Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis

BACKGROUND

Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care.

METHODS

We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken.

RESULTS

Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low.

CONCLUSIONS

The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.

Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis

BACKGROUND

An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care 'at-risk' of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis.

METHODS AND FINDINGS

We carried out a systematic review and meta-analysis of the effectiveness of case management for 'at-risk' patients in primary care. Six bibliographic databases were searched using terms for 'case management', 'primary care', and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health--self-assessed health status, mortality; Cost--total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction--patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial 'strength' of primary care.

CONCLUSIONS

This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future.

REVIEW PROTOCOL

The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824).

An empirical investigation of suicide schemas in individuals with Posttraumatic Stress Disorder

Posttraumatic Stress Disorder (PTSD) has been strongly associated with suicidality. Despite the growing evidence suggesting that suicidality is heightened by the presence of an elaborated suicide schema, investigations of suicide schemas are sparse. Using novel methodologies, this study aimed to compare the suicide schema of PTSD individuals with and without suicidal ideation in the past year. Fifty-six participants with a diagnosis of PTSD (confirmed via the Clinician Administered PTSD Scale) completed questionnaires to assess suicidality, depressive severity and hopelessness. A series of direct and indirect cognitive tasks were used to assess suicide schemas. The pathfinder technique was employed to construct graphical representations of the groups׳ suicide schemas. The suicidal group reported significantly more severe PTSD symptoms, depressive symptoms, hopelessness and suicidality. The suicide schema of the suicidal group was significantly more extensive compared to the non-suicidal group even after taking into account in the analyses group differences in clinical measures. Moreover, the suicide schemas of the two groups were qualitatively distinct from each other. These findings provide support for contemporary theories of suicide which view suicide schemas as an important indicator of suicide risk. The investigation of schema constructs opens a new avenue of research for understanding suicide.

Contributory factors to patient safety incidents in primary care: protocol for a systematic review

BACKGROUND

Organisations need to systematically identify contributory factors (or causes) which impact on patient safety in order to effectively learn from error. Investigations of error have tended to focus on taking a reactive approach to learning from error, mainly relying on incident-reporting systems. Existing frameworks which aim to identify latent causes of error rely almost exclusively on evidence from non-healthcare settings. In view of this, the Yorkshire Contributory Factors Framework (YCFF) was developed in the hospital setting. Eighty-five percent of healthcare contacts occur in primary care. As a result, this review will build on the work that produced the YCFF, by examining the empirical evidence that relates to the contributory factors of error within a primary care setting.

METHODS/DESIGN

Four electronic bibliographic databases will be searched: MEDLINE, Embase, PsycInfo and CINAHL. The database search will be supplemented by additional search methodologies including citation searching and snowballing strategies which include reviewing reference lists and reviewing relevant journal table of contents, that is, BMJ Quality and Safety. Our search strategy will include search combinations of three key blocks of terms. Studies will not be excluded based on design. Included studies will be empirical studies conducted in a primary care setting. They will include some description of the factors that contribute to patient safety. One reviewer (SG) will screen all the titles and abstracts, whilst a second reviewer will screen 50% of the abstracts. Two reviewers (SG and AH) will perform study selection, quality assessment and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected include study characteristics (year, objective, research method, setting, country), participant characteristics (number, age, gender, diagnoses), patient safety incident type and characteristics, practice characteristics and study outcomes.

DISCUSSION

The review will summarise the literature relating to contributory factors to patient safety incidents in primary care. The findings from this review will provide an evidence-based contributory factors framework for use in the primary care setting. It will increase understanding of factors that contribute to patient safety incidents and ultimately improve quality of health care.

The development of the Short Defeat and Entrapment Scale (SDES)

Previous research has suggested that defeat (conceptualized as a failed social struggle) and entrapment (conceptualized as a perceived inability to escape from aversive situations) form a single construct that reliably predicts psychopathological outcomes in clinical and community settings. However, scales designed to assess defeat and entrapment measure the constructs separately, whereas recent evidence suggests a single scale would be appropriate. Existing scales may also be too lengthy to have clinical utility. The present study developed and evaluated a scale that measured both defeat and entrapment. Exploratory and confirmatory factor analyses demonstrated that defeat and entrapment were best defined by a single factor, and 8 items were selected that best represented this construct to form the short scale. The scale had high internal consistency (α = .88 to .94), showed criterion validity with hopelessness (r = .45 to .93) and incremental validity for caregiver burden when controlling for depression and positive symptoms of psychosis when controlling for hopelessness (β = .45 to .60). Additionally, the scale had excellent test-retest reliability using single measures absolute agreement intraclass correlation coefficients across 12 months (ricc = .88 to .92) within 4 samples: people with posttraumatic stress disorder, people with psychosis, care home employees, and people from community settings. The scale demonstrated known group validity through discrimination between clinical and nonclinical groups of participants. This scale could be implemented within therapeutic settings to help clinicians identify patients experiencing defeat and entrapment, and incorporate these factors into their clinical assessment and case formulations for treatment.

Suicidality and posttraumatic stress disorder (PTSD) in adolescents: a systematic review and meta-analysis

PURPOSE

There is growing evidence in the literature that a diagnosis of Posttraumatic Stress Disorder (PTSD) is an important contributory factor to suicidality in adolescents. However, there is no existing review of the literature examining the relationship between PTSD and suicidality in adolescents. This study aims to provide the first systematic review and meta-analysis of the association between PTSD and suicidality in adolescents.

METHODS

Five bibliographic databases (Medline, EMBASE, PsycINFO, Web of Science and PILOT) were screened for suitable articles. Twenty-eight studies (which provided 28 independent samples) were included in the review. The overall meta-analyses of the association between PTSD and suicidality were followed by subgroup and meta-regression analyses.

RESULTS

A highly significant positive association was found between PTSD and suicidality (d = 0.701, 95% CI 0.555-0.848). The subgroup and meta-regression analyses showed that the association between PTSD and suicidality persisted whilst adjusting for various sources of between-study heterogeneity, such as, different levels of severity of suicidality, target groups, and methodological quality of the studies.

CONCLUSIONS

Suicidality in adolescents with PTSD is a major problem which requires further research effort. The implications of these results are discussed.

Completed suicides and self-harm in Malaysia: a systematic review

OBJECTIVE

Most of the research into suicide and self-harm has been conducted in the United States and Europe, yet the volume of research does not reflect the distribution of suicide globally, with Asia accounting for up to 60% of all suicides. The present study systematically reviews the literature to assess the prevalence and correlates of suicidal acts in Malaysia in Southeast Asia.

METHODS

Five relevant databases were searched from inception up to February 2014, and a narrative synthesis of the results from the included studies was performed. Studies were eligible for inclusion if they were correlational survey research and archival/observational research describing self-harm and suicide. Outcomes included completed suicides and self-harm including suicide attempts and self-poisoning, suicide plans and suicidal ideation.

RESULTS

In total, 39 studies met the inclusion criteria. The principal findings were that the prevalence of suicide in Malaysia is approximately 6-8 per 100,000 population per year and that there is an excess of suicide among men, people younger than 40 years and the Indian minority group. The past-month prevalence rates of suicidal ideation, plans and attempts are 1.7, 0.9% and 0.5%, respectively, whereas the past-year prevalence rates of suicidal ideation range between 6% and 8%.

CONCLUSIONS

The present research marks a first step towards understanding the prevalence and correlates of suicide and self-harm in Malaysia. However, the heterogeneity of the included studies was high. Further research into the antecedents, consequences and interventions for suicide and self-harm in the Malaysian context is required.

Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis

Background

A critical part of future service delivery will involve improving the degree to which people become engaged in ‘self-management’. Providing better support for self-management has the potential to make a significant contribution to NHS efficiency, as well as providing benefits in patient health and quality of care.

Objective

To determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions.

Data sources

Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, EconLit (the American Economic Association’s electronic bibliography), EMBASE, Health Economics Evaluations Database, MEDLINE (the US National Library of Medicine’s database), MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database (NHS EED) and PsycINFO (the behavioural science and mental health database), as well as the reference lists of published reviews of self-management support.

Methods

We included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. Main outcome measures were quantitative measures of service utilisation (including hospital use) and quality of life (QoL). We presented the results for each condition group using a permutation plot, plotting the effect of interventions on utilisation and outcomes simultaneously and placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. We also conducted conventional meta-analyses of outcomes.

Results

We found 184 studies that met the inclusion criteria and provided data for analysis. The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management. Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as we found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias.

Limitations

Self-management support is a complex area in which to undertake literature searches. Our analyses were limited by poor reporting of outcomes in the included studies, especially concerning health-care utilisation and costs.

Conclusions

Very few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support.

Study registration

This study is registered as PROSPERO CRD42012002694.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Overview of the prevalence, impact, and management of depression and anxiety in chronic obstructive pulmonary disease

More than one third of individuals with chronic obstructive pulmonary disease (COPD) experience comorbid symptoms of depression and anxiety. This review aims to provide an overview of the burden of depression and anxiety in those with COPD and to outline the contemporary advances and challenges in the management of depression and anxiety in COPD. Symptoms of depression and anxiety in COPD lead to worse health outcomes, including impaired health-related quality of life and increased mortality risk. Depression and anxiety also increase health care utilization rates and costs. Although the quality of the data varies considerably, the cumulative evidence shows that complex interventions consisting of pulmonary rehabilitation interventions with or without psychological components improve symptoms of depression and anxiety in COPD. Cognitive behavioral therapy is also an effective intervention for managing depression in COPD, but treatment effects are small. Cognitive behavioral therapy could potentially lead to greater benefits in depression and anxiety in people with COPD if embedded in multidisciplinary collaborative care frameworks, but this hypothesis has not yet been empirically assessed. Mindfulness-based treatments are an alternative option for the management of depression and anxiety in people with long-term conditions, but their efficacy is unproven in COPD. Beyond pulmonary rehabilitation, the evidence about optimal approaches for managing depression and anxiety in COPD remains unclear and largely speculative. Future research to evaluate the effectiveness of novel and integrated care approaches for the management of depression and anxiety in COPD is warranted.

A prospective study of suicidal ideation in posttraumatic stress disorder: the role of perceptions of defeat and entrapment

OBJECTIVES

This study aimed to provide the first prospective test of the ability of defeat and entrapment to predict suicidal ideation in posttraumatic stress disorder (PTSD) after controlling for the effects of PTSD severity, comorbid depressive symptoms, and hopelessness on suicidal ideation.

METHODS

Participants were 52 individuals diagnosed with PTSD. Baseline and follow-up assessments were 13 to 15 months apart. Defeat and entrapment were conceptualized and analyzed as a unique construct (defeat/entrapment) in this study. Multiple regression analysis was applied to examine the predictive effects of defeat/entrapment on suicidal ideation.

RESULTS

Defeat/entrapment scores predicted changes in the levels of suicidal ideation at follow-up while controlling for baseline suicidal ideation, PTSD severity, comorbid depressive symptoms, and hopelessness.

CONCLUSIONS

These outcomes provide support to contemporary models of suicidality that suggest that defeat/entrapment is a strong predictor of suicidality in PTSD.

Perceived social support buffers the impact of PTSD symptoms on suicidal behavior: implications into suicide resilience research

BACKGROUND

A growing body of research has highlighted the importance of identifying resilience factors against suicidal behavior. However, no previous study has investigated potential resilience factors among individuals with Posttraumatic Stress Disorder (PTSD). The aim of this study was to examine whether perceived social support buffered the impact of PTSD symptoms on suicidal behavior.

METHODS

Fifty-six individuals who had previously been exposed to a traumatic event and reported PTSD symptoms in the past month (n = 34, 60.7% participants met the full criteria for a current PTSD diagnosis) completed a range of self-report measures assessing PTSD symptoms, perceived social support and suicidal behavior. Hierarchical regression analyses were conducted to examine whether perceived social support moderates the effects of PTSD symptoms on suicidal behavior.

RESULTS

The results showed that perceived social support moderated the impact of the number and severity of PTSD symptoms on suicidal behavior. For those who perceived themselves as having high levels of social support, an increased number and severity of PTSD symptoms were less likely to lead to suicidal behavior.

CONCLUSIONS

The current findings suggest that perceived social support might confer resilience to individuals with PTSD and counter the development of suicidal thoughts and behaviors. The milieu of social support potentially provides an area of further research and an important aspect to incorporate into clinical interventions for suicidal behavior in PTSD or trauma populations.

Telephone based self-management support by 'lay health workers' and 'peer support workers' to prevent and manage vascular diseases: a systematic review and meta-analysis

Background

Improved prevention and management of vascular disease is a global priority. Non-health care professionals (such as, ‘lay health workers’ and ‘peer support workers’) are increasingly being used to offer telephone support alongside that offered by conventional services, to reach disadvantaged populations and to provide more efficient delivery of care. However, questions remain over the impact of such interventions, particularly on a wider range of vascular related conditions (such as, chronic kidney disease), and it is unclear how different types of telephone support impact on outcome. This study assessed the evidence on the effectiveness and cost-effectiveness of telephone self-management interventions led by ‘lay health workers’ and ‘peer support workers’ for patients with vascular disease and long-term conditions associated with vascular disease.

Methods

Systematic review of randomised controlled trials. Three electronic databases were searched. Two authors independently extracted data according to the Cochrane risk of bias tool. Random effects meta-analysis was used to pool outcome measures.

Results

Ten studies were included, primarily based in community settings in the United States; with participants who had diabetes; and used ‘peer support workers’ that shared characteristics with patients. The included studies were generally rated at risk of bias, as many methodological criteria were rated as ‘unclear’ because of a lack of information.

Overall, peer telephone support was associated with small but significant improvements in self-management behaviour (SMD = 0.19, 95% CI 0.05 to 0.33, I² = 20.4%) and significant reductions in HbA1c level (SMD = -0.26, 95% CI −0.41 to −0.11, I² = 47.6%). There was no significant effect on mental health quality of life (SMD = 0.03, 95% CI −0.12 to 0.18, I² = 0%). Data on health care utilisation were very limited and no studies reported cost effectiveness analyses.

Conclusions

Positive effects were found for telephone self-management interventions via ‘lay workers’ and ‘peer support workers’ for patients on diabetes control and self-management outcomes, but the overall evidence base was limited in scope and quality. Well designed trials assessing non-healthcare professional delivered telephone support for the prevention and management of vascular disease are needed to identify the content of effective components on health outcomes, and to assess cost effectiveness, to determine if such interventions are potentially useful alternatives to professionally delivered care.

A meta-analysis of the association between posttraumatic stress disorder and suicidality: the role of comorbid depression

OBJECTIVE

A considerable number of studies have reported an increased frequency of suicidal behaviors among individuals diagnosed with posttraumatic stress disorder (PTSD). This study aims, first, to provide a comprehensive systematic review and meta-analysis of the association between a PTSD diagnosis and frequency of suicidality and, second, to examine the role of comorbid depression in the association between suicidality and PTSD.

METHODS

Searches of Medline (June 2010), EMBASE (June 2010), PsycINFO (June 2010), PILOTS (June 2010), and Web of Science (June 2010) were conducted to identify studies that examined the association between PTSD and suicidality. The studies had to include an effect size of the association between PTSD and suicidality to be included in the meta-analysis. Sixty-three studies were eligible for inclusion in the meta-analysis. Overall and subgroup effect sizes were examined.

RESULTS

A highly significant positive association between a PTSD diagnosis and suicidality was found. The PTSD-suicidality association persisted across studies using different measures of suicidality, current and lifetime PTSD, psychiatric and nonpsychiatric samples, and PTSD populations exposed to different types of traumas. Comorbid major depression significantly compounded the risk for suicide in PTSD populations.

CONCLUSION

The current meta-analysis provides strong evidence that a PTSD diagnosis is associated with increased suicidality. The crucial role of comorbid major depression in the etiology of suicidality in PTSD is also supported.

Negative self-appraisals and suicidal behavior among trauma victims experiencing PTSD symptoms: the mediating role of defeat and entrapment

BACKGROUND

A considerable body of literature has shown a strong association between posttraumatic stress disorder (PTSD) and suicidal behavior but only a limited number of studies have investigated the putative psychological mechanisms underlying suicidal behavior in PTSD. Based on a recent theoretical model of suicide, the Schematic Appraisals Model, the current study aimed to examine whether perceptions of defeat and entrapment mediated the effects of three types of negative self-appraisals (emotion coping, problem solving, and social support) on suicidal behavior among individuals experiencing PTSD symptoms in the past month.

METHODS

The sample comprised 56 individuals who had been previously exposed to a traumatic event and reported at least one PTSD symptom in the past month (confirmed through the Posttraumatic Diagnostic Scale). The mediational analyses were conducted using a nonparametric, bootstrapping method.

RESULTS

The results showed that defeat and entrapment fully mediated the effect of all three types of self-appraisals on suicidal behavior. When controlling for PTSD symptom severity, defeat and entrapment continued to mediate fully the effect of two types of self-appraisals, namely the perceived ability to control negative emotions (emotion coping) and the perceived ability to cope with difficult situations/problems (problem solving) on suicidal behavior.

CONCLUSIONS

The current findings provide support for the Schematic Appraisals Model of Suicide and suggest that both specific types of negative self-appraisals and general perceptions of defeat and entrapment are strongly related to suicidal behavior in those with PTSD. The findings have important clinical implications.

Pathways to suicidal behavior in posttraumatic stress disorder

This study investigated paths to suicidal behavior in 94 civilian participants with chronic posttraumatic stress disorder (PTSD). Two statistical modeling programs, TETRAD II version 2.1 and Mplus 5.21 were used to construct a working model of suicide in PTSD. Two paths to suicidal behavior were identified. In the first path, suicidal behavior was directly associated with greater life impairment, which in turn was associated with poorer occupational and social functioning. In the second path, suicidal behavior was directly associated with depressive symptoms, which in turn were associated with more severe PTSD symptoms. Psychotropic medication, employment status, and threat to life further contributed to the model. The findings suggest that negative perceptions of functional impairment and depression are strongly associated with suicidal behavior in PTSD.