Understanding the Methodological Issues and Solutions in the Research Design of Stroke Caregiving Technology

The rise in the number of cases of stroke has resulted in a significant burden on the healthcare system. As a result, the majority of care for the person living with stroke occurs within the community, resulting in caregivers being a central and challenged agent in care. To better support caregivers during the recovery trajectory poststroke, we investigated the role of health technologies to promote education and offer various kinds of support. However, the introduction of any new technology comes with challenges due to the growing need for more user-centric systems. The integration of user-centric systems in stroke caregiving has the potential to ensure long-term acceptance, success, and engagement with the technology, thereby ensuring better care for the person living with stroke. We first briefly characterize the affordances of available technologies for stroke caregiving. We then discuss key methodological issues related to the acceptance to such technologies. Finally, we suggest user-centered design strategies for mitigating such challenges.

The association between clusters of chronic conditions and psychological well-being in younger and older people-A cross-sectional, population-based study from the Lolland-Falster Health Study, Denmark

Aim:

To investigate the association between clusters of conditions and psychological well-being across age groups.

Method:

This cross-sectional study used data collected in the Danish population-based Lolland-Falster Health Study. We included adults over the age of 18 years. Self-reported chronic conditions were divided into 10 groups of conditions. The primary outcome was psychological well-being (the WHO-5 Well-Being Index). Factor analysis constructed the clusters of conditions, and regression analysis investigated the association between clusters and psychological well-being.

Results:

Of 10,781 participants, 31.4% were between 18 and 49 years, 35.7% were between 50 and 64 years and 32.9% were above ≥65 years. 35.2% had conditions represented in 1 and 32.9% in at least 2 of 10 condition groups. Across age groups, living with one or more chronic conditions was associated with poorer psychological well-being. Two chronic condition patterns were identified; one comprised cardiovascular, endocrine, kidney, musculoskeletal and cancer conditions, the second mental, lung, neurological, gastrointestinal and sensory conditions. Both patterns were associated with poorer psychological well-being (Pattern 1: −4.5 (95% CI: −5.3 to −3.7), Pattern 2: −9.1 (95% CI −13.8 to −8.2). For pattern 2, participants ≥65 years had poorer psychological well-being compared to younger (−12.6 (95% CI −14.2 to −11.0) vs −6.6 (95% CI: −7.8 to −5.4) for 18–49 years and −8.7 (95% CI: −10.1 to −7.3) for 50–64 years, interaction: p ≤ 0.001)

Conclusion:

Living with one or more chronic conditions is associated with poorer psychological well-being. Findings point toward a greater focus on supporting psychological well-being in older adults with both mental and somatic conditions.

mHealth applications to support caregiver needs and engagement during stroke recovery: A content review

Caregiving in stroke results in severe physical, psychological, and social impacts on the caregiver. Over the past few years, researchers have explored the use of mHealth technologies to support healthcare-related activities due to their ability to provide real-time care at any given place or time. The purpose of this content review is to investigate mHealth apps in supporting stroke caregiving engagement based on three aspects: motivation, value, and satisfaction. We searched app stores and repositories for apps related to stroke caregiving published up to September 2020. Extracted apps were reviewed and filtered using inclusion criteria, and then downloaded onto compatible devices to determine eligibility. Results were compared with evidence-based frameworks to identify the ability of these apps in engaging and supporting the caregiver. Forty-seven apps were included in this review that enabled caregivers to support their needs, such as adjustment to new roles and relationships, involvement in care and caring for oneself using several different functionalities. These functionalities include information resources, risk assessment, remote monitoring, data sharing, reminders and so on. However, no single app was identified that focuses on all aspects of stroke caregiving. We also identified several challenges faced by users through their reviews and the factors associated with value and satisfaction. Our findings can add to the knowledge of existing mHealth technologies and their functionalities to support stroke caregiving needs, and the importance of considering user engagement in the design. They can be used by developers and researchers looking to design better mHealth apps for stroke caregiving.

Medication-related experiences of patients with polypharmacy: a systematic review of qualitative studies

BACKGROUND

We aimed to synthesise qualitative studies exploring medication-related experiences of polypharmacy among patients with multimorbidity.

METHODS

We systematically searched PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature in February 2020 for primary, peer-reviewed qualitative studies about multimorbid patients' medication-related experiences with polypharmacy, defined as the use of four or more medications. Identified studies were appraised for methodological quality by applying the Critical Appraisal Skills Programme checklist for qualitative research, and data were extracted and synthesised by the meta-aggregation approach.

RESULTS

We included 13 qualitative studies, representing 499 patients with polypharmacy and a wide range of chronic conditions. Overall, most Critical Appraisal Skills Programme items were reported in the studies. We extracted 140 findings, synthesised these into 17 categories, and developed five interrelated syntheses: (1) patients with polypharmacy are a heterogeneous group in terms of needing and appraising medication information; (2) patients are aware of the importance of medication adherence, but it is difficult to achieve; (3) decision-making about medications is complex; (4) multiple relational factors affect communication between patients and physicians, and these factors can prevent patients from disclosing important information; and (5) polypharmacy affects patients' lives and self-perception, and challenges with polypharmacy are not limited to practical issues of medication-taking.

DISCUSSION

Polypharmacy poses many challenges to patients, which have a negative impact on quality of life and adherence. Thus, when dealing with polypharmacy patients, it is crucial that healthcare professionals actively solicit individual patients' perspectives on challenges related to polypharmacy. Based on the reported experiences, we recommend that healthcare professionals upscale communicative efforts and involve patients' social network on an individualised basis to facilitate shared decision-making and treatment adherence in multimorbidpatients with polypharmacy.

A complex intervention for multimorbidity in primary care: A feasibility study

Aim

To assess the feasibility of a patient-centered complex intervention for multimorbidity (CIM) based on general practice in collaboration with community health-care centers and outpatient clinics.

Methods

Inclusion criteria were age ≥18 years, diagnoses of two or more of three chronic conditions (diabetes, chronic obstructive pulmonary disease (COPD), and chronic heart conditions), and a hospital contact during the previous year. The CIM included extended consultations and nurse care manager support in general practice and intensified cross-sectorial collaboration. Elements included a structured care plan based on patients' care goals, coordination of services, and, if appropriate, shifting outpatient clinic visits to general practice, medication review, referral to rehabilitation, and home care. The acceptability dimension of feasibility was assessed with validated questionnaires, observations, and focus groups.

Results

Forty-eight patients were included (mean age 72.2 (standard deviation (SD) 9.5, range 52-89); 23 (48%) were men. Thirty-seven patients had two diseases; most commonly COPD and cardiovascular disease (46%), followed by diabetes and cardiovascular disease (23%), and COPD and diabetes (15%). Eleven (23%) patients had all three conditions. Focus group interviews with patients with multimorbidity identified three main themes: (1) lack of care coordination existed across health-care sectors before the CIM, (2) extended consultations provided better care coordination, and (3) patients want to be involved in planning their treatment and care. In focus groups, health-care professionals discussed two main themes: (1) patient-centered care and (2) culture and organizational change. Completion rates for questionnaires were 98% (47/48).

Conclusions

Patients and health-care professionals found the CIM acceptable.

Total burden of disease in cancer patients at diagnosis-a Danish nationwide study of multimorbidity and redeemed medication

Background

Multimorbidity is a growing challenge worldwide. In this nationwide study, we investigated the prevalence of multimorbidity and polypharmacy at the time of diagnosis across 20 cancers.

Methods

We conducted a nationwide register-based cohort study of all Danish residents with a first primary cancer diagnosed between 1 January 2005 and 31 December 2015. Multimorbidity was defined as one or more of 20 conditions (131 specific diagnoses) registered in the Danish National Patient Registry < 5 years before the cancer diagnosis. Polypharmacy was defined as five or more medications registered in the Danish National Prescription Registry and redeemed twice 2–12 months before the cancer diagnosis.

Results

We included 261,745 patients with a first primary cancer, of whom 55% had at least one comorbid condition at diagnosis and 27% had two or more. The most prevalent conditions at the time of cancer diagnosis were cardiovascular disease, chronic obstructive pulmonary disease, diabetes, stroke and depression/anxiety disorder. Polypharmacy was present in one-third of the cancer patients with antihypertensives, anti-thrombotic agents, anti-hyperlipidaemic agents, analgesics and diuretics as the most prevalent redeemed medications.

Conclusion

Among patients with a newly established cancer diagnosis, 55% had at least one comorbid condition and 32% were exposed to polypharmacy.

Supervised pulmonary tele-rehabilitation versus pulmonary rehabilitation in severe COPD: a randomised multicentre trial

RATIONALE

Pulmonary rehabilitation (PR) is an effective, key standard treatment for people with COPD. Nevertheless, low participant uptake, insufficient attendance and high drop-out rates are reported. Investigation is warranted of the benefits achieved through alternative approaches, such as pulmonary tele-rehabilitation (PTR).

OBJECTIVE

To investigate whether PTR is superior to conventional PR on 6 min walk distance (6MWD) and secondarily on respiratory symptoms, quality of life, physical activity and lower limb muscle function in patients with COPD and FEV₁ <50% eligible for routine hospital-based, outpatient PR.

METHODS

In this single-blinded, multicentre, superiority randomised controlled trial, patients were assigned 1:1 to 10 weeks of groups-based PTR (60 min, three times weekly) or conventional PR (90 min, two times weekly). Assessments were performed by blinded assessors at baseline, end of intervention and at 22 weeks' follow-up from baseline. The primary analysis was based on the intention-to-treat principle.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was change in 6MWD from baseline to 10 weeks; 134 participants (74 females, mean±SD age 68±9 years, FEV₁ 33%±9% predicted, 6MWD 327±103 metres) were included and randomised. The analysis showed no between-group differences for changes in 6MWD after intervention (9.2 metres (95% CI: -6.6 to 24.9)) or at 22 weeks' follow-up (-5.3 metres (95% CI: -28.9 to 18.3)). More participants completed the PTR intervention (n=57) than conventional PR (n=43) (χ² test p<0.01).

CONCLUSION

PTR was not superior to conventional PR on the 6MWD and we found no differences between groups. As more participants completed PTR, supervised PTR would be relevant to compare with conventional PR in a non-inferiority design. Trial registration number ClinicalTrials.gov (NCT02667171), 28 January 2016.

Albuminuria measurement in diabetic care: a multilevel analysis measuring the influence of accreditation on institutional performance

Background

Studies assessing institutional performance regarding quality of care are frequently performed using single-level statistical analyses investigating differences between provider averages of various quality indicators. However, such analyses are insufficient as they do not consider patients’ heterogeneity around those averages. Hence, we apply a multilevel analysis of individual-patient heterogeneity that distinguishes between ‘general’ (‘latent quality’ or measures of variance) and ‘specific’ (measures of association) contextual effects. We assess general contextual effects of the hospital departments and the specific contextual effect of a national accreditation programme on adherence to the standard benchmark for albuminuria measurement in Danish patients with diabetes.

Methods

From the Danish Adult Diabetes Database, we extracted data on 137 893 patient cases admitted to hospitals between 2010 and 2013. Applying multilevel logistic and probit regression models for every year, we quantified general contextual effects of hospital department by the intraclass correlation coefficient (ICC) and the area under the receiver operating characteristic curve (AUC) values. We evaluated the specific effect of hospital accreditation using the ORs and the change in the department variance.

Results

In 2010, the department context had considerable influence on adherence with albuminuria measurement (ICC=21.8%, AUC=0.770), but the general effect attenuated along with the implementation of the national accreditation programme. The ICC value was 16.5% in 2013 and the rate of compliance with albuminuria measurement increased from 91.6% in 2010 to 96% in 2013.

Conclusions

Parallel to implementation of the national accreditation programme, departments’ compliance with the standard benchmark for albuminuria measurement increased and the ICC values decreased, but remained high. While those results indicate an overall quality improvement, further intervention focusing on departments with the lowest compliance could be considered.

Polypharmacy and medication deprescribing: A survey among multimorbid older adults in Denmark

Polypharmacy is common among multimorbid adults and associated with increased morbidity and mortality. Excessive polypharmacy (ie, ≥10 medicine) is strongly associated with inappropriate medication use, but little is known about attitudes toward deprescribing in patients with excessive polypharmacy. We surveyed 100 Danish individuals aged 65 years and above with ≥10 prescribed medications, using the validated Patients' Attitudes Towards Deprescribing (PATD) instrument. Most participants (81, 81%) thought they took a large number of medications, and 79 (79%) believed that their medications were necessary. Even so, 85 (85%) reported that they would be willing to stop taking one or more of their regular medications if their doctor told them they could, and 11 (11%) felt that they took at least one regular medication that they no longer needed. When presented with visual presentation of various amounts of tablets and capsules, 62 (62%) of participants reported that they would be comfortable taking fewer medications than they did. Forty-two (42%) participants had experience with stopping a regular medication. Almost all participants (92%) wanted to receive follow-up by various means if a medication was discontinued. Forty-one (41%) participants were interested in a consultation at an outpatient clinic specializing in polypharmacy. Overall, the answers to the PATD questionnaire suggest that our cohort of Danish, multimorbid outpatients with extensive polypharmacy have a high confidence in their healthcare providers for medication-related decisions, even though some feel that they are taking more medications than they would like to and feel that some medications may be unnecessary. Our results underline the need for healthcare providers to offer medication reviews in patients with multimorbidity.

Intra- and inter-rater reproducibility of the 6-minute walk test and the 30-second sit-to-stand test in patients with severe and very severe COPD

Background

In patients with COPD, the 6-minute walk test (6MWT) and the 30-second sit-to-stand test (30sec-STS) are widely used as clinical outcome measures of walking capacity, lower limb muscle strength, and functional ability. Due to a documented learning effect, at least two trials are recommended for assessment. The aim of our study was to investigate the intra- and inter-rater reliability and agreement of the two tests in patients with severe and very severe COPD (FEV₁ <50%).

Patients and methods

Fifty patients (22 females; mean [SD]: age 67 [9] years, FEV₁ predicted 32 [9]%) were assessed with the 6MWT and the 30sec-STS twice by the same assessor on test-day 1 (T1) and by another assessor 7–10 days later on test-day 2 (T2).

Results

The 6MWT intra- and inter-rater reliability (intraclass correlation coefficient, ICC_1.1) was 0.98 (lower limit 95% CI: 0.94) and 0.96 (lower limit 95% CI: 0.94), respectively, and agreement (standard error of the measurement, SEM) was 14.8 and 20.5 m, respectively. The 30sec-STS intra- and inter-rater reliability and agreement results were, respectively, ICC_1.1 0.94 (lower limit 95% CI: 0.90) and 0.92 (lower limit 95% CI: 0.86), with SEM of 0.97 and 1.14 repetitions. There was no difference (95% CI: −5.3; 8.1) between the 6MWT distances on T1, while the mean walking distance improved 7.9 m (0.0 m; 15.8 m) from T1 to T2. Improvement on the same test date was less likely (OR: 3.6 [95% CI: 1.1; 11.8], Fisher’s exact test, P=0.047) in patients who walked less than 350 m in the 6MWT. We found no clinically relevant learning effect in the 30sec-STS.

Conclusion

In patients with severe and very severe COPD the 6MWT and the 30sec-STS showed excellent intra- and inter-rater reliability and acceptable agreement. No learning effect was documented for the tests when performed on the same day. Our data suggest that in clinical practice using different assessors is acceptable, and that a single test trial may be sufficient to assess patients with severe and very severe COPD.

Quality of care for people with multimorbidity - a case series

Background

Multimorbidity is becoming increasingly prevalent and presents challenges for healthcare providers and systems. Studies examining the relationship between multimorbidity and quality of care report mixed findings. The purpose of this study was to investigate quality of care for people with multimorbidity in the publicly funded healthcare system in Denmark.

Methods

To investigate the quality of care for people with multimorbidity different groups of clinicians from the hospital, general practice and the municipality reviewed records from 23 persons with multimorbidity and discussed them in three focus groups. Before each focus group, clinicians were asked to review patients’ medical records and assess their care by responding to a questionnaire. Medical records from 2013 from hospitals, general practice, and health centers in the local municipality were collected and linked for the 23 patients. Further, two clinical pharmacologists reviewed the appropriateness of medications listed in patient records.

Results

The review of the patients’ records conducted by three groups of clinicians revealed that around half of the patients received adequate care for the single condition which prompted the episode of care such as a hospitalization, a visit to an outpatient clinic or the general practitioner. Further, the care provided to approximately two-thirds of the patients did not take comorbidities into account and insufficiently addressed more diffuse symptoms or problems. The review of the medication lists revealed that the majority of the medication lists contained inappropriate medications and that there were incongruity in medication listed in the primary and secondary care sector. Several barriers for providing high quality care were identified. These included relative short consultation times in general practice and outpatient clinics, lack of care coordinators, and lack of shared IT-system proving an overview of the treatment.

Conclusions

Our findings reveal quality of care deficiencies for people with multimorbidity. Suggestions for care improvement for people with multimorbidity includes formally assigned responsibility for care coordination, a change in the financial incentive structure towards a system rewarding high quality care and care focusing on prevention of disease exacerbation, as well as implementing shared medical record systems.

COPD online-rehabilitation versus conventional COPD rehabilitation - rationale and design for a multicenter randomized controlled trial study protocol (CORe trial)

BACKGROUND

Rehabilitation of patients with chronic obstructive pulmonary disease (COPD) is a key treatment in COPD. However, despite the existing evidence and a strong recommendation from lung associations worldwide, 50% of patients with COPD decline to participate in COPD rehabilitation program and 30-50% drop-out before completion. The main reasons are severe symptoms, inflexible accessibility and necessity for transportation. Currently there are no well-established and evident rehabilitation alternatives. Supervised online screen rehabilitation could be a useful approach to increase accessibility and compliance. The aim of this multicenter RCT study is to compare the potential benefits of a 10-week online COPD rehabilitation program (CORe) with conventional outpatient COPD rehabilitation (CCRe).

METHODS

This study is a randomized assessor- and statistician blinded superiority multicenter trial with two parallel groups, employing 1:1 allocation to the intervention and the comparison group.On the basis of a sample size calculation, 134 patients with severe or very severe COPD and eligible to conventional hospital based outpatient COPD rehabilitation will be included and randomized from eight different hospitals. The CORe intervention group receives group supervised resistance- and endurance training and patient education, 60 min, three times/week for 10 weeks at home via online-screen. The CCRe comparison group receives group based supervised resistance- and endurance training and patient education, 90 min, two times/week for 10 weeks (two hospitals) or 12 weeks (six hospitals) in groups at the local hospital. The primary outcome is change in the 6-min walking distance after 10/12 weeks; the secondary outcomes are changes in 30 s sit-to-stand chair test, physical activity level, symptoms, anxiety and depression symptoms, disease specific and generic quality of life. Primary endpoint is 10/12 weeks from baseline, while secondary endpoints are 22, 36, 62 weeks from baseline assessments.

DISCUSSION

The study will likely contribute to knowledge regarding COPD tele-rehabilitation and to which extent it is more feasible and thereby more efficient than conventional COPD rehabilitation in patients with severe and very severe COPD.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02667171 . Registration data: January 28th 2016.

Assessment of short and long-term outcomes of diabetes patient education using the health education impact questionnaire (HeiQ)

BACKGROUND

Type 2 diabetes is a progressive chronic illness that will affect more than 500 million people worldwide by 2030. It is a significant cause of morbidity and mortality. Finding the right care management for diabetes patients is necessary to effectively address the growing population of affected individuals and escalating costs. Patient education is one option for improving patient self-management. However, there are large discrepancies in the outcomes of such programs and long-term data are lacking. We assessed the short and long-term outcomes of diabetes patient education using the health education impact questionnaire (HeiQ).

METHODS

We conducted a observational cohort study of 83 type 2 diabetes patients participating in patient education programs in Denmark. The seven-scale HeiQ was completed by telephone interview at baseline and 2 weeks (76 participants, 93%) and 12 months (66, 80%) after the patient education ended. Changes over time were assessed using mean values and standard deviation at each time point and Cohen effect sizes.

RESULTS

Patients reported improvements 2 weeks after the program ended in 4 of 7 constructs: skills and technique acquisition (ES = 0.59), self-monitoring and insight (ES = 0.52), constructive attitudes and approaches (ES = 0.43) and social integration and support (ES = 0.27). After 12 months, patients reported improvements in 3 of 7 constructs: skills and technique acquisition (ES = 0.66), constructive attitudes and approaches (ES = 0.43), and emotional wellbeing (ES = 0.44). Skills and technique showed the largest short- and long-term effect size. No significant changes were found in health-related activity or positive and active engagement in life over time.

CONCLUSION

After 12 months, diabetes patients who participated in patient education demonstrated increased self-management skills, improved acceptance of their chronic illness and decreased negative emotional response to their disease. Applying HeiQ as an outcome measure yielded new knowledge as to what patients with diabetes can obtain by participating in a patient education.

Social disparities in the prevalence of multimorbidity - A register-based population study

BACKGROUND

Prevalences of multimorbidity vary between European studies and several methods and definitions are used. In this study we examine the prevalence of multimorbidity in relation to age, gender and educational attainment and the association between physical and mental health conditions and educational attainment in a Danish population.

METHODS

A cross-sectional design was used to study the prevalence of multimorbidity, defined as two or more chronic conditions, and of comorbid physical and mental health conditions across age groups and educational attainment levels among 1,397,173 individuals aged 16 years and older who lived in the Capital Region of Denmark on January 1st, 2012. After calculating prevalence, odds ratios for multimorbidity and mental health conditions were derived from logistic regression on gender, age, age squared, education and number of physical conditions (only for odds ratios for mental health conditions). Odds ratios for having multimorbidity and mental health conditions for each variable were adjusted for all other variables.

RESULTS

Multimorbidity prevalence was 21.6%. Half of the population aged 65 and above had multimorbidity, and prevalence was inversely related to educational attainment: 26.9% (95% CI, 26.8-26.9) among those with lower secondary education versus 13.5% (95% CI, 13.5-13.6) among people with postgraduate education. Adjusted odds ratios for multimorbidity were 0.50 (95% CI, 0.49-0.51) for people with postgraduate education, compared to people with lower secondary education. Among all population members, 4.9% (95% CI, 4.9-4.9) had both a physical and a mental health condition, a proportion that increased to 22.6% of people with multimorbidity. Physical and mental health comorbidity was more prevalent in women (6.33%; 95% CI, 6.3-6.4) than men (3.34%; 95% CI, 3.3-3.4) and approximately 50 times more prevalent among older persons than younger ones. Physical and mental health comorbidity was also twice as prevalent among people with lower secondary education than among those with postgraduate education. The presence of a mental health condition was strongly associated with the number of physical conditions; those with five or more physical conditions had an adjusted odds ratio for a mental health condition of 3.93 (95% CI, 3.8-4.1), compared to those with no physical conditions.

CONCLUSION

Multimorbidity prevalence and patterns in the Danish population are comparable to those of other European populations. The high prevalence of mental and physical health conditions highlights the need to ensure that healthcare systems deliver care that takes physical and mental comorbidity into account. Further, the higher prevalence of multimorbidity among persons with low educational attainment emphasizes the importance of having a health care system providing care that is beneficial to all regardless of socioeconomic status.

Self-rated health as a predictor of outcomes of type 2 diabetes patient education programmes in Denmark

OBJECTIVE

To explore if self-rated health (SRH) can predict differences in outcomes of patient education programmes among patients with type 2 diabetes over time.

STUDY DESIGN

This is an observational cohort study conducted among 83 patients with type 2 diabetes participating in patient education programmes in the Capital Region of Denmark.

METHODS

Questionnaire data were collected by telephone interview at baseline and 2 weeks (77 participants, 93%) and 12 months (66, 80%) after the patient education ended. The seven-scale Health Education Impact Questionnaire (HeiQ) was the primary outcome. The independent variable was SRH, which was dichotomized into optimal or poor SRH. Changes over time were assessed using mean values and standard deviation (SD) at each time point and Cohen effect sizes. Odds ratios and 95% confidence intervals were calculated for the likelihood of having poor SRH for each baseline sociodemographic and health-related variable.

RESULTS

Twelve months after patient education programmes, 60 (72%) patients with optimal SRH at baseline demonstrated increased self-management skills, overall acceptance of chronic illness, positive social interaction with others, and improved emotional well-being. Participants with poor SRH (23, 28%) reported no improvements over time. Not being married (odds ratio [OR] 7.79, P < 0.001), living alone (OR 4.93, P = 0.003), having hypertension (OR 8.00, P = 0.031), and being severely obese (OR 4.07, P = 0.009) were significantly associated with having poor SRH. After adjusting for sex, age and vocational training, marital status (OR 9.35, P < 0.001), cohabitation status (OR = 4.96, P = 0.005) and hypertension (OR 10.9, P = 0.03) remained associated with poor SRH.

CONCLUSIONS

We found a strong association between SRH and outcomes of patient education, as measured by the HeiQ, at 12 months. Only participants with optimal SRH appeared to benefit from patient education. Other patient characteristics may be responsible to explain the observed difference between patients with optimal and poor SRH.

Implementing integrated care: A synthesis of experiences in three European countries

Many countries are experimenting with new models to better integrate care; yet, innovative care models are often implemented as time-limited, localised projects with limited impact on service delivery more broadly. This paper seeks to understand the processes behind successful projects that achieved some form of ‘routinisation’ and informed system-wide integrated care strategies. It draws on detailed case studies of three integrated care experiments: the ‘Integrated effort for people living with chronic diseases’ project in Denmark; the Gesundes Kinzigtal network in Germany; and Zio, a care group in the Maastricht region in the Netherlands. It explores how they were developed, implemented and sustained, and how they impacted the wider system context. All three models implicitly or explicitly adopted processes shown to be conducive to the dissemination of innovations, including dedicated time and resources, support and advocacy, leadership and management, stakeholder involvement, communication and networks, adaptation to local context and feedback. Each showed robust evidence of improvements on a number of service and patient outcomes and these findings were central to their wider impacts, shaping country-wide integrated care polices. However, the wider dissemination of projects occurred in an incremental and somewhat haphazard way. To further redesign health and social care a more formal strategy, alongside resources, may thus be needed to provide funders and providers with genuine incentives to invest in new business models of care. There remains a crucial need for better understanding of specific local conditions that influence implementation and sustainability to enable translation to other contexts and settings.

The use of COPD maintenance therapy following spirometry in General Practice

BACKGROUND

Several studies have shown that the use of pulmonary medication is widespread and often initiated without initial spirometry. Early detection of chronic obstructive pulmonary disease (COPD) by spirometry in General Practice is essential for an early and correct implementation of medical treatment.

AIM

The aim of the present study was to evaluate the use of regular therapy following diagnostic spirometry for COPD in General Practice from February 2008 to February 2009.

METHOD

Spirometry data and results were linked through Statistics Denmark with information from the Register of Medicinal Product Statistics using the unique personal identification code. Data were analysed to evaluate the impact of screening on use of regular COPD therapy. Primary outcome was initiation of regular therapy following COPD diagnosis with spirometry.

RESULTS

In a population of 3,376 individuals at risk, 1,458 underwent spirometric assessment with 631 being diagnosed with COPD; 110 of those received regular therapy before assessment with this figure increasing to 161 after spirometry. Of 827 participants not receiving a COPD diagnosis, 36 received regular therapy prior to assessment and 42 received regular therapy after spirometry despite no established COPD diagnosis.

CONCLUSION

There is a significant chance of receiving regular therapy after being diagnosed with COPD. However, a large proportion of subjects diagnosed with COPD did not receive regular therapy following diagnosis. Efforts should be made to ensure correct diagnosis and correct medical treatment according to guidelines in individuals with COPD.

Short Term Survival after Admission for Heart Failure in Sweden: Applying Multilevel Analyses of Discriminatory Accuracy to Evaluate Institutional Performance

BACKGROUND

Hospital performance is frequently evaluated by analyzing differences between hospital averages in some quality indicators. The results are often expressed as quality charts of hospital variance (e.g., league tables, funnel plots). However, those analyses seldom consider patients heterogeneity around averages, which is of fundamental relevance for a correct evaluation. Therefore, we apply an innovative methodology based on measures of components of variance and discriminatory accuracy to analyze 30-day mortality after hospital discharge with a diagnosis of Heart Failure (HF) in Sweden.

METHODS

We analyzed 36,943 patients aged 45-80 treated in 565 wards at 71 hospitals during 2007-2009. We applied single and multilevel logistic regression analyses to calculate the odds ratios and the area under the receiver-operating characteristic (AUC). We evaluated general hospital and ward effects by quantifying the intra-class correlation coefficient (ICC) and the increment in the AUC obtained by adding random effects in a multilevel regression analysis (MLRA). Finally, the Odds Ratios (ORs) for specific ward and hospital characteristics were interpreted jointly with the proportional change in variance (PCV) and the proportion of ORs in the opposite direction (POOR).

FINDINGS

Overall, the average 30-day mortality was 9%. Using only patient information on age and previous hospitalizations for different diseases we obtained an AUC = 0.727. This value was almost unchanged when adding sex, country of birth as well as hospitals and wards levels. Average mortality was higher in small wards and municipal hospitals but the POOR values were 15% and 16% respectively.

CONCLUSIONS

Swedish wards and hospitals in general performed homogeneously well, resulting in a low 30-day mortality rate after HF. In our study, knowledge on a patient's previous hospitalizations was the best predictor of 30-day mortality, and this information did not improve by knowing the sex and country of birth of the patient or where the patient was treated.

A qualitative study of integrated care from the perspectives of patients with chronic obstructive pulmonary disease and their relatives

Background

Disease management programmes have been developed for chronic obstructive pulmonary disease (COPD) to facilitate the integration of care across healthcare settings. The purpose of the present study was to examine the experiences of COPD patients and their relatives of integrated care after implementation of a COPD disease management programme.

Methods

Seven focus groups and five individual interviews were held with 34 patients with severe or very severe COPD and two focus groups were held with eight of their relatives. Data were analysed using inductive content analysis.

Results

Four main categories of experiences of integrated care emerged: 1) a flexible system that provides access to appropriate healthcare and social services and furthers patient involvement; 2) the responsibility of health professionals to both take the initiative and follow up; 3) communication and providing information to patients and relatives; 4) coordination and professional cooperation. Most patients were satisfied with their care and raised few criticisms. However, patients with more unstable and severe disease tended to experience more problems.

Conclusions

Participant suggestions for optimizing the integration of healthcare included assigning patients a care coordinator, telehealth solutions for housebound patients and better information technology to support interprofessional cooperation. Further studies are needed to explore these and other possible solutions to problems with integrated care among COPD patients. A future effort in this field should be informed by detailed knowledge of the extent and relative importance of the identified problems. It should also be designed to address variable levels of severity of COPD and relevant comorbidities and to deliver care in ways appropriate to the respective healthcare setting. Future studies should also take health professionals’ views into account so that interventions may be planned in the light of the experiences of all those involved in the treatment of COPD patients.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-471) contains supplementary material, which is available to authorized users.