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Mainali S, Aiyagari V, Alexander S, Bodien Y, Boerwinkle V, Boly M, Brown E, Brown J, Claassen J, Edlow BL, Fink EL, Fins JJ, Foreman B, Frontera J, Geocadin RG, Giacino J, Gilmore EJ, Gosseries O, Hammond F, Helbok R, Claude Hemphill J, Hirsch K, Kim K, Laureys S, Lewis A, Ling G, Livesay SL, McCredie V, McNett M, Menon D, Molteni E, Olson D, O'Phelan K, Park S, Polizzotto L, Javier Provencio J, Puybasset L, Venkatasubba Rao CP, Robertson C, Rohaut B, Rubin M, Sharshar T, Shutter L, Sampaio Silva G, Smith W, Stevens RD, Thibaut A, Vespa P, Wagner AK, Ziai WC, Zink E, I Suarez J. Proceedings of the Second Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2022; 37:326-350. [PMID: 35534661 PMCID: PMC9283342 DOI: 10.1007/s12028-022-01505-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/29/2022] [Indexed: 12/21/2022]
Abstract
This proceedings article presents actionable research targets on the basis of the presentations and discussions at the 2nd Curing Coma National Institutes of Health (NIH) symposium held from May 3 to May 5, 2021. Here, we summarize the background, research priorities, panel discussions, and deliverables discussed during the symposium across six major domains related to disorders of consciousness. The six domains include (1) Biology of Coma, (2) Coma Database, (3) Neuroprognostication, (4) Care of Comatose Patients, (5) Early Clinical Trials, and (6) Long-term Recovery. Following the 1st Curing Coma NIH virtual symposium held on September 9 to September 10, 2020, six workgroups, each consisting of field experts in respective domains, were formed and tasked with identifying gaps and developing key priorities and deliverables to advance the mission of the Curing Coma Campaign. The highly interactive and inspiring presentations and panel discussions during the 3-day virtual NIH symposium identified several action items for the Curing Coma Campaign mission, which we summarize in this article.
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Affiliation(s)
- Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
| | - Venkatesh Aiyagari
- Neurological Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sheila Alexander
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Varina Boerwinkle
- Division of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Melanie Boly
- Departments of Neurology and Psychiatry, Wisconsin Institute for Sleep and Consciousness, University of Wisconsin, Madison, WI, USA
| | - Emery Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer Frontera
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Romergryko G Geocadin
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph Giacino
- Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Flora Hammond
- Indiana University Department of Physical Medicine and Rehabilitation, University of Indiana School of Medicine, Indianapolis, IN, USA
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Karen Hirsch
- Division of Neurocritical Care, Department of Neurology, Stanford University, Stanford, CA, USA
| | - Keri Kim
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Center, University of Liege, Liege, Belgium
- Department of Neurology, Centre Hospitalier Universitaire Sart Tilman, University of Liege, Liege, Belgium
| | - Ariane Lewis
- Department of Neurology and Neurosurgery, New York University Langone Health, New York, NY, USA
| | - Geoffrey Ling
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly McNett
- College of Nursing, Ohio State University, Columbus, OH, USA
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - DaiWai Olson
- Neuroscience Intensive Care Unit, O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristine O'Phelan
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Soojin Park
- Department of Neurology and Neurocritical Care, Columbia University, New York, NY, USA
| | - Len Polizzotto
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Jose Javier Provencio
- Department of Neurology and Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - Louis Puybasset
- Department of Neuroradiology, University of Paris VI, Pierre et Marie Curie, Pitié-Salpêtrière Hospital, Paris, France
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Courtney Robertson
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins Children's Center, The Johns Hopkins University School of Medcine, Baltimore, MD, USA
| | - Benjamin Rohaut
- Neuroscience Intensive Care Unit, Department of Neurology, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Michael Rubin
- Neurological Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | | | - Gisele Sampaio Silva
- Hospital Israelita Albert Einstein, Academic Research Organization and Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Wade Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Paul Vespa
- Ronald Reagan UCLA Medical Center, UCLA Santa Monica Medical Center, Santa Monica, CA, USA
| | - Amy K Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Zink
- Department of Neuroscience Nursing, The Johns Hopkins Hospital, The Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abbott JH, Ward AL, Crane C, Chapple CM, Stout K, Hutton L, Martin V, Harcombe H, Ribeiro DC, Gwynne Jones D. Implementation of a 'Joint Clinic' to resolve unmet need for orthopaedic services in patients with hip and knee osteoarthritis: a program evaluation. BMC Musculoskelet Disord 2019; 20:324. [PMID: 31299929 PMCID: PMC6624903 DOI: 10.1186/s12891-019-2702-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 07/01/2019] [Indexed: 01/29/2023] Open
Abstract
Background Osteoarthritis is the most common form of arthritis, principally affecting the older population. Highly prevalent, disabling diseases such as osteoarthritis strain the capacity of health systems, and can result in unmet need for services. The Joint Clinic was initiated to provide secondary care consultations and access to outpatient services for people with advanced hip or knee osteoarthritis, who were referred by their general practitioner for orthopaedic consultation but not offered an orthopaedic specialist appointment. Methods This longitudinal programme evaluation comprised four components: a proof-of-concept evaluation; an implementation evaluation; a process evaluation; and an outcomes evaluation. Interviews and surveys of general practitioners, staff, and patients were conducted pre- and post-implementation. Interviews were transcribed, and thematic analysis was completed. In addition, Joint Clinic patient visits and outcomes were reviewed. Results One hundred and eleven primary care physicians (GPs) and 66 patients were surveyed, and 28 semi-structured interviews of hospital staff and GPs were conducted. Proof of concept was satisfied. Interim and final implementation evaluations indicated adherence to the concept model, high levels of acceptance of and confidence in the programme and its staff, and timely completion within budget. Process evaluation revealed positive impacts of the programme and positive stakeholder perceptions, with some weaknesses in communication to the outer context of primary care. The Joint Clinic saw a total of 637 patient visits during 2 years of operation. Unmet need was reduced by 90%. Patient and referring physician satisfaction was high. Hospital management confirmed that the programme will continue. Conclusions This evaluation indicates that the Joint Clinic concept model is fit for purpose, functioned well within the organisation, and achieved its primary objective of reducing unmet need of secondary care consultation for those suffering advanced hip or knee osteoarthritis. Electronic supplementary material The online version of this article (10.1186/s12891-019-2702-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Haxby Abbott
- Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Aimee L Ward
- Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Chris Crane
- Southern District Health Board, Dunedin, New Zealand
| | - Catherine M Chapple
- Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Southern District Health Board, Dunedin, New Zealand.,Centre for Health Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Kirsten Stout
- Southern District Health Board, Dunedin, New Zealand
| | - Liam Hutton
- Southern District Health Board, Dunedin, New Zealand
| | | | - Helen Harcombe
- Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Daniel Cury Ribeiro
- Centre for Health Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - David Gwynne Jones
- Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Southern District Health Board, Dunedin, New Zealand
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Nabelsi V, Croteau S. An Evidence-Based Health Care Knowledge Integration System: Assessment Protocol. JMIR Res Protoc 2019; 8:e11754. [PMID: 30855235 PMCID: PMC6431825 DOI: 10.2196/11754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/17/2018] [Accepted: 12/13/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The rapid advancements in health care can make it difficult for general physicians and specialists alike to keep their knowledge up to date. In medicine today, there are deficiencies in the application of knowledge translation (KT) in clinical practice. Some medical procedures are not required, and therefore, no value is added to the patient's care. These unnecessary procedures increase pressures on the health care system's resources, reduce the quality of care, and expose the patients to stress and to other potential risks. KT tools and better access to medical recommendations can lead to improvements in physicians' decision-making processes depending on the patient's specific clinical situation. These tools can provide the physicians with the available options and promote an efficient professional practice. Software for the Evolution of Knowledge in MEDicine (SEKMED) is a technological solution providing access to high-quality evidence, based on just-in-time principles, in the application of medical recommendations for clinical decision-making processes recognized by community members, accreditation bodies, the recommendations from medical specialty societies made available through campaigns such as Choosing Wisely, and different standards or accreditive bodies. OBJECTIVE The main objective of this protocol is to assess the usefulness of the SEKMED platform used within a real working clinical practice, specifically the Centre intégré de santé et des services sociaux de l'Outaouais in Quebec, Canada. To achieve our main objective, 20 emergency physicians from the Hull and Gatineau Hospitals participate in the project as well as 20 patient care unit physicians from the Hull Hospital. In addition, 10 external students or residents studying family medicine from McGill University will also participate in our study. METHODS The project is divided into 4 phases: (1) orientation; (2) data synthesis; (3) develop and validate the recommendations; and (4) implement, monitor, and update the recommendations. These phases will enable us to meet our 6 specific research objectives that aim to measure the integration of recommendations in clinical practices, the before and after improvements in practices, the value attributed by physicians to recommendations, the user's platform experience, the educational benefits according to medical students, and the organizational benefits according to stakeholders. The knowledge gained during each phase will be applied on an iterative and continuous basis to all other phases over a period of 2 years. RESULTS This project was funded in April 2018 by the Fonds de soutien à l'innovation en santé et en services sociaux for 24 months. Ethics approval has been attained, the study began in June 2018, the data collection will be complete at the end of December 2019, and the data analysis will start in winter 2020. Both major city hospitals in the Outaouais region, Quebec, Canada, have agreed to participate in the project. CONCLUSIONS If results show preliminary efficacy and usability of the system, a large-scale implementation will be conducted. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/11754.
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Affiliation(s)
- Véronique Nabelsi
- Département des sciences administratives, Université du Québec en Outaouais, Gatineau, QC, Canada
| | - Sylvain Croteau
- Hôpital de Gatineau, Centre intégré de santé et des services sociaux de l'Outaouais, Gatineau, QC, Canada
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Fogel BN, Samuels RC, Finkelstein J. Resident Experience and Education in Academic and Community Pediatric Primary Care Sites: Lessons for a Changing Healthcare Landscape. MEDICAL SCIENCE EDUCATOR 2019; 29:29-33. [PMID: 34457445 PMCID: PMC8360245 DOI: 10.1007/s40670-018-00633-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Efforts to improve pediatric primary care training in residency are important both for the residents and for the patients cared for in residency clinics. Pediatric residents typically get their primary care training at primary care centers affiliated with an academic center or at community-based locations. We aimed to compare residents' experience of continuity clinic in academic centers and community settings, and to identify relative strengths and weaknesses of each. METHODS Survey data was evaluated for residents at one large pediatric residency program. RESULTS Community sites had relative strengths in patient flow, population management, and perception of overall quality of care. Academic sites had relative strengths in continuity of care and ease of follow-up of results. CONCLUSIONS Community and academic pediatric primary care training sites have varied strengths that could inform efforts to improve residency training to better meet the needs of residents and patients.
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Affiliation(s)
- Benjamin N. Fogel
- Present Address: Department of Pediatrics, Penn State College of Medicine, 500 University Drive, Mail Code HS83, Hershey, PA 17033-0850 USA
| | - Ronald C. Samuels
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Jonathan Finkelstein
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
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Stadtmann MP, Maercker A, Binder J, Schnepp W. Why do I have to suffer? Symptom management, views and experiences of persons with a CPTSD: a grounded theory approach. BMC Psychiatry 2018; 18:392. [PMID: 30567517 PMCID: PMC6299949 DOI: 10.1186/s12888-018-1971-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 12/03/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND For the 11th version of the International Classification of Diseases, a new stress related diagnosis has been proposed: complex post-traumatic stress disorder (CPTSD). It is described as a chronic condition with several severe and concurrent symptoms. In the literature, these symptoms are discussed as a common reason for seeking psychiatric treatment as they can influence and impair the quality of life not only for affected persons but also for their social and familial system. AIM This research studies symptom management in everyday life by exploring and reconstructing the views, perceptions, experiences, facilitators and barriers of adults with CPTSD. METHODS A theoretical sampling was used to recruit 18 to 65 years old patients diagnosed with CPTSD from an inpatient setting. The 17 semi-structured interviews were audio recorded and transcribed verbatim. The transcriptions were uploaded into MAXQDA, and a Grounded Theory method based on Corbin and Strauss was used to analyse the data. RESULTS We provide a process model with 5 interacting phases: trauma experience, emotional ignorance, overcompensation, paroxysm, and perspectives. Each phase is specified with subcategories. CONCLUSIONS The participants did not recognise their symptoms as such and were unaware of their diagnosis for many years. Nevertheless, they used various resources and were able to develop skills and techniques to deal with their symptoms and to function on a day-to-day basis. Overall, the process of symptom management was extremely exhausting for the participants and they felt left alone with it. The participants were eager to gain support from healthcare professionals and, when necessary, financial support from the government. Thus, these results indicate an essential need to develop support and tailored interventions for the symptom management of persons with a CPTSD. TRIAL REGISTRATION Ethical approval was obtained from the Swiss Cantonal Ethic Commission (Nr 201,500,096). This research was also registered at the World Health Organization Clinical Trials Search Portal through the German Clinical Trial Register, Trial DRKS00012268 .
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Affiliation(s)
- Manuel P. Stadtmann
- 0000 0000 9024 6397grid.412581.bDepartment of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany ,0000 0004 0570 3485grid.491855.4Centre for Trauma Disorders, Integrierte Psychiatrie Winterthur, Technikumstrasse 81, Winterthur, Switzerland
| | - Andreas Maercker
- 0000 0004 1937 0650grid.7400.3Department of Psychology, Psychopathology and Clinical Intervention, University of Zurich, Binzmühlestrasse 14/17, 8050 Zürich, Switzerland
| | - Jochen Binder
- 0000 0004 0570 3485grid.491855.4Centre for Trauma Disorders, Integrierte Psychiatrie Winterthur, Technikumstrasse 81, Winterthur, Switzerland
| | - Wilfried Schnepp
- 0000 0000 9024 6397grid.412581.bDepartment of Health, University of Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
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Stadtmann MP, Maercker A, Binder J, Schnepp W. Mastering life together - symptom management, views, and experiences of relatives of persons with CPTSD: a grounded theory study. J Patient Rep Outcomes 2018. [PMCID: PMC6195499 DOI: 10.1186/s41687-018-0070-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Complex posttraumatic stress disorder is described as a chronic condition with several severe and concurrent symptoms. Symptoms influence and impair not only the affected individuals but also their social surroundings and their relatives. The literature describes relatives as a key factor in managing symptoms, both as a barrier and a facilitator. Aim This research aimed to explore and to reconstruct the views, perceptions, experiences, facilitations and barriers of relatives who support the symptom management of persons with CPTSD in everyday life. Methods A theoretical sampling was used to recruit for an interview 18- to 65-year-old relatives of patients with diagnosed CPTSD. The 17 semi-structured interviews were audio-recorded and transcribed verbatim. The transcriptions were uploaded into MAXQDA, and a Grounded Theory method based on that of Corbin and Strauss was used to analyse the data. Results We provide a process model with 5 interacting phases: the initial situation, state of permanence, being an anchor, recognizing limits, and potential outcomes. Each phase is further divided into subcategories. Discussion Participants experienced their condition as unpredictable. Although they mastered different strategies through own exploration and in cooperation, there is a clear need for more education, advice and support for relatives caring for those affected by CPTSD. Health care services should consider providing family support, educational services and increase the involvement of relatives in treatment. Over all, well-supported relatives can play a facilitative, key role in improving symptom management. Trial registration Ethical approval was obtained from the Swiss Cantonal Ethic Commission (Nr 201,500,096). This research was also registered at the World Health Organization Clinical Trials Search Portal through the German Clinical Trial Register, Trial DRKS00012268.
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Yeoh EK, Wong MCS, Wong ELY, Yam C, Poon CM, Chung RY, Chong M, Fang Y, Wang HHX, Liang M, Cheung WWL, Chan CH, Zee B, Coats AJS. Benefits and limitations of implementing Chronic Care Model (CCM) in primary care programs: A systematic review. Int J Cardiol 2018; 258:279-288. [PMID: 29544944 DOI: 10.1016/j.ijcard.2017.11.057] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/07/2017] [Accepted: 11/16/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic Care Model (CCM) has been developed to improve patients' health care by restructuring health systems in a multidimensional manner. This systematic review aims to summarize and analyse programs specifically designed and conducted for the fulfilment of multiple CCM components. We have focused on programs targeting diabetes mellitus, hypertension and cardiovascular disease. METHOD AND RESULTS This review was based on a comprehensive literature search of articles in the PubMed database that reported clinical outcomes. We included a total of 25 eligible articles. Evidence of improvement in medical outcomes and the compliance of patients with medical treatment were reported in 18 and 14 studies, respectively. Two studies demonstrated a reduction of the medical burden in terms of health service utilization, and another two studies reported the effectiveness of the programs in reducing the risk of heart failure and other cardiovascular diseases. However, CCMs were still restricted by limited academic robustness and social constraints when they were implemented in primary care. Higher professional recognition, tighter system collaborations and increased financial support may be necessary to overcome the limitations of, and barriers to CCM implementation. CONCLUSION This review has identified the benefits of implementing CCM, and recommended suggestions for the future development of CCM.
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Affiliation(s)
- E K Yeoh
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Martin C S Wong
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Eliza L Y Wong
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Carrie Yam
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - C M Poon
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Roger Y Chung
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Marc Chong
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Yuan Fang
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Harry H X Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, PR China; General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Miaoyin Liang
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Wilson W L Cheung
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Chun Hei Chan
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Benny Zee
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
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Long term outcomes of cluster randomized trial to improve cardiovascular health at population level: The Cardiovascular Health Awareness Program (CHAP). PLoS One 2018; 13:e0201802. [PMID: 30188912 PMCID: PMC6126805 DOI: 10.1371/journal.pone.0201802] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 07/23/2018] [Indexed: 12/21/2022] Open
Abstract
Study question The Cardiovascular Health Awareness Program (CHAP) cardiovascular risk reduction program consisted of sessions run by local volunteers in local pharmacies during which cardiovascular risk was assessed, healthy lifestyle and preventive care was promoted, and the participants were oriented to local resources to support changes in modifiable risk factors. A clustered randomized trial implemented in September 2006 across 39 communities targeting community-dwelling individuals 65 years and older showed a significant reduction in hospitalization one year after its implementation (rate ratio of 91 [95% confidence interval (CI): 86%-97%]). This study explores the impact of CHAP in the first five years. Methods Using health administrative data housed at the Institute for Clinical Evaluative Sciences, we established a closed cohort consisting of all individuals eligible in these communities at the study onset whom we followed over time. We assessed hospitalizations and survival using a negative binomial model for count data and Cox regression to assess time to first event, accounting for the clustered design. The primary outcome was the rate of cardiovascular-related hospitalizations defined as congestive heart failure, stroke or acute myocardial infarction. Results Most estimates pointed to an advantage for the intervention arm, but only all-cause mortality reached statistical significance (hazard ratio [95% CI] = 0.955 [0.914–0.999]). The hospitalization cardiovascular-related hospitalization rate ratio was (0.958, 95% CI: 0.898–1.022) in favour of the intervention communities, translating to an estimated 408 averted hospitalizations over the five-year period. There was no evidence of the effect of time from start of intervention. Conclusions The consistent direction of the outcomes in favour of the intervention arms suggests that CHAP likely had a meaningful impact on reducing cardiovascular-related morbidity and mortality. Given the low cost of the intervention, further development of CHAP should be pursued.
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Brooks JV, Singer SJ, Rosenthal M, Chien AT, Peters AS. Feeling inadequate: Residents' stress and learning at primary care clinics in the United States. MEDICAL TEACHER 2018; 40:920-927. [PMID: 29228837 DOI: 10.1080/0142159x.2017.1413236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Educators hope that residents' experiences in primary care continuity clinics will influence more trainees to enter primary care careers. Unfortunately, evidence shows that outpatient primary care training in the United States is stressful and fails to promote primary care careers. We conducted qualitative interviews with residents to understand the source of stress and to explain this failure. METHODS In-person individual interviews were conducted with 37 primary care residents training at outpatient clinics in the US. Analysis used the constant comparative method and included open and focused coding, allowing themes to emerge inductively from the data. RESULTS 73% of residents interviewed reported negative emotions about clinic. Beyond stress, residents reported feeling inadequate as primary care physicians at clinic. Four factors contributed: mental distractions, unfamiliarity with primary care medicine, management of outpatients, and relationships with patients. Residents' comparisons of hospital-based and outpatient experiences favored the former in relation to the four factors. CONCLUSIONS Residents feel unprepared for primary care and inadequate as primary care physicians, and these feelings discourage them from practicing primary care. This phenomenon must be studied within the entire context of residency, as residents' attitudes about their outpatient experiences were shaped in relation to their inpatient experiences.
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Affiliation(s)
- Joanna Veazey Brooks
- a Department of Health Policy & Management , University of Kansas School of Medicine , Kansas City , KS , USA
| | - Sara J Singer
- b Department of Health Policy & Management , Harvard Chan School of Public Health , Boston , MA , USA
| | - Meredith Rosenthal
- b Department of Health Policy & Management , Harvard Chan School of Public Health , Boston , MA , USA
| | - Alyna T Chien
- c Department of Medicine, Division of General Pediatrics , Boston Children's Hospital and Harvard Medical School , Boston , MA , USA
| | - Antoinette S Peters
- d Department of Population Medicine , Harvard Pilgrim Health Care Institute and Harvard Medical School , Boston , MA , USA
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Serrano N, Cordes C, Cubic B, Daub S. The State and Future of the Primary Care Behavioral Health Model of Service Delivery Workforce. J Clin Psychol Med Settings 2017; 25:157-168. [DOI: 10.1007/s10880-017-9491-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Figueiredo S, Mayo NE, Thomas A. Future Rehabilitation Professionals' Intentions to Use Self-Management Support: Helping Students to Help Patients. Physiother Can 2017; 69:73-80. [PMID: 28154447 DOI: 10.3138/ptc.2015-68e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: We evaluated whether education in self-management support (SMS) increases future clinicians' intentions to use a new way of delivering rehabilitation services. Methods: A convenience sample of 10 students took a 5-week theoretical course, followed by 6 weeks spent assessing patients, establishing treatment plans, and monitoring their performance by telephone. Focus groups were held before and after the educational modules, with deductive mapping of themes to the Theory of Planned Behaviour and inductive analysis of additional themes. Results: Five themes and 22 subcategories emerged from the deductive-inductive focus group content analysis. After participating in the educational modules, students reported gaining knowledge about SMS and highlighted the lack of similar preparation during their academic courses. Nonetheless, they were hesitant to adopt SMS. Conclusion: Future clinicians gained knowledge and skills after being exposed to SMS courses, but their intention to adopt SMS in their future daily practice remained low. We also noted a lack of formal training in SMS in the academic setting. The findings from this study support incorporating SMS training into the curriculum, but to increase students' intention to use SMS as part of patient care, training may need to be in more depth than it was in the modules we used.
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Affiliation(s)
- Sabrina Figueiredo
- Faculty of Medicine, School of Physical and Occupational Therapy; Division of Clinical Epidemiology
| | - Nancy E Mayo
- Faculty of Medicine, School of Physical and Occupational Therapy; Division of Clinical Epidemiology; Department of Geriatrics, Faculty of Medicine
| | - Aliki Thomas
- Faculty of Medicine, School of Physical and Occupational Therapy; Centre for Medical Education, Faculty of Medicine, McGill University; Centre for Interdisciplinary Research in Rehabilitation, Jewish Rehabilitation Hospital, Montreal
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Affiliation(s)
| | | | - Thomas Bodenheimer
- Corresponding author: Thomas Bodenheimer, MD, San Francisco General Hospital, Building 80-83, 995 Potrero Avenue, San Francisco, CA 94110, 415.269.5021,
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Fogel BN, Warrick S, Finkelstein JA, Klein M. Change in Residents' Experience in Continuity Clinic After Patient-Focused Primary Care Redesign. Acad Pediatr 2016; 16:616-20. [PMID: 27016158 DOI: 10.1016/j.acap.2016.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 02/19/2016] [Accepted: 03/15/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Evaluation of efforts to redesign primary care has primarily focused on clinical services, with limited assessment of the effect on learners. This study evaluated the change in pediatric residents' perception of training, teamwork, and patient care in 2 different continuity clinic settings that were implementing patient-focused primary care redesign. METHODS Continuity clinic residents at 2 large urban pediatric training programs completed a survey, developed de novo, before and after primary care redesign. Differences in the proportion of positive (≥4 of 5) ratings before and after redesign were compared using chi-squared tests in 2 practice sites, each of which focused on improving specific aspects of their practice. RESULTS The response rate was >70% in both sites and in both years. Residents in the site focused on teamwork and continuity were more likely to report improved teamwork training (64% vs 83%; P < .05) and teamwork among residents (82% vs 98%; P < .05) after redesign. Perception of overall quality of care in clinic also improved (47% vs 68%; P < .05). Residents in the site focused on clinic flow were more likely to report that physicians, nurses, and administrative staff worked together to optimize patient flow after redesign (25% vs 48%; P < .05). No improvements were seen in domains without focused interventions in either site. CONCLUSIONS Practice redesign focused on clinical outcomes can positively affect resident perception of their training and clinical experience in continuity clinic. Future redesign efforts deliberately involving residents might further enhance continuity clinic training.
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Affiliation(s)
- Benjamin N Fogel
- Penn State College of Medicine, Department of Pediatrics, Hershey, Penn.
| | - Stephen Warrick
- Cincinnati Children's Hospital Medical Center, Division of General and Community Pediatrics, Cincinnati, Ohio
| | - Jonathan A Finkelstein
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Melissa Klein
- Cincinnati Children's Hospital Medical Center, Division of General and Community Pediatrics, Cincinnati, Ohio
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14
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Zwijsen SA, Nieuwenhuizen NM, Maarsingh OR, Depla MFIA, Hertogh CMPM. Disentangling the concept of "the complex older patient" in general practice: a qualitative study. BMC FAMILY PRACTICE 2016; 17:64. [PMID: 27255457 PMCID: PMC4891906 DOI: 10.1186/s12875-016-0455-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 05/19/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND The rising life expectancy in the developed world leads to an increase in the number of older patients and the complexity of their complaints in general practice. Although interventions and support for general practitioners are available, implementation lags. Knowledge on what determines a complex older patient, the problems of which general practitioners encounter and the situations they actually need support for, is necessary for better implementation. METHODS To provide support to general practitioners in their struggle with complex older patients, the aim of this research was to disentangle the concept of the complex older patient in general practice. A qualitative approach was used consisting of 15 semi-structured interviews with general practitioners. The general practitioner was asked to prepare a case of a complex older patient out of their own practice that could be discussed during the interview. Transcripts of the interview were analysed using inductive thematic analysis. RESULTS Analysis of the interviews resulted in twelve themes that could be categorised into five factors that contribute to the complexity of cases of older patients. The five factors are: not being in charge, different views on necessary care, encountering the boundaries of medicine, limits to providing social care, ill-equipped. CONCLUSION The factors that were found imply that a better organisational structure for elderly care and consulting elderly care physicians could support general practitioners in providing care for older complex patients. Furthermore, understanding the current concept of patient autonomy seems unjustified in cases of complex older patients.
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Affiliation(s)
- S A Zwijsen
- Department of General Practice and Elderly Care Medicine/EMGO Institute for Health and Care Research, VU Medical Center, Van der Boechorststraat, 71081 BT, Amsterdam, The Netherlands.
| | - N M Nieuwenhuizen
- Verenso, the Dutch Association of Elderly Care Physicians and Social Geriatricians, Utrecht, Netherlands
| | - O R Maarsingh
- Department of General Practice and Elderly Care Medicine/EMGO Institute for Health and Care Research, VU Medical Center, Van der Boechorststraat, 71081 BT, Amsterdam, The Netherlands
| | - M F I A Depla
- Department of General Practice and Elderly Care Medicine/EMGO Institute for Health and Care Research, VU Medical Center, Van der Boechorststraat, 71081 BT, Amsterdam, The Netherlands
| | - C M P M Hertogh
- Department of General Practice and Elderly Care Medicine/EMGO Institute for Health and Care Research, VU Medical Center, Van der Boechorststraat, 71081 BT, Amsterdam, The Netherlands
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Kim JG, Morris CG, Heidrich FE. A Tool to Assess Family Medicine Residents' Patient Encounters Using Secure Messaging. J Grad Med Educ 2015; 7:649-53. [PMID: 26692980 PMCID: PMC4675423 DOI: 10.4300/jgme-d-14-00558.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Secure messages exchanged between patients and family medicine residents via an electronic health record (EHR) could be used to assess residents' clinical and communication skills, but the mechanism is not well understood. OBJECTIVE To design and test a secure messaging competency assessment for family medicine residents in a patient-centered medical home (PCMH). METHODS Using the existing literature and evidence-based guidelines, we designed an assessment tool to evaluate secure messaging competency for family medicine residents training in a PCMH. Core faculty performed 2-stage validity and reliability testing (n = 2 and n = 9, respectively). A series of randomly selected EHR secure messages (n = 45) were assessed from a sample of 10 residents across all years of training. RESULTS The secure message assessment tool provided data on a set of competencies and a framework for resident feedback. Assessment showed 10% (n = 2) of residents at the novice level, 50% (n = 10) as progressing, and 40% (n = 8) as proficient. The most common deficiencies for residents' secure messages related to communication rather than clinical competencies (n = 37 [90%] versus n = 4 [10%]). Interrater reliability testing ranged from 60% to 78% agreement and 20% to 44% disagreement. Disagreement centered on interpersonal communication factors. After 2 stages of testing, the assessment using residents' secure messages was incorporated into our existing evaluation process. CONCLUSIONS Assessing family medicine residents' secure messaging for patient encounters closed an evaluation gap in our family medicine program, and offered residents feedback on their clinical and communication skills in a PCMH.
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Affiliation(s)
- Jung G. Kim
- Corresponding author: Jung G. Kim, MPH, Group Health Family Medicine Residency, CSB-545, 125 16th Avenue E, Seattle, WA 91112, 206.326.3585,
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Bogetz JF, Rassbach CE, Bereknyei S, Mendoza FS, Sanders LM, Braddock CH. Training health care professionals for 21st-century practice: a systematic review of educational interventions on chronic care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:1561-1572. [PMID: 26039140 DOI: 10.1097/acm.0000000000000773] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care. METHOD A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention. RESULTS A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives. CONCLUSIONS The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.
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Affiliation(s)
- Jori F Bogetz
- J.F. Bogetz is postdoctoral fellow and clinical instructor, Division of General Pediatrics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California. C.E. Rassbach is associate residency program director, pediatric hospitalist, and clinical assistant professor, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California. S. Bereknyei is a research scholar, Stanford Center for Medical Education Research and Innovation (SCeMERI), Stanford University School of Medicine, Palo Alto, California. F.S. Mendoza is professor of pediatrics and chief, Division of General Pediatrics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California. L.M. Sanders is associate professor of pediatrics, Division of General Pediatrics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California. C.H. Braddock III is professor of medicine and vice dean for education, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California
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Flarup L, Carlsen AH, Moth G, Christensen MB, Vestergaard M, Olesen F, Vedsted P. The 30-day prognosis of chronic-disease patients after contact with the out-of-hours service in primary healthcare. Scand J Prim Health Care 2014; 32:208-16. [PMID: 25471829 PMCID: PMC4278395 DOI: 10.3109/02813432.2014.984964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Little is known about the prognosis of patients with chronic disease who contact the out-of-hours (OOH) service in primary care. The characteristics of contacts with the Danish out-of-hours service and daytime general practice, hospitalization, and death were studied during a 30-day follow-up period in patients with chronic heart diseases. DESIGN Cohort study. SETTING AND SUBJECTS The study was based on data from 11 897 adults aged 18 + years from a Danish survey of OOH contacts, including information on consultation type. Reason for encounter (RFE) was categorized by OOH GPs at triage as either "exacerbation" or "new health problem". Registry data were used to identify eligible patients, and the cohort was followed for 30 days after OOH contact through nationwide registries on healthcare use and mortality. MAIN OUTCOME MEASURES The 30-day prognosis of chronic-disease patients after OOH contact. RESULTS Included patients with chronic disease had a higher risk of new OOH contact, daytime GP contact, and hospitalization than other patients during the 30-day follow-up period. OOH use was particularly high among patients with severe mental illness. A strong association was seen between chronic disease and risk of dying during follow-up. CONCLUSION Patients with chronic disease used both daytime general practice and the out-of-hours service more often than others during the 30-day follow-up period; they were more often hospitalized and had higher risk of dying. The findings call for a proactive approach to future preventive day care and closer follow-up of this group, especially patients with psychiatric disease.
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Affiliation(s)
- Lone Flarup
- Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark
| | - Anders Helles Carlsen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark
| | - Grete Moth
- Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark
| | | | - Mogens Vestergaard
- Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark
- Section for General Medical Practice, Department of Public Health, Aarhus University, Denmark
| | - Frede Olesen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Denmark
- Danish Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Denmark
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18
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Flarup L, Moth G, Christensen MB, Vestergaard M, Olesen F, Vedsted P. Daytime use of general practice and use of the out-of-hours primary care service for patients with chronic disease: a cohort study. BMC FAMILY PRACTICE 2014; 15:156. [PMID: 25238694 PMCID: PMC4262984 DOI: 10.1186/1471-2296-15-156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/15/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND The importance of proactive chronic care has become increasingly evident. Yet, it is unknown whether the use of general practice (GP) during daytime may affect the use of Out-of-Hours (OOH) Primary Care Service for people with chronic disease. We aimed to analyse the association between use of daytime general practice (GP) and use of OOH services for heart disease, lung disease, diabetes, psychiatric disease, or cancer. In particular, we intended to study the association between OOH contacts due to chronic disease exacerbation and recent use of daytime GP. METHODS Data comprised a random sample of contacts to the OOH services ('LV-KOS2011'). Included patients were categorised into the following chronic diseases: heart disease, lung disease, diabetes, psychiatric disease, or cancer. Information on face-to-face contacts to daytime GP was obtained from the Danish National Health Insurance Service Registry and information about exacerbation or new episodes from the LVKOS2011 survey. Associations between number of regular daytime consultations and annual follow-up consultations during one, three, six, and 12 months prior to index contacts, and outcomes of interest were estimated by using logistic regression. RESULTS In total, 11,897 patients aged ≥ 18 years were included. Of these, 2,665 patients (22.4%) were identified with one of the five selected chronic diseases; 673 patients (5.7%) had two or more. A higher odds ratio (OR) for exacerbation as reason for encounter (RFE) at the index contact was observed among patients with psychiatric disease (OR = 2.15) and cancer (OR = 2.17) than among other patients for ≥2 daytime recent contacts. When receiving an annual follow-up, exacerbation OR at index contact lowered for patients with lung disease (OR = 0.68), psychiatric disease (OR = 0.42), or ≥2 diseases (OR = 0.61). CONCLUSION Recent and frequent use of daytime GP for patients with the selected chronic diseases was associated with contacts to the OOH services due to exacerbation. These findings indicate that the most severely chronically ill patients tend to make more use of general practice. The provision of an annual follow-up daytime GP consultation may indicate a lower risk of contacting OOH due to exacerbation.
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Affiliation(s)
- Lone Flarup
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
| | - Grete Moth
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
| | - Morten Bondo Christensen
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
| | - Mogens Vestergaard
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
- />Department of Public Health, Section for General Medical Practice, Aarhus University, Aarhus, Denmark
| | - Frede Olesen
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
| | - Peter Vedsted
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
- />Department of Public Health, Danish Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Aarhus, Denmark
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Peek CJ, Glasgow RE, Stange KC, Klesges LM, Purcell EP, Kessler RS. The 5 R's: an emerging bold standard for conducting relevant research in a changing world. Ann Fam Med 2014; 12:447-55. [PMID: 25354409 PMCID: PMC4157982 DOI: 10.1370/afm.1688] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 05/13/2014] [Accepted: 06/02/2014] [Indexed: 11/09/2022] Open
Abstract
Research often fails to find its way into practice or policy in a timely way, if at all. Given the current pressure and pace of health care change, many authors have recommended different approaches to make health care research more relevant and rapid. An emerging standard for research, the "5 R's" is a synthesis of recommendations for care delivery research that (1) is relevant to stakeholders; (2) is rapid and recursive in application; (3) redefines rigor; (4) reports on resources required; and (5) is replicable. Relevance flows from substantive ongoing participation by stakeholders. Rapidity and recursiveness occur through accelerated design and peer reviews followed by short learning/implementation cycles through which questions and answers evolve over time. Rigor is the disciplined conduct of shared learning within the specific changing situations in diverse settings. Resource reporting includes costs of interventions. Replicability involves designing for the factors that may affect subsequent implementation of an intervention or program in different contexts. These R's of the research process are mutually reinforcing and can be supported by training that fosters collaborative and reciprocal relationships among researchers, implementers, and other stakeholders. In sum, a standard is emerging for research that is both rigorous and relevant. Consistent and bold application will increase the value, timeliness, and applicability of the research enterprise.
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Affiliation(s)
- C J Peek
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Russell E Glasgow
- Department of Family Medicine and Colorado Health Outcomes Program, University of Colorado, Denver, Colorado
| | - Kurt C Stange
- Department of Family Medicine & Community Health, Department of Epidemiology & Biostatistics, and Department of Sociology, Case Comprehensive Cancer Center, Cleveland Clinical & Translational Science Collaborative, Case Western Reserve University, Cleveland, Ohio
| | - Lisa M Klesges
- School of Public Health, University of Memphis, Memphis, Tennessee
| | - E Peyton Purcell
- Clinical Research Directorate/CMRP, SAIC-Frederick, Inc, Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Rodger S Kessler
- Department of Family Medicine and the Center for Clinical and Translational Science, University of Vermont College of Medicine, Burlington, Vermont
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Acri MC, Palinkas L, Hoagwood KE, Shen S, Schoonover D, Reutz JR, Landsverk J. Interorganizational relationships among family support organizations and child mental health agencies. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2014; 41:447-54. [PMID: 22865099 PMCID: PMC3534836 DOI: 10.1007/s10488-012-0434-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study examined: (1) qualitative aspects of close working relationships between family support organizations and child mental health agencies, including effective and ineffective characteristics of the relationship and aspects that they would change, and (2) the impact of the working relationship upon the family support organization. Semi-structured interviews were conducted with 40 directors of family support organizations characterized as having a close working relationship with a child mental health agency. Three main themes emerged regarding the quality of the working relationship: (a) interactional factors, including shared trust, communication, collaboration and service coordination; (b) aspects of the inner context of the family support organization, mental health agency, or both, including alignment of goals and values and perceptions of mental health services; and (c) outer contextual factors external to the organizations, such as financial and county regulations. Responses to the perceived impact of the relationship was divided into two themes: positive impacts (e.g. gained respect, influence and visibility), and negative impacts (e.g. lack of trust). This study lays the foundation for future research to better understand the mechanisms underlying interorganizational relationships in communities among different types of providers to create a more seamless continuum of services for families of children with mental health conditions.
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Affiliation(s)
- Mary C Acri
- Department of Child and Adolescent Psychiatry, New York University School of Medicine, One Park Avenue at East 33rd, 8th Floor, New York, NY, 10016, USA,
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Ladden MD, Bodenheimer T, Fishman NW, Flinter M, Hsu C, Parchman M, Wagner EH. The emerging primary care workforce: preliminary observations from the primary care team: learning from effective ambulatory practices project. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:1830-1834. [PMID: 24128622 DOI: 10.1097/acm.0000000000000027] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Many primary care practices are changing the roles played by the members of their health care teams. The purpose of this article is to describe some of these new roles, using the authors' preliminary observations from 25 site visits to high-performing primary care practices across the United States in 2012-2013. These sites visits, to practices using their workforce creatively, were part of the Robert Wood Johnson Foundation-funded initiative, The Primary Care Team: Learning From Effective Ambulatory Practices.Examples of these new roles that the authors observed on their site visits include medical assistants reviewing patient records before visits to identify care gaps, ordering and administering immunizations using protocols, making outreach calls to patients, leading team huddles, and coaching patients to set self-management goals. The registered nurse role has evolved from an emphasis on triage to a focus on uncomplicated acute care, chronic care management, and hospital-to-home transitions. Behavioral health providers (licensed clinical social workers, psychologists, or licensed counselors) were colocated and integrated within practices and were readily available for immediate consults and brief interventions. Physicians have shifted from lone to shared responsibility for patient panels, with other team members empowered to provide significant portions of chronic and preventive care.An innovative team-based primary care workforce is emerging. Spreading and sustaining these changes will require training both health professionals and nonprofessionals in new ways. Without clinical experiences that model this new team-based care and role models who practice it, trainees will not be prepared to practice as a team.
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Affiliation(s)
- Maryjoan D Ladden
- Dr. Ladden is senior program officer, Robert Wood Johnson Foundation, Princeton, New Jersey. Dr. Bodenheimer is adjunct professor, Department of Family and Community Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Ms. Fishman is interim team director and senior program officer, Robert Wood Johnson Foundation, Princeton, New Jersey. Dr. Flinter is senior vice president and clinical director, CHC, Inc., Middletown, Connecticut. Dr. Hsu is research associate IV, Center for Community Health and Evaluation, Group Health Research Institute, Seattle, Washington. Dr. Parchman is director, MacColl Center for Health Care Innovation, Group Health Research Institute, Seattle, Washington. Dr. Wagner is director emeritus, MacColl Center for Health Care Innovation, Group Health Research Institute, Seattle, Washington
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Gupta R, Davis E, Horton C. Interval examination: building primary care teams in an urban academic teaching clinic. J Gen Intern Med 2013; 28:1517-21. [PMID: 24043568 PMCID: PMC3797361 DOI: 10.1007/s11606-013-2598-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 07/11/2013] [Accepted: 08/02/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Reena Gupta
- Division of General Internal Medicine, San Francisco General Hospital, University of California, 1001 Potrero Ave, SFGH Box 1364, San Francisco, CA, 94110, USA,
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MacNeil Vroomen JL, Boorsma M, Bosmans JE, Frijters DHM, Nijpels G, van Hout HPJ. Is it time for a change? A cost-effectiveness analysis comparing a multidisciplinary integrated care model for residential homes to usual care. PLoS One 2012; 7:e37444. [PMID: 22655047 PMCID: PMC3360056 DOI: 10.1371/journal.pone.0037444] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 04/19/2012] [Indexed: 11/18/2022] Open
Abstract
Objective The objective of this study was to evaluate the cost-effectiveness of a Multidisciplinary Integrated Care (MIC) model compared to Usual Care (UC) in Dutch residential homes. Methods The economic evaluation was conducted from a societal perspective alongside a 6 month, clustered, randomized controlled trial involving 10 Dutch residential homes. Outcome measures included a quality of care weighted sum score, functional health (COOP WONCA) and Quality Adjusted Life-Years (QALY). Missing cost and effect data were imputed using multiple imputation. Bootstrapping was used to analyze differences in costs and cost-effectiveness. Results The quality of care sum score in MIC was significantly higher than in UC. The other primary outcomes showed no significant differences between the MIC and UC. The costs of providing MIC were approximately €225 per patient. Total costs were €2,061 in the MIC group and €1,656 for the UC group (mean difference €405, 95% −13; 826). The probability that the MIC was cost-effective in comparison with UC was 0.95 or more for ceiling ratios larger than €129 regarding patient related quality of care. Cost-effectiveness planes showed that the MIC model was not cost-effective compared to UC for the other outcomes. Interpretation Clinical effect differences between the groups were small but quality of care was significantly improved in the MIC group. Short term costs for MIC were higher. Future studies should focus on longer term economic and clinical effects. Trial Registration Controlled-Trials.com ISRCTN11076857
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Affiliation(s)
- Janet L MacNeil Vroomen
- Department of General Practice, VU University Medical Center, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands.
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