101
|
Goderis G, Borgermans L, Mathieu C, Van Den Broeke C, Hannes K, Heyrman J, Grol R. Barriers and facilitators to evidence based care of type 2 diabetes patients: experiences of general practitioners participating to a quality improvement program. Implement Sci 2009; 4:41. [PMID: 19624848 PMCID: PMC2719589 DOI: 10.1186/1748-5908-4-41] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 07/22/2009] [Indexed: 11/24/2022] Open
Abstract
Objective To evaluate the barriers and facilitators to high-quality diabetes care as experienced by general practitioners (GPs) who participated in an 18-month quality improvement program (QIP). This QIP was implemented to promote compliance with international guidelines. Methods Twenty out of the 120 participating GPs in the QIP underwent semi-structured interviews that focused on three questions: 'Which changes did you implement or did you observe in the quality of diabetes care during your participation in the QIP?' 'According to your experience, what induced these changes?' and 'What difficulties did you experience in making the changes?' Results Most GPs reported that enhanced knowledge, improved motivation, and a greater sense of responsibility were the key factors that led to greater compliance with diabetes care guidelines and consequent improvements in diabetes care. Other factors were improved communication with patients and consulting specialists and reliance on diabetes nurse educators. Some GPs were reluctant to collaborate with specialists, and especially with diabetes educators and dieticians. Others blamed poor compliance with the guidelines on lack of time. Most interviewees reported that a considerable minority of patients were unwilling to change their lifestyles. Conclusion Qualitative research nested in an experimental trial may clarify the improvements that a QIP may bring about in a general practice, provide insight into GPs' approach to diabetes care and reveal the program's limits. Implementation of a QIP encounters an array of cognitive, motivational, and relational obstacles that are embedded in a patient-healthcare provider relationship.
Collapse
Affiliation(s)
- Geert Goderis
- Department of General Practice, Katholieke Universiteit, Leuven, Belgium.
| | | | | | | | | | | | | |
Collapse
|
102
|
Griffin BL, Burkiewicz JS, Peppers LR, Warholak TL. International Normalized Ratio values in group versus individual appointments in a pharmacist-managed anticoagulation clinic. Am J Health Syst Pharm 2009; 66:1218-23. [DOI: 10.2146/ajhp080278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Jill S. Burkiewicz
- Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL
| | | | - Terri L. Warholak
- Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson
| |
Collapse
|
103
|
Loney-Hutchinson LM, Provilus AD, Jean-Louis G, Zizi F, Ogedegbe O, McFarlane SI. Group visits in the management of diabetes and hypertension: effect on glycemic and blood pressure control. Curr Diab Rep 2009; 9:238-42. [PMID: 19490826 DOI: 10.1007/s11892-009-0038-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Diabetes is a major public health problem that is reaching epidemic proportions in the United States and worldwide. Over 22 million Americans currently have diabetes and it is forecast that over 350 million people worldwide will be affected by 2030. Furthermore, the economic cost of diabetes care is enormous. Despite current efforts on the part of health care providers and their patients, outcomes of care remain largely suboptimal, with only 3% to 7% of the entire diabetes population meeting recommended treatment goals for glycemic, blood pressure, and lipid control. Therefore, alternative approaches to diabetes care are desperately needed. Group visits may provide a viable option for patients and health care providers, with the potential to improve outcomes and cost effectiveness. In this review, we highlight the magnitude of the diabetes epidemic, the barriers to optimal diabetes care, and the utility of the concept of group visits as a chronic disease management strategy for diabetes care.
Collapse
Affiliation(s)
- Lisel M Loney-Hutchinson
- Division of Endocrinology, State University of New York-Downstate Medical Center, Kings County Hospital Center, Brooklyn, NY 11203, USA. lisel.
| | | | | | | | | | | |
Collapse
|
104
|
Schillinger D, Handley M, Wang F, Hammer H. Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Diabetes Care 2009; 32:559-66. [PMID: 19131469 PMCID: PMC2660485 DOI: 10.2337/dc08-0787] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Despite the importance of self-management support (SMS), few studies have compared SMS interventions, involved diverse populations, or entailed implementation in safety net settings. We examined the effects of two SMS strategies across outcomes corresponding to the Chronic Care Model. RESEARCH DESIGN AND METHODS A total of 339 outpatients with poorly controlled diabetes from county-run clinics were enrolled in a three-arm trial. Participants, more than half of whom spoke limited English, were uninsured, and/or had less than a high school education, were randomly assigned to usual care, interactive weekly automated telephone self-management support with nurse follow-up (ATSM), or monthly group medical visits with physician and health educator facilitation (GMV). We measured 1-year changes in structure (Patient Assessment of Chronic Illness Care [PACIC]), communication processes (Interpersonal Processes of Care [IPC]), and outcomes (behavioral, functional, and metabolic). RESULTS Compared with the usual care group, the ATSM and GMV groups showed improvements in PACIC, with effect sizes of 0.48 and 0.50, respectively (P < 0.01). Only the ATSM group showed improvements in IPC (effect sizes 0.40 vs. usual care and 0.25 vs. GMV, P < 0.05). Both SMS arms showed improvements in self-management behavior versus the usual care arm (P < 0.05), with gains being greater for the ATSM group than for the GMV group (effect size 0.27, P = 0.02). The ATSM group had fewer bed days per month than the usual care group (-1.7 days, P = 0.05) and the GMV group (-2.3 days, P < 0.01) and less interference with daily activities than the usual care group (odds ratio 0.37, P = 0.02). We observed no differences in A1C change. CONCLUSIONS Patient-centered SMS improves certain aspects of diabetes care and positively influences self-management behavior. ATSM seems to be a more effective communication vehicle than GMV in improving behavior and quality of life.
Collapse
Affiliation(s)
- Dean Schillinger
- Division of General Internal Medicine, University of California, San Francisco, San Francisco,California, USA.
| | | | | | | |
Collapse
|
105
|
Balamurugan A, Hall-Barrow J, Blevins MA, Brech D, Phillips M, Holley E, Bittle K. A pilot study of diabetes education via telemedicine in a rural underserved community--opportunities and challenges: a continuous quality improvement process. DIABETES EDUCATOR 2009; 35:147-54. [PMID: 19244570 DOI: 10.1177/0145721708326988] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Telemedicine technology may offer an avenue to implement diabetes self-management education (DSME) for people with diabetes in underserved rural communities. The continuous quality improvement process was used to identify the problem, collect and analyze data, and develop and implement a DSME program via telemedicine (DSME-T) in an underserved rural community. METHODS A pilot study was conducted in 2006, implementing a DSME-T utilizing facilities at the University of Arkansas for Medical Sciences and a rural community hospital in Arkansas (Ozark Health, Inc). A total of 38 people were enrolled to receive DSME-T. Participant knowledge, self-efficacy, and self-care practices were assessed before participants began the education program and after they had completed it. Also, select clinical measures (glycosylated hemoglobin, lipid profile, and urine microalbumin) were collected. RESULTS A total of 66% of participants (n = 25) completed the DSME-T program. A significantly greater proportion of participants demonstrated improved knowledge (39% vs 83%; P = .012), endorsed greater self-efficacy (54% vs 86%; P = .016), and reported more frequent self-care practices to manage their diabetes at the conclusion of the study period. CONCLUSIONS The results of this pilot study suggest that DSME-T may offer opportunities for DSME among rural residents with diabetes. Plans are in place to explore the possibility of sustaining and expanding the program to other underserved rural communities.
Collapse
Affiliation(s)
- Appathurai Balamurugan
- The Epidemiology Branch at the Center for Public Health Practice, Arkansas Department of Health, Little Rock, Arkansas (Dr Balamurugan, Dr Phillips),The University of Arkansas for Medical Sciences, Little Rock, Arkansas (Dr Balamurugan, Ms Hall-Barrow, Dr Phillips, Ms Holley)
| | - Julie Hall-Barrow
- The University of Arkansas for Medical Sciences, Little Rock, Arkansas (Dr Balamurugan, Ms Hall-Barrow, Dr Phillips, Ms Holley)
| | - Mary Alice Blevins
- The Arkansas Diabetes Prevention and Control Program, Arkansas Department of Health, Little Rock, Arkansas (Ms Blevins)
| | - Detri Brech
- Ouachita Baptist University, Arkadelphia, Arkansas (Dr Brech)
| | - Martha Phillips
- The Epidemiology Branch at the Center for Public Health Practice, Arkansas Department of Health, Little Rock, Arkansas (Dr Balamurugan, Dr Phillips)
| | - Elizabeth Holley
- The University of Arkansas for Medical Sciences, Little Rock, Arkansas (Dr Balamurugan, Ms Hall-Barrow, Dr Phillips, Ms Holley)
| | - Kim Bittle
- Ozark Health, Inc, Clinton, Arkansas (Ms Bittle)
| |
Collapse
|
106
|
|
107
|
|
108
|
A before and after study of medical students' and house staff members' knowledge of ACOVE quality of pharmacologic care standards on an acute care for elders unit. ACTA ACUST UNITED AC 2008; 6:82-90. [DOI: 10.1016/j.amjopharm.2008.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2008] [Indexed: 11/22/2022]
|
109
|
Robertson B, Aycock DM, Darnell LA. Comparison of centering pregnancy to traditional care in Hispanic mothers. Matern Child Health J 2008; 13:407-14. [PMID: 18465216 DOI: 10.1007/s10995-008-0353-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2007] [Accepted: 04/22/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare maternal and infant outcomes in Hispanic women participating in the Centering Pregnancy Model (CPM) to those receiving prenatal care via the traditional model and determine acceptability of the CPM. METHODS Forty-nine women (n = 24 CPM; n = 25 traditional) participated in this quasi-experimental prospective comparative design. Participants self selected the model of care delivery. Data were collected via questionnaires at the initial visit, 34-36 weeks gestation, and postpartum. Outcome measures included: satisfaction with care delivery model, health behaviors, prenatal/postnatal care knowledge, self-esteem and depression. Breastfeeding initiation and continuation, infant birth weight, gestational age at delivery, mode of delivery and infant length of stay were also collected. RESULTS Traditional participants had a history of more pregnancies, more living children, and higher levels of postpartum self-esteem compared to centering participants. Knowledge deficits and health behaviors were similar between groups. No differences were found for infant outcomes. CONCLUSIONS This study provides information regarding Hispanic mothers' responses to an alternative care delivery model. Preliminary evidence suggests CPM compares with traditional care and yields a high degree of patient satisfaction. Specific pregnancy-related knowledge deficits were identified in both groups that could focus prenatal education. In light of similar outcomes in both groups; patient and provider satisfaction and economics would therefore be a factor when choosing a model of prenatal care delivery.
Collapse
Affiliation(s)
- Bethany Robertson
- The Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, Suite 364, Atlanta, GA 30322, USA.
| | | | | |
Collapse
|
110
|
Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2008; 371:725-35. [PMID: 18313501 PMCID: PMC2262920 DOI: 10.1016/s0140-6736(08)60342-6] [Citation(s) in RCA: 491] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND In old age, reduction in physical function leads to loss of independence, the need for hospital and long-term nursing-home care, and premature death. We did a systematic review to assess the effectiveness of community-based complex interventions in preservation of physical function and independence in elderly people. METHODS We searched systematically for randomised controlled trials assessing community-based multifactorial interventions in elderly people (mean age at least 65 years) living at home with at least 6 months of follow-up. Outcomes studied were living at home, death, nursing-home and hospital admissions, falls, and physical function. We did a meta-analysis of the extracted data. FINDINGS We identified 89 trials including 97 984 people. Interventions reduced the risk of not living at home (relative risk [RR] 0.95, 95% CI 0.93-0.97). Interventions reduced nursing-home admissions (0.87, 0.83-0.90), but not death (1.00, 0.97-1.02). Risk of hospital admissions (0.94, 0.91-0.97) and falls (0.90, 0.86-0.95) were reduced, and physical function (standardised mean difference -0.08, -0.11 to -0.06) was better in the intervention groups than in other groups. Benefit for any specific type or intensity of intervention was not noted. In populations with increased death rates, interventions were associated with reduced nursing-home admission. Benefit in trials was particularly evident in studies started before 1993. INTERPRETATION Complex interventions can help elderly people to live safely and independently, and could be tailored to meet individuals' needs and preferences.
Collapse
Affiliation(s)
- Andrew D Beswick
- Department of Social Medicine, University of Bristol, Bristol, UK.
| | | | | | | | | | | | | |
Collapse
|
111
|
|
112
|
McClung JA. End-of-life care in the treatment of heart failure in the elderly. Heart Fail Clin 2007; 3:539-47. [PMID: 17905388 DOI: 10.1016/j.hfc.2007.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Much of the literature dedicated to the topic of medical care of dying patients has revolved around terminal care provided to patients who have neoplastic diagnoses. Heart failure (HF) presents its own unique challenges to the clinician. This article focuses on specific clinical recommendations and an analysis of some of the ethical issues involved in the provision of care to elderly patients in the terminal stages of HF.
Collapse
Affiliation(s)
- John Arthur McClung
- Westchester Medical Center/New York Medical College, Valhalla, NY 10595, USA.
| |
Collapse
|
113
|
Fisher L, Glasgow RE. A call for more effectively integrating behavioral and social science principles into comprehensive diabetes care. Diabetes Care 2007; 30:2746-9. [PMID: 17901532 DOI: 10.2337/dc07-1166] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
114
|
Crespo R, Shrewsberry M. Factors associated with integrating self-management support into primary care. DIABETES EDUCATOR 2007; 33 Suppl 6:126S-131S. [PMID: 17620391 DOI: 10.1177/0145721707304138] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this article is to expand the understanding of self-management support by describing factors that contribute to implementing a comprehensive self-management program in primary care. METHODS Four rural health centers in medically underserved areas participated in a study to document the implementation of a self-management program. This program consisted of a social marketing plan and decision-making tools to guide patients in making self-management behavior changes. The stages of change constructs of the transtheoretical model were used to design the social marketing plan. Key informant interviews were conducted at 6-month and 9-month intervals to document the implementation process. A standardized set of questions was used in the interviews. The data from the interviews were analyzed using content analysis techniques. RESULTS One of the principle findings is that self-management support requires putting a system in place, not just adding a new component to primary care. The health centers that fully implemented the self-management program made an organizational commitment to keep self-management on the agenda in management meetings, clinical staff set the example by adopting self-management behaviors, and patient self-management support was implemented in multiple patient care venues. CONCLUSION Primary care centers with limited financial resources are able to integrate self-management support into their system of chronic illness care.
Collapse
Affiliation(s)
- Richard Crespo
- The Joan C. Edwards School of Medicine, Marshall University, Department of Family and Community Health, Huntington, West Virginia (Dr Crespo)
| | | |
Collapse
|
115
|
Abstract
The aim of this study was to observe how chronic obstructive pulmonary disease (COPD) is diagnosed and treated in primary care settings and to identify best practices. Researchers interviewed or visited physicians and staff at 25 primary care practices across the United States, focusing on small practices. All interviewers used a standard interview tool to capture anecdotal and quantitative data. It was discovered that primary care physicians underuse spirometry as a diagnostic tool, even when available in the office or clinic. Formal smoking-cessation programs are uncommon, as are outcomes measurements through clinical monitoring. Physicians reported not having enough time to improve performance, mainly owing to an average 15-minute patient visit allotment. Practice inefficiencies are responsible for many clinical shortcomings in COPD management. Although improving clinical understanding is important, it is equally important that overburdened and rushed primary care practices optimize workflow. This can be accomplished through better use of support staff and improved scheduling of spirometry testing in order to implement clinical guidelines without interfering with other essential practice tasks.
Collapse
|
116
|
van Bruggen JAR, Gorter KJ, Stolk RP, Rutten GEHM. Shared and delegated systems are not quick remedies for improving diabetes care: a systematic review. Prim Care Diabetes 2007; 1:59-68. [PMID: 18632021 DOI: 10.1016/j.pcd.2007.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 04/10/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Type 2 diabetes is an important, chronic condition notorious for its costly and disabling complications. Nowadays, enhanced cooperation is expected to improve the quality of diabetes care and reduce risks for chronically ill patients. It is, however, questionable whether this assumption is evidence based. METHODS Using a structured literature search, we selected systematic reviews, randomised controlled trials (RCTs) and other effect evaluations regarding the sharing and allocation of diabetes care. RESULTS We selected 22 studies to include in this review. The process of care improved in all studies investigating this quality aspect. HbA1c improved in seven reviews and in five other studies. All included reviews and four RCTs were unable to demonstrate a positive effect on blood pressure. Total cholesterol improved in two reviews and five other studies. CONCLUSIONS The sharing and allocation of diabetes care leads to significant reduction in HbA1c and improves the process of care. However, this improvement has not as yet led to better cardiovascular risk management. For a number of reasons, a truly accurate estimation of the results of shared and allocated diabetes care within the Dutch diabetes care system is not possible.
Collapse
Affiliation(s)
- J A R van Bruggen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.
| | | | | | | |
Collapse
|
117
|
Clancy DE, Huang P, Okonofua E, Yeager D, Magruder KM. Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med 2007; 22:620-4. [PMID: 17443369 PMCID: PMC1852919 DOI: 10.1007/s11606-007-0150-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 12/15/2006] [Accepted: 01/30/2007] [Indexed: 12/02/2022]
Abstract
BACKGROUND Current diabetes management guidelines offer blueprints for providers, yet type 2 diabetes control is often poor in disadvantaged populations. The group visit is a new treatment modality originating in managed care for efficient service delivery to patients with chronic health problems. Group visits offer promise for delivering care to diabetic patients, as visits are lengthier and can be more frequent, more organized, and more educational. OBJECTIVE To evaluate the effect of group visits on clinical outcomes, concordance with 10 American Diabetes Association (ADA) guidelines [American Diabetes Association, Diabetes Care, 28:S4-36, 2004] and 3 United States Preventive Services Task Force (USPSTF) cancer screens [U.S. Preventive Services Task Force, http://www.ahrq.gov/clinic/uspstf/resource.htm, 2003]. RESEARCH DESIGN AND METHODS A 12-month randomized controlled trial of 186 diabetic patients comparing care in group visits with care in the traditional patient-physician dyad. Clinical outcomes (HbA1c, blood pressure [BP], lipid profiles) were assessed at 6 and 12 months and quality of care measures (adherence to 10 ADA guidelines and 3 USPSTF cancer screens) at 12 months. RESULTS At both measurement points, HbA1c, BP, and lipid levels did not differ significantly for patients attending group visits versus those in usual care. At 12 months, however, patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators (p < .0001) and higher screening rates for cancers of the breast (80 vs. 68%, p = .006) and cervix (80 vs 68%, p = .019). CONCLUSIONS Group visits can improve the quality of care for diabetic patients, but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes.
Collapse
Affiliation(s)
- Dawn E Clancy
- Department of Medicine, Medical University of South Carolina, Charleston, SC 250591, USA.
| | | | | | | | | |
Collapse
|
118
|
Abstract
Much of the literature dedicated to the topic of medical care of dying patients has revolves around terminal care provided to patients who have neoplastic diagnoses. Heart failure (HF) presents its own unique challenges to the clinician. This article focuses on specific clinical recommendations and an analysis of some of the ethical issues involved in the provision of care to elderly patients in the terminal stages of HF.
Collapse
Affiliation(s)
- John Arthur McClung
- Division of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY 10595, USA.
| |
Collapse
|
119
|
Wetzels R, Harmsen M, Van Weel C, Grol R, Wensing M. Interventions for improving older patients' involvement in primary care episodes. Cochrane Database Syst Rev 2007; 2007:CD004273. [PMID: 17253501 PMCID: PMC7197439 DOI: 10.1002/14651858.cd004273.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is a growing expectation among patients that they should be involved in the delivery of medical care. Accumulating evidence from empirical studies shows that patients of average age who are encouraged to participate more actively in treatment decisions have more favourable health outcomes, in terms of both physiological and functional status, than those who do not. Interventions to encourage more active participation may be focused on different stages, including: the use of health care; preparation for contact with a care provider; contact with the care provider; or feedback about care. However, it is unclear whether the benefits of these interventions apply to the elderly as well. OBJECTIVES To assess the effects of interventions in primary medical care that improve the involvement of older patients (>=65 years) in their health care. SEARCH STRATEGY We searched: the Cochrane Consumers and Communication Review Group Specialised Register (May 2003); the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library issue 1, 2004; MEDLINE (Ovid) (1966 to June 2004); EMBASE (1988 to June 2004); PsycINFO (1872 to June 2004); DARE, The Cochrane Library issue 1, 2004; ERIC (1966 to June 2004); CINAHL (1982 to June 2004); Sociological Abstracts (1963 to June 2004); Dissertation Abstracts International (1861 to June 2004); and reference lists of articles. SELECTION CRITERIA Randomised controlled trials or quasi-randomised trials of interventions to improve the involvement of older patients (>= 65 years) in single consultations or episodes of primary medical care. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. Results are presented narratively as meta-analysis was not possible. MAIN RESULTS We identified three studies involving 433 patients. Overall, the quality of studies was not high, and there was moderate to high risk of bias. Interventions of a pre-visit booklet and a pre-visit session (either combined or pre-visit session alone) led to more questioning behaviour and more self-reported active behaviour in the intervention group (3 studies). One study (booklet and pre-visit session) showed no difference in consultation length and time engaged in talk between the intervention and control groups. The booklet and pre-visit session in one study was associated with more satisfaction with interpersonal aspects of care for the intervention group although no difference in overall satisfaction between intervention and control. There was no long-term follow up to see if effects were sustained. No studies measured outcomes relating to the use of health care, health status and wellbeing, or health behaviour. AUTHORS' CONCLUSIONS Overall this review shows some positive effects of specific methods to improve the involvement of older people in primary care episodes. Because the evidence is limited, however, we can not recommend the use of the reviewed interventions in daily practice. There should be a balance between respecting patients' autonomy and stimulating their active participation in health care. Face-to-face coaching sessions, whether or not complemented with written materials, may be the way forward. As this is impractical for the whole population, it could be worthwhile to identify a subgroup of older patients who might benefit the most from enhanced involvement, ie. those who want to be involved, but lack the necessary skills. This group could be coached either individually or, more practically, in group sessions.
Collapse
Affiliation(s)
- R Wetzels
- Radboud University Nijmegen Medical Centre, Centre for Quality of Care Research (WOK), (117 KWAZO), PO Box 9101, Nijmegen, Netherlands, 6500 HB.
| | | | | | | | | |
Collapse
|
120
|
Abstract
This review summarizes key factors that have interfered with translation of research to practice and what public health researchers can do to hasten such transfer, focusing on characteristics of interventions, target settings, and research designs. The need to address context and to utilize research, review, and reporting practices that address external validity issues-such as designs that focus on replication, and practical clinical and behavioral trials-are emphasized. Although there has been increased emphasis on social-ecological interventions that go beyond the individual level, interventions often address each component as if it were an independent intervention. Greater attention is needed to connectedness across program levels and components. Finally, examples are provided of evaluation models and current programs that can help accelerate translation of research to practice and policy.
Collapse
|
121
|
Barkauskas VH, Schafer P, Sebastian JG, Pohl JM, Benkert R, Nagelkerk J, Stanhope M, Vonderheid SC, Tanner CL. Clients Served and Services Provided by Academic Nurse-Managed Centers. J Prof Nurs 2006; 22:331-8. [DOI: 10.1016/j.profnurs.2006.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Indexed: 11/30/2022]
|
122
|
Fletcher SG, Clark SJ, Overstreet DL, Steers WD. An Improved Approach to Followup Care for the Urological Patient: Drop-in Group Medical Appointments. J Urol 2006; 176:1122-6; discussion 1126. [PMID: 16890706 DOI: 10.1016/j.juro.2006.04.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE To increase prompt access to routine office visits the concept of the group appointment was developed in the primary care setting. Drop-in group medical appointments have been piloted at our department. We hypothesized that 1) efficiency could be improved by seeing 6 to 14 patients at 1 appointment, 2) access to appointment times would increase and 3) patient satisfaction would be enhanced with 60 minutes of didactic contact and discussion with the urologist. MATERIALS AND METHODS Patients were invited to participate in a drop-in group medical appointment. Appointments were made based on sex and not on diagnosis. A 60-minute group teaching session was followed by a private 2 to 5-minute physical examination or further testing, as indicated. Confidential satisfaction surveys were administered to drop-in group medical appointment participants and patients seen at traditional individual (solo) appointments. Results were compared. RESULTS From September 22, 2003 to August 30, 2004, 279 patients attended a drop-in group medical appointment. Mean patient age was 63 years and 142 patients were 65 years or older. Most diagnoses were prostate cancer, erectile dysfunction, benign prostatic hyperplasia, incontinence, neurogenic bladder and chronic discomfort syndromes. Of the patients 287 were surveyed, including 177 at drop-in group medical appointments and 110 at solo appointments. Patient satisfaction with the drop-in group medical appointment format was as high as that of solo patients with 87% of drop-in group medical appointment patients rating their experience as excellent or very good vs 88% by solo patients. CONCLUSIONS Drop-in group medical appointments can be implemented successfully in a urological practice with high patient satisfaction despite the sensitive nature of topics discussed. Ideal patients are those with chronic or complex conditions and those requiring repetitive discussions, such as elderly individuals.
Collapse
Affiliation(s)
- Sophie G Fletcher
- Department of Urology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | | | | | | |
Collapse
|
123
|
Massey Z, Rising SS, Ickovics J. CenteringPregnancy group prenatal care: Promoting relationship-centered care. J Obstet Gynecol Neonatal Nurs 2006; 35:286-94. [PMID: 16620257 DOI: 10.1111/j.1552-6909.2006.00040.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
CenteringPregnancy is an innovative model of group prenatal care that has been implemented at more than 100 prenatal care sites since 1995. CenteringPregnancy provides group prenatal care that is relationship centered, nurturing and transforming relationships among women, their families, and health care professionals. Complete prenatal care is provided in a group setting. Prenatal assessment, education, and support occur in a facilitative environment. The model offers effective and efficient care that is sustainable and can enhance the health of women, their families, health care providers, and communities.
Collapse
Affiliation(s)
- Zohar Massey
- Yale School of Public Health, New Haven, CT 06510, USA.
| | | | | |
Collapse
|
124
|
Siminerio LM. Implementing diabetes self-management training programs: breaking through the barriers in primary care. Endocr Pract 2006; 12 Suppl 1:124-30. [PMID: 16627396 DOI: 10.4158/ep.12.s1.124] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review issues, examples, and recommendations for the delivery of diabetes self-management training (DSMT) services in the primary care setting. METHODS Barriers to provision of DSMT at the point of care and strategies to overcome such challenges are discussed. In addition, new avenues to support continuing diabetes education are presented. RESULTS Diabetes is a complex disease that requires education, monitoring, and medication adjustment to achieve treatment goals. Unfortunately, adequate support is seldom available for the increased time and effort needed for optimal management of diabetes. Health-care delivery systems are designed to provide a response to acute illnesses and are poorly configured to meet the needs of patients with complex chronic illnesses. Although team care and DSMT have proved to be effective, they have infrequently been integrated in primary care offices, where most patients with diabetes receive treatment. It is encouraging that the studies conducted to date have generally found office-based counseling and educational strategies to be effective for the vast majority of patients with diabetes. Community-based programs that extend DSMT have also been successful. CONCLUSION Diabetes is a chronic disease that requires providers to deliver multifaceted care and patients to be proficient in many self-care skills. Team care and DSMT approaches have been found to yield beneficial results, yet such strategies are seldom used in the primary care office. Thus, models that support the team approach to delivery of diabetes care and self-management education interventions should be explored and encouraged.
Collapse
Affiliation(s)
- Linda M Siminerio
- Diabetes Institute, Adult Clinical Services, University of Pittsburgh Medical Center, Pennsylvania, USA
| |
Collapse
|
125
|
McCusker J, Verdon J. Do geriatric interventions reduce emergency department visits? A systematic review. J Gerontol A Biol Sci Med Sci 2006; 61:53-62. [PMID: 16456194 DOI: 10.1093/gerona/61.1.53] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hospital emergency departments (EDs) serve an aging population with an increased burden on health resources. Few studies have examined the effects of comprehensive geriatric assessment interventions on ED use. This study aimed to systematically review the literature and compare the effects of these interventions on ED visits. METHODS Relevant articles were identified through electronic databases and a search of reference lists and personal files. Inclusion criteria included: original research (written in English or French) on interventions conducted in noninstitutionalized populations 60 years old or older, not restricted to a particular medical condition, in which ED visits were a study outcome. Data were abstracted and checked by the first author and a research assistant using a standard protocol. RESULTS Twenty-six relevant studies were identified, reported in 28 articles, with study samples obtained from EDs (9), hospitals (4), outpatient or primary care settings (10), home care (4), and community (1). The study designs included 17 randomized controlled trials, 3 trials with nonrandom allocation, 4 before-after studies, 1 quasi-experimental time-series study, and 1 cross-sectional study. Hospital-based interventions (mostly short-term assessment and/or liaison) had little overall effect on ED utilization, whereas many interventions in outpatient and/or primary care or home care settings (including geriatric assessment and management and case management) reduced ED utilization. Heterogeneity in study methods, measures of comorbidity, functional status, and ED utilization precluded meta-analysis of the results. CONCLUSION Further research, using improved methodologies and standardized measures, is needed to address the effects of innovative geriatric interventions on ED visits.
Collapse
Affiliation(s)
- Jane McCusker
- Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital Center, 3830 Lacombe Ave., Room 2508, Montreal, QC H3T 1M5.
| | | |
Collapse
|
126
|
Abstract
OBJECTIVE To evaluate the effect of observing group visits on trainees' perceptions of group visits as a method of health care delivery. RESEARCH DESIGN AND METHODS Thirty-two trainees assigned to month-long rotations at an academic Internal Medicine Primary Care Clinic serving underinsured patients were recruited to observe between 1 and 4 group visits. Prior to observation of their first, and subsequent to observation of their last group visit, each trainee completed the Patient-Physician Orientation Scale (PPOS), a validated survey evaluating their tendencies toward being patient-centered or provider-centered. Additionally, they completed a Group Visit Questionnaire (GVQ) evaluating their perceptions of group visits as a method of health care delivery. RESULTS Trainee gender, type, and level of training were similarly represented across the study population of trainees. While there were no significant differences noted on pre- and postobservation PPOS scores, the postobservation GVQs scores were significantly improved after observing at least one group visit (P<.0001). CONCLUSION Trainees' perceptions of group visits as a method of health care delivery improved significantly after observation of at least 1 group as measured by the GVQ.
Collapse
Affiliation(s)
- Kimberly S Davis
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | | | | | | | | |
Collapse
|
127
|
Wagner EH, Bennett SM, Austin BT, Greene SM, Schaefer JK, Vonkorff M. Finding common ground: patient-centeredness and evidence-based chronic illness care. J Altern Complement Med 2006; 11 Suppl 1:S7-15. [PMID: 16332190 DOI: 10.1089/acm.2005.11.s-7] [Citation(s) in RCA: 257] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Health outcomes for patients with major chronic illnesses depend on the appropriate use of proven pharmaceuticals and other therapeutic technologies, and effective self-management by patients. Effective chronic illness care then bases clinical decisions on the best, rigorous scientific evidence, or evidence-based medicine. Effective support for patient self-management includes efforts to increase patient participation in care and collaborative goal-setting and planning of treatment. These interventions appear somewhat consistent with recent conceptualizations of patient-centered care. The consistent delivery of proven therapies and information and support for self-management requires practice systems organized for that purpose. The Chronic Care Model is a compilation of those practice system changes shown to improve chronic care. This paper explores the concept of patient-centeredness and its relationship to the Chronic Care Model. We conclude that the Model is both evidence-based and patient-centered and that these can be properties of health systems, and not just of individual practitioners.
Collapse
Affiliation(s)
- Edward H Wagner
- MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative, Seattle, WA, USA.
| | | | | | | | | | | |
Collapse
|
128
|
Heisler M, Piette JD. "I help you, and you help me": facilitated telephone peer support among patients with diabetes. DIABETES EDUCATOR 2006; 31:869-79. [PMID: 16288094 DOI: 10.1177/0145721705283247] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The feasibility and acceptability of using an Interactive Voice Response (IVR)-based platform to facilitate peer support among older adults with diabetes was evaluated. METHODS Diabetes patients with poor glycemic control receiving care at a Veterans' Affairs medical center completed a baseline survey, received rudimentary training, and were matched based on their diabetes-related self-management needs. They were asked to contact their partner weekly using the toll-free IVR calling line. At the completion of the 6-week period, participants completed follow-up surveys and brief telephone interviews. RESULTS Forty of 76 patients screened for eligibility by telephone agreed to participate, and 38 completed the 6-week intervention (50% of eligible patients). More than 80% of the pairs spoke at least once a week for 2 of the 6 weeks of the intervention. A total of 79% of the participants reported that the IVR system was easy to use, and 90% stated that they would be more satisfied with their health care if this type of peer support service were available. Of the participants, 70% found the calls helpful in managing diabetes symptoms, 73% reported that their partner helped them improve their self-care, and 70% stated that they helped their partner do things to stay healthy. There were significant improvements in participants' reported diabetes self-care self-efficacy between baseline and follow-up assessments (P < .01). Qualitative assessments suggested that participants found meaning and positive reinforcement for their own self-care through supporting their partner's efforts to manage diabetes. CONCLUSIONS An IVR peer support intervention is feasible, acceptable to patients, and may have positive effects on patients' diabetes self-management and health outcomes that warrant more rigorous evaluation in a randomized trial.
Collapse
Affiliation(s)
- Michele Heisler
- The Veterans Affairs Center for Practice Management & Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; the Department of Internal Medicine, Michigan Diabetes Research and Training Center; and The University of Michigan School of Medicine, Ann Arbor
| | - John D Piette
- The Veterans Affairs Center for Practice Management & Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; the Department of Internal Medicine, Michigan Diabetes Research and Training Center; and The University of Michigan School of Medicine, Ann Arbor
| |
Collapse
|
129
|
Fenton JJ, Von Korff M, Lin EHB, Ciechanowski P, Young BA. Quality of preventive care for diabetes: effects of visit frequency and competing demands. Ann Fam Med 2006; 4:32-9. [PMID: 16449394 PMCID: PMC1466990 DOI: 10.1370/afm.421] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We sought to determine the association between timely receipt of diabetes-related preventive services and the longitudinal pattern of outpatient service use as characterized by a novel taxonomy that prioritized visits based on the Oregon State Prioritized Health Services List. METHODS We performed a cross-sectional analysis of mail survey and automated health care data for a population-based sample of patients with diabetes enrolled in a health maintenance organization in Washington State (N = 4,463). Outcomes included American Diabetes Association-recommended preventive services, including regular hemoglobin A1C (HbA1C) monitoring, retinal examination, and microalbuminuria screening. Patients with fewer than 8 visits during the 2-year study period were considered infrequent users, while patients with 8 or more visits were classified as lower-priority users if most visits were for conditions of relatively low rank on the Oregon list and as higher-priority users otherwise. RESULTS After adjustment for social, demographic, and clinical factors, and depression, infrequent users had significantly reduced odds of receiving at least 1 HbA1C test (odds ratio [OR] = 0.35, 95% confidence interval [CI], 0.24-0.51), retinal examination (OR = 0.74, 95% CI, 0.63-0.86), and microalbuminuria screening (OR = 0.75, 95% CI, 0.58-0.96) relative to higher-priority users during the previous year. Lower-priority users also had relatively reduced odds of receiving at least 1 HbA(1C) test (OR = 0.59, 95% CI, 0.35-1.01), retinal examination (OR = 0.68, 95% CI, 0.56-0.84), and microalbuminuria screening (OR = 0.79, 95% CI, 0.57-1.09) despite attending a similar mean number of total visits as higher-priority users. CONCLUSIONS Patients who attend relatively few outpatient visits or who attend more frequent visits for predominantly lower-priority conditions are more likely to receive substandard preventive care for diabetes.
Collapse
Affiliation(s)
- Joshua J Fenton
- Department of Family and Community Medicine, University of California, Davis, Sacramento, Calif 95817, USA.
| | | | | | | | | |
Collapse
|
130
|
Managing Patient Appointments in Primary Care. INTERNATIONAL SERIES IN OPERATIONS RESEARCH & MANAGEMENT SCIENCE 2006. [DOI: 10.1007/978-0-387-33636-7_5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
|
131
|
Affiliation(s)
- Halsted R Holman
- Stanford University School of Medicine, 1000 Welch Road, Ste 203, Palo Alto, CA 94304, USA.
| |
Collapse
|
132
|
Fisher EB, Brownson CA, O'Toole ML, Shetty G, Anwuri VV, Glasgow RE. Ecological approaches to self-management: the case of diabetes. Am J Public Health 2005; 95:1523-35. [PMID: 16051929 PMCID: PMC1449392 DOI: 10.2105/ajph.2005.066084] [Citation(s) in RCA: 206] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
In the Diabetes Initiative of The Robert Wood Johnson Foundation, an ecological perspective helped identify the following key resources and supports for self-management (RSSM): individualized assessment, collaborative goal setting, skills enhancement, follow-up and support, access to resources, and continuity of quality clinical care. These RSSM reflect the grounding of diabetes self-management in the context of social and environmental influences. Research supports the value of each of these key resources and supports. Differences among self-management interventions may be seen as complementary, rather than conflicting, ways of providing RSSM. This way of understanding differences among interventions may aid development of varied programs to reach diverse audiences. In contrast to the "5 A's" model of key provider services (Assess, Advise, Agree, Assist, and Arrange), RSSM articulate self-management from the perspective of individuals' needs. Both approaches emphasize identification of goals, teaching of skills, and facilitation and reinforcement of the use of those skills.
Collapse
Affiliation(s)
- Edwin B Fisher
- Washington University, Division of Health Behavior Research, 4444 Forest Park Ave, St Louis, MO 63108, USA.
| | | | | | | | | | | |
Collapse
|
133
|
García-Morillo JS, Bernabeu-Wittel M, Ollero-Baturone M, Aguilar-Guisad M, Ramírez-Duque N, González de la Puente MA, Limpo P, Romero-Carmona S, Cuello-Contreras JA. Incidencia y características clínicas de los pacientes con pluripatología ingresados en una unidad de medicina interna. Med Clin (Barc) 2005; 125:5-9. [PMID: 15960937 DOI: 10.1157/13076399] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Our objective was to assess the incidence and clinical features of patients with numerous disorders--comorbidity patients (CP)--and to clinically validate the CP criteria defined by a panel of experts (patients with 2 or more chronic diseases, distributed into seven categories). PATIENTS AND METHOD Prospective observational study of all patients, attended in internal medicine areas of a tertiary teaching hospital, during June 2003. Patients were stratified in 3 cohorts: CP, palliative, and general (GE). Incidence of CP, functional evaluation (at baseline, at admission, and at discharge), and burden of hospital care (by means of urgent and programmed visits, as well as episodes of hospitalization) in the last 12 months were analyzed. A multivariate analysis of predictors of survival and functional deterioration (fall in Barthel's scale > or = 10 points between baseline-discharge values) was performed in the CP cohort. RESULTS 339 patients (CP cohort: 132; palliative: 52; GE: 155) were included. The overall incidence was 38.9/100 admissions/month. CP were older (75 [11] vs 67 [16]); had higher mortality (19.3% vs 6.1%; relative risk [RR]: 3.66 [95% confidence interval [CI], 1.65-8.13]; lower functional ability at baseline (45 vs 95), at admission (20 vs 75), and at discharge (20 vs 95); higher rates of significant functional deterioration (16% vs 7%; RR = 2.47 [95% CI, 1.15-5.35]); and required more burden of hospital care by means of urgent care (3.6 [3.4] episodes vs 2.4 [1.9]), and hospitalizations (1.9 [1.3] vs 1.5 [1]) than GE patients. Chronic digestive/hepatic diseases (odds ratio [OR] = 48.3 [2.4-980.9], peripheric vascular disease/diabetes with visceral involvement (OR = 5.6 [CI 95%, 1.1-28.6]), and better functional ability at admission were associated with survival. Female gender (OR ) 46.6 [CI 95%, 4.5-486.9]), chronic lung disease (OR = 8.9 [CI 95%, 1.2-64]), and neurologic disease with disability (OR = 8 [CI 95%, 1.1-58.9]), were associated with significant functional deterioration during hospital stay. CONCLUSIONS The defined CP criteria were highly accurate in detecting a population of patients with high attention in Internal Medicine areas, high mortality rates, clinical frailty (more need of hospital care), and significant functional deterioration. Barthel's scale identified correctly this group of patients, and was independently associated with survival.
Collapse
Affiliation(s)
- José Salvador García-Morillo
- Unidad Clínica de Atención Médica Integral, Servicio de Medicina Interna, Hospitales Universitarios Virgen del Rocío, 41013 Sevilla, España.
| | | | | | | | | | | | | | | | | |
Collapse
|
134
|
Østbye T, Yarnall KSH, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005; 3:209-14. [PMID: 15928223 PMCID: PMC1466884 DOI: 10.1370/afm.310] [Citation(s) in RCA: 466] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Revised: 01/10/2005] [Accepted: 02/03/2005] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Despite the availability of national practice guidelines, many patients fail to receive recommended chronic disease care. Physician time constraints in primary care are likely one cause. METHODS We applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalences similar to those of the general population, and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician. RESULTS Eight hundred twenty-eight hours per year, or 3.5 hours a day, were required to provide care for the top 10 chronic diseases, provided the disease is stable and in good control. We recalculated this estimate based on increased time requirements for uncontrolled disease. Estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2,484 hours, or 10.6 hours a day. CONCLUSIONS Current practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall. Streamlined guidelines and alternative methods of service delivery are needed to meet recommended standards for quality health care.
Collapse
Affiliation(s)
- Truls Østbye
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC 27710, USA.
| | | | | | | | | | | |
Collapse
|
135
|
Holman H, Lorig K. Patient self-management: a key to effectiveness and efficiency in care of chronic disease. Public Health Rep 2004; 119:239-43. [PMID: 15158102 PMCID: PMC1497631 DOI: 10.1016/j.phr.2004.04.002] [Citation(s) in RCA: 393] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Halsted Holman
- Stanford University School of Medicine, Stanford, CA, USA.
| | | |
Collapse
|
136
|
Toseland RW, McCallion P, Smith T, Banks S. Supporting caregivers of frail older adults in an HMO setting. THE AMERICAN JOURNAL OF ORTHOPSYCHIATRY 2004; 74:349-64. [PMID: 15291711 DOI: 10.1037/0002-9432.74.3.349] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The long-term effectiveness of a structured health education program (HEP) for spouses and frail older adults was evaluated in a staff model health maintenance organization (HMO). HEP is a multicomponent group program that includes emotion-focused and problem-focused coping strategies, education, and support. For caregivers, HEP was more effective than usual care (UC) in reducing depression, increasing knowledge of community services and how to access them, and changing caregivers' feelings of competence and the way they respond to the caregiving situation. For care recipients, HEP was more effective than UC in preventing increases in somatic symptoms and symptoms of anxiety/insomnia. ((c) 2004 APA, all rights reserved)
Collapse
Affiliation(s)
- Ronald W Toseland
- University at Albany, State University of New York, Institute of Gerontology, School of Social Welfare, Albany, NY 12222, USA.
| | | | | | | |
Collapse
|
137
|
Miller D, Zantop V, Hammer H, Faust S, Grumbach K. Group medical visits for low-income women with chronic disease: a feasibility study. J Womens Health (Larchmt) 2004; 13:217-25. [PMID: 15072736 DOI: 10.1089/154099904322966209] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Group medical visits (GMVs) have been proposed as a means of providing comprehensive primary care services to patients with chronic disease. We studied the feasibility of implementing a GMV model with low-income women in an innercity clinic setting. METHODS The intervention consisted of six GMV sessions cofacilitated by a physician/nurse practitioner team. Participants included 28 women with at least one chronic disease diagnosis (71% Latina). Thematic analysis of open-ended interviews assessed participants' experiences in the GMV. Patient charts and provider logs provided information on health service utilization patterns and provider productivity. RESULTS An average of 7 women attended each session, with 16 women attending three or more sessions. In open-ended interviews, the most commonly mentioned positive aspects of the GMV were personalized attention (77%), self-care education (69%), access to medication refills and examinations (69%), and advice from peers (62%). Negative aspects included insufficient personal attention (23%), logistical barriers (8%), and loss of confidentiality (4%). On average, patients required 20 minutes of physician time plus 21 minutes of nurse practitioner time per session. Medical record reviews revealed a significant decrease in urgent care visits (p < 0.05) during the 9 months of the intervention compared with a prior 9-month period. CONCLUSIONS In this innercity clinic setting, the GMV model was well tolerated by patients, did not alter provider productivity, and may have encouraged participants to avoid more expensive urgent care services. The results of this pilot study suggest that GMVs represent a cost-effective ambulatory care alternative that is acceptable to low-income women with chronic disease.
Collapse
Affiliation(s)
- Daphne Miller
- Department of Family and Community Medicine, University of California, San Francisco, California, USA.
| | | | | | | | | |
Collapse
|
138
|
Glasgow RE, Davis CL, Funnell MM, Beck A. Implementing practical interventions to support chronic illness self-management. ACTA ACUST UNITED AC 2003; 29:563-74. [PMID: 14619349 DOI: 10.1016/s1549-3741(03)29067-5] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Self-management support (SMS) is the area of disease management least often implemented and most challenging to integrate into usual care. This article outlines a model of SMS applicable across different chronic illnesses and health care systems, presents recommendations for assisting health care professionals and practice teams to make changes, and provides tips and lessons learned. Strategies can be applied across a wide range of conditions and settings by health educators, care managers, quality improvement specialists, researchers, program evaluators, and clinician leaders. Successful SMS programs involve changes at multiple levels: patient-clinician interactions; office environment changes; and health system, policy, and environmental supports. PATIENT-CLINICIAN INTERACTION LEVEL: Self-management by patients is not optional but inevitable because clinicians are present for only a fraction of the patient's life, and nearly all outcomes are mediated through patient behavior. Clinicians who believe they are in control or responsible for a patient's well-being are less able to adopt an approach that acknowledges the central role of the patient in his or her care. SUMMARY AND CONCLUSIONS Self-management should be an integral part of primary care, an ongoing iterative process, and patient centered; use collaborative goal setting and decision making; and include problem solving, outreach, and systematic follow-up.
Collapse
|
139
|
|
140
|
Lorig KR, Holman HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 2003. [DOI: 10.1207/s15324796abm2601_01 order by 1-- gadu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
|
141
|
Lorig KR, Holman HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 2003. [DOI: 10.1207/s15324796abm2601_01 order by 8029-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
|
142
|
Lorig KR, Holman HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 2003. [DOI: 10.1207/s15324796abm2601_01 order by 8029-- awyx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
|
143
|
Lorig KR, Holman HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 2003. [DOI: 10.1207/s15324796abm2601_01 and 1880=1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
|
144
|
Abstract
Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks--medical management, role management, and emotional management--and six self-management skills--problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.
Collapse
|
145
|
Lorig KR, Holman HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 2003. [DOI: 10.1207/s15324796abm2601_01 order by 1-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
|
146
|
Lorig KR, Holman HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 2003. [DOI: 10.1207/s15324796abm2601_01 order by 1-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
|
147
|
Lorig KR, Holman HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 2003. [DOI: 10.1207/s15324796abm2601_01 order by 8029-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
|
148
|
Clancy DE, Cope DW, Magruder KM, Huang P, Wolfman TE. Evaluating concordance to American Diabetes Association standards of care for type 2 diabetes through group visits in an uninsured or inadequately insured patient population. Diabetes Care 2003; 26:2032-6. [PMID: 12832308 DOI: 10.2337/diacare.26.7.2032] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of a managed care approach to health care delivery, group visits, in the management of uninsured or inadequately insured patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 120 patients with uncontrolled type 2 diabetes were randomly assigned to receive their care in group visits or usual care for 6 months. After 6 months, concordance with 10 process-of-care indicators recommended by the American Diabetes Association (ADA) standards of care was evaluated through chart abstraction. The 10 items evaluated were up-to-date HbA(1c) levels and lipid profiles, urine for microalbumin, appropriate use of ACE inhibitor or angiotensin receptor blockers, use of lipid-lowering agents where indicated, daily aspirin use, annual foot examinations, annual referrals for retinal examinations, and immunizations against streptococcal pneumonia and influenza. RESULTS Patients who received care in group visits showed statistically significant improvement in concordance with these 10 process-of-care indicators (P < 0.001). Of the patients, 76% who received care in group visits had at least 9 of these 10 items up to date, as compared with 23% of control patients; 86% of patients in group visits had at least 8 of the 10 indicators compared with 47% of control patients. CONCLUSIONS Group visits proved more effective in promoting concordance with ADA standards of care than usual care in the treatment of uninsured or inadequately insured patients with type 2 diabetes.
Collapse
Affiliation(s)
- Dawn E Clancy
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
| | | | | | | | | |
Collapse
|
149
|
Reuben DB, Shekelle PG, Wenger NS. Quality of care for older persons at the dawn of the third millennium. J Am Geriatr Soc 2003; 51:S346-50. [PMID: 12823666 DOI: 10.1046/j.1365-2389.2003.51346.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
During the past quarter century, researchers, providers, insurers, and governmental agencies have devoted considerable effort to improving and standardizing the quality of health care provided to older persons. Because older persons differ from younger persons as a result of their life expectancy, disease prevalence and comorbidity, social resources, goals of treatment, and preferences for care, defining and measuring quality of care has been more difficult for this age group. Nevertheless, several decades of research have led to reliable, although imperfect, methods of measuring quality, including those for geriatric conditions. Using these measurement approaches, a variety of studies using different patient populations and sampling strategies have consistently identified deficiencies in quality of care provided to older persons. Moreover, efforts to improve quality of care for older persons have been difficult to design, implement, and sustain. Some have been successful, including having effects on outcome measures, but have not made the transition from research to clinical settings. Others have used quality improvement methods to improve the care of diseases (e.g., diabetes mellitus, congestive heart failure) that commonly affect older persons. However, the lack of alignment of incentives between providers and insurers for most older persons is a major barrier to this approach. In addition, there is no concerted effort among providers, regulatory agencies, and insurers to move the quality-of-care agenda for most Medicare recipients. Despite substantial progress in defining and measuring high-quality care for older persons, the goal of ensuring that older persons receiving such care remains a distant hope.
Collapse
Affiliation(s)
- David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095,USA.
| | | | | |
Collapse
|
150
|
Abstract
Recent exploration of the experiences of pregnant and parenting adolescents has uncovered the need to address the unique developmental, social, and cultural aspects of adolescent pregnancy. Many adolescents, especially those from urban areas, live in communities with limited opportunities, poverty, violence, and a lack of support. Programs that help young women discover their inner strength, create environments for empowerment, and build community may help adolescents to achieve goals and parent successfully. Centering Pregnancy is a model of group prenatal care that provides for the assessment, education, and support of pregnant women and may be particularly useful in adolescent populations. The model is described and the ways adolescents may benefit from Centering Pregnancy's unique design is discussed.
Collapse
Affiliation(s)
- Carrie S Klima
- University of Illinois-Chicago College of Nursing, Department of Maternal-Child Nursing, 60612, USA
| |
Collapse
|