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Fredens M, Palmhøj Nielsen C, Grønkjær M, Kjærside Nielsen B, Konstantin Nissen N, Benthien KS, Toft U, Rasmussen K, Kidholm K, Deleuran Terkildsen M. Nurses' perspectives on challenges and facilitators when implementing a self-management support intervention as an everyday healthcare practice: A qualitative study. J Adv Nurs 2024; 80:2475-2486. [PMID: 38012863 DOI: 10.1111/jan.15988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023]
Abstract
AIM To explore registered nurses' perspectives on challenges and facilitators to implementing a telephone-based self-management support (SMS) intervention (Proactive Health Support) as an everyday healthcare practice, during the early stages of implementation. DESIGN Data were collected using a qualitative research design involving focus-group interviews and participant observations. METHODS We conducted participant observation following nine nurses and four focus group interviews with 14 nurses. Data were analysed using thematic analyses. RESULTS Proactive Health Support was implemented in units organized independently of the existing organizational units within healthcare services. This independent organization, along with the intervention's generic (non-disease specific) design, empowered nurses to become autonomous practitioners capable of prioritizing the operationalization of SMS as an everyday healthcare practice. However, unlearning already embedded medical practices and establishing new nursing roles necessary to accommodate the intervention in practice was experienced a challenge. Education and supervision were identified as valuable tools for successful implementation. CONCLUSION Our study highlights the significance of organizational context and autonomy in successful SMS implementation. Balancing external factors like organizational context, priority and time is vital, but navigating the internal shift in professional practice is equally crucial. Role transition processes can constitute challenges demanding accommodation. IMPLICATIONS FOR THE PROFESSION From a nursing perspective, this study highlights that practising SMS requires substantial training and education. Generic SMS interventions can introduce higher levels of contingency due to their versatile nature. Thus, equipping nurses with competencies that enable them to navigate this unpredictability flexibly is crucial. IMPACT Policymakers and administrators should allocate resources and support implementation processes in ways that accommodate both internal and external conditions to facilitate nurses in delivering effective SMS. REPORTING METHOD This study adheres to the SRQR guideline. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Mia Fredens
- DEFACTUM - Public Health Research, Central Denmark Region, Aarhus, Denmark
| | - Camilla Palmhøj Nielsen
- DEFACTUM - Public Health Research, Central Denmark Region, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Mette Grønkjær
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | - Kirstine Skov Benthien
- Palliative Care Unit, Copenhagen University Hospital, Hvidovre, Denmark
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Ulla Toft
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Knud Rasmussen
- Department of Data and Development Research, Zealand Region, Sorø, Denmark
| | - Kristian Kidholm
- Centre for Innovative Medical Technology, Odense University Hospital, Odense, Denmark
| | - Morten Deleuran Terkildsen
- DEFACTUM - Public Health Research, Central Denmark Region, Aarhus, Denmark
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Rasmussen MK, Benthien KS, Nielsen CP, Rasmussen K, Grønkjær M, Toft U, Kidholm K. Cost-effectiveness of proactive health support-telephone-based self-management support compared with standard care for persons at risk of hospital admission. Age Ageing 2024; 53:afae036. [PMID: 38476101 DOI: 10.1093/ageing/afae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND A small share of patients account for a large proportion of costs to the healthcare system in Denmark as in many Western countries. A telephone-based self-management support, proactive health support (PaHS), was suggested for prevention of hospitalisations for persons at risk of hospital admission. These persons have chronic diseases, unplanned hospitalisations and age ≥ 65 years. However, evidence is limited on whether this type of intervention is cost-effective. AIM The aim of this study was to assess the incremental cost-utility ratio (ICER) of PaHS, compared with standard care. METHODS The economic evaluation was nested within a randomised controlled trial, and was based on a health system perspective, with follow-up and time horizon of 12 months. We measured incremental costs per quality-adjusted life years (QALY) gained. Total average costs per patient included PaHS programme costs, and costs in hospitals, primary care and municipalities. We analysed differences by generalised linear models with Gamma distribution for costs and mixed models for QALY. RESULTS We analysed data on 6,139 patients, where 3,041 received PaHS and 3,098 received usual care. We found no difference in healthcare costs, and programme costs were on average €1,762 per patient, providing incremental costs of €2,075. Incremental effects on QALY were 0.007, resulting in an ICER of €296,389 per QALY gained. CONCLUSION We found no evidence of PaHS being cost-effective in this study, but the results will be used to identify new ways to organise similar interventions and identify patients with the objective to reduce health system costs per patient.
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Affiliation(s)
- Maja Kjær Rasmussen
- Centre for Innovative Medical Technology, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Kirstine Skov Benthien
- Centre for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Palliative Care Unit, Copenhagen University Hospital, Hvidovre, Denmark
| | - Camilla Palmhøj Nielsen
- DEFACTUM-Social & Health Services and Labour Market, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Knud Rasmussen
- Department of Data and Development Support, Region Zealand, Sorø, Denmark
| | - Mette Grønkjær
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Ulla Toft
- Centre for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Kristian Kidholm
- Centre for Innovative Medical Technology, Odense University Hospital and University of Southern Denmark, Odense, Denmark
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Benthien KS, Nielsen CP, Rasmussen K, Kidholm K, Grønkjær M, Toft U. Who benefits from self-management support? Results from a randomized controlled trial. Heliyon 2023; 9:e17752. [PMID: 37449182 PMCID: PMC10336573 DOI: 10.1016/j.heliyon.2023.e17752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/21/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023] Open
Abstract
Background Self-management support models adapted to accommodate the needs of each patient are complex interventions that should be evaluated for intervention mechanisms. In a national randomized controlled trial (RCT), we evaluated the efficacy of telephone-based self-management support that demonstrated improved health-related quality of life (HRQoL), no reduction in hospital admissions, and an unexpected increase in primary healthcare services. Objective The objective of this study is to identify RCT impact mechanisms and explore which participants could benefit the most from the PaHS intervention. Methods This study evaluates intervention mechanisms through interaction analyses of predefined intervention moderators (sex, age, education, chronic disease, risk of hospital admissions, and coping) and post-hoc intervention mediators (contacts in primary care and anxiety medication). The one co-primary outcome HRQoL was assessed with SF26v2 and analyzed with generalized linear mixed models and the other co-primary hospital admissions was analyzed with poisson regression. Results PaHS interacted with diabetes, multimorbidity, coping, and anxiety medication on the outcome hospital admissions. PaHS led to a significant reduction in hospital admissions in participants with diabetes or multimorbidity and an increase in hospital admissions in participants with higher baseline coping and participants using anxiety medication. The interaction analyses revealed significant intervention mediation in the outcome HRQoL by sex and diabetes. Conclusions Participants with diabetes, multimorbidity, and women could benefit the most from telephone-based self-management support, but the intervention involves the risk of over-treatment.
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Affiliation(s)
- Kirstine Skov Benthien
- Palliative Care Unit, Copenhagen University Hospital, Hvidovre, Denmark
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Frederiksberg, Denmark
| | - Camilla Palmhøj Nielsen
- DEFACTUM - Social & Health Services and Labour Market, Aarhus, Denmark
- Department of Public Health, Aarhus University, Denmark
| | - Knud Rasmussen
- Data and Development Support, Region Zealand, Sorø, Denmark
| | - Kristian Kidholm
- Centre for Innovative Medical Technology, Odense University Hospital, Denmark
| | - Mette Grønkjær
- Clinical Nursing Research Unit, Aalborg University Hospital, Denmark
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Ulla Toft
- Center for Clinical Research and Prevention, Copenhagen University Hospital - Frederiksberg, Denmark
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Benthien KS, Rasmussen K, Nielsen CP, Kidholm K, Grønkjær M, Toft U. Proactive Health Support: a randomised controlled trial of telephone-based self-management support for persons at risk of hospital admission. Age Ageing 2022; 51:6749361. [PMID: 36201327 DOI: 10.1093/ageing/afac212] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Persons with frequent hospital admissions have a disease burden that may exceed their self-management skills. The evidence base of telephone-based interventions to support self-management is poor with mixed results. The aim of this study is to evaluate the effect of Proactive Health Support (PaHS): telephone-based self-management support for persons with risk of hospitalizations. METHODS This study is a national randomised controlled trial of PaHS versus usual universal tax-funded healthcare. Participants were persons at risk of emergency hospital admissions. The intervention began with a physical start-up session followed by telephone sessions of self-management support. The two co-primary outcomes were Health-Related Quality of Life (HRQoL) (Mental Health Component Summary Score of SF36v2) analysed with mixed models and hospital admissions analysed with Poisson regression at 6 months. Secondary outcomes were at 3- and 12-month follow-up and disease subgroup analyses. RESULTS During the study period, 6,402 persons were randomised (3,190 intervention, 3,212 control). HRQoL was significantly improved at 6 months (Est. 1.4992, P = <0.0001) and at 3 and 12 months on all 10 scales. There was no overall effect on hospital admissions at 6 months with an adjusted estimate of 0.0074 (P = 0.8691). Persons with diabetes had significant improvement of HRQoL and reduced hospital admissions. CONCLUSIONS The PaHS intervention improved HRQoL for all participants and reduced hospital admissions for persons with diabetes only.
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Affiliation(s)
- Kirstine Skov Benthien
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Palliative Care Unit, Copenhagen University Hospital - Hvidovre, Denmark
| | - Knud Rasmussen
- Data and Development Support, Region Zealand, Sorø, Denmark
| | - Camilla Palmhøj Nielsen
- DEFACTUM - Social & Health Services and Labour Market, Aarhus, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Kristian Kidholm
- Centre for Innovative Medical Technology, Odense University Hospital, Odense, Denmark
| | - Mette Grønkjær
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ulla Toft
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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Skov Benthien K, Kart Jacobsen R, Hjarnaa L, Mehl Virenfeldt G, Rasmussen K, Toft U. Predicting Individual Risk of Emergency Hospital Admissions - A Retrospective Validation Study. Risk Manag Healthc Policy 2021; 14:3865-3872. [PMID: 34552360 PMCID: PMC8450160 DOI: 10.2147/rmhp.s314588] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/27/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose A high number of hospital admissions may indicate poor general health and less than optimal health care across sectors. To prevent hospital admissions, previous studies have focused on predicting readmissions relating to a defined index admission and specific condition, whereas generic models suited for community-dwelling persons are lacking. The aim of this study was to validate a generic model that predicted risk of emergency hospital admission within the following three months and to investigate regional variation. Materials and Methods This study is an observational register-based validation study of a prediction model. The prediction model was based on a population of frail elderly, persons with non-communicable diseases, and persons with three emergency hospital admissions using information about diagnoses and hospital contacts. The prediction model consisted of two stages. In the first stage, covariate associations to admissions are estimated from observed data in one year. In the second stage, admissions are predicted in the coming three months based on observed estimations from the first stage. The validity of the model was calculated by comparing predicted and observed admissions from August 1st to October 31st, 2016. Results The study included 112,026 persons. In nationwide data, area under the curve (AUC) was 0.7742 (95% CI 0.7698–0.7786), and the positive predictive value was 52% for the 99th percentile (the top 1%). AUC varied between regions from 0.6914 in Southern Denmark (95% CI 0.6779–0.7049) to 0.8224 (95% CI 0.8064–0.8384) in North Denmark. AUC was higher with nationwide data compared to regional. Conclusion The model performed satisfactorily in predicting individual risk of emergency hospital admission.
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Affiliation(s)
- Kirstine Skov Benthien
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Rikke Kart Jacobsen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Louise Hjarnaa
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Gert Mehl Virenfeldt
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Knud Rasmussen
- Data and Development Support, Region Zealand, Sorø, Denmark
| | - Ulla Toft
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
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Winther S, Fredens M, Skov Benthien K, Konstantin Nissen N, Palmhøj Nielsen C, Grønkjaer M. Exploring patient experiences of participating in a telephone-based self-management support intervention: Proactive Health Support (PaHS). J Adv Nurs 2020; 76:3563-3572. [PMID: 33022769 DOI: 10.1111/jan.14590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/28/2020] [Accepted: 09/07/2020] [Indexed: 11/28/2022]
Abstract
AIM Proactive Health Support is a telephone-based self-management intervention that is carried out in Denmark by Registered Nurses who provide self-management support to people at risk of hospital admission. We aimed to explore participants' experiences of Proactive Health Support and to identify what the participants find important and meaningful during the intervention process. DESIGN Qualitative design involving semi-structured interview. METHODS Using a phenomenological-hermeneutical framework, we conducted semi-structured interviews with 62 participants in their own homes (32 women, 30 men; aged 20-81 years) in spring and fall 2018. RESULTS The participants felt confident that they could discuss every matter with the nurses. Participants benefitted from accessibility to the nurses' professional and medical competences and they felt relief that the nurses contacted them via the telephone due to their multiple health conditions. The participants felt that the nurses were available and helped them to navigate the healthcare system. CONCLUSION The participants valued the intervention because they benefitted from the nurses' holistic approach. They described the nurses' knowledge and professionalism in relation to their symptoms, treatments, and medicine as important and meaningful. Accordingly, the intervention seemed to promote feelings of independence and self-management among the participants. IMPACT From a nursing perspective, the study highlights that it is possible to establish a close relationship and behavioural change among participants through regular telephone contact.
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Affiliation(s)
- Susanne Winther
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Mia Fredens
- DEFACTUM - Social & Health Services and Labor Market, Aarhus, Denmark
| | - Kirstine Skov Benthien
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | | | | | - Mette Grønkjaer
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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