. The trial was conducted in collaboration with primary care providers of two large managed care organizations. PARTICIPANTS: A total of 201 chronically ill older adults seniors aged 70 and older recruited through medical practices. INTERVENTION: A targeted, multi-component disability prevention and disease self-management program led by a geriatric nurse practitioner (GNP). MEASUREMENTS: Self-reported Physical function, physical performance tests, health care utilization, and health behaviors. RESULTS: Each of 101 intervention participants met with the GNP from 1 to 8 times (median = 3) during the study year. The intervention group showed less decline in function, as measured by disability days and lower scores on the Health Assessment Questionnaire. Other measures of function, including the SF-36 and a battery of physical performance tests, did not change with the intervention. The number of hospitalized participants increased by 69% among the controls and decreased by 38% in the intervention group (P = .083). The total number of inpatient hospital days during the study year was significantly less in the intervention group compared with controls (total days = 33 vs 116, P = .049). The intervention led to significantly higher levels of physical activity and senior center participation and significant reductions in the use of psychoactive medications. CONCLUSIONS: This project provides evidence that a community-based collaboration with primary care providers can improve function and reduce inpatient utilization in chronically ill older adults. Linking organized medical care with complementary community-based interventions may be a promising direction for research and practice.

To pilot test a new behavioral intervention to increase walking in sedentary older adults.Pre-post community-based pilot study.Three senior centers in greater Los Angeles.Forty-six sedentary adults aged 65 and older.At four weekly 1-hour group sessions held at the senior centers, a trained health educator applied a theoretically grounded, standardized "attribution retraining" curriculum developed by a multidisciplinary team of investigators. Participants were taught that becoming sedentary is not inevitable with aging and that older adults should attribute being sedentary to modifiable attributes rather than to old age. A 1-hour exercise class including strength, endurance, and flexibility training followed each weekly attribution retraining session.Change from baseline in steps per week recorded using a digital pedometer was measured after 7 weeks. Age expectations (measured using the Expectations Regarding Aging-38 survey, a previously tested instrument on which higher scores indicate that the participant expects high functioning with aging and lower scores indicate that the participant expects physical and mental decline) and health-related quality of life were measured using in-person interviews.Mean steps per week increased from 24,749 to 30,707, a 24% increase-equivalent to 2.5 miles (2-sided t-test P=.002). Age expectation scores increased 30% (P.001), and the changes in age expectations and steps per week correlated (correlation coefficient=0.39, P=.01). Participants experienced improved mental health-related quality of life (P=.049) and reported less difficulty with activities of daily living (P=.04). More than 50% of participants reported improvements in pain, energy level, and sleep quality.In this small pre-post community-based pilot study, a structured attribution retraining curriculum accompanied by a weekly exercise class was associated with increased walking levels and improved quality of life in sedentary older adults. Attribution retraining deserves further investigation as a potential means of increasing physical activity in sedentary older adults.

The core functions of case management, assessment, planning, linking, monitoring, advocacy, and outreach assume a new perspective in the context of systems that have adopted the Chronic Care Model. This article considers case management through the experience of three systems that have implemented the Chronic Care Model. A movement toward condition neutral case management, focused on care that is more wholly patient centric, is also examined.

Current estimates are that there are 2.3 million individuals with epilepsy among 99 million Americans suffering from chronic medical conditions. The healthcare system is designed to treat acutely ill patients and, as a result, often fails to meet the needs of the chronically ill. Care is provided in brief, problem-focused visits. Multiple studies have shown that this type of standard practice produces suboptimal care and outcomes, and is unsatisfactory to both patients and care providers. We developed the Chronic Care Model in an effort to synthesize system and practice changes associated with better outcomes. In patient care as described in this model, patient–provider interactions are planned in advance in accordance with evidence-based guidelines. A primary focus is on assisting patients and their families in becoming competent self-managers. The Chronic Care Model has been successfully implemented by more than 200 healthcare systems. In this paper, we explore the applicability of the Chronic Care Model in managing patients with epilepsy.

The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.

Introduction Self-management programmes are complex interventions aimed at improving the way individuals self-manage chronic conditions, but there are questions about the overall impact of these programmes on disadvantaged populations, in terms of their capacity to engage with and receive the benefits from these initiatives. Given the increased resources being directed towards self-management initiatives, clinicians and policy makers need knowledge on how self-management interventions work for these populations. Most systematic reviews of self-management interventions do not consider the complex interactions between implementation contexts, intervention strategies, and mechanisms that influence how self-management interventions work in real life for disadvantaged groups. Methods To address the need for better understanding of these mechanisms and to create context-relevant knowledge, we are conducting a realist synthesis of evidence on self-management interventions for disadvantaged populations living with chronic conditions. The primary research question is: What are the key mechanisms operating in chronic condition self-management interventions among disadvantaged populations? In this protocol, we outline the steps we will take to identify the programme theory for self-management interventions and candidate middle-range theories; to search for evidence in academic and grey literature; to appraise and extract the collected evidence; to synthesise and interpret the findings to generate key context-mechanism-outcome configurations and to disseminate results to relevant stakeholder and to peer-review publications. Dissemination Understandings of how chronic conditions self-management interventions work among disadvantaged populations is essential knowledge for clinicians and other decision makers who need to know which programmes they should implement for which groups. Results will also benefit medical researchers who want to direct effort towards current gaps in knowledge in order to advance the self-management field. In addition, the study will make a contribution to the evolving body of knowledge on the realist synthesis method and, in particular, to its application to behaviour change interventions for disadvantaged populations.

Article-at-a-Glance Background Despite rapid advances in the clinical and psycho-educational management of diabetes, the quality of care received by the average patient with diabetes remains lackluster. The "collaborative" approach—the Breakthrough Series (BTS; Institute for Healthcare Improvement [IHI]; Boston)—coupled with a Chronic Care Model was used in an effort to improve clinical care of diabetes in 26 health care organizations. Methods Descriptive and pre-post data are presented from 23 health care organizations participating in the 13-month (August 1998–September 1999) BTS to improve diabetes care. The BTS combined the system changes suggested by the chronic care model, rapid cycle improvement, and evidence-based clinical content to assist teams with change efforts. The characteristics of organizations participating in the diabetes BTS, the collaborative process and content, and results of system-level changes are described. Results Twenty-three of 26 teams completed participation. Both chart review and self-report data on care processes and clinical outcomes suggested improvement based on changes teams made in the collaborative. Many of the organizations evidencing the largest improvements were community health centers, which had the fewest resources and the most challenged populations. Discussion The initial Chronic Illness BTS was sufficiently encouraging that replication and evaluation of the BTS collaborative model is being conducted in more than 50 health care systems for diabetes, congestive heart failure, depression, and asthma. This model represents a feasible method of improving the quality of care across different health care organizations and across multiple chronic illnesses.

Caring for patients with chronic illness in an era of cost constraints and performance monitoring has led to a sharp growth in "disease management" efforts by health systems utilizing internal innovators or outside firms. This paper describes surveys and site visits of the chronic disease management activities of 72 programs nominated by experts in the field of chronic illness care as being particularly innovative and effective. The survey and analysis were guided by a Model for Effective Chronic Illness Care derived from a process of literature synthesis and expert review. The model proved to be useful in describing the characteristics consistently shared by successful programs, and the surveys indicated common barriers to further expansion of innovative pilot programs. The survey indicated that most of the nominated programs were limited in their effectiveness and reach by their reliance on traditional patient education, rather than modern self-management support, poor linkages to primary care, and reliance on referrals rather than population-based approaches.

Renal dysfunction is a common complication in patients with end-stage cirrhosis. Since the original publication of the definition and diagnostic criteria for the hepatorenal syndrome (HRS), there have been major advances in our understanding of its pathogenesis. The prognosis of patients with cirrhosis who develop HRS remains poor, with a median survival without liver transplantation of less than six months. However, a number of pharmacological and other therapeutic strategies have now become available which offer the ability to prevent or treat renal dysfunction more effectively in this setting. Accordingly, we sought to review the available evidence, make recommendations and delineate key questions for future studies. We undertook a systematic review of the literature using Medline, PubMed and Web of Science, data provided by the Scientific Registry of Transplant Recipients and the bibliographies of key reviews. We determined a list of key questions and convened a two-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated recommendations and/or directions for future research. Of the 30 questions considered, we found inadequate evidence for the majority of questions and our recommendations were mainly based on expert opinion. There was insufficient evidence to grade three questions, but we were able to develop a consensus definition for acute kidney injury in patients with cirrhosis and provide consensus recommendations for future investigations to address key areas of uncertainty. Despite a paucity of sufficiently powered prospectively randomized trials, we were able to establish an evidence-based appraisal of this field and develop a set of consensus recommendations to standardize care and direct further research for patients with cirrhosis and renal dysfunction.

1. A normal daily variation in body temperature is found in the elderly. Normal oral temperature in an older person is lower than in a younger person, and the temperature peaks in the early afternoon and is lowest in the early morning hours before awakening. 2. Elderly subjects may be more prone to hypothermia in the early morning hours when their body temperature is naturally lower. Bathing may cause the body temperature to drop up to 1 degree C and add to this risk. 3. Many factors should be considered when analyzing temperature data for the determination of fever. Time of day, as well as symptoms of infection, should be considered. 4. Disturbances in circadian temperature rhythms accompany central nervous system dysfunction and may be an early indicator of other illnesses.