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Busquet-Duran X, Jiménez-Zafra EM, Tura-Poma M, Bosch-de la Rosa O, Moragas-Roca A, Martin-Moreno S, Martínez-Losada E, Crespo-Ramírez S, Lestón-Lado L, Salamero-Tura N, Llobera-Estrany J, Oriol-Peregrina N, Moreno-Gabriel E, Manresa-Domínguez JM, Torán-Monserrat P. Assessing Face Validity of the HexCom Model for Capturing Complexity in Clinical Practice: A Delphi Study. Healthcare (Basel) 2021; 9:healthcare9020165. [PMID: 33557220 PMCID: PMC7913893 DOI: 10.3390/healthcare9020165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 12/14/2022] Open
Abstract
Capturing complexity is both a conceptual and a practical challenge in palliative care. The HexCom model has proved to be an instrument with strong reliability and to be valid for describing the needs and strengths of patients in home care. In order to explore whether it is also perceived to be helpful in enhancing coordinated and patient-centred care at a practical level, a methodological study was carried out to assess the face validity of the model. In particular, a Delphi method involving a group of 14 experts representing the full spectrum of healthcare professionals involved in palliative care was carried out. The results show that there is a high level of agreement, with a content validity index-item greater than 0.92 both with regard to the complexity model and the HexCom-Red, HexCom-Basic, and the HexCom-Clin instruments, and higher than 0.85 regarding the HexCom-Figure and the HexCom-Patient instruments. This consensus confirms that the HexCom model and the different instruments that are derived from it are valued as useful tools for a broad range of healthcare professional in coordinately capturing complexity in healthcare practice.
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Affiliation(s)
- Xavier Busquet-Duran
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (L.L.-L.); (N.S.-T.); (J.L.-E.)
- Multidisciplinary Research Group on Health and Society (GREMSAS), (2017 SGR 917), 08007 Barcelona, Spain; (E.M.-G.); (J.M.M.-D.); (P.T.-M.)
- Nursing Department, Fundació Universitària Bages (FUB), University of Vic, 08500 Vic, Spain
- Correspondence:
| | - Eva Maria Jiménez-Zafra
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (L.L.-L.); (N.S.-T.); (J.L.-E.)
| | - Magda Tura-Poma
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (L.L.-L.); (N.S.-T.); (J.L.-E.)
| | - Olga Bosch-de la Rosa
- Red Cross Psychosocial Care Team (EAPS), 08402 Granollers, Spain; (O.B.-d.l.R.); (S.C.-R.)
| | - Anna Moragas-Roca
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (L.L.-L.); (N.S.-T.); (J.L.-E.)
| | - Susana Martin-Moreno
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (L.L.-L.); (N.S.-T.); (J.L.-E.)
| | - Emilio Martínez-Losada
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (L.L.-L.); (N.S.-T.); (J.L.-E.)
| | - Silvia Crespo-Ramírez
- Red Cross Psychosocial Care Team (EAPS), 08402 Granollers, Spain; (O.B.-d.l.R.); (S.C.-R.)
| | - Lola Lestón-Lado
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (L.L.-L.); (N.S.-T.); (J.L.-E.)
| | - Núria Salamero-Tura
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (L.L.-L.); (N.S.-T.); (J.L.-E.)
| | - Joana Llobera-Estrany
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (L.L.-L.); (N.S.-T.); (J.L.-E.)
| | - Núria Oriol-Peregrina
- Degree in Speech and Language Therapy, University of Vic-Central University of Catalonia/UOC, 08242 Manresa, Spain;
- Sociosanitari Vallparadís, 08221 Terrassa, Spain
| | - Eduard Moreno-Gabriel
- Multidisciplinary Research Group on Health and Society (GREMSAS), (2017 SGR 917), 08007 Barcelona, Spain; (E.M.-G.); (J.M.M.-D.); (P.T.-M.)
- Research Support Unit Metropolitana Nord, Primary Care Research Institut Jordi Gol (IDIAPJGol), 08303 Barcelona, Spain
| | - Josep Maria Manresa-Domínguez
- Multidisciplinary Research Group on Health and Society (GREMSAS), (2017 SGR 917), 08007 Barcelona, Spain; (E.M.-G.); (J.M.M.-D.); (P.T.-M.)
- Research Support Unit Metropolitana Nord, Primary Care Research Institut Jordi Gol (IDIAPJGol), 08303 Barcelona, Spain
- Nursing Department, Faculty of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Pere Torán-Monserrat
- Multidisciplinary Research Group on Health and Society (GREMSAS), (2017 SGR 917), 08007 Barcelona, Spain; (E.M.-G.); (J.M.M.-D.); (P.T.-M.)
- Research Support Unit Metropolitana Nord, Primary Care Research Institut Jordi Gol (IDIAPJGol), 08303 Barcelona, Spain
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52
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Nwadiugwu MC. Multi-Morbidity in the Older Person: An Examination of Polypharmacy and Socioeconomic Status. Front Public Health 2021; 8:582234. [PMID: 33537273 PMCID: PMC7848189 DOI: 10.3389/fpubh.2020.582234] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 11/18/2020] [Indexed: 12/30/2022] Open
Abstract
There has been increased focus on clinically managing multi-morbidity in the older population, but it can be challenging to find appropriate paradigm that addresses the socio-economic burden and risk for polypharmacy. The Commission on Social Determinants of Health (CSDH) has examined the need for institutional change and the parallel need to address the social causes of poor health. This study explored three potential interventions namely, meaningful information from electronic health records (EHR), social prescribing, and redistributive welfare policies from a person-centered perspective using the CARE (connecting, assessing, responding, and empowering) approach. Economic instruments that immediately redistribute state welfare and reduce income disparity such as direct taxation and conditional cash transfers could be adopted to enable older people with long-term conditions have access to healthcare services. Decreased socioeconomic inequality and unorthodox prescriptive interventions that reduce polypharmacy could mitigate barriers to effectively manage the complexities of multi-morbidity.
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Affiliation(s)
- Martin C Nwadiugwu
- Faculty of Health and Sports University of Stirling, Stirling, United Kingdom.,Department of Biomedical Informatics, University of Nebraska, Omaha, NE, United States
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53
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Sperber NR, Bruening R, Dadolf J, Miller K, Henius J, Kabat M, Perez J, Houtven CHV. 'The face of the programme': How local clinicians shape decisions about eligibility for a national caregiver support programme in the USA. J Health Serv Res Policy 2020; 26:180-188. [PMID: 33375864 DOI: 10.1177/1355819620983371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine the causes of variation for determining clinical eligibility for a national caregiver programme in the US Veterans Health Administration (VHA) and so help inform standardization of clinical eligibility assessment for support and establish conditions for more consistent caregiver experiences across the USA. METHODS We used mixed methods, including a national survey of caregiver support coordinators (CSCs) across VHA medical centres, semi-structured interviews with a purposive sample of 53 CSCs and interdisciplinary team members, and observations of four VHA medical centre sites. RESULTS A majority (70%) of CSCs across VHA medical centres reported that they used interdisciplinary teams to conduct assessments. Interdisciplinary teams were seen to help mitigate potential harm to therapeutic relationships from eligibility decisions. Survey respondents reported using a range of assessment tools provided by the national VHA Caregiver Support Program office, but participants expressed concerns that the tools did not necessarily effectively assess clinical need. Some local sites had developed innovative person-centered approaches, in which the assessment process provided an opportunity to assess veterans' holistic clinical needs, in contrast to a programme-centered approach, which focused on assessing whether veterans/their caregivers meet eligibility criteria. CONCLUSION Discretion by those involved in making decisions on programme eligiblity is important for implementing a national social services programme based on clinical need. Interdisciplinary teams can help mitigate potential harm to therapeutic relationships. Discretion allows for innovation. This work has implications for setting policy in other programme contexts in which applying eligibility criteria requires clinical judgement.
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Affiliation(s)
- Nina R Sperber
- Health Science Researcher, Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, USA
| | - Rebecca Bruening
- Research Analyst, Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, USA
| | - Joshua Dadolf
- Caregiver Support Coordinator, Durham Veterans Affairs Health Care System, USA
| | - Katherine Miller
- Program Coordinator, Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, USA
| | - Jennifer Henius
- Senior Health Systems Specialist, Caregiver Support Program, Department of Veterans Affairs, Washington, DC, USA
| | | | - Jennifer Perez
- National Director, Transition and Care Management Services, Department of Veterans Affairs, Washington, DC, USA
| | - Courtney H Van Houtven
- Health Science Researcher, Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, USA
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Tannou T, Trimaille H, Mathieu-Nicot F, Koeberle S, Aubry R, Godard-Marceau A. Investigation of opposition to diagnostic or therapeutic procedures in older people hospitalized in acute geriatric services: the OPTAH pilot study protocol. Pilot Feasibility Stud 2020; 6:194. [PMID: 33308277 PMCID: PMC7734746 DOI: 10.1186/s40814-020-00742-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 12/03/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Shared decision-making is a process that involves collaborative discussions between a patient and a care team to ensure informed healthcare decisions. This process becomes more complex when the older person's decision-making capacities are affected. In these situations, surrogate decision-making processes are used to define a person-centered care plan. Despite these processes, the implementation of the care plan defined in the best interest of the patient may nevertheless be rejected by the patient, particularly in cases of neurocognitive disorders or delirium. This concept of opposition and/or refusal is frequently used in research. This is not yet well understood in the medical literature, and there is a lack of consensus on its definition. We, therefore, explored this concept by defining opposition to diagnostic or therapeutic proposals. METHOD Our pilot study protocol is based on a mixed methodology (epidemiological and qualitative research) to quantify this phenomenon, validate the proposed definition, and explore its core elements. Opposition and refusal of care will be quantified, and semi-structured interviews will be conducted with patients, their relatives, and referring carers. Multidisciplinary meetings that will be associated with these situations will also be observed and analyzed. Methodological approaches that can be used to explore opposition and refusal of care in a scientific, reproducible framework are presented. This methodology considers the specificities of the geriatric, polypathological population with neurocognitive disorders. DISCUSSION Opposition and refusal of care are key concepts in clinical research on ethics, particularly in the geriatric field. These concepts are frequently mentioned in studies involving older patients but have not been specifically defined or studied. This study would undoubtedly lead to greater awareness among professional caregivers and relatives of the significance of such opposition, and more respectful interactions in these complex hospitalization cases. TRIAL REGISTRATION ClinicalTrial.gov, NCT03373838 . Registered on 14 December 2017.
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Affiliation(s)
- Thomas Tannou
- Geriatrics Department, University Hospital of Besançon, Besançon, France.
- Equipe "Ethique et Progrès Médical" Inserm, CIC 1431, Centre d'Investigation Clinique, University Hospital of Besançon, Besançon, France.
- EA 481 Neurosciences, UBFC, Besançon, France.
| | - Hélène Trimaille
- Equipe "Ethique et Progrès Médical" Inserm, CIC 1431, Centre d'Investigation Clinique, University Hospital of Besançon, Besançon, France
| | - Florence Mathieu-Nicot
- Equipe "Ethique et Progrès Médical" Inserm, CIC 1431, Centre d'Investigation Clinique, University Hospital of Besançon, Besançon, France
- EA 3188 Laboratoire de psychologie, UBFC, Besançon, France
| | - Séverine Koeberle
- Geriatrics Department, University Hospital of Besançon, Besançon, France
- Equipe "Ethique et Progrès Médical" Inserm, CIC 1431, Centre d'Investigation Clinique, University Hospital of Besançon, Besançon, France
| | - Régis Aubry
- Geriatrics Department, University Hospital of Besançon, Besançon, France
- Equipe "Ethique et Progrès Médical" Inserm, CIC 1431, Centre d'Investigation Clinique, University Hospital of Besançon, Besançon, France
- EA 481 Neurosciences, UBFC, Besançon, France
| | - Aurélie Godard-Marceau
- Equipe "Ethique et Progrès Médical" Inserm, CIC 1431, Centre d'Investigation Clinique, University Hospital of Besançon, Besançon, France
- EA 481 Neurosciences, UBFC, Besançon, France
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55
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Steele Gray C, Tang T, Armas A, Backo-Shannon M, Harvey S, Kuluski K, Loganathan M, Nie JX, Petrie J, Ramsay T, Reid R, Thavorn K, Upshur R, Wodchis WP, Nelson M. Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study. JMIR Res Protoc 2020; 9:e20220. [PMID: 33237037 PMCID: PMC7725647 DOI: 10.2196/20220] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/10/2020] [Accepted: 09/13/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. OBJECTIVE This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. METHODS The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure-3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. RESULTS This project is underway and expected to be complete by Spring 2024. CONCLUSIONS Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. TRIAL REGISTRATION ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/20220.
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Affiliation(s)
- Carolyn Steele Gray
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Alana Armas
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Mira Backo-Shannon
- Clinical, Health System Strategy, Integration and Planning, Ontario Health (Central Region), Mississauga Halton Local Health Integration Network, Toronto, ON, Canada
| | | | - Kerry Kuluski
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - Mayura Loganathan
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Mount Sinai Academic Family Health Team, Toronto, ON, Canada
| | - Jason X Nie
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - John Petrie
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - Tim Ramsay
- Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Robert Reid
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - Kednapa Thavorn
- Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ross Upshur
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Walter P Wodchis
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - Michelle Nelson
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- March of Dimes Canada, Toronto, ON, Canada
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Lam Wai Shun P, Swaine B, Bottari C. Combining scoping review and concept analysis methodologies to clarify the meaning of rehabilitation potential after acquired brain injury. Disabil Rehabil 2020; 44:817-825. [PMID: 32551986 DOI: 10.1080/09638288.2020.1779825] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Purpose: Clinicians make judgments about patients' rehabilitation potential because it is considered by many as a prerequisite for referral to rehabilitation. However, the concept is rarely defined. This research aimed to clarify the concept of rehabilitation potential in the context of acquired brain injury patient referral to post-acute rehabilitation.Method: Literature search (conducted in Medline, CINAHL and Embase) and article selection followed a scoping review methodology while a concept analysis methodology guided data extraction and analysis.Results: Eighteen documents met inclusion criteria. Findings suggest four defining attributes of the concept. Rehabilitation potential (1) emerges from clinicians' interpretation of patient characteristics and is influenced by the health care environment, (2) involves the prediction of how a patient might improve with rehabilitation interventions, (3) is a multi-level concept and (4) can change over time. The most critical consequence to assessing a patient's rehabilitation potential is the impact on the patient's opportunity to access post-acute rehabilitation services.Conclusion: Rehabilitation potential is a concept rooted in clinical reasoning. We propose an operational definition and a conceptual model to provide a solid foundation for future research to advance policy and clinical decision-making regarding equitable access to post-acute rehabilitation.IMPLICATIONS FOR REHABILITATIONRehabilitation potential is a concept rooted in clinical reasoning and emerges from clinicians' prediction of how a patient might improve with rehabilitation interventions.Rehabilitation potential is not a dichotomous concept but a multi-level concept with each level falling along a continuum.It may be inaccurate/inappropriate to definitively state that a patient has or does not have rehabilitation potential, as patients may demonstrate varying levels of rehabilitation potential.Rehabilitation potential can change with time requiring re-assessment to readjust recommendations accordingly with regards to appropriate rehabilitation interventions at any given time.
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Affiliation(s)
- Priscilla Lam Wai Shun
- School of rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada
| | - Bonnie Swaine
- School of rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada
| | - Carolina Bottari
- School of rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada
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Vinjerui KH, Boeckxstaens P, Douglas KA, Sund ER. Prevalence of multimorbidity with frailty and associations with socioeconomic position in an adult population: findings from the cross-sectional HUNT Study in Norway. BMJ Open 2020; 10:e035070. [PMID: 32546489 PMCID: PMC7299023 DOI: 10.1136/bmjopen-2019-035070] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 03/11/2020] [Accepted: 04/09/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To explore prevalences and occupational group inequalities of two measures of multimorbidity with frailty. DESIGN Cross-sectional study. SETTING The Nord-Trøndelag Health Study (HUNT), Norway, a total county population health survey, 2006-2008. PARTICIPANTS Participants older than 25 years, with complete questionnaires, measurements and occupation data were included. OUTCOMES ≥2 of 51 multimorbid conditions with ≥1 of 4 frailty measures (poor health, mental illness, physical impairment or social impairment) and ≥3 of 51 multimorbid conditions with ≥2 of 4 frailty measures. ANALYSIS Logistic regression models with age and occupational group were specified for each sex separately. RESULTS Of 41 193 adults, 38 027 (55% female; 25-100 years old) were included. Of them, 39% had ≥2 multimorbid conditions with ≥1 frailty measure, and 17% had ≥3 multimorbid conditions with ≥2 frailty measures. Prevalence differences in percentage points (pp) with 95% confidence intervals of those in high versus low occupational group with ≥2 multimorbid conditions and ≥1 frailty measure were largest in women age 30 years, 17 (14 to 20) pp and 55 years, 15 (13 to 17) pp and in men age 55 years, 15 (13 to 17) pp and 80 years, 14 (9 to 18) pp. In those with ≥3 multimorbid conditions and ≥2 frailty measures, prevalence differences were largest in women age 30 years, 8 (6 to 10) pp and 55 years, 10 (8 to 11) ppand in men age 55 years, 9 (8 to 11) pp and 80 years, 6 (95% CI 1 to 10) pp. CONCLUSION Multimorbidity with frailty is common, and social inequalities persist until age 80 years in women and throughout the lifespan in men. To manage complex multimorbidity, strategies for proportionate universalism in medical education, healthcare, public health prevention and promotion seem necessary.
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Affiliation(s)
- Kristin Hestmann Vinjerui
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, HUNT Research Centre, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
- Psychiatric Department, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | | | - Kirsty A Douglas
- Australian National University Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Erik R Sund
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, HUNT Research Centre, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
- Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
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58
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Vinjerui KH, Bjerkeset O, Bjorngaard JH, Krokstad S, Douglas KA, Sund ER. Socioeconomic inequalities in the prevalence of complex multimorbidity in a Norwegian population: findings from the cross-sectional HUNT Study. BMJ Open 2020; 10:e036851. [PMID: 32546494 PMCID: PMC7299021 DOI: 10.1136/bmjopen-2020-036851] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/31/2020] [Accepted: 05/12/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Multimorbidity, the co-occurrence of multiple long-term conditions, is common and increasing. Definitions and assessment methods vary, yielding differences in estimates of prevalence and multimorbidity severity. Sociodemographic characteristics are associated with complicating factors of multimorbidity. We aimed to investigate the prevalence of complex multimorbidity by sex and occupational groups throughout adulthood. DESIGN Cross-sectional study. SETTING The third total county survey of The Nord-Trøndelag Health Study (HUNT), 2006-2008, Norway. PARTICIPANTS Individuals aged 25-100 years with classifiable occupational data and complete questionnaires and measurements. OUTCOME MEASURE Complex multimorbidity defined as 'the co-occurrence of three or more chronic conditions affecting three or more different body (organ) systems within one person without defining an index chronic condition'. ANALYSIS Logistic regression models with age and occupational group were specified for each sex separately. RESULTS 38 027 of 41 193 adults (55% women) were included in our analyses. 54% of the participants were identified as having complex multimorbidity. Prevalence differences in percentage points (pp) of those in the low occupational group (vs the high occupational group (reference)) were 19 (95% CI, 16 to 21) pp in women and 10 (8 to 13) pp in men at 30 years; 12 (10 to 14) pp in women and 13 (11 to 15) pp in men at 55 years; and 2 (-1 to 4) pp in women and 7 (4 to 10) pp in men at 75 years. CONCLUSION Complex multimorbidity is common from early adulthood, and social inequalities persist until 75 years in women and 90 years in men in the general population. These findings have policy implications for public health as well as healthcare, organisation, treatment, education and research, as complex multimorbidity breaks with the specialised, fragmented paradigm dominating medicine today.
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Affiliation(s)
- Kristin Hestmann Vinjerui
- HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Levanger, Trøndelag, Norway
- Psychiatric Department, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Trøndelag, Norway
| | - Ottar Bjerkeset
- Faculty of Nursing and Health Sciences, Nord Universitet - Levanger Campus, Levanger, Norway
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - Johan H Bjorngaard
- Faculty of Nursing and Health Sciences, Nord Universitet - Levanger Campus, Levanger, Norway
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - Steinar Krokstad
- HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Levanger, Trøndelag, Norway
- Psychiatric Department, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Trøndelag, Norway
| | - Kirsty A Douglas
- Academic Unit of General Practice, Australian National University Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Erik R Sund
- HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Levanger, Trøndelag, Norway
- Faculty of Nursing and Health Sciences, Nord Universitet - Levanger Campus, Levanger, Norway
- Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Trøndelag, Norway
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Caregiver-reported physical health status of children and young people with fetal alcohol spectrum disorder. J Dev Orig Health Dis 2020; 12:420-427. [PMID: 32513328 DOI: 10.1017/s2040174420000537] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While fetal alcohol spectrum disorder (FASD) has primarily been thought of as a neurodevelopmental condition, research is beginning to highlight its 'whole-body' implications. Accordingly, the current study sought to provide a snapshot of potential health issues. Caregivers of children (median age of 12 years) with an FASD diagnosis were invited to participate in an online survey. Information relating to sample demographics, FASD status of the child and health outcomes were collected. The prevalence of health conditions reported in the FASD sample was compared against national prevalence data. Multiple linear regression utilising a stepwise approach was used to investigate potential predictors of the number of diagnosed health conditions. Survey data were from an international cohort (n = 197), with the majority of respondents based in Australia (40.2%) or the United States (27.7%). The most commonly reported diagnosed health conditions were eye conditions (44.7%), asthma (34.5%), heart conditions (34.0%) and skin conditions (27.4%). Binomial testing indicated the proportion of children diagnosed with these disorders was generally higher in the current FASD population, compared to national prevalence data. Indicators of metabolic dysfunction including diabetes and obesity were not significantly different compared to national prevalence data. Age of FASD diagnosis, existence of comorbid mental health conditions and the primary caregiver being in paid work were identified as being associated with the prevalence of diagnosed health conditions. Overall, the study has provided an up-to-date snapshot of health problems reported in a sample of children with FASD, confirming their increased risk of adverse health outcomes.
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Corrao S, Natoli G, Nobili A, Mannucci PM, Pietrangelo A, Perticone F, Argano C. Comorbidity does not mean clinical complexity: evidence from the RePoSI register. Intern Emerg Med 2020; 15:621-628. [PMID: 31650434 DOI: 10.1007/s11739-019-02211-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/09/2019] [Indexed: 11/28/2022]
Abstract
In the last 2-3 decades internists have confronted dramatic changes in the pattern of patients acutely admitted to hospital wards. Internists observed a shift from younger subjects affected by a single organ disease to more complex patients, usually older, with multiple chronic conditions, attended by different specialists, with poor integration and treated with multiple drugs. In this regard, the concept of complex patients is addressed daily in clinical practice even if there is no agreed definition of patient complexity. To try to evaluate clinical complexity different instruments have been proposed. Among these, the number of comorbidities (NoC) was considered a marker of clinical complexity. However, this instrument would not give information about the clinical relevance of each condition. On the contrary, cumulative illness rating scale (CIRS) addresses the problem calculating both CIRS severity index (CIRS-SI) and CIRS comorbidity index (CIRS-CI). In light of this, 4714 patients from the RePoSI register were retrospectively analyzed to show if CIRS assessment of comorbidity burden is different from the simple count of comorbidities in predicting the length of hospital stay (LOS) and all-cause of mortality in hospitalized elderly patients and if NoC could be a valid tool to measure patient's complexity. CIRS-SI resulted the best predictor of all-cause in-hospital mortality [OR: 2.66 (1.88-3.77)] in comparison with NoC that did not result statistically significant (p = 0.551). CIRS-SI was also the best predictor of all-cause of post-discharge mortality corrected for age and sex [OR: 2.12 (1.53-2.95)]. CIRS-SI (coefficient ± standard error: 1.23 ± 0.59; p < 0.0381) and CIRS-CI (coefficient ± standard error: 0.27 ± 0.10; p < 0.011) were strong predictors of LOS in comparison with NoC that did not result statistically significant (coefficient ± standard error: 0.04 ± 0.06 p < 0.0561). In conclusion, CIRS assessment of comorbidity burden is a better clinical tool in comparison with the simple count of comorbidities especially considering the length of hospital stay and all-cause mortality in hospitalized elderly patients.
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Affiliation(s)
- Salvatore Corrao
- Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", PROMISE, University of Palermo, 90133, Palermo, Italy.
- Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, 90127, Palermo, Italy.
| | - Giuseppe Natoli
- Department of Organizational, Clinical, and Translational Research, I.E.ME.S.T., 90139, Palermo, Italy
| | - Alessandro Nobili
- Department of Neuroscience, IRCCS, Istituto Di Ricerche Farmacologiche Mario Negri, 20156, Milan, Italy
| | | | - Antonello Pietrangelo
- Department of Internal Medicine II, Center for Hemochromatosis, University of Modena and Reggio Emilia Policlinico, 41100, Modena, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, 88100, Catanzaro, Italy
| | - Christiano Argano
- Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, 90127, Palermo, Italy
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How does decisional capacity evolve with normal cognitive aging: systematic review of the literature. Eur Geriatr Med 2020; 11:117-129. [PMID: 32297227 DOI: 10.1007/s41999-019-00251-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Aging is associated with increased needs related to complex decisions, particularly in medical and social issues. However, the complexity of decision-making involves many neurological functions and structures which are potentially altered by cognitive aging. METHODOLOGY A systematic review was conducted in accordance with PRISMA guidelines to examine changes in decision-making occurring in normal cognitive aging. The keywords "decision making" and "normal aging" were used to find the clinical studies and literature reviews focused on these changes. RESULTS A total of 97 articles were considered in the review, and ultimately 40 articles were selected, including 30 studies and 10 literature reviews. The data from these studies were of uneven quality and too disparate to allow meta-analysis according to PRISMA criteria. Nevertheless, a key result of the analysis is the decrease of processing speed with aging. In ambiguous decision-making situations, the alteration of the ventromedial system is associated with changes in motivation profiles. These changes can be compensated by experience. However, difficulties arise for older adults in the case of one-off decisions, which are very common in the medical or medico-social domains. CONCLUSIONS Cognitive aging is associated with a slowdown in processing speed of decision-making, especially in ambiguous situations. However, decision-making processes which are based on experience and cases in which sufficient time is available are less affected by aging. These results highlight the relativity of decision-making capacities in cognitive aging.
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Huber E, Kleinknecht‐Dolf M, Kugler C, Spirig R. Patient‐related complexity of nursing care in acute care hospitals – an updated concept. Scand J Caring Sci 2020; 35:178-195. [DOI: 10.1111/scs.12833] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/05/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Evelyn Huber
- Department of Nursing Science Faculty for Health University Witten/Herdecke Witten Germany
- Department Public Health, Nursing Science University of Basel Basel Switzerland
| | - Michael Kleinknecht‐Dolf
- Department of Nursing and Allied Health Care Professionals University Hospital Zurich Zurich Switzerland
| | - Christiane Kugler
- Institute of Nursing Science Faculty of Medicine University of Freiburg Freiburg Germany
| | - Rebecca Spirig
- Department of Nursing Science Faculty for Health University Witten/Herdecke Witten Germany
- Department Public Health, Nursing Science University of Basel Basel Switzerland
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De Oliveira A, Chavannes B, Steinecker M, Denantes M, Chastang J, Ibanez G. How French general practitioners adapt their care to patients with social difficulties? Fam Med Community Health 2020; 7:e000044. [PMID: 32148723 PMCID: PMC6910763 DOI: 10.1136/fmch-2018-000044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 11/29/2022] Open
Abstract
Objective Several studies have shown the role of the primary care system in access to care and in reducing social inequalities in health. The objective of this study was to describe the practices of general practitioners (GPs) in taking into account the social environment of their patient, and the ways they adapted to social difficulties. Design Qualitative study comprising interviews and focus groups. Setting French primary care settings. Participants Twenty semistructured interviews and two focus groups were conducted with 33 GPs. Sessions were audio recorded, transcribed verbatim and analysed using thematic analysis. The reporting of findings was guided by consolidated criteria for reporting qualitative research. Result This study identified adaptations at three levels: in the individual management of patients (alert system, full involvement in prevention, better communication, prioritised additional examinations, financial facilities, help in administrative tasks), in the collective management of patients in an office (consultation without appointment, pay-for-performance indicators, medical staffs, multidisciplinary protocols, medical practice in group, medical student), and in the community management (patients description, cooperation with associations, public health sector and politics). Conclusion In France, GPs can take into account the social determinants of health in practice through simple or more complex actions.
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Affiliation(s)
- Annie De Oliveira
- Department of General Practice, Medicine Sorbonne University, Paris, France
| | - Barbara Chavannes
- Department of General Practice, Medicine Sorbonne University, Paris, France
| | - Magali Steinecker
- Department of General Practice, Medicine Sorbonne University, Paris, France
| | - Mady Denantes
- Department of General Practice, Medicine Sorbonne University, Paris, France
| | - Julie Chastang
- Department of General Practice, Medicine Sorbonne University, Paris, France
| | - Gladys Ibanez
- Department of General Practice, Medicine Sorbonne University, Paris, France.,Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, (IPLESP), F75012, Paris, France
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Gordon K, Steele Gray C, Dainty KN, DeLacy J, Ware P, Seto E. Exploring an Innovative Care Model and Telemonitoring for the Management of Patients With Complex Chronic Needs: Qualitative Description Study. JMIR Nurs 2020; 3:e15691. [PMID: 34345777 PMCID: PMC8279442 DOI: 10.2196/15691] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/31/2019] [Accepted: 01/23/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The growing number of patients with complex chronic conditions presents an urgent challenge across the Canadian health care system. Current care delivery models are overburdened, struggling to monitor and stabilize the complex needs of this growing patient population. OBJECTIVE This qualitative study aimed to explore the needs and perspectives of patients and members of the care team to inform the development of an innovative integrated model of care and the needs of telemonitoring (TM) for patients with complex chronic conditions. Furthermore, we explored how these needs could be successfully embedded to support this novel model of complex chronic care. METHODS A qualitative description design was utilized to conduct and analyze 29 semistructured interviews with patients (n=16) and care team members (CTM) (n=13) involved in developing the model of care in an ambulatory care facility in Southern Ontario. Participants were identified through purposive sampling. Two researchers performed an iterative thematic analysis using NVivo 12 (QSR International; Melbourne, Australia) to gain insights from examining multiple perspectives of different participants on complex chronic care needs. RESULTS The analysis revealed 3 themes and 13 subthemes, including the following: (1) adequate health care delivery remains challenging for patients with complex care needs, (2) insights into how to structure an integrated care model, and (3) opportunities for TM in an integrated model of care. Participants not only identified continued challenges in accessing and navigating care in a fragmented and disconnected delivery system but also identified the need for more self-management support. Patients and CTM described the structure of an integrated model of care, including the need for a clear referral and triage processes and composing a tight-knit circle of collaborating interdisciplinary providers led by a nurse practitioner (NP). Finally, opportunities for TM in an integrated model of care were identified, including increasing access and communication, the ability to monitor specific signs and symptoms, and building a clinical workflow around TM-enabled care. CONCLUSIONS Despite entrenched health care service delivery models, a new model of care is acutely needed to care for patients with complex chronic needs (CCN). NPs are in a unique position to lead TM-enabled integrated models of care. TM can facilitate frequent and necessary monitoring of patients with CCN with more than one condition in integrated models of care.
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Affiliation(s)
- Kayleigh Gordon
- University of Toronto Toronto, ON Canada
- Centre for Global eHealth Innovation Techna Institute University Health Network Toronto, ON Canada
| | - Carolyn Steele Gray
- University of Toronto Toronto, ON Canada
- Bridgepoint Collaboratory for Research and Innovation Lunenfeld-Tanenbaum Research Institute Sinai Health System Toronto, ON Canada
| | - Katie N Dainty
- University of Toronto Toronto, ON Canada
- North York General Hospital North York, ON Canada
| | - Jane DeLacy
- William Osler Health System Brampton, ON Canada
| | - Patrick Ware
- Centre for Global eHealth Innovation Techna Institute University Health Network Toronto, ON Canada
| | - Emily Seto
- University of Toronto Toronto, ON Canada
- Centre for Global eHealth Innovation Techna Institute University Health Network Toronto, ON Canada
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Huber E, Kleinknecht‐Dolf M, Kugler C, Müller M, Spirig R. Validation of the instrument "Complexity of Nursing Care"-A mixed-methods study. Nurs Open 2020; 7:212-224. [PMID: 31871705 PMCID: PMC6917930 DOI: 10.1002/nop2.383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/13/2019] [Accepted: 09/02/2019] [Indexed: 11/12/2022] Open
Abstract
Aims This study aimed to psychometrically test the instrument "Complexity of Nursing Care" and to broaden the understanding of the instrument's psychometrics and applicability. Design Embedded mixed-methods design. Methods We performed a cross-sectional study assessing all stationary patients of five Swiss hospitals daily for up to 5 days with the instrument "Complexity of Nursing Care" over a 1-month period in 2015. The scale's psychometrics were analysed using partial least square structural equation modelling. In the qualitative study section, we completed 12 case studies and analysed them case-wise and across cases. Quantitative and qualitative results were synthesized in tables. Results Structural equation modelling confirmed a reflective-formative second-order model of the instrument with good psychometric properties leading to a formula for the calculation of a complexity score. Qualitative results evolved descriptions of low and high extent of complexity. Narrative considerations of two raters deepened the understanding of the inter-rater reliability.
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Affiliation(s)
- Evelyn Huber
- Department of Nursing ScienceFaculty for HealthUniversity Witten/HerdeckeWittenGermany
| | - Michael Kleinknecht‐Dolf
- Department of Nursing and Allied Health Care ProfessionalsUniversity Hospital ZurichZurichSwitzerland
| | - Christiane Kugler
- Faculty of MedicineInstitute of Nursing ScienceUniversity of FreiburgFreiburgGermany
| | - Marianne Müller
- Institute of Data Analysis and Process DesignSchool of EngineeringZurich University of Applied SciencesWinterthurSwitzerland
| | - Rebecca Spirig
- Department of Nursing ScienceFaculty for HealthUniversity Witten/HerdeckeWittenGermany
- Department of Nursing and Allied Health Care ProfessionalsUniversity Hospital ZurichZurichSwitzerland
- Department Public HealthInstitute of Nursing ScienceUniversity of BaselBaselSwitzerland
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Shukor AR, Joe R, Sincraian G, Klazinga N, Kringos DS. A Multi-sourced Data Analytics Approach to Measuring and Assessing Biopsychosocial Complexity: The Vancouver Community Analytics Tool Complexity Module (VCAT-CM). Community Ment Health J 2019; 55:1326-1343. [PMID: 31177480 PMCID: PMC6823655 DOI: 10.1007/s10597-019-00417-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 05/16/2019] [Indexed: 01/09/2023]
Abstract
Operationalization of the fundamental building blocks of primary care (i.e. empanelment, team-based care and population management) within the context of Community Health Centers requires accurate and real-time measures of biopsychosocial complexity, at both client and population-levels. This article describes the conceptualization, design and development of a novel software tool (the VCAT-Complexity Module) that can calculate and report real-time person-oriented biopsychosocial complexity profiles, using multiple data sources. The tool aligns with a profile approach to conceptualizing health outcomes, and represents a potentially significant advance over disease-oriented complexity assessment tools. The results and face validity of the software's complexity score outputs are discussed, along with their practical implications on functions related to the development of primary care within Vancouver Coastal Health, a Canadian Regional Health Authority.
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Affiliation(s)
- Ali Rafik Shukor
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Ronald Joe
- Vancouver Coastal Health (VCH), 520 West 6th Ave, Vancouver, BC Canada
| | | | - Niek Klazinga
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Dionne Sofia Kringos
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Bulsara SM, Wainberg ML, Audet CM, Newton-John TR. Retention in HIV Care in Australia: The Perspectives of Clinicians and Clients, and the Impact of Medical and Psychosocial Comorbidity. AIDS Patient Care STDS 2019; 33:415-424. [PMID: 31390222 DOI: 10.1089/apc.2019.0094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Significant advances in our understanding and treatment of HIV have led to improvements in the medical management of the illness, as HIV infection has evolved from an acute to a chronic illness. Increasing our understanding of the medical and/or psychosocial comorbidities, which can interact to determine "clinical complexity" and impact HIV management, will further strengthen this process. Retention in care is a critical step of the HIV Treatment Cascade, which facilitates effective management of these comorbidities and their impact on HIV medical management. This study sought to build on literature regarding medical and/or psychosocial comorbidity that impacts retention in care, and it often leads to clinically complex presentations, by gaining the perspectives of people living with HIV (PLHIV), and medical and allied health clinicians in the field in Sydney, Australia. A total of 16 clinicians (medical doctors, nurses, clinical psychologists, and social workers) and 14 clients participated in a series of focus groups; they were asked to comment on the perceived barriers to retention and the potential solutions to overcome these. The results indicated a significant degree of overlap between clinician and client perspectives, and they identified "service-specific factors," "logistic/practical factors," "medical/physical factors," and "psychosocial factors" as potential barriers to retention. Results are reviewed in the context of similarities and differences in perspectives between clinicians and PLHIV, and limitations regarding the generalizability of findings are discussed. The broader context of comorbidity and clinical complexity is also examined.
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Affiliation(s)
- Shiraze M. Bulsara
- Clinical Psychology, Graduate School of Health, University of Technology Sydney (UTS), Sydney, Australia
- The Albion Centre, Sydney, Australia
| | | | - Carolyn M. Audet
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Toby R.O. Newton-John
- Clinical Psychology, Graduate School of Health, University of Technology Sydney (UTS), Sydney, Australia
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Bulsara SM, Begley K, Smith DE, Chan DJ, Furner V, Coote KV, Hennessy RM, Alperstein DM, Price A, Smith M, Wyson A, Wand H. The development of an HIV-specific complexity rating scale. Int J STD AIDS 2019; 30:1265-1274. [PMID: 31566095 PMCID: PMC6886116 DOI: 10.1177/0956462419868359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
As treatment for HIV improves, an ageing population is experiencing comorbidity which often leads to complex clinical presentations requiring an interdisciplinary care approach. This study sought to quantify clinician assessment of the level of clinical complexity, through the development of a rating scale for people living with HIV (PLHIV), to improve client care through an interdisciplinary care model. An existing alcohol and other drug complexity rating scale was selected and modified for use with PLHIV. HIV-specific items were included through consultation with an interdisciplinary team. A risk-prediction model was developed and validated using clinician ratings of clients attending The Albion Centre, a tertiary HIV clinic in Sydney, Australia, resulting in the development of the Clinical Complexity Rating Scale for HIV (CCRS-HIV). Multivariable logistic regression models identified eight characteristics based on clinician assessment of complexity in PLHIV: financial instability, social isolation, problematic crystal methamphetamine use, mental illness and/or other problematic substance use, cognitive/neurological impairment, polypharmacy, current hepatitis C infection and/or cancer, and other physical health comorbidity. A weighted risk-prediction model was developed and validated. The final model accurately predicted 85% of complex clients, with a sensitivity of 80% and specificity of 91%. This study developed an HIV-specific clinician-rated complexity scale. Further investigations are required to validate the CCRS-HIV with broader HIV populations. This simple complexity screening tool is a promising adjunct to clinical assessment to identify clients with complex physical and psychosocial needs who may benefit from interdisciplinary care interventions and allocation of resources.
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Affiliation(s)
- S M Bulsara
- The Albion Centre, Surry Hills, Australia.,Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - K Begley
- The Albion Centre, Surry Hills, Australia
| | - D E Smith
- The Albion Centre, Surry Hills, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - D J Chan
- The Albion Centre, Surry Hills, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - V Furner
- The Albion Centre, Surry Hills, Australia
| | - K V Coote
- The Albion Centre, Surry Hills, Australia
| | | | | | - A Price
- The Albion Centre, Surry Hills, Australia
| | - M Smith
- The Albion Centre, Surry Hills, Australia
| | - A Wyson
- The Albion Centre, Surry Hills, Australia
| | - H Wand
- The Kirby Institute, University of New South Wales, Sydney, Australia
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Abstract
PURPOSE OF REVIEW The growing number of patients with terminal and chronic conditions and co-morbidities constitutes a challenge for any healthcare system, to provide effective and efficient patient-centred care at the end of life. Resources are limited, and complexity is rising within patients' situations and healthcare professionals interventions. This review presents the state of art of the role of complexity in specialist palliative care provision. RECENT FINDINGS Although studies related to complexity in palliative care are still limited, interesting reviews on complexity frameworks in co-morbidity conditions and palliative care are growing more present in current literature. They identify multidimensional issues, resource utilisation, and the relationship between them as fundamental aspects of complexity constructs, helping to define and understand complexity, and to therefore design validated tools to support healthcare professionals identifying the most complex patients, such as Hui's criteria, PALCOM, INTERMED, and IDC-Pal which is presented in this review. SUMMARY There is an urgent need to guarantee quality and equity of care for all the patients eligible for palliative care, from those who need a palliative care approach to those needing specialist intensive palliative care. Implementing complexity theory into practice is paramount. In this review, complexity science, complexity frameworks, as well as tools evaluating complexity in palliative care are described.
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Clinical risk groups and patient complexity: a case study with a primary care clinic in Alberta. HEALTH AND TECHNOLOGY 2019. [DOI: 10.1007/s12553-019-00333-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Sanson G, Welton J, Vellone E, Cocchieri A, Maurici M, Zega M, Alvaro R, D’Agostino F. Enhancing the performance of predictive models for Hospital mortality by adding nursing data. Int J Med Inform 2019; 125:79-85. [DOI: 10.1016/j.ijmedinf.2019.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/28/2019] [Accepted: 02/25/2019] [Indexed: 12/29/2022]
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Tang T, Heidebrecht C, Coburn A, Mansfield E, Roberto E, Lucez E, Lim ME, Reid R, Quan SD. Using an electronic tool to improve teamwork and interprofessional communication to meet the needs of complex hospitalized patients: A mixed methods study. Int J Med Inform 2019; 127:35-42. [PMID: 31128830 DOI: 10.1016/j.ijmedinf.2019.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 01/29/2019] [Accepted: 04/12/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Teamwork and interprofessional communication are important in addressing the comprehensive care needs of complex hospitalized patients. The objective of this study is to evaluate the impact of an electronic interprofessional communication and collaboration platform on teamwork, communication, and adverse events in the hospital setting. MATERIALS AND METHODS In this mixed methods study, we used a quasi-experimental design in the quantitative component and deployed the electronic tool in a staged fashion to 2 hospital wards 3 months apart. We measured teamwork, communication, and adverse events with Relational Coordination survey, video recordings of team rounds, and retrospective chart review. We conducted qualitative semi-structured interviews with clinicians to understand the perceived impacts of the electronic tool and other contextual factors. RESULTS Teamwork sustainably improved (overall Relational Coordination score improved from 3.68 at baseline to 3.84 at three and six months after intervention, p = 0.03) on ward 1. A small change in face-to-face communication pattern during team rounds was observed (making plans increased from 22% to 24%, p = 0.004) at 3 months on ward 1 but was not sustained at 6 months. Teamwork and communication did not change after the intervention on ward 2. There was no meaningful change to adverse event rates on either ward. Clinicians reported generally positive views about the electronic tool's impact but described non-technology factors on each ward that affected teamwork and communication. CONCLUSION The impact of using an electronic tool to improve teamwork and communication in the hospital setting appears mixed, but can be positive in some settings. Improving teamwork and communication likely require both appropriate technology and addressing non-technology factors.
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Affiliation(s)
- Terence Tang
- Institute for Better Health and Program of Medicine, Trillium Health Partners, 100 Queensway West, Clinical Administrative Building, 6th floor, Mississauga, Ontario, L5B 1B8, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | | | - Andrea Coburn
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Elizabeth Mansfield
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada; Department of Occupational Science and Occupational Therapy, University of Toronto, Canada
| | - Ellen Roberto
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Emanuel Lucez
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Morgan E Lim
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada
| | - Robert Reid
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada
| | - Sherman D Quan
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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Eaton AD, Chan Carusone S, Craig SL, Telegdi E, McCullagh JW, McClure D, Wilson W, Zuniga L, Berney K, Ginocchio GF, Wells GA, Montess M, Busch A, Boyce N, Strike C, Stewart A. The ART of conversation: feasibility and acceptability of a pilot peer intervention to help transition complex HIV-positive people from hospital to community. BMJ Open 2019; 9:e026674. [PMID: 30928956 PMCID: PMC6475144 DOI: 10.1136/bmjopen-2018-026674] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To pilot a peer-based intervention for people living with HIV who used substances, had challenges with antiretroviral adherence and would be discharged from hospital to community. STUDY DESIGN A community-based, quasi-experimental pilot intervention study designed to assess feasibility, acceptability and connection to a community-based HIV organisation. SETTING This study was conducted in Toronto, Canada, at Casey House (CH; hospital for people living with HIV) in collaboration with the AIDS Committee of Toronto (ACT; community-based HIV organisation). PARTICIPANTS People living with HIV who were CH inpatient between 1 April 2017 and 31 March 2018, struggled with antiretroviral adherence, actively used substances and would be discharged to community were eligible. Forty people met criteria, 19 were approached by an inpatient nurse and 17 consented. Average age was 48.8 years (SD=11.4), 58.8% were male and participants averaged 7.8 physical and mental health comorbidities (SD=3.1). INTERVENTION Titled 'The ART of Conversation', the three-pronged personalised intervention was developed through input from CH clients and ACT volunteers, all living with HIV. Intervention components were (a) predischarge goal-setting (adherence, substance use and self-identified goal) with the study nurse; (b) predischarge meeting with an HIV+ peer volunteer (PV) and (c) nine postdischarge phone calls between PV and participant, once per day for 3 days, then once per week for 6 weeks. PRIMARY OUTCOMES Feasibility was measured through proportion of eligible participants recruited and PV availability. Acceptability was assessed through participant interviews at three times (preintervention, post-intervention and 6 weeks follow-up) and through PV call logs. Client records determined connection to ACT within the study timeframe. RESULTS Twelve participants completed the intervention and nine connected with ACT. Predischarge goal-setting and PV meeting were both feasible and acceptable. Postdischarge phone calls were a challenge as half of completers missed at least one call. CONCLUSIONS Although predischarge goal-setting and PV meeting were feasible, methods to maintain connection following discharge require further investigation.
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Affiliation(s)
- Andrew David Eaton
- University of Toronto, Factor-Inwentash Faculty of Social Work, Toronto, Ontario, Canada
- AIDS Committee of Toronto, Toronto, Ontario, Canada
| | - Soo Chan Carusone
- Casey House, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shelley L Craig
- University of Toronto, Factor-Inwentash Faculty of Social Work, Toronto, Ontario, Canada
| | | | | | | | | | | | - Kevin Berney
- AIDS Committee of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Adam Busch
- AIDS Committee of Toronto, Toronto, Ontario, Canada
| | - Nick Boyce
- Ontario Harm Reduction Network, Toronto, Ontario, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ann Stewart
- St. Michael's Hospital, Toronto, Ontario, Canada
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Corazza GR, Formagnana P, Lenti MV. Bringing complexity into clinical practice: An internistic approach. Eur J Intern Med 2019; 61:9-14. [PMID: 30528261 DOI: 10.1016/j.ejim.2018.11.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/22/2018] [Accepted: 11/24/2018] [Indexed: 12/13/2022]
Abstract
Modern medicine, still largely focused on single diseases, is unprepared for managing clinical complexity (CC), which is an emerging issue. Ageing of the general population has favoured the occurrence of chronic diseases, which generate multimorbidity that has been considered for many years the main feature of CC. However, more recent studies have shown that CC is something more and different and originates from the dynamic interaction among the patient's intrinsic factors (age, gender, multimorbidity, frailty) as well as contextual factors (socioeconomic, behavioural, cultural, and environmental). The result of these interactions is non-linear and unpredictable behaviour, which is difficult to manage both in clinical practice and in the organisation of care. Up to now, the prevalent approach has consisted of breaking down and separately analysing each CC component. Consequently, only incomplete strategies to improve health outcomes have been developed, such as limited patient-centred algorithms, deprescription of therapies, and local clinical governance interventions. Medical education has a pivotal role in transmitting the knowledge of complexity, making it realistically understandable and manageable. Future research should aim at implementing our knowledge of CC, developing new tools for its quantitation, and finding new solutions to improve important health outcomes at a sustainable cost.
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Affiliation(s)
- Gino Roberto Corazza
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.
| | - Pietro Formagnana
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Marco Vincenzo Lenti
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
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75
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Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018; 18:143. [PMID: 30453902 PMCID: PMC6245623 DOI: 10.1186/s12874-018-0611-x] [Citation(s) in RCA: 3682] [Impact Index Per Article: 613.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 11/06/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Scoping reviews are a relatively new approach to evidence synthesis and currently there exists little guidance regarding the decision to choose between a systematic review or scoping review approach when synthesising evidence. The purpose of this article is to clearly describe the differences in indications between scoping reviews and systematic reviews and to provide guidance for when a scoping review is (and is not) appropriate. RESULTS Researchers may conduct scoping reviews instead of systematic reviews where the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts or to investigate research conduct. While useful in their own right, scoping reviews may also be helpful precursors to systematic reviews and can be used to confirm the relevance of inclusion criteria and potential questions. CONCLUSIONS Scoping reviews are a useful tool in the ever increasing arsenal of evidence synthesis approaches. Although conducted for different purposes compared to systematic reviews, scoping reviews still require rigorous and transparent methods in their conduct to ensure that the results are trustworthy. Our hope is that with clear guidance available regarding whether to conduct a scoping review or a systematic review, there will be less scoping reviews being performed for inappropriate indications better served by a systematic review, and vice-versa.
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Affiliation(s)
- Zachary Munn
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005 South Australia
| | - Micah D. J. Peters
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005 South Australia
| | - Cindy Stern
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005 South Australia
| | - Catalin Tufanaru
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005 South Australia
| | - Alexa McArthur
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005 South Australia
| | - Edoardo Aromataris
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005 South Australia
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76
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Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018. [PMID: 30453902 DOI: 10.1186/s12874-018-0611-x.pmid] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Scoping reviews are a relatively new approach to evidence synthesis and currently there exists little guidance regarding the decision to choose between a systematic review or scoping review approach when synthesising evidence. The purpose of this article is to clearly describe the differences in indications between scoping reviews and systematic reviews and to provide guidance for when a scoping review is (and is not) appropriate. RESULTS Researchers may conduct scoping reviews instead of systematic reviews where the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts or to investigate research conduct. While useful in their own right, scoping reviews may also be helpful precursors to systematic reviews and can be used to confirm the relevance of inclusion criteria and potential questions. CONCLUSIONS Scoping reviews are a useful tool in the ever increasing arsenal of evidence synthesis approaches. Although conducted for different purposes compared to systematic reviews, scoping reviews still require rigorous and transparent methods in their conduct to ensure that the results are trustworthy. Our hope is that with clear guidance available regarding whether to conduct a scoping review or a systematic review, there will be less scoping reviews being performed for inappropriate indications better served by a systematic review, and vice-versa.
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Affiliation(s)
- Zachary Munn
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005, South Australia.
| | - Micah D J Peters
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005, South Australia
| | - Cindy Stern
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005, South Australia
| | - Catalin Tufanaru
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005, South Australia
| | - Alexa McArthur
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005, South Australia
| | - Edoardo Aromataris
- The Joanna Briggs Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5005, South Australia
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D'Agostino F, Vellone E, Cocchieri A, Welton J, Maurici M, Polistena B, Spandonaro F, Zega M, Alvaro R, Sanson G. Nursing Diagnoses as Predictors of Hospital Length of Stay: A Prospective Observational Study. J Nurs Scholarsh 2018; 51:96-105. [PMID: 30411479 DOI: 10.1111/jnu.12444] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE To investigate whether the number of nursing diagnoses on hospital admission is an independent predictor of the hospital length of stay. DESIGN A prospective observational study was carried out. A sample of 2,190 patients consecutively admitted (from July to December 2014) in four inpatient units (two medical, two surgical) of a 1,547-bed university hospital were enrolled for the study. METHODS Data were collected from a clinical nursing information system and the hospital discharge register. Two regression analyses were performed to investigate if the number of nursing diagnoses on hospital admission was an independent predictor of length of stay and length of stay deviation after controlling for patients' sociodemographic characteristics (age, gender), clinical variables (disease groupers, disease severity morbidity indexes), and organizational hospital variables (admitting inpatient unit, modality of admission). FINDINGS The number of nursing diagnoses was shown to be an independent predictor of both the length of stay (β = .15; p < .001) and the length of stay deviation (β = .19; p < .001). CONCLUSIONS The number of nursing diagnoses is a strong independent predictor of an effective hospital length of stay and of a length of stay longer than expected. CLINICAL RELEVANCE The systematic inclusion of standard nursing care data in electronic health records can improve the predictive ability on hospital outcomes and describe the patient complexity more comprehensively, improving hospital management efficiency.
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Affiliation(s)
- Fabio D'Agostino
- Mu Upsilon, Research Fellow, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Ercole Vellone
- Assistant Professor, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - John Welton
- Professor & Senior Scientist Health Systems Research, University of Colorado College of Nursing, Aurora, CO, USA
| | - Massimo Maurici
- Assistant Professor, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Barbara Polistena
- Research Fellow, Department of Economics and Finance, University of Rome Tor Vergata, C.R.E.A. Sanità, Rome, Italy
| | - Federico Spandonaro
- Aggregate Professor, Department of Economics and Finance, University of Rome Tor Vergata, Chair C.R.E.A. Sanità, Rome, Italy
| | - Maurizio Zega
- Director of Health Professions, University Hospital Agostino Gemelli, Rome, Italy
| | - Rosaria Alvaro
- Associate Professor, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Gianfranco Sanson
- Adjunct Professor, School of Nursing, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
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LaDonna KA, Field E, Watling C, Lingard L, Haddara W, Cristancho SM. Navigating complexity in team-based clinical settings. MEDICAL EDUCATION 2018; 52:1125-1137. [PMID: 30345686 DOI: 10.1111/medu.13671] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/11/2018] [Accepted: 06/05/2018] [Indexed: 06/08/2023]
Abstract
CONTEXT Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio-relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. METHODS Constructivist grounded theory informed data collection and analysis; during semi-structured interviews, we used rich pictures to elicit team members' perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. RESULTS Routine care became complex when the prognosis was unknown, when treatment was either non-existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants' training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. CONCLUSIONS Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non-physician team members in advocacy training.
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Affiliation(s)
- Kori A LaDonna
- Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Emily Field
- Department of Women's Studies, Western University, London, Ontario, Canada
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Christopher Watling
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Clinical Neurological Sciences, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Lorelei Lingard
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Faculty of Education, Western University, London, Ontario, Canada
| | - Wael Haddara
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Sayra M Cristancho
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Faculty of Education, Western University, London, Ontario, Canada
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79
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Nicholson K, Makovski TT, Griffith LE, Raina P, Stranges S, van den Akker M. Multimorbidity and comorbidity revisited: refining the concepts for international health research. J Clin Epidemiol 2018; 105:142-146. [PMID: 30253215 DOI: 10.1016/j.jclinepi.2018.09.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 09/04/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Kathryn Nicholson
- Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Tatjana T Makovski
- Epidemiology and Public Health Research Unit, Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg; Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands; Chairgroup of Complex Genetics and Epidemiology, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Parminder Raina
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Saverio Stranges
- Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada; Epidemiology and Public Health Research Unit, Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg; Department of Family Medicine, Western University, London, Ontario, Canada
| | - Marjan van den Akker
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands; Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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80
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Griffith LE, Gruneir A, Fisher KA, Nicholson K, Panjwani D, Patterson C, Markle-Reid M, Ploeg J, Bierman AS, Hogan DB, Upshur R. Key factors to consider when measuring multimorbidity: Results from an expert panel and online survey. JOURNAL OF COMORBIDITY 2018; 8:2235042X18795306. [PMID: 30363320 PMCID: PMC6169974 DOI: 10.1177/2235042x18795306] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/26/2018] [Indexed: 11/28/2022]
Abstract
Background: There are multiple multimorbidity measures but little consensus on which
measures are most appropriate for different circumstances. Objective: To share insights gained from discussions with experts in the fields of
ageing research and multimorbidity on key factors to consider when measuring
multimorbidity. Design: Descriptive study of expert opinions on multimorbidity measures, informed by
literature to identify available measures followed by a face-to-face meeting
and an online survey. Results: The expert group included clinicians, researchers and policymakers in Canada
with expertise in the fields of multimorbidity and ageing. Of the 30 experts
invited, 15 (50%) attended the in-person meeting and 14 (47%) responded to
the subsequent online survey. Experts agreed that there is no single
multimorbidity measure that is suitable for all research studies. They cited
a number of factors that need to be considered in selecting a measure for
use in a research study including: (1) fit with the study purpose; (2) the
conditions included in multimorbidity measures; (3) the role of episodic
conditions or diseases; and (4) the role of social factors and other
concepts missing in existing approaches. Conclusions: The suitability of existing multimorbidity measures for use in a specific
research study depends on factors such as the purpose of the study, outcomes
examined and preferences of the involved stakeholders. The results of this
study suggest that there are areas that require further building out in both
the conceptualization and measurement of multimorbidity for the benefit of
future clinical, research and policy decisions.
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Affiliation(s)
- Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Gruneir
- Department of Family Medicine, Institute of Clinical Evaluative Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Kathryn A Fisher
- School of Nursing, and Aging, Community and Health Research Unit, McMaster University, Hamilton, Ontario, Canada
| | - Kathryn Nicholson
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dilzayn Panjwani
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | | | - Maureen Markle-Reid
- School of Nursing, and Aging, Community and Health Research Unit, McMaster University, Hamilton, Ontario, Canada
| | - Jenny Ploeg
- School of Nursing, and Aging, Community and Health Research Unit, McMaster University, Hamilton, Ontario, Canada
| | - Arlene S Bierman
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - David B Hogan
- Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ross Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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81
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Markle-Reid M, Ploeg J, Valaitis R, Duggleby W, Fisher K, Fraser K, Ganann R, Griffith LE, Gruneir A, McAiney C, Williams A. Protocol for a program of research from the Aging, Community and Health Research Unit: Promoting optimal aging at home for older adults with multimorbidity. JOURNAL OF COMORBIDITY 2018; 8:2235042X18789508. [PMID: 30191144 PMCID: PMC6083759 DOI: 10.1177/2235042x18789508] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: The goal of the Aging, Community and Health Research Unit (ACHRU) is to
promote optimal aging at home for older adults with multimorbidity (≥2
chronic conditions) and to support their family/friend caregivers. This
protocol paper reports the rationale and plan for this patient-oriented,
cross-jurisdictional research program. Objectives: The objectives of the ACHRU research program are (i) to codesign integrated
and person-centered interventions with older adults, family/friend
caregivers, and providers; (ii) to examine the feasibility of newly designed
interventions; (iii) to determine the intervention effectiveness on Triple
Aim outcomes: health, patient/caregiver experience, and cost; (iv) to
examine intervention context and implementation barriers and facilitators;
(v) to use diverse integrated knowledge translation (IKT) strategies to
engage knowledge users to support scalability and sustainability of
effective interventions; and (vi) to build patient-oriented research
capacity. Design: The research program was informed by the Knowledge-to-Action Framework and
the Complexity Model. Six individual studies were conceptualized as
integrated pieces of work. The results of the three initial descriptive
studies will inform and be followed by three pragmatic randomized controlled
trials. IKT and capacity building activities will be embedded in all six
studies and tailored to the unique focus of each study. Conclusions: This research program will inform the development of effective and scalable
person-centered interventions that are sustainable through interagency and
intersectoral partnerships with community-based agencies, policy makers, and
other health and social service agencies. Implementation of these
interventions has the potential to transform health-care services and
systems and improve the quality of life for older adults with multimorbidity
and their caregivers. Trial registration: NCT02428387 (study 4), NCT02158741 (study 5), and NCT02209285 (study 6).
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Affiliation(s)
- Maureen Markle-Reid
- School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Aging, Community and Health Research Unit, McMaster University, Hamilton, Ontario, Canada.,McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada
| | - Jenny Ploeg
- School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Aging, Community and Health Research Unit, McMaster University, Hamilton, Ontario, Canada.,McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada.,Department of Health, Aging and Society, McMaster University, Hamilton, Ontario, Canada
| | - Ruta Valaitis
- School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Aging, Community and Health Research Unit, McMaster University, Hamilton, Ontario, Canada.,McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada
| | - Wendy Duggleby
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kathryn Fisher
- School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Aging, Community and Health Research Unit, McMaster University, Hamilton, Ontario, Canada
| | - Kimberly Fraser
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Rebecca Ganann
- School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Aging, Community and Health Research Unit, McMaster University, Hamilton, Ontario, Canada.,McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada
| | - Lauren E Griffith
- Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.,McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Gruneir
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Carrie McAiney
- McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada.,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada.,Program for Interprofessional Practice, Education and Research, McMaster University, Hamilton, Ontario, Canada
| | - Allison Williams
- School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada
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Steele Gray C, Barnsley J, Gagnon D, Belzile L, Kenealy T, Shaw J, Sheridan N, Wankah Nji P, Wodchis WP. Using information communication technology in models of integrated community-based primary health care: learning from the iCOACH case studies. Implement Sci 2018; 13:87. [PMID: 29940992 PMCID: PMC6019521 DOI: 10.1186/s13012-018-0780-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Information communication technology (ICT) is a critical enabler of integrated models of community-based primary health care; however, little is known about how existing technologies have been used to support new models of integrated care. To address this gap, we draw on data from an international study of integrated models, exploring how ICT is used to support activities of integrated care and the organizational and environmental barriers and enablers to its adoption. METHODS We take an embedded comparative multiple-case study approach using data from a study of implementation of nine models of integrated community-based primary health care, the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study. Six cases from Canada, three each in Ontario and Quebec, and three in New Zealand, were studied. As part of the case studies, interviews were conducted with managers and front-line health care providers from February 2015 to March 2017. A qualitative descriptive approach was used to code data from 137 interviews and generate word tables to guide analysis. RESULTS Despite different models and contexts, we found strikingly similar accounts of the types of activities supported through ICT systems in each of the cases. ICT systems were used most frequently to support activities like care coordination by inter-professional teams through information sharing. However, providers were limited in their ability to efficiently share patient data due to data access issues across organizational and professional boundaries and due to system functionality limitations, such as a lack of interoperability. CONCLUSIONS Even in innovative models of care, managers and providers in our cases mainly use technology to enable traditional ways of working. Technology limitations prevent more innovative uses of technology that could support disruption necessary to improve care delivery. We argue the barriers to more innovative use of technology are linked to three factors: (1) information access barriers, (2) limited functionality of available technology, and (3) organizational and provider inertia.
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Affiliation(s)
- Carolyn Steele Gray
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 1 Bridgepoint Drive, Toronto, M4M 2B5, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada.
| | - Jan Barnsley
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada
| | - Dominique Gagnon
- Unité d'enseignement et de recherche en sciences du développement humain et social, Université du Québec en Abitibi-Témiscamingue, Val-d'Or, Canada
| | - Louise Belzile
- Gerontology, Université de Sherbrooke, Sherbrooke, Canada
| | - Tim Kenealy
- South Auckland Clinical School, University of Auckland, Auckland, New Zealand
| | - James Shaw
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada
- Institute for Health System Solutions and Virtual Care, Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Nicolette Sheridan
- Centre for Nursing and Health Research, School of Nursing, College of Health Te Kura Hauora Tengata, Massey University, Wellington, New Zealand
| | - Paul Wankah Nji
- Sciences de la Santé, Centre de Recherche-Hôpital Charles LeMoyne, Université de Sherbrooke-Campus Longueuil, Longueuil, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada
- Implementation and Evaluation Science, Institute for Better Health, Trillium Health Partners, Mississauga, Canada
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83
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Durbin A, Balogh R, Lin E, Wilton AS, Lunsky Y. Emergency Department Use: Common Presenting Issues and Continuity of Care for Individuals With and Without Intellectual and Developmental Disabilities. J Autism Dev Disord 2018; 48:3542-3550. [DOI: 10.1007/s10803-018-3615-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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84
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Complex Care Needs in Multiple Chronic Conditions: Population Prevalence and Characterization in Primary Care. A Study Protocol. Int J Integr Care 2018; 18:16. [PMID: 30127700 PMCID: PMC6095050 DOI: 10.5334/ijic.3292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Chronicity, and particularly complex care needs for people with chronic diseases is one of the main challenges of health systems. Objective: To determine the population prevalence of people with chronic diseases and complex care needs and to characterize these needs considering features of health and social complexity in Primary Care. Design: Cross-sectional population-based study. Scope: Patients who have one or more chronic health conditions from three Primary Care urban centres of a reference population of 43.647 inhabitants older than 14 years old. Methodology: Data will be obtained from the review of electronical medical records. Complexity will be defined by: 1) the independent clinical judgment of primary care physicians and nurses and 2) the aid of three complexity domains (clinical and social). Patients with advanced chronic disease and limited life prognosis will be also described. Conclusions: This research protocol intends to describe and analyse complex care needs from a primary care professional perspective in order to improve knowledge of complexity beyond multimorbidity and previous consumption of health resources. Knowing about health and social complexity with a more robust empirical basis could help for a better integration of social and health policies and a more proactive and differentiated care approach in this most vulnerable population.
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85
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Froger R, Allenet B, Guillem P. [Coordinating complex nursing care: building a guidance tool for cancer patients, to direct them towards the coordination nurse]. Rech Soins Infirm 2018:54-65. [PMID: 28944630 DOI: 10.3917/rsi.128.0054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Introduction : following the 2009-2013 Cancer Plan, the experimental oncology nursing coordination (IDEC) showed a positive impact on the fluidity of care pathways. The 2014-2019 cancer plan guides their mission to complex cases. The objective of this study is to build a tool to facilitate the recruitment of patients likely to experience a complex path. Method : two phases have formed this research. The first one collected the elements of the dimensions that can predict the complexity of the care path, by focus group. The second consisted of reduction and selection of priority items and to estimate their importance by the Delphi method. Results : from the 12 selected items, two are recognized as a significant risk scoring, seven probably correlated with a complex pathway and three unrelated to the complexity of the pathways. Discussion : later this instrument would be validated by a test sample to evaluate its psychometric properties, metrological and feasibility.
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86
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Katz A, Chateau D, Enns JE, Valdivia J, Taylor C, Walld R, McCulloch S. Association of the Social Determinants of Health With Quality of Primary Care. Ann Fam Med 2018; 16:217-224. [PMID: 29760025 PMCID: PMC5951250 DOI: 10.1370/afm.2236] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 01/22/2018] [Accepted: 03/06/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE In primary care, there is increasing recognition of the difficulty of treating patients' immediate health concerns when their overall well-being is shaped by underlying social determinants of health. We assessed the association of social complexity factors with the quality of care patients received in primary care settings. METHODS Eleven social complexity factors were defined using administrative data on poverty, mental health, newcomer status, and justice system involvement from the Manitoba Population Research Data Repository. We measured the distribution of these factors among primary care patients who made at least 3 visits during 2010-2013 to clinicians in Manitoba, Canada. Using generalized linear mixed modeling, we measured 26 primary care indicators to compare the quality of care received by patients with 0 to 5 or more social complexity factors. RESULTS Among 626,264 primary care patients, 54% were living with at least 1 social complexity factor, and 4% were living with 5 or more. Social complexity factors were strongly associated with poorer outcomes with respect to primary care indicators for prevention (eg, breast cancer screening; odds ratio [OR] = 0.77; 99% CI, 0.73-0.81), chronic disease management (eg, diabetes management; OR = 0.86; 99% CI, 0.79-0.92), geriatric care (eg, benzodiazepine prescriptions; OR = 1.63; 99% CI, 1.48-1.80), and use of health services (eg, ambulatory visits; OR = 1.09; 99% CI, 1.08-1.09). CONCLUSIONS Linking health and social data demonstrates how social determinants are associated with primary care service provision. Our findings provide insight into the social needs of primary care populations, and may support the development of focused interventions to address social complexity in primary care.
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Affiliation(s)
- Alan Katz
- Manitoba Centre for Health Policy, University of Manitoba, Manitoba, Canada .,Departments of Family Medicine, University of Manitoba, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Manitoba, Canada
| | - Dan Chateau
- Manitoba Centre for Health Policy, University of Manitoba, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Manitoba, Canada
| | - Jennifer E Enns
- Manitoba Centre for Health Policy, University of Manitoba, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Manitoba, Canada
| | - Jeff Valdivia
- Manitoba Centre for Health Policy, University of Manitoba, Manitoba, Canada
| | - Carole Taylor
- Manitoba Centre for Health Policy, University of Manitoba, Manitoba, Canada
| | - Randy Walld
- Manitoba Centre for Health Policy, University of Manitoba, Manitoba, Canada
| | - Scott McCulloch
- Manitoba Centre for Health Policy, University of Manitoba, Manitoba, Canada
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87
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Steele Gray C, Wodchis WP, Baker GR, Carswell P, Kenealy T, McKillop A, Breton M, Parsons J, Sheridan N. Mapping for Conceptual Clarity: Exploring Implementation of Integrated Community-Based Primary Health Care from a Whole Systems Perspective. Int J Integr Care 2018; 18:14. [PMID: 30127683 PMCID: PMC6095076 DOI: 10.5334/ijic.3082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 02/20/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Studying implementation of integrated models of community-based primary health care requires a "whole systems" multidisciplinary approach to capture micro, meso and macro factors. However, there is, as yet, no clear operationalization of a "whole systems" approach to guide multidisciplinary research programs. Theoretical frameworks and approaches from diverse academic traditions specify different aspects of the health system in more depth. Enabling analysis across the system, when data and ideas are captured using different taxonomies, requires that we map terms and constructs across the models. THEORY AND METHODS This paper uses concept mapping techniques to compare and contrast the theoretical frameworks and approaches used in the iCOACH project including: Ham's Ten Characteristics of the High-Performing Chronic Care System (capturing patient/carer and provider perspectives), the Organizational Context and Capabilities for Integrating Care framework (capturing the organizational perspective), and the Health Policy Monitor framework (capturing the policy system perspective). The aim of the paper is to link concepts across different theoretical framework to guide the iCOACH study. RESULTS A concept map was developed that identifies 8 overarching concepts across the heuristic models. A preliminary analysis of one of these overarching concepts, care coordination, demonstrates how different perspectives will assign different meanings, values, and drivers of seemingly similar ideas. For patients and carers care coordination is about having a responsive team of health care providers. Building relationships in teams that exist within and across different organizations is essential for providers to achieve care coordination, where managers and policy makers see care coordination as being more about creating linkages and addressing systems gaps. DISCUSSION AND CONCLUSION This work represents a first step towards development of a fully formed conceptual framework that includes key domains, concepts, and mechanisms of implementing integrated community-based primary health care.
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Affiliation(s)
- Carolyn Steele Gray
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, CA
- Institute of Health Policy, Management and Evaluation, University of Toronto, CA
| | - Walter P. Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, CA
- Research Chair in Implementation and Evaluation Science, Institute for Better Health, Trillium Health Partners, CA
| | - G. Ross Baker
- Institute of Health Policy, Management and Evaluation, University of Toronto, CA
| | - Peter Carswell
- School of Population Health, The University of Auckland, NZ
| | - Tim Kenealy
- South Auckland Clinical School, The University of Auckland, NZ
| | - Ann McKillop
- School of Nursing, Faculty of Medical and Health Services, The University of Auckland, NZ
| | - Mylaine Breton
- Charles LeMoyne Hospital Research Center, Université de Sherbrooke, Quebec, CA
| | - John Parsons
- School of Nursing, Faculty of Medical and Health Services, The University of Auckland, NZ
| | - Nicolette Sheridan
- School of Nursing, College of Health Te Kura Haurora Tengata, Massey University, NZ
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88
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Bandini F, Guidi S, Blaszczyk S, Fumarulo A, Pierini M, Pratesi P, Spolveri S, Padeletti M, Petrone P, Zoppi P, Landini G. Complexity in internal medicine wards: A novel screening method and implications for management. J Eval Clin Pract 2018; 24:285-292. [PMID: 29318709 DOI: 10.1111/jep.12875] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 11/29/2017] [Accepted: 12/11/2017] [Indexed: 12/22/2022]
Abstract
RATIONALE Complexity is increasingly recognized as a critical variable in health care. However, there is still lack of practical tools to assess it and tackle the challenges that stem from it, particularly within hospitals. AIMS AND OBJECTIVE To validate a simple novel screening method based on both objective and subjective criteria to identify patients with clinically complex hospitalization events. To evaluate the prevalence of patients with complex events, identify their features, and compare them with those of the other patients and to those of patients with multimorbidities. METHOD We monitored the level of complexity of the hospitalization events of 240 patients admitted to an internal medicine ward in Tuscany over the course of 56 days. We compared the demographic features, the length of stay, and the prognosis of patients with and without complex events. RESULTS Sixty-nine patients (28.8% of the sample) had a complex episode during their stay, and 115 (47.9%) had phases of low complexity. Patients with complex episodes were younger and more comorbid than patients without. They stayed longer in-hospital (+4.5 days; 95% CI: 2.5-6.5) and had higher mortality (OR: 24.93; 95% CI: 6.97-171.63) and a lower probability of home discharge (OR: 0.25; 95% CI: 0.13-0.48). CONCLUSIONS The results show that using a simple screening method is possible to identify complex patients within IM wards and that every day, about one-third of the patients are complex. The results are discussed in implications for the dynamic management of patients with complex and simple phases during hospitalization.
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Affiliation(s)
- Fabrizio Bandini
- Cardiology Unit Borgo San Lorenzo and Serristori, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Stefano Guidi
- Cardiology Unit Borgo San Lorenzo and Serristori, Local Healthcare Unit Tuscany Centre, Florence, Italy.,Department of Social, Political and Cognitive Sciences, University of Siena, Siena, Italy
| | - Silvia Blaszczyk
- Internal Medicine Unit, Local Healthcare Unit Tuscany Centre, Ospedale del Mugello, Florence, Italy
| | | | - Michela Pierini
- Department of Nursing, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Paolo Pratesi
- Department of Nursing, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Stefano Spolveri
- Internal Medicine Unit, Local Healthcare Unit Tuscany Centre, Ospedale del Mugello, Florence, Italy
| | - Margherita Padeletti
- Cardiology Unit Borgo San Lorenzo and Serristori, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Pasquale Petrone
- Cardiology Unit Borgo San Lorenzo and Serristori, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Paolo Zoppi
- Department of Nursing, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Giancarlo Landini
- Department of Medicine and Medical Specialties, Local Healthcare Unit Tuscany Centre, Florence, Italy
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89
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Sultan M, Kuluski K, McIsaac WJ, Cafazzo JA, Seto E. Turning challenges into design principles: Telemonitoring systems for patients with multiple chronic conditions. Health Informatics J 2018; 25:1188-1200. [PMID: 29320911 DOI: 10.1177/1460458217749882] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
People with multiple chronic conditions often struggle with managing their health. The purpose of this research was to identify specific challenges of patients with multiple chronic conditions and to use the findings to form design principles for a telemonitoring system tailored for these patients. Semi-structured interviews with 15 patients with multiple chronic conditions and 10 clinicians were conducted to gain an understanding of their needs and preferences for a smartphone-based telemonitoring system. The interviews were analyzed using a conventional content analysis technique, resulting in six themes. Design principles developed from the themes included that the system must be modular to accommodate various combinations of conditions, reinforce a routine, consolidate record keeping, as well as provide actionable feedback to the patients. Designing an application for multiple chronic conditions is complex due to variability in patient conditions, and therefore, design principles developed in this study can help with future innovations aimed to help manage this population.
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90
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Carduff E, Johnston S, Winstanley C, Morrish J, Murray SA, Spiller J, Finucane A. What does 'complex' mean in palliative care? Triangulating qualitative findings from 3 settings. BMC Palliat Care 2018; 17:12. [PMID: 29301524 PMCID: PMC5753489 DOI: 10.1186/s12904-017-0259-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 12/04/2017] [Indexed: 11/16/2022] Open
Abstract
Background Complex need for patients with a terminal illness distinguishes those who would benefit from specialist palliative care from those who could be cared for by non-specialists. However, the nature of this complexity is not well defined or understood. This study describes how health professionals, from three distinct settings in the United Kingdom, understand complex need in palliative care. Methods Semi-structured qualitative interviews were conducted with professionals in primary care, hospital and hospice settings. Thirty-four professionals including doctors, nurses and allied health professionals were recruited in total. Data collected in each setting were thematically analysed and a workshop was convened to compare and contrast findings across settings. Results The interaction between diverse multi-dimensional aspects of need, existing co-morbidities, intractable symptoms and complicated social and psychological issues increased perceived complexity. Poor communication between patients and their clinicians contributed to complexity. Professionals in primary and acute care described themselves as ‘generalists’ and felt they lacked confidence and skill in identifying and caring for complex patients and time for professional development in palliative care. Conclusions Complexity in the context of palliative care can be inherent to the patient or perceived by health professionals. Lack of confidence, time constraints and bed pressures contribute to perceived complexity, but are amenable to change by training in identifying, prognosticating for, and communicating with patients approaching the end of life. Electronic supplementary material The online version of this article (10.1186/s12904-017-0259-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emma Carduff
- Marie Curie Hospice, 133 Balornock Road, Glasgow, G21 3US, UK. .,School of School of Medicine, Nursing and Healthcare, University of Glasgow, 59 Oakfield Avenue, Glasgow, G12 8LL, UK.
| | - Sarah Johnston
- Faculty of Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Jamie Morrish
- Faculty of Medicine, University of Aberdeen, Aberdeen, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, Centre for Population Health Sciences, The Usher Institute, The University of Edinburgh, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Juliet Spiller
- Marie Curie Hospice Edinburgh, Frogston Road West, Edinburgh, EH10 7DR, UK
| | - Anne Finucane
- Marie Curie Hospice Edinburgh, Frogston Road West, Edinburgh, EH10 7DR, UK
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91
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Ho JW, Kuluski K, Im J. "It's a fight to get anything you need" - Accessing care in the community from the perspectives of people with multimorbidity. Health Expect 2017; 20:1311-1319. [PMID: 28544493 PMCID: PMC5689221 DOI: 10.1111/hex.12571] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND There is a growing interest in redesigning health-care systems to better manage the increasing numbers of people with multimorbidity. Knowing how patients experience health-care delivery and what they need from the health-care system are critical pieces of evidence that can be used to guide health system reforms. OBJECTIVE The purpose of this study was to understand the challenges patients with multimorbidity face in accessing care in the community, and the implications for patients and their families. METHODS A secondary analysis of qualitative data was conducted on semi-structured interviews with 116 patients who were receiving care in an urban rehabilitation facility in 2011. Exploratory interpretive analysis was used to identify themes about access to care. RESULTS Challenges occurred at two levels: at the health system level and at the individual (patient) level. Issues at the health system level fell into two broad categories: availability of services (failing to qualify, coping with wait times, struggling with scarcity and negotiating the location of care) and service delivery (unreliable care, unmet needs, incongruent care and inflexible care). Challenges at the patient level fell into the themes of logistics of accessing care and financial strain. Patients interacted and responded to these challenges by: managing the system, making personal sacrifices, substituting with informal care, and resigning to system constraints. CONCLUSION Identifying the barriers patients encounter and the lengths they go to in order to access care highlights areas where policy initiatives can focus to develop appropriate and supportive services that are more person and family-centred.
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Affiliation(s)
- Julia W. Ho
- Institute of Health PolicyManagement and EvaluationUniversity of TorontoTorontoOntarioCanada
- Collaboratory for Research and InnovationSinai Health SystemLunenfeld‐Tanenbaum Research InstituteTorontoOntarioCanada
| | - Kerry Kuluski
- Institute of Health PolicyManagement and EvaluationUniversity of TorontoTorontoOntarioCanada
- Collaboratory for Research and InnovationSinai Health SystemLunenfeld‐Tanenbaum Research InstituteTorontoOntarioCanada
| | - Jennifer Im
- Institute of Health PolicyManagement and EvaluationUniversity of TorontoTorontoOntarioCanada
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92
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Bujold M, Pluye P, Légaré F, Haggerty J, Gore GC, Sherif RE, Poitras MÈ, Beaulieu MC, Beaulieu MD, Bush PL, Couturier Y, Débarges B, Gagnon J, Giguère A, Grad R, Granikov V, Goulet S, Hudon C, Kremer B, Kröger E, Kudrina I, Lebouché B, Loignon C, Lussier MT, Martello C, Nguyen Q, Pratt R, Rihoux B, Rosenberg E, Samson I, Senn N, Li Tang D, Tsujimoto M, Vedel I, Ventelou B, Wensing M. Decisional needs assessment of patients with complex care needs in primary care: a participatory systematic mixed studies review protocol. BMJ Open 2017; 7:e016400. [PMID: 29133314 PMCID: PMC5695438 DOI: 10.1136/bmjopen-2017-016400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 07/28/2017] [Accepted: 08/23/2017] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers). METHODS AND ANALYSIS This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs' qualitative decisional need assessment (semistructured interviews and focus group with stakeholders). ETHICS AND DISSEMINATION This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs' decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network. PROSPERO REGISTRATION NUMBER CRD42015020558.
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Affiliation(s)
- Mathieu Bujold
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Pierre Pluye
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | - Jeannie Haggerty
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | | | - Reem El Sherif
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Marie-Ève Poitras
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | | | | | - Paula L Bush
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Yves Couturier
- École de travail social, Université de Sherbrooke, Canada
| | | | - Justin Gagnon
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Anik Giguère
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Vera Granikov
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Serge Goulet
- Department of Family Medicine, Université de Sherbrooke, Canada
| | - Catherine Hudon
- Department of Family Medicine, Université de Sherbrooke, Canada
| | | | | | - Irina Kudrina
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Bertrand Lebouché
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | | | | | - Cristiano Martello
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Quynh Nguyen
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Rebekah Pratt
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, United States
| | - Benoit Rihoux
- Centre de Science Politique et de Politique Comparée, Université catholique de Louvain, Belgium
| | - Ellen Rosenberg
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Isabelle Samson
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | | | - David Li Tang
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | | | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
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Kirst M, Im J, Burns T, Baker GR, Goldhar J, O'Campo P, Wojtak A, Wodchis WP. What works in implementation of integrated care programs for older adults with complex needs? A realist review. Int J Qual Health Care 2017; 29:612-624. [PMID: 28992156 PMCID: PMC5890872 DOI: 10.1093/intqhc/mzx095] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 06/08/2017] [Accepted: 07/04/2017] [Indexed: 12/29/2022] Open
Abstract
PURPOSE A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience. DATA SOURCES International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies. STUDY SELECTION Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English. DATA EXTRACTION Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes. RESULTS OF DATA SYNTHESIS A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs. CONCLUSIONS This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.
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Affiliation(s)
- Maritt Kirst
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- Department of Psychology, Wilfrid Laurier University, 75 University Ave. West, Waterloo, ON, Canada N2L 3C5
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
| | - Jennifer Im
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
| | - Tim Burns
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
| | - G. Ross Baker
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
| | - Jodeme Goldhar
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- The Change Foundation, 200 Front Street West, Toronto, Canada M5V 3M1
| | - Patricia O'Campo
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St., Toronto, Canada M5B 1W8
| | - Anne Wojtak
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- Toronto Central Local Health Integration Network, 250 Dundas St. West, Toronto, Canada M5T 2Z5
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- Toronto Rehabilitation Institute, 550 University Ave., Toronto, Canada M5G 2A2
- Institute for Clinical Evaluative Sciences, 2075 Bayview Ave., Toronto, Canada M4N 3M5
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Nelson ML, McKellar KA, Munce S, Kelloway L, Hans PK, Fortin M, Lyons R, Bayley M. Addressing the Evidence Gap in Stroke Rehabilitation for Complex Patients: A Preliminary Research Agenda. Arch Phys Med Rehabil 2017; 99:1232-1241. [PMID: 28947162 DOI: 10.1016/j.apmr.2017.08.488] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/16/2017] [Accepted: 08/23/2017] [Indexed: 12/21/2022]
Abstract
Evidence suggests that a stroke occurs in isolation (no comorbid conditions) in less than 6% of patients. Multimorbidity, compounded by psychosocial issues, makes treatment and recovery for stroke increasingly complex. Recent research and health policy documents called for a better understanding of the needs of this patient population, and for the development and testing of models of care that meet their needs. A research agenda specific to complexity is required. The primary objective of the think tank was to identify and prioritize research questions that meet the information needs of stakeholders, and to develop a research agenda specific to stroke rehabilitation and patient complexity. A modified Delphi and World Café approach underpinned the think tank meeting, approaches well recognized to foster interaction, dialogue, and collaboration between stakeholders. Forty-three researchers, clinicians, and policymakers attended a 2-day meeting. Initial question-generating activities resulted in 120 potential research questions. Sixteen high-priority research questions were identified, focusing on predetermined complexity characteristics-multimorbidity, social determinants, patient characteristics, social supports, and system factors. The final questions are presented as a prioritized research framework. An emergent result of this activity is the development of a complexity and stroke rehabilitation research network. The research agenda reflects topics of importance to stakeholders working with stroke patients with increasingly complex care needs. This robust process resulted in a preliminary research agenda that could provide policymakers with the evidence needed to make improvements toward better-organized services, better coordination between settings, improved patient outcomes, and lower system costs.
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Affiliation(s)
- Michelle L Nelson
- Bridgepoint Collaboratory, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
| | - Kaileah A McKellar
- Bridgepoint Collaboratory, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Sarah Munce
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Linda Kelloway
- Cardiac Care Network of Ontario, Toronto, Ontario, Canada
| | - Parminder Kaur Hans
- Bridgepoint Collaboratory, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Martin Fortin
- Department of Family Medicine, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Renee Lyons
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mark Bayley
- University of Toronto, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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95
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The provider perspective: investigating the effect of the Electronic Patient-Reported Outcome (ePRO) mobile application and portal on primary care provider workflow. Prim Health Care Res Dev 2017; 19:151-164. [PMID: 28899449 PMCID: PMC6452954 DOI: 10.1017/s1463423617000573] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Aim This qualitative study investigates how the Electronic Patient-Reported Outcome (ePRO) mobile application and portal system, designed to capture patient-reported measures to support self-management, affected primary care provider workflows. Background The Canadian health system is facing an ageing population that is living with chronic disease. Disruptive innovations like mobile health technologies can help to support health system transformation needed to better meet the multifaceted needs of the complex care patient. However, there are challenges with implementing these technologies in primary care settings, in particular the effect on primary care provider workflows. Methods Over a six-week period interdisciplinary primary care providers (n=6) and their complex care patients (n=12), used the ePRO mobile application and portal to collaboratively goal-set, manage care plans, and support self-management using patient-reported measures. Secondary thematic analysis of focus groups, training sessions, and issue tracker reports captured user experiences at a Toronto area Family Health Team from October 2014 to January 2015. Findings Key issues raised by providers included: liability concerns associated with remote monitoring, increased documentation activities due to a lack of interoperability between the app and the electronic patient record, increased provider anxiety with regard to the potential for the app to disrupt and infringe upon appointment time, and increased demands for patient engagement. Primary care providers reported the app helped to focus care plans and to begin a collaborative conversation on goal-setting. However, throughout our investigation we found a high level of provider resistance evidenced by consistent attempts to shift the app towards fitting with existing workflows rather than adapting much of their behaviour. As health systems seek innovative and disruptive models to better serve this complex patient population, provider change resistance will need to be addressed. New models and technologies cannot be disruptive in an environment that is resisting change.
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96
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Identifying High-Cost, High-Risk Patients Using Administrative Databases in Tuscany, Italy. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9569348. [PMID: 28770229 PMCID: PMC5523251 DOI: 10.1155/2017/9569348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 04/16/2017] [Accepted: 05/24/2017] [Indexed: 12/31/2022]
Abstract
Objective (1) Assessing the performance of the algorithm in terms of sensitivity and positive predictive value, considering General Practitioners' (GPs) judgement as benchmark, and (2) describing adverse events (hospitalisation, death, and health services' consumption) of complex patients compared to the general population. Data Sources (i) Tuscany administrative database containing health data (2013-5); (ii) lists of complex patients indicated by GPs; and (iii) annual health registry of Tuscany. Study Design The present study is a validation study. It compares a list of complex patients extracted through an administrative algorithm (criteria of high health consumption) to a gold standard list of patients indicated by GPs. GPs' decision was subjective but fairly well reasoned. The study compares also adverse outcomes (Emergency Room visits, hospitalisation, and death) between identified complex patients and general population. Principal Findings Considering GPs' judgement, the algorithm showed a sensitivity of 72.8% and a positive predictive value of 64.4%. The complex cases presented here have higher incidence rates/100,000 (death 46.8; ER visits 223.2, hospitalisations 110.87, laboratory tests 1284.01, and specialist examinations 870.37) compared to the general population. Conclusions The final validated algorithm showed acceptable sensitivity and positive predictive value.
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Ploeg J, Matthew-Maich N, Fraser K, Dufour S, McAiney C, Kaasalainen S, Markle-Reid M, Upshur R, Cleghorn L, Emili A. Managing multiple chronic conditions in the community: a Canadian qualitative study of the experiences of older adults, family caregivers and healthcare providers. BMC Geriatr 2017; 17:40. [PMID: 28143412 PMCID: PMC5282921 DOI: 10.1186/s12877-017-0431-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 01/24/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The prevalence of multiple chronic conditions (MCC) among older persons is increasing worldwide and is associated with poor health status and high rates of healthcare utilization and costs. Current health and social services are not addressing the complex needs of this group or their family caregivers. A better understanding of the experience of MCC from multiple perspectives is needed to improve the approach to care for this vulnerable group. However, the experience of MCC has not been explored with a broad sample of community-living older adults, family caregivers and healthcare providers. The purpose of this study was to explore the experience of managing MCC in the community from the perspectives of older adults with MCC, family caregivers and healthcare providers working in a variety of settings. METHODS Using Thorne's interpretive description approach, semi-structured interviews (n = 130) were conducted in two Canadian provinces with 41 community-living older adults (aged 65 years and older) with three or more chronic conditions, 47 family caregivers (aged 18 years and older), and 42 healthcare providers working in various community settings. Healthcare providers represented various disciplines and settings. Interview transcripts were analyzed using Thorne's interpretive description approach. RESULTS Participants described the experience of managing MCC as: (a) overwhelming, draining and complicated, (b) organizing pills and appointments, (c) being split into pieces, (d) doing what the doctor says, (e) relying on family and friends, and (f) having difficulty getting outside help. These themes resonated with the emotional impact of MCC for all three groups of participants and the heavy reliance on family caregivers to support care in the home. CONCLUSIONS The experience of managing MCC in the community was one of high complexity, where there was a large gap between the needs of older adults and caregivers and the ability of health and social care systems to meet those needs. Healthcare for MCC was experienced as piecemeal and fragmented with little focus on the person and family as a whole. These findings provide a foundation for the design of care processes to more optimally address the needs-service gap that is integral to the experience of managing MCC.
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Affiliation(s)
- Jenny Ploeg
- Aging, Community and Health Research Unit, School of Nursing, Faculty of Health Sciences, McMaster University, 1280 Main Street West, HSc3N25C, Hamilton, ON L8S 4K1 Canada
- Department of Health, Aging and Society, McMaster University, 1280 Main Street West, HSc3N25C, Hamilton, ON L8S 4K1 Canada
| | - Nancy Matthew-Maich
- Health Science Research and Innovation, School of Nursing, Mohawk College of Applied Arts and Technology, 1400 Main Street West, IAHS - 354, Hamilton, ON L8S 1C7 Canada
| | - Kimberly Fraser
- Faculty of Nursing, University of Alberta, 5-185 Edmonton Clinic Health Academy, Edmonton, AB T6G 1C9 Canada
| | - Sinéad Dufour
- School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, 1400 Main Street West, IAHS Rm 403, Hamilton, ON L8S 4K1 Canada
| | - Carrie McAiney
- Department of Psychiatry & Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, St. Joseph’s Healthcare Hamilton, West 5th Campus, 100 West 5th Street, Room G102, Hamilton, ON L8N 3K7 Canada
| | - Sharon Kaasalainen
- School of Nursing, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Maureen Markle-Reid
- Aging, Community and Health Research Unit, School of Nursing, Faculty of Health Sciences, McMaster University, 1280 Main Street West, HSc3N25C, Hamilton, ON L8S 4K1 Canada
- Aging, Chronic Disease and Health Promotion Interventions, 1280 Main Street West, HSc3N25B, Hamilton, ON L8S 4K1 Canada
- Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, 1280 Main Street West, HSc3N25B, Hamilton, ON L8S 4K1 Canada
| | - Ross Upshur
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, M.33 1 Bridgepoint Drive, Toronto, ON M4M 2B5 Canada
- Bridgepoint Collaboratory for Research and Innovation, Sinai Health System, AM.33 1 Bridgepoint Drive, Toronto, ON M4M 2B5 Canada
| | - Laura Cleghorn
- School of Nursing and Department of Family Medicine, Health TAPESTRY, McMaster University, 1280 Main Street West, David Braley Health Science Centre, 5th Floor, Hamilton, ON L9S 4K1 Canada
| | - Anna Emili
- McMaster University, Main West Medical Group, 1685 Main Street West, Hamilton, ON L8S 1G5 Canada
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98
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Carusone SC, O'Leary B, McWatt S, Stewart A, Craig S, Brennan DJ. The Lived Experience of the Hospital Discharge "Plan": A Longitudinal Qualitative Study of Complex Patients. J Hosp Med 2017; 12:5-10. [PMID: 28125825 DOI: 10.1002/jhm.2671] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Transitions in care are a high-risk time for patients. Complex patients account for the largest proportion of healthcare costs but experience lower quality and discontinuity of care. The experiences of complex patients can be used to identify gaps in hospital discharge practices and design interventions to improve outcomes. METHODS We used a case study approach with serial interviews and chart abstraction to explore the hospital discharge and transition experience over 6 weeks. Participants were recruited from a small hospital in Toronto that provides care to complex patients living with human immunodeficiency virus (HIV). Framework analysis was used to compare data across time-points and sources. RESULTS Data were collected from 9 cases. Participants presented with complex medical and psychosocial challenges, including substance use (n = 9), mental health diagnoses (n = 8) and a mean of 5 medical comorbidities in addition to HIV. Data were analyzed and reported in 4 key themes: 1) social support; 2) discharge process and transition experience; 3) post-discharge follow-up; and 4) patient priorities. After hospital discharge, the complexity of participants' lives resulted in a change in priorities and subsequent divergence from the discharge plan. Despite the comprehensive discharge plans, with referrals designed to support their health and activities of daily living, participants experienced challenges with social support and referral uptake, resulting in a loss of stability achieved while in hospital. CONCLUSION Further investigation and changes in practice are necessary to ensure that discharge plans for complex patients are realistic within the context of their lives outside of the hospital. Journal of Hospital Medicine 2017;12:5-10.
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Affiliation(s)
- Soo Chan Carusone
- Casey House, Toronto, Ontario, Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Bill O'Leary
- Casey House, Toronto, Ontario, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | | | - Ann Stewart
- Casey House, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley Craig
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - David J Brennan
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
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Evaluation of a Specialized Yoga Program for Persons Admitted to a Complex Continuing Care Hospital: A Pilot Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 2016:6267879. [PMID: 28115969 PMCID: PMC5223015 DOI: 10.1155/2016/6267879] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 10/07/2016] [Accepted: 11/07/2016] [Indexed: 12/20/2022]
Abstract
Introduction. The purpose of this study was to evaluate a specialized yoga intervention for inpatients in a rehabilitation and complex continuing care hospital. Design. Single-cohort repeated measures design. Methods. Participants (N = 10) admitted to a rehabilitation and complex continuing care hospital were recruited to participate in a 50–60 min Hatha Yoga class (modified for wheelchair users/seated position) once a week for eight weeks, with assigned homework practice. Questionnaires on pain (pain, pain interference, and pain catastrophizing), psychological variables (depression, anxiety, and experiences with injustice), mindfulness, self-compassion, and spiritual well-being were collected at three intervals: pre-, mid-, and post-intervention. Results. Repeated measures ANOVAs revealed a significant main effect of time indicating improvements over the course of the yoga program on the (1) anxiety subscale of the Hospital Anxiety and Depression Scale, F(2,18) = 4.74, p < .05, and ηp2 = .35, (2) Self-Compassion Scale-Short Form, F(2,18) = 3.71, p < .05, and ηp2 = .29, and (3) Magnification subscale of the Pain Catastrophizing Scale, F(2,18) = 3. 66, p < .05, and ηp2 = .29. Discussion. The results suggest that an 8-week Hatha Yoga program improves pain-related factors and psychological experiences in individuals admitted to a rehabilitation and complex continuing care hospital.
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100
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Roosan D, Weir C, Samore M, Jones M, Rahman M, Stoddard GJ, Del Fiol G. Identifying complexity in infectious diseases inpatient settings: An observation study. J Biomed Inform 2016; 71S:S13-S21. [PMID: 27818310 DOI: 10.1016/j.jbi.2016.10.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 10/02/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Understanding complexity in healthcare has the potential to reduce decision and treatment uncertainty. Therefore, identifying both patient and task complexity may offer better task allocation and design recommendation for next-generation health information technology system design. OBJECTIVE To identify specific complexity-contributing factors in the infectious disease domain and the relationship with the complexity perceived by clinicians. METHOD We observed and audio recorded clinical rounds of three infectious disease teams. Thirty cases were observed for a period of four consecutive days. Transcripts were coded based on clinical complexity-contributing factors from the clinical complexity model. Ratings of complexity on day 1 for each case were collected. We then used statistical methods to identify complexity-contributing factors in relationship to perceived complexity of clinicians. RESULTS A factor analysis (principal component extraction with varimax rotation) of specific items revealed three factors (eigenvalues>2.0) explaining 47% of total variance, namely task interaction and goals (10 items, 26%, Cronbach's Alpha=0.87), urgency and acuity (6 items, 11%, Cronbach's Alpha=0.67), and psychosocial behavior (4 items, 10%, Cronbach's alpha=0.55). A linear regression analysis showed no statistically significant association between complexity perceived by the physicians and objective complexity, which was measured from coded transcripts by three clinicians (Multiple R-squared=0.13, p=0.61). There were no physician effects on the rating of perceived complexity. CONCLUSION Task complexity contributes significantly to overall complexity in the infectious diseases domain. The different complexity-contributing factors found in this study can guide health information technology system designers and researchers for intuitive design. Thus, decision support tools can help reduce the specific complexity-contributing factors. Future studies aimed at understanding clinical domain-specific complexity-contributing factors can ultimately improve task allocation and design for intuitive clinical reasoning.
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Affiliation(s)
- Don Roosan
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA; IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA; Health Services Research Section, Baylor College of Medicine, 2450 Holcombe Blvd, Houston, TX 77030, USA.
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA; IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Matthew Samore
- IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Makoto Jones
- IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Mumtahena Rahman
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA.
| | - Gregory J Stoddard
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA; IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA; IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
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