Case Study Power Points

CASE IX

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Presentation

J.T. is a 72-year-old man with chronic hepatitis C and Child-Pugh grade A (clinically well-compensated) cirrhosis. He takes propranolol (propranolol 20 mg PO BID) for esophageal variceal bleeding prophylaxis. He had a blood transfusion 25 years ago. Hepatitis C was diagnosed 10 years ago, and cirrhosis was diagnosed by liver biopsy 2 years ago. He does not drink alcohol. He has never been overweight. He has no personal or family history of diabetes. Over the past year, random plasma glucose levels have ranged from 110 to 180 mg/dl. The most recent random glucose was 210 mg/dl. The patient denies polydipsia, polyuria, nocturia, or any other symptoms of hyperglycemia. He weighs 150 lb. (BMI 22 kg/m2).

Physical examination findings are normal except for mild palmar erythema, spider angiomata on the upper chest, and a palpable spleen tip. Fasting blood glucose was 136 mg/dl, and hemoglobin A1c (A1C) was 6.3%. Another fasting glucose several weeks later was 128 mg/dl.

At first glance, many clinicians might assume this patient has type 2 diabetes. The history is compatible with this diagnosis. However, the absence of classic risk factors for type 2 diabetes and the appearance of new hyperglycemia in the setting of known cirrhosis makes it more likely he has “liver diabetes,” also known as hepatogenous diabetes.1,2 Patients with cirrhosis have insulin resistance. Impaired glucose tolerance (IGT) is common, and about 20–40% have diabetes.1,3 While there is no definitive test to distinguish type 2 diabetes from diabetes caused by liver disease, liver diabetes appears to be caused by hepatic dysfunction. It should be noted that the American Diabetes Association and the World Health Organization do not recognize liver diabetes as a specific type of diabetes. Regardless of whether the diagnosis is that of liver diabetes or type 2 diabetes, decisions about when and how to treat hyperglycemia should take into account comorbid conditions such as hepatic dysfunction.

This patient has only a minimal elevation in A1C, and the value is within standard treatment goals for diabetes. However, it should be noted that A1C reference ranges assume a normal erythrocyte life span. Older erythrocytes have higher A1C levels than younger cells. Any condition that reduces erythrocyte survival, such as cirrhosis4 or hemolysis resulting from hypersplenism can cause spuriously low A1C levels. Therefore, in this patient, it would be desirable to institute home blood glucose monitoring in order to better assess the severity of his hyperglycemia. The decision about whether to start treatment for any condition is based on a comparison of the risks and benefits of that treatment. First, a review is in order of the risks of each therapeutic option that should be considered for patients with hepatic dysfunction.

Diet and exercise are usually considered a very safe first-line of therapy for patients with mild hyperglycemia. However, many patients with cirrhosis are malnourished, and dietary restriction with a goal of weight loss may exacerbate hypoalbuminuria and worsen overall prognosis. If dietary restriction results in lower vitamin K intake, then a coagulopathy may result. Every class of oral hypoglycemic medication currently available in the United States has been associated with at least a small risk of hepatotoxicity. For patients with marginal hepatic function at baseline, even mild hepatotoxicity can be fatal. Hepatic dysfunction can also cause an exaggerated response to a standard dose of medication and a higher risk of side effects if the drug is metabolized by the liver. Sulfonylureas, repaglinide, metformin, and thiazolidinediones are all extensively metabolized by the liver. It is generally advised that metformin and thiazolidinediones should not be used in patients with significant hepatic dysfunction. For these reasons, many clinicians use insulin as a first-line agent to treat diabetes in cirrhotic patients. The main risk of insulin is severe hypoglycemia. Patients with cirrhosis have reduced hepatic glycogen stores. Glucagon may stimulate less hepatic glycogenolysis in cirrhotic patients than in patients without liver disease.1 Also, many patients with severe hepatic dysfunction have hepatic encephalopathy, which may impair their ability to comply with instructions about therapy. Patients with cirrhosis and diabetes have a shorter life expectancy than do nondiabetic patients with cirrhosis, but they typically die of complications of liver disease, such as gastrointestinal hemorrhage, rather than from complications of diabetes, such as cardiovascular disease.2,3,5 This suggests that in cirrhotic patients, the development of diabetes reflects a greater degree of liver failure. No studies have been conducted to determine whether patients with cirrhosis benefit from diabetes treatment. However, there are several situations in which cirrhotic patients would be expected to benefit from glucose control. Treatment for symptomatic hyperglycemia should be used to reduce symptoms. Treatment of persistent hyperglycemia would be expected to lessen the risk of infection. Patients with A1C results ≥ 7% who are awaiting liver transplantation or whose life expectancy is expected to be several years might benefit from a lower risk of diabetes complications if their diabetes is treated.

In J.T.’s case, he was observed off therapy for about 6 months. He eventually started low-dose insulin (lispro 3 units SQ before meals and glargine 5 units SQ Q HS) for persistent hyperglycemia > 200 mg/dl, A1C > 7.5%, and patient preference. He did not have any episodes of severe hypoglycemia.

INSTRUCTIONS

You are the nurse during his initial visit to the hospital. After completing a comprehensive health history and physical examination, you move on to provide client education on his medications and three health promotion topics appropriate to his case.

Clinical Pearls

• Severe hepatic dysfunction can cause IGT and diabetes. The clinical distinction between type 2 diabetes and liver diabetes is based on the onset of diabetes relative to the onset of cirrhosis and on whether the patient has typical risk factors for type 2 diabetes.

• A1C results may be spuriously low in patients with severe liver dysfunction.

• All currently available oral hypoglycemic agents pose some risk of hepatotoxicity. Metformin and thiazolidinediones should be avoided in patients with significant hepatic dysfunction. Many clinicians consider insulin to be the first-line agent for treating diabetes in patients with significant liver disease, although some clinicians advocate the cautious use of sulfonylureas in this situation.1

• Patients with cirrhosis are especially susceptible to hypoglycemia and may respond poorly to glucagon.

• Among patients with cirrhosis and diabetes, the main cause of death is hepatic failure rather than cardiovascular disease or other complications of diabetes.

• An individualized assessment of risks of benefits of diabetes treatment should be considered for each patient.

Marguerite McNeely, MD, MPH, is an assistant professor in the Division of General Internal Medicine at the University Of Washington School Of Medicine in Seattle.

REFERENCES

1 Petrides AS: Liver disease and diabetes mellitus. Diabetes Revs 2:2–18, 1994 2

2Holstein A, Hinze S, Thieben E, Plaschke A, Egberts E-H: Clinical implications of hepatogenous diabetes in liver cirrhosis. J Gastroenterol Hepatol 17:677–681, 2002

3 Marchesini G, Ronchi M, Forlani G, Bugianesi E, Bianchi G, Fabbri A, Zoli M, Melchionda N: Cardiovascular disease in cirrhosis. Am J Gastroenterol 94:655–662, 1999

4 Owens D, Jones EA, Carson ER: Studies on the kinetics of unconjugated [14C] bilirubin metabolism in normal subjects and patients with compensated cirrhosis. Clin Sci Mol Med 52:555–570, 1977

5 Bianchi G, Marchesini G, Zoli M, Bugianesi E, Fabbri A, Pisi E: Prognostic significance of diabetes in patients with cirrhosis. Hepatology 20:119–125, 1994

Competitive Advantage.

  1. Discuss the resource-based view of competitive advantage. Why is it important to understand organizational differences to use this approach?
  2. Briefly define what is meant by competitive advantage. Are competitive advantage and sustained competitive advantage identical concepts? Compare and contrast the two concepts.

Professional Development:

Case Study #12: AIDSCAP Nepal

  • Conduct an internal environmental analysis, identifying the value-creating strengths and weaknesses for each value chain component. Model your response after Exhibit 4-4 (p. 144) “Value Creating Strengths and Value Reducing Weaknesses.”
  • For each strength, assess the competitive relevance, using Exhibit 4-6 (p. 149) as an example.
  • Exhibit 4–4: Value Creating Strengths and Value Reducing Weaknesses for American Healthways, Inc.
  • Value Chain Component
  • Service Delivery, Pre-Service
  • Service Delivery, Point-ofService
  • Service Delivery, AfterService
  • Support Activities, Culture
  • Support Activities, Strategic Resources
  • Value Reducing Weakness
  • • Limited brand identity • Disease management and care enhancement contracts require extensive selling because of lack of knowledge of key benefits • Revenues subject to seasonal pressures from enrollment processes of contracted health plans
  • • Company/employees have less experience in care enhancement programs in expanded product line areas such as end-state renal disease, fibromyalgia, etc. • A majority of company’s revenues accounted for by three health plans
  • • Incomplete or inaccurate data could render independent evaluation of clinical interventions useless
  • • Acquisition of StatusOne Health System with different culture • Company’s reluctance to declare cash dividend may discourage some classes of investors
  • • Hospital contracts decreasing • Cost to maintain IT for compliance with federal and state regulations • High labor costs from competition for staff • Volatility of stock price and trading volume
  • Value Creating Strength
  • • Customer benefit: care enhancement/disease management concept (attractive to health plans, hospitals, physicians, patients) • Customer benefit developed: geographical coverage (attractive to large health plans) • Six care enhancement centers
  • • Successful management of diseases leading to reduced costs and increased customer satisfaction • Company employees highly experienced in implementing care enhancement programs in certain areas, such as diabetes • Integrated care product line attracts broad range of patients • Number of covered lives increasing making economies of scale possible
  • • Alliance with Johns Hopkins Health System to independently evaluate effectiveness of clinical interventions
  • • First disease management and care enhancement provider in nation accredited by all three accrediting agencies • Highly professionalized culture • Experienced management team of individuals with extensive health care experience and longevity with the company • Conservative fiscal management philosophy: retain earnings for future growth and development • Company has state-of-the-art medical information technology • Company has sound financial position: cash, working capital, stockholder equity increasing over past year • Earnings per share of common stock has increased despite 3:2 stock split in 2001 and 2:1 stock split in 2003.

Exhibit 4–6: Strategic Thinking Map of Competitive Advantages Relative to Strengths in General

Is the Value of the Strength High or Low? (High/Low?)

H

H

H

H

H

H

H

H

Is the Strength Rare? (Yes/No)

N

N

N

N

Y

Y

Y

Y

Is the Strength Easy or Difficult to Imitate? (Easy/Difficult)

E

E

D

D

E

E

D

D

Can the Strength Be Sustained? (Yes/No)

Y

N

Y

N

Y

N

Y

N

Implications

No competitive advantage. Most competitors have the strength and those that do not can develop it easily. All can sustain it. Maintenance strategy.

No competitive advantage. All competitors have the strength which is easy to develop. Strength is not sustainable so it represents only a short-term advantage.

No competitive advantage. Many competitors possess the strength but it is difficult to develop, so care should be taken to maintain this strength.

No competitive advantage. Many competitors possess the strength but it is difficult to develop, and those who do possess it will not be able to sustain the strength. Only a short-term advantage.

Not a source of long-term competitive advantage. Because it is valuable and rare, competitors will do what is necessary to develop this easy-to-imitate strength. Short-term advantage. Should not base strategy on this type of strength but should obtain benefits of short-term advantage.

Not a source of competitive advantage. The strength is easy to imitate and cannot be sustained. Short-term advantage. Do not base strategy on this type of strength but obtain benefits of short-term advantage.

Source of long-term competitive advantage. If value is very high, it may be worth “betting the organization” on this strength.

Possible source of short-term competitive advantage but not a strength that can be sustained over the long run.

Ginter, P. M., Duncan, W. J., & Swayne, L. E. (2013). Strategic Management of Health Care Organizations (7th ed.). San Francisco: Jossey-Bass.

Failure Of Democracy And The Rise Of Totalitarianism

Required Resources
Read/review the following resources for this activity:

  • Textbook: Chapter 4, 5
  • Lesson
  • Minimum of 1 scholarly source (in addition to the textbook)

Initial Post Instructions
During the 1930s, much of the world seemed to give up on their hope for a democratic solution to their problems and instead turned to totalitarianism, both in Europe and in Asia.

For the initial post, select and address one of the following:

  • Germany/Hitler
  • USSR/Stalin
  • Japan/Tojo

Address the following questions for your selection:

  • What effects did the history, politics, and economies of those areas play in their decisions to turn to totalitarianism?
  • What role did the Great Depression in the United States play in their plight?

Assessment 2 Instructions: Ethical And Policy Factors In Care Coordination

Select a community organization or group that you feel would be interested in learning about ethical and policy issues that affect the coordination of care. Then, develop and record a 10-12-slide, 20-minute presentation, with audio, intended for that audience. Create a detailed narrative script for your presentation, 4-5 pages in length.

As coordinators of care, nurses must be aware of the code of ethics for nurses and health policy issues that affect the coordination of care within the context of the community. To help patients navigate the continuum of care, nurses must be proficient at interpreting and applying the code of ethics for nurses and health policy, specifically, the Affordable Care Act (ACA). Being knowledgeable about ethical and policy issues helps ensure that care coordinators are upholding ethical standards and navigating policy issues that affect patient care.

This assessment provides an opportunity for you to develop a presentation for a local community organization of your choice, which provides an overview of ethical standards and relevant policy issues that affect the coordination of care. Completing this assessment will strengthen your understanding of ethical issues and policies related to the coordination and continuum of care, and will empower you to be a stronger advocate and nursing professional.

It would be an excellent choice to complete the Vila Health: Ethical Decision Making activity prior to developing the presentation. The activity provides a helpful update on the ethical principles that will help with success in this assessment.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

  • Competency 4: Defend decisions based on the code of ethics for nursing.
    • Assess the impact of the code of ethics for nurses on the coordination and continuum of care.
  • Competency 5: Explain how health care policies affect patient-centered care.
    • Explain how governmental policies related to the health and/or safety of a community affect the coordination of care.
    • Identify national, state, and local policy provisions that raise ethical questions or dilemmas for care coordination.
  • Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
    • Communicate key ethical and policy issues in a presentation affecting the coordination and continuum of care for a selected community organization or support group. Either speaker notes or audio voice-over are included.

Preparation

Your nurse manager at the community care center is well connected and frequently speaks to a variety of community organizations and groups. She has noticed the good work you are doing in your new care coordination role and respects your speaking and presentation skills. Consequently, she thought that an opportunity to speak publicly about contemporary issues in care coordination would be beneficial for your career and has suggested reaching out to a community organization or support group to gauge their interest in hearing from you, as a care center representative, on a topic of interest to both you and your prospective audience.

You have agreed that this is a good idea and have decided to research a community organization or support group that might be interested in learning about ethical and policy issues related to the coordination of care. Your manager has suggested the following community organizations and support groups, but acknowledges that the choice is yours.

  • Homeless shelters.
  • Local religious groups.
  • Nursing homes.
  • Local community organizations (Rotary Club or Kiwanis Club).

To prepare for this assessment, you may wish to:

  • Research your selected community organization or support group.
  • Review the Code of Ethics for Nurses With Interpretive Statements and associated health policy issues, specifically, the ACA.
  • Review the assessment instructions and scoring guide to ensure you understand the work you will be asked to complete.
  • Allocate sufficient time to rehearse your presentation before recording the final version for submission.

Note: Remember that you can submit all, or a portion of, your draft presentation to Smarthinking Tutoring for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Recording Equipment Setup and Testing

Check that your audio speaker and PowerPoint software are working properly. You can record audio directly to your slides, using PowerPoint or other presentation software.

Note: Technical support about the use of PowerPoint, including voice recording and speaker notes, can be found on Campus’s Microsoft Office Software page.

  • If using Kaltura, refer to the Using Kaltura tutorial for directions on recording and uploading your presentation in the courseroom.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact DisabilityServices@capella.edu to request accommodations.

Instructions

For this assessment:

  • Choose the community organization or support group that you plan to address.
  • Develop and record a presentation, with typed speaker notes (the script for your voice recording) and audio voice-over recording, intended for that audience. Video is not required.

Note: PowerPoint has a feature to type the speaker notes directly into the presentation. You are encouraged to use that feature or you may choose to submit a separate document. See Microsoft Office Software for technical support about the use of PowerPoint, including voice recording and speaker notes.

Note: For this assessment, develop your presentation slides and speaker notes, then record your presentation. You are not required to deliver your presentation to an actual audience but you certainly could if you chose to.

Presentation Format and Length

You may use PowerPoint (recommended) or other suitable presentation software to create your slides and add your voiceover. If you elect to use an application other than PowerPoint, check with your faculty to avoid potential file compatibility issues. You can also record your presentation using Kaltura or similar software.

Be sure that your slide deck includes the following slides:

  • Title slide.
    • Presentation title.
    • Your name.
    • Date.
    • Course number and title.
  • References (at the end of your presentation).

Your slide deck should consist of 10–12 slides, not including a title and references slide with typed speaker notes and audio voice over. Your presentation should not exceed 20 minutes.

Create a detailed narrative script for your presentation, approximately 4–5 pages in length.

Supporting Evidence

Cite 3–5 credible sources from peer-reviewed journals or professional industry publications to support your presentation. Include your source citations on a references page appended to your narrative script.

Grading Requirements

The requirements outlined below correspond to the grading criteria in the Ethical and Policy Factors in Care Coordination Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

  • Explain how governmental policies related to the health and/or safety of the community affect the coordination of care.
    • Provide examples of a specific policy affecting the organization or group.
    • Refer to the assessment resources for help in locating relevant policies.
    • Be sure influential policies include the Health Insurance Portability and Accountability Act (HIPPA).
  • Identify national, state, and local policy provisions that raise ethical questions or dilemmas for care coordination.
    • What are the implications and consequences of specific policy provisions?
    • What evidence do you have to support your conclusions?
  • Assess the impact of the code of ethics for nurses on the coordination and continuum of care.
    • Consider the factors that contribute to health, health disparities, and access to services.
    • Consider the social determinants of health identified in Healthy People 2020 as a framework for your assessment.
    • Provide evidence to support your conclusions.
  • Communicate key ethical and policy issues in a presentation affecting the coordination and continuum of care for a selected community organization or support group. Either speaker notes or audio voice-over are included.
    • Present a concise overview.
    • Support your main points and conclusions with relevant and credible evidence.
Additional Requirements

Before submitting your assessment, proofread your presentation slides and speaker notes to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your presentation.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.