Evidence-Based Practice - Case Study Example

Evidence-Based Practice Before internet entered millions of lives, the role of physicians, nurses and other medical personnel were simply to providepatients instructions and care on disease management (Aujoulat, d’Hoore, & Deccache, 2007). They are considered medical experts and their decisions for patients usually remain unquestioned, giving them an active role in either improving or maintaining the health of their clients. Patients have a more passive role in this relationship, mostly listening and practising health instructions or drinking any prescriptions given by their doctors, trusting their medical knowledge fully (Epstein & Street, 2011). Until the early 90’s, patients mostly ask medical personnel health questions, however this passive role changed when some patients grew became proactive in health or medical self-management. Other than physicians, nurses, dieticians, and other health care personnel patients got medical or health information through television, magazines, and the internet, changing how health care is delivered (Jordan & Osborne, 2007; McMullan, 2006). But medical personnel were also able to use the internet, to find up-to-date information in their field to apply as needed. Some of them also use it to communicate with patients, allowing them to ask questions about their conditions or anything about improving their health without leaving their homes or work (Aujoulat, et al., 2007). This makes the medical personnel-patient relationship function beyond long distances or the lack of physical contact (McMullan, 2006). Physicians must take advantage of this situation by allowing the patients to ask more about their health conditions, have open communications regarding internet-sourced information, and show them respect and rapport to increase their receptiveness to other kinds of health information, alternative health solutions, and be more honest of their medications or other alternative treatments and prevent possible negative side-effects. This way, both sides are empowered especially patients in their hopes of improved health and wellness. Clinical Scenario Mr Miller, a computer programmer, is a moderately obese 51 year old man with type 2 diabetes, first diagnosed 8 years ago. He is trying to quit his smoking habit of some 30 years. Recently at work they offered him an employer-subsidised treatment with nicotine patches to help him quit smoking. However this had previously failed once before and he was reluctant to take bupropion as it was an antidepressant, a group of drugs which he had concerns about. No diabetes complications have been detected thus far and his blood sugar levels appear well controlled. He does have osteoarthritis that has manifested in both knees (which harbour old sporting injuries). His blood pressure has recently become mildly elevated averaging 160/94 mmHg during his past two visits. Mr Miller regularly searches the internet if he has a health question. His wife has encouraged him to take large doses of vitamin E and fish oil for his heart, glucosamine for his knees, and St Johns Wort to help him stop smoking, based on health information gained from their internet searches. Introduction of Evidence-Based Medicine and Evidence-Based Practice to the Millers The scenario shows the Millers are proactive in efforts to stay healthy and are capable of using the internet in guiding their choices. Mr Miller works mostly in the information technology sector hence he has competence and abilities in searching the internet for pertinent health information. His wife may not be as much of an expert but she can also find information in the internet as well. Physicians or medical personnel can easily provide assistance and guidance to the Millers by giving them supplementary information on various health aspects since most the health information is generally accessible to anyone on the internet. This is a great opportunity to introduce to the Millers Evidence-Based Practice and Evidence-Based Medicine, considered to be reliable due to being the products of conclusive results from various clinical and experimental tests (Epstein & Street, 2011). Introducing the couple to evidence-based practice and medicine can help them make informed choices, since the collation of data can either back-up or bring down many of their beliefs and ideas concerning health and wellness. Areas of Concern Relying mostly on the internet rather than health practitioners can cause potential problems for the couple due to their incomplete knowledge such as on drug interactions and different drug effects in the body. Informing the couple about information normally withheld in sites catering the general public helps them gain more confidence in screening important internet health information and become more open and trusting to medical personnel in airing their issues or other health concerns. In the clinical scenario, the Millers have no reservations in using alternative and over-the-counter medicine. Heavy reliance on alternative or over-the-counter medicine is a serious concern, especially since the Millers readily apply information from the internet. Most of the time this does not cause any health concerns, but because Mr Miller has health conditions such as diabetes, obesity and hypertension, reliance on over-the-counter drugs or alternative medicine without sufficient knowledge or pertinent supporting information regarding product use can cause potential health problems such as interactions between the active ingredients of various drugs, negation of drug effectiveness from drug interactions, liver or kidney problems from drug metabolites, or inhibitions of various enzymes and affect organs (Borrelli & Izzo, 2009). Since the internal organs of diabetics already have additional burdens from impaired fatty-acid metabolism, glucose metabolism resistance and fat-deposition in internal organs such as the liver, heart or the blood vessels, added external stressors such as excessive vitamins or drugs could put strain in the organs, and may result to organ damage or failure (Després & Lemieux, 2006). The Millers must be notified as early as possible of the negative effects of drug usage without sanctions from physicians while Mr Miller has no diabetes complications, so they could be properly informed and through informed choices prevent any further damage to the patient’s organs. Aside from over-the-counter and alternative medicine reliance, another major concern is Mr Miller’s body-mass-index, which remained moderately-obese despite having diabetes for eight years. Mr Miller’s awareness of this condition helped manage diabetes, but might have given lesser attention to weight reduction and management. The Millers must know that while weight and waist circumference reduction may be the biggest roadblock for Mr Miller to achieve better health, overcoming this hurdle can greatly improve Mr Miller’s other health conditions due to the strong link between obesity and other diseases such as diabetes, joint pains, and high blood pressure (Bray, 2004; Després & Lemieux, 2006; Eckel, Grundy, & Zimmet, 2005). The last major concern is Mr Miller’s 30 year-old smoking habit. It seems he favours ceasing the habit more than weight loss due to his previous attempt to quit using nicotine patches. Mr Miller did not disclose reasons bupropion-use reluctance, but it is still important that he and his wife are informed of other non-nicotine replacement therapies available, briefly describe the effects of each drug, how each works and drug success rates compared with nicotine-replacement therapies (Eisenberg, et al., 2008; Japuntich, et al., 2011). Also, the effectiveness or side-effects of alternative medications must be discussed to them using data from evidence-based practices and medicine, should they choose herbal remedies for smoking cessation. Explaining how pharmacological therapies and alternative medicine differ to from one another can inform the couple better in aiding Mr Miller’s smoking cessation. Potential Areas of Sensitivity The Millers’ reliance on internet makes them seem reluctant on consulting medical personnel about health concerns. Thus the major area of sensitivity for the couple would be communications between medical personnel. To address this, personnel interacting with the couple must establish rapport with them so that they can be more agreeable for interactions and suggestions from medical professionals. This is because many patients shy away from medical personnel not because of competence or qualifications, but rather due to the professionals’ reluctance in addressing patient inquiry carefully and respectfully without any judgment (Pelzang, 2010). Also, due to readily-available health information in the internet and time constraints from either or both the patients and the medical personnel, patients tend to ease their worries by finding answers in the most immediate source available: the internet (McMullan, 2006). Rather than reacting negatively to such efforts, medical professionals must recognise such health efforts to empower and encourage the couple to improve their health through lifestyle changes, regular health check-ups or other activities entailing more interaction and communication with health care professionals rather than solely relying on non-evidence based internet information. To prevent untoward incident from patients acting on their own and simply relying on internet information medical personnel must introduce patient-centred health care through shared decision making, allowing proper patient monitoring while having their choices and values taken into consideration (Watson, Thomson, & Murtagh, 2008). Through this shared decision patients can tell their physicians health-related concerns and beliefs, and allows for a dialogue between practitioner and patient on medical intervention effectiveness and respectful interactions through exchanges of trust between both parties. Professionals can provide pertinent information on what the patients need, and patients can share their concerns or worries about treatment methods or drug side-effects to professionals (Groene, 2011). To make the Millers feel comfortable in sharing information such as values or beliefs, practitioners that work with them including myself must interact respectfully, neutrally and supportively as possible, without indifference or bias to prevent miscommunications that could further push them away from seeking medical professional help. Communication and Advice Strategies Mr and Mrs Miller seem to openly communicate with each other on maintaining health, therefore an overall strategy I will use when talking with them about Mr Miller’s health issues is to involve both Mr and Mrs Miller in each step of the treatment process, share important information that they can also search on their own and resolve health concerns through shared decision-making with them. In meeting the Millers for initial assessment, I will ask the couple if they have goals for Mr Miller’s better health such as smoking cessation, normalising blood glucose and blood pressure levels, decreasing body-mass index, or achieving better health through lifestyle changes such as better dietary habits or increased daily physical activity, to better understand the couple’s needs and create a care plan suitable to them. (Pelzang, 2010). Also, I will ask the couple how they get and use health information, and if they do share how I will listen fully to their explanations without showing any disrespect. I will also commend them on their efforts to improve their health, since it seems that despite relying more on physicians regarding treatment plans, they still try their best to be healthy, which is better than not caring all about their health. This will also help them become much comfortable with me and become more open about their ideas and health habits, such as Mr Miller’s concern over the use of bupropion to quit smoking. Establishing connection with the couple is important for the therapy to work since it has been reported that patients’ reluctance to talk and listen to physicians stem from being intimidated by some attendants or physicians and their lack of rapport (Jordan & Osborne, 2007). Since the couple seems capable of using the internet for their health concerns, this is a good opportunity to introduce them to evidence-based practice and evidence-based medicine, how these two work, how to find these in the internet and other related information they might need. I will also explain the importance of informed decision-making on health, and potential dangers of following health claims without finding experimental proof of effectiveness, especially in relation to Mr Miller’s consumption of over-the-counter medicines without physician supervision or the use of alternative medicine such as St John’s wort with insufficient backing information on its effects on the body, or lack of it (Borrelli & Izzo, 2009). I will not only explain evidence-based practice and medicine to the Millers, but also the present state of Mr Miller’s overall health, its implications on him and his wife, some problems that can arise from Mr Miller’s conditions and what to do to prevent them by citing some facts based on evidence-based medicine along with some sources they can find online. Informing them that not making necessary health and lifestyle changes immediately can affect their quality of life through Mr Miller’s future acquisition of diseases such as stroke, lung diseases or organ failure due to hypertension, smoking and diabetes and decrease his lifespan, in turn affecting Mrs Miller as well (Després & Lemieux, 2006; Klein, et al., 2004; Wadden, Butryn, & Wilson, 2007; Olijhoek, et al., 2004). This is because while Mr Miller may not feel any disease complications now, his obesity, diabetes and smoking still causes incremental damage to his organs through fatty deposition, organ and lung damage and his body will suffer a few years from now, which could have been prevented even with a weight loss of 5% total weight, reduction of insulin resistance and early smoking cessation (Atkins & Zimmet, 2010; Eckel, Grundy, & Zimmet, 2005; Fletcher, et al., 2005). Since the Millers demonstrated good communications with one another and capability in finding information through internet browsing, they will benefit more from sites containing health information collected through clinical trials, meta-analyses, reviews, or through syntheses. Database sites can be referred to the couple such as The Cochrane Database of Systematic Reviews, The US National Library of Medicine, BioMed Central, and PLOS Medicine, if they need additional information that they forgot to ask their general practitioner or family physician. Motivating and empowering the couple to visit sites providing information based on tests conducted by experts can better inform them, help them be more scrupulous in believing or adapting any readily available health-related information on the internet, and create achievable health goals based more on evidence-based practice and medicine. Care Plan The following care plan will be presented to the Millers for reading, evaluation and assessment, to incorporate their ideas and ask for additional actions, so they could feel a degree of control on managing their health and be motivated to be more proactive. Significant Problem: Obesity/Weight-loss and Waistline reduction Goals: Reduce body-mass index and waist-to-hip ratio to normal (BMI near 25, waist-to-height ratio below 1.0) within a year Adapt healthy eating habits and additional physical activities into daily routine Pursue long-term lifestyle changes through behaviour-modification Increase physical activity tolerance, from baseline to 15-20 minutes per session and up to 30 minutes, 5-6 sessions per week Needs: Record initial health measurements and laboratory examination results (e.g. weight, height, waist circumference, blood sugar levels, total cholesterol, etc.) Cardiologist’s assistance to get baseline physical activity tolerance Physiotherapist’s assistance in aiding choices for individual or joint physical activities Nutritionist-dietician’s assistance for a healthy diet plan Accommodate patient queries on care plan or other alternative treatment methods Patient’s Role in the Care Plan: Select preferred physical activities If patient wants programmed activities (exercises), select low-impact exercises like walking or swimming and exercise a total of three hours per week Must report to physician or cardiologist any discomfort such as chest or knee pain while doing the exercises, and set appointment for a health assessment Immediate relations are encouraged to join in these activities for patient’s additional motivation and enjoyment Freely choose what to eat, as long as these are within the ranges recommended or prescribed by the nutritionist-dietician Expected Outcome: Increased time spent on physical activities per week Increased physical activity tolerance limit Decreased weight gradually without any other health complications Decreased waistline size gradually Be more knowledgeable, sensitive, and actively partake in food preparations and portion allotment based on daily nutritional requirement/as prescribed by nutritionist-dietician Overall improvement in quality of life Supporting Literature: Obesity causes metabolic changes such as insulin resistance resulting to diabetes mellitus, excess cholesterol causing gallbladder disease, hypertension and cardiovascular diseases resulting from blood vessel constrictions due to fat deposits, and non-metabolic problems such as osteoarthritis due to additional pressure of excess body mass (Bray, 2004; Després & Lemieux, 2006; Klein, et al., 2004). Reducing body weight at least 5-10% is enough to reduce diabetes, hypertension and cardiovascular diseases risks (Eckel, Grundy, & Zimmet, 2005; Klein, et al., 2007; Wadden, et al., 2007). Motivation through medical personnel and family members, continued contacts with other health team members and behavioural modification improves patient morale and empowerment, increaing patient likelihood of attaining normal body-mass index, waist-to-hip ratio, blood glucose and cholesterol levels (Jordan, et al., 2008; Klein, et al., 2004; Poirier, et al., 2006; Tan, et al., 2006; Wadden, et al., 2007). Significant Problem: Hypertension Goal: Reach and maintain normal blood pressure levels (below 135/85 mm Hg) within a year Needs: Check patient’s initial average blood pressure Periodically check average blood pressure changes Prescribe maintenance drugs (antihypertensive medicine or anticoagulants) or supplements (fish oil, vitamin E capsules) in moderation Nutritionist-dietician assistance in making a diet plan to reduce blood pressure levels Foods with protective properties (e.g. fish, flaxseeds, other sources of omega-3 and docosahexaenoic acid) Reduce blood levels of low-density lipoprotein cholesterol and increase high-density lipoprotein cholesterol levels Accommodate patient queries on care plan or other alternative treatment methods Patient’s Role in the Care Plan: Monitor blood pressure daily, especially before and after physical activities Report any kind of discomfort or health issues due to hypertension medication or supplement use Adhere to prescribed medicines’ dosages Freely choose foods containing healthy levels of omega-3 and other protectants, as prescribed by the nutritionist-dietician Talk to general practitioner or physician on other alternatives in lowering blood pressure levels Expected Outcome: Reach and maintain normal blood pressure levels within a year Patient cholesterol levels at or near normal range Better dietary habits and consciousness for patient and immediate family Increase physical activity tolerance Supporting Literature: Obesity and fatty tissue depositions alter cardiac tissue and blood vessel structure, causing heart function complications and the reduced elasticity and diameter of blood vessels leading to heart failure, coronary heart disease, hypertension, increased prevalence of peripheral arterial disease and aneurysm (Fletcher, et al., 2005; Olijhoek, et al., 2004; Poirier, et al., 2006). Frequently monitoring blood pressure levels contribute to reduction of blood pressure levels and subsequently reduce the risks for vascular complications, cardiovascular events, (Cappuccio, et al., 2004; Trialists’ Collaboration, B.P.L.T., 2005). Consumption of foods rich in omega-3, docohesaxaenoic acid, alpha-linolenic acid and high-density lipoprotein cholesterol assist in reducing the risks of cardiovascular events through a combination of antithrombotic, antiarrythmic, antiatherosclerotic, and anti-inflammatory effects, improving blood vessel and endothelial tissue elasticity, and reducing triglyceride concentrations in the bloodstream (Din, Newby, & Flapan, 2004; Esposito, et al., 2004; Fletcher, et al., 2005; Holub & Holub, 2004; Rodriguez-Leyva, et al., 2010; Trialists’ Collaboration, B.P.L.T., 2005). Vitamin E may aid in cardiovascular improvement by decreasing low-density lipoprotein cholesterol levels and inflammation events, but excesses could still negate positive effects due to oxidative stress and free-radical formation (Devaraj, et al., 2008; Mafra, et al., 2009). Significant Problem: Diabetes Goals: Reduce and maintain fasting blood glucose levels at less than 1g/L or 5.5 mmol/L Reduce Haemoglobin A1c levels down to less than 7.0% Better insulin response Needs: Check patient’s initial fasting blood glucose, random blood glucose and Haemoglobin A1c levels Endocrinologist assistance for other tests Diabetic medications prescription Nutritionist-dietician assistance on low-glycaemic index meals Accommodate patient queries regarding care plan or other alternative treatment methods Patient’s Role in the Care Plan: Perform daily blood glucose tests at home Periodically-assess blood glucose level changes Report any discomfort or symptoms from diabetic drugs use Choose low glycaemic-index food as recommended or prescribed by the nutritionist-dietician Talk to general practitioner or family physician on other alternative blood glucose level reduction methods Expected Outcome: Reach and maintain normal blood glucose and Haemoglobin A1c levels safely Improved food choices and dietary habits Improved insulin response Reduced diabetic medication reliance Supporting Literature: Structured patient and family education combined with integrated and patient-centred health care on diabetes management can significantly improve blood glucose levels and insulin response (Choe, et al., 2005; Home, et al., 2008) Periodic blood glucose level self-assessments by diabetic patients can reduce blood glucose levels (Deakin, et al., 2005). Since diabetes can contribute to vital organ diseases such as end-stage renal failure and chronic liver disease, blood pressure medications and improved insulin response can reduce end-stage renal disease due to diabetes (Atkins & Zimmet, 2010; Cushman, et al., 2010; Younossi, et al, 2011). Physician or general practitioner communication with patient can affect treatment adherence, and lack of open communications can cause patient to lose motivation and treatment adherence, and general practitioner support and guidance (Eckel, et al., 2005; Klein, et al., 2004; Wens, et al., 2005). Significant Problem: Smoking Goal: Reduce or quit smoking within a year Needs: Record initial daily cigarette consumption Monitor progress in daily cigarette consumption Provide information available on other non-nicotine replacement therapies Discuss each drug effect as clearly as possible Accommodate patient queries regarding care plan or other alternative treatment methods Refer patient to a behavioural therapist for additional motivation and counselling if needed Patient’s Role in the Care Plan: Report initial daily cigarette consumption Talk to general practitioner about periodic targets in reducing daily cigarette use Choose non-nicotine replacement therapy to use Report any side-effects or other experiences in drug-use Monthly assess therapy effectiveness (e.g. withdrawal symptoms) Assess or detect any health changes or improvements Talk to general practitioner or physician on alternative smoking cessation methods Expected Outcome: Reduced or ceased cigarette use Reduced reliance on St John’s Wort or other herbal remedies Improved respiratory health Supporting Literature: Smoking cessation and abstinence cause anxiety, depressive symptoms and weight gain, thus patients are prescribed with nicotine-replacement drugs and anti-depressants aside from behavioural modification interventions (Hajek, et al., 2009; Parsons et al., 2009). St. John’s Wort smoking cessation effectiveness has not been established, some trials state high relapse and dropout rates suggesting lack of effectiveness (Sood, et al., 2010). Antidepressant properties also varies among trials: countries having a long-standing tradition of its use report having better results than placebo possibly due to a cultural effect, in other studies its effectiveness is limited to minor depression only (Carpenter, et al. 2008; Linde, Berner, & Kriston, 2008). Use of St John’s Wort among diabetics must be minimised or removed entirely due to possible disease complications, especially since the active ingredients in St John’s Wort can interact with other drugs and reduce efficacy (Borrelli & Izzo, 2009; Xu, et al., 2009). Patient must be informed of smoking cessation “milestones”: achieving short-term abstinence, avoiding a lapse, and if lapse occurs, avoid a relapse, for patient to create achievable and realistic goals, and for physician to provide assistance and support in abstinence, to prevent frustrations on the patient’s part (Chapman & MacKenzie, 2010; Japuntich, et al., 2011). Commonly used smoking cessation drugs include nicotine replacement therapy like various nicotine-containing products (patches, nasal spray, tablet, gum and lozenge), and non-nicotine replacement therapy including bupropion (tablet, patch, lozenge), varenicline, nortiptyline, clonidine, mecamylamine, and monoamine oxidase inhibitors such as moclobemide (Eisenberg, et al., 2008; Japuntich, et al., 2011; Piper, et al., 2009; Roddy, 2004). Significant Problem: Osteoarthritis Goal: Reduce glucosamine reliance or other over-the-counter osteoarthritis medicines Needs: Record patient’s glucosamine daily intake Reduce dosage with observed weight loss Periodic assessments on joint condition improvements Accommodate patient queries regarding care plan or other alternative treatment methods Patient’s Role in the Care Plan: Report initial glucosamine dosage to general practitioner Report any changes or lack of changes in joint pain during the weight-loss period Decide whether to continue glucosamine intake or choose other alternative joint medications Expected Outcome: Less reliance on glucosamine Reduced glucosamine consumption Improved mobility from weight loss and reduced glucosamine intake combined Supporting Literature: There has been few supporting literature on glucosamine eliminating osteoarthritis or curing it completely (Black, et al., 2009; Towheed, et al., 2009). However, it is highly effective in terms of suppressing disease progression and pain elimination compared with placebo, possibly due to anti-catabolic rather than anabolic effects (Reginster, Bruyere, & Neuprez, 2007; Vlad, et al., 2007). Compared with other pain-killers, glucosamine does not have any significant differences to other non-steroidal anti-inflammatory drugs, and lacking any healing effect is not cost-effective (Black, et al., 2009; Wandel, et al., 2010). Read More