Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse

Collaborative care approaches for people with severe mental illness

BACKGROUND

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies.

OBJECTIVES

To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community.

SEARCH METHODS

We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro.

MAIN RESULTS

Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years.

AUTHORS' CONCLUSIONS

This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Physically active primary care physicians consult more on physical activity and exercise for patients: A public teaching-hospital study

Physical activity and exercise (PAE) improve quality of life and reduce the effects of chronic diseases. Primary care physicians (PCPs) play an important role to encourage PAE in patients. We aim to assess PCPs' current PAE consultation practices and their enablers/barriers in daily clinical practice. We had 64 PCPs (age [35.3 ​± ​4.7] y, 47 women) that completed self-administered questionnaires on PAE consultation practices, training, and confidence levels. PCPs (n ​= ​42) also completed the International Physical Activity Questionnaire-Short Form to assess their physical activity (PA) levels. We conducted correlation, one-way analysis of variance and a linear regression to assess the associations between enablers, barriers and PA levels to PAE consultation practices. On average, PCPs consulted on PAE in 49.7% of their daily clinical appointments. Majority of PCPs (70%) strongly agreed that more PAE knowledge were needed to increase consultation practices. Top three barriers related (p ​< ​0.001) to practices were lack of PAE education (r ​= ​0.47), patients' preference of pharmaceutical interventions (r ​= ​0.45) and lack of continuing education in PAE for PCPs (r ​= ​0.37). Physically active PCPs (health-enhancing PA levels, n ​= ​6) gave significantly more daily consultations in PAE, 73.2% ​± ​21.9%, compared to inactive PCPs (n ​= ​13), 37.4% ​± ​22.8% (p ​= ​0.013). In our regression output, PCPs who had higher PA levels consulted more on PAE daily (R2 ​= ​0.38, p ​< ​0.001) while controlling for age. Conclusion, PCPs require more knowledge on PAE and need be physically active themselves to increase PAE consultation for patients in their daily practice. Medical education should consider including more PA and exercise topics that may benefit both physicians and their patients.

Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care

BACKGROUND, AIMS AND OBJECTIVES

This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care.

METHODS

Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations.

RESULTS

Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions.

CONCLUSIONS

Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.

Relations between clinical characteristics and cognitive deficits among adult patients diagnosed with major depressive disorder

OBJECTIVE

The present study examined the relations between clinical characteristics and cognitive deficits in adult patients with major depressive disorder (MDD) from a local outpatient psychiatric clinic in Malaysia.

METHODS

The present sample included 110 participants aged 20-60 years old. Participants were invited to provide their information on sociodemographic variables (age, gender, and educational level) and clinical characteristics (age at onset of depression and duration of illness) and to complete a series of cognitive performance measures including the Trail Making Tests A (psychomotor speed) and B (executive function), the Digit Symbol Substitution Test (attention), and the Auditory Verbal Learning Test (immediate free recall, acquisition phase, and delayed recall). The Mini International Neuropsychiatric Interview Version 6.0 was used to confirm the diagnosis of MDD and the Montgomery-Åsberg Depression Rating Scale was used to assess illness severity.

RESULTS

At the bivariate level, relations of age and educational level to all cognitive deficit domains were significant. At the multivariate level, only educational level and illness severity consistently and significantly predicted all cognitive deficits domains.

CONCLUSIONS

Therapeutic modalities should be individualised whilst considering the impacts of cognitive deficits in an attempt to prevent further deterioration in psychosocial functioning of MDD patients.KEY POINTSCognitive deficits are an elemental component of Major Depressive Disorder (MDD) persisting during a current major depressive episode or during remission, altering individuals' ability to process information and changes the way they perceive and interact with the environment.Cognitive deficits in MDD are evident among the upper-middle income groups in South-Eastern Asian countries warranting more local research as such deficits could lead to functional decline and work performance such as absenteeism and presenteeism.Therapeutic modalities should be individualised by taking the impacts of cognitive deficits into consideration to promote psychosocial functioning of MDD patients.

Assessment of mental health status among Chinese nursing staff in the intensive care unit: a network analysis

Backgrounds

Nursing is the key group to provide healthcare services, and it is easy for nursing staff to develop mental health problems.

Aims

The study aimed to evaluate prevalence of psychological symptoms in nurses working in an intensive care unit (ICU) and the inter-relationship of associations of psychological symptoms using network analysis.

Methods

This study is a cross-sectional design study. The Chinese version of the Symptom Check List-90 (SCL-90) was used to measure the psychological status of ICU nurses. The network structure of psychological symptoms was characterised, and indices of 'Expected influence' were used to identify symptoms central to the network. Network stability was examined using a case-dropping bootstrap procedure.

Results

Multiple logistic regression analysis found those who had worked more than 15 years were less likely to experience positive psychological symptoms, whereas nurses working in emergency ICU and other ICUs, nurses working in departments with over 16 beds were more likely to develop psychological symptoms. In addition, 'Anxiety', 'Mental degeneration' and 'Depression' were central symptoms in the network.

Conclusions

ICU nurses reported a high level of psychological symptoms, which may affect the quality of their work and worsen public health problems.

Barriers and facilitators to the implementation of lifestyle management in polycystic ovary syndrome: Endocrinologists' and obstetricians and gynaecologists' perspectives

OBJECTIVE

To study the barriers and facilitators to lifestyle management in PCOS from the perspectives of endocrinologists and obstetricians and gynecologists (Ob/Gyns) to inform the translation and implementation of the international evidence-based guideline on lifestyle management in PCOS.

METHODS

11 endocrinologists and ten Ob/Gyns participated in semi-structured interviews and transcripts were thematically analyzed on NVIVO software.

RESULTS

Both endocrinologists and Ob/Gyns supported lifestyle as key to PCOS management but faced systemic barriers of lack of access to allied health services and had limited capacity for in-depth lifestyle discussions. They suggested team-based approach to address these barriers. Endocrinologists reported lifestyle could be a less effective treatment option and most of their patients had challenges with past failed lifestyle attempts while Ob/Gyns perceived the desire to conceive among patients a facilitator. The importance of credible, individualised and PCOS-specific lifestyle advice was highlighted.

CONCLUSION

Endocrinologists and Ob/Gyns perceived lifestyle management as integral to PCOS management but experience barriers to lifestyle management related to specialist care.

PRACTICE IMPLICATIONS

Resources that provide credible, individualized and PCOS-specific lifestyle advice, team care approach and professional development on motivating patients for lifestyle modification may address these barriers.

Trauma-informed Collaborative Care for African American Primary Care Patients in Federally Qualified Health Centers: A Pilot Randomized Trial

BACKGROUND

African Americans have nearly double the rate of posttraumatic stress disorder (PTSD) compared with other racial/ethnic groups.

OBJECTIVE

To understand whether trauma-informed collaborative care (TICC) is effective for improving PTSD among African Americans in New Orleans who receive their care in Federally Qualified Health Centers (FQHCs).

DESIGN AND METHOD

In this pilot randomized controlled trial, we assigned patients within a single site to either TICC or to enhanced usual care (EUC). We performed intent to treat analysis by nonparametric exact tests for small sample sizes.

PARTICIPANTS

We enrolled 42 patients from October 12, 2018, through July 2, 2019. Patients were eligible if they considered the clinic their usual source of care, had no obvious physical or cognitive obstacles that would prevent participation, were age 18 or over, self-identified as African American, and had a provisional diagnosis of PTSD.

MEASURES

Our primary outcome measures were PTSD measured as both a symptom score and a provisional diagnosis based on the PTSD Checklist for DSM-5 (PCL-5).

KEY RESULTS

Nine months following baseline, both PTSD symptom scores and provisional PTSD diagnosis rates decreased substantially more for patients in TICC than in EUC. The decreases were by 26 points in EUC and 36 points in TICC for symptoms (P=0.08) and 33% in EUC and 57% in TICC for diagnosis rates (P=0.27). We found no effects for mediator variables.

CONCLUSIONS

TICC shows promise for addressing PTSD in this population. A larger-scale trial is needed to fully assess the effectiveness of this approach in these settings.

Leveraging technology to address unhealthy drug use in primary care: Effectiveness of the Substance use Screening and Intervention Tool (SUSIT)

Background: Screening for unhealthy drug use is now recommended for adult primary care patients, but primary care providers (PCPs) generally lack the time and knowledge required to screen and deliver an intervention during the medical visit. To address these barriers, we developed a tablet computer-based 'Substance Use Screening and Intervention Tool (SUSIT)'. Using the SUSIT, patients self-administer screening questionnaires prior to the medical visit, and results are presented to the PCP at the point of care, paired with clinical decision support (CDS) that guides them in providing a brief intervention (BI) for unhealthy drug use. Methods: PCPs and their patients with moderate-risk drug use were recruited from primary care and HIV clinics. A pre-post design compared a control 'screening only' (SO) period to an intervention 'SUSIT' period. Unique patients were enrolled in each period. In both conditions, patients completed screening and identified their drug of most concern (DOMC) before the visit, and completed a questionnaire about BI delivery by the PCP after the visit. In the SUSIT condition only, PCPs received the tablet with the patient's screening results and CDS. Multilevel models with random intercepts and patients nested within PCPs examined the effect of the SUSIT intervention on PCP delivery of BI. Results: 20 PCPs and 79 patients (42 SO, 37 SUSIT) participated. Most patients had moderate-risk marijuana use (92.4%), and selected marijuana as the DOMC (68.4%). Moderate-risk use of drugs other than marijuana included cocaine (15.2%), hallucinogens (12.7%), and sedatives (12.7%). Compared to the SO condition, patients in SUSIT had higher odds of receiving any BI for drug use, with an adjusted odds ratio of 11.59 (95% confidence interval: 3.39, 39.25), and received more elements of BI for drug use. Conclusions: The SUSIT significantly increased delivery of BI for drug use by PCPs during routine primary care encounters.

Discharging the complex patient - changing our focus to patients' networks of care providers

Background

A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning.

Methods

This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical.

Results

We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network’s scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial.

Conclusions

Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06841-2.

"They were all together … discussing the best options for me": Integrating specialist diabetes care with primary care in Australia

Over one-third of diabetes-related encounters with healthcare providers in Australia fail to meet clinical guidelines. Evidence is mounting that care provision within an integrated framework may facilitate greater adherence to clinical guidelines and improved outcomes for patients. The Diabetes Alliance Program was implemented across a large healthcare district to enhance diabetes care capacity at the primary care level through intensive case-conferencing involving the primary care team, patients and visiting specialist team, whole practice performance review and regular diabetes education for practitioners. Here, we provide an in-depth patient assessment of the case-conferencing process and impact on diabetes management. Two practices with high pre-intervention HbA1c monitoring and three practices with low HbA1c monitoring provided the sampling frame. Patients were selected according to their score on the Patient Activation Measure^TM to achieve maximum variation, with up to two patients with high scores and three with low scores, selected from each practice. Patients were sampled until data saturation was achieved and then subjected to thematic content analysis (n = 19). Patients mostly described the model of care as a positive experience, reporting a boost in confidence in diabetes self-management (particularly around nutrition). The program was also seen to be helpful in providing an opportunity to refocus when "life gets in the way". Other valued aspects of the program included the holistic approach to healthcare, reduced travel time, familiarity in environment and clinical care, top-down knowledge transfer as well as mutual learning by the patient and their primary care team. Despite this, difficulties in coping with diabetes and adherence to treatment recommendations remained for a minority of patients. Integrating specialist teams within primary care has the ability to provide efficient healthcare delivery, better patient experience and health outcomes. Investment in such approaches will be critical to navigating healthcare provision in order to meet the demands of an ageing population.

Primary Care Variation in Rates of Unplanned Hospitalizations, Functional Ability, and Quality of Life of Older People

PURPOSE

To investigate variability in older people's outcomes according to general practitioner (GP) and practice characteristics in New Zealand and the Netherlands.

METHODS

We used data from 2 primary care-based, cluster-randomized, controlled trials to separately fit mixed models of unplanned admission rates, functional ability, and quality of life (QOL) and examine variation according to GP- and practice-level characteristics after adjusting for participant-level characteristics. For the New Zealand sample (n = 3,755 aged 75+ years in 60 practices), we modeled 36-month unplanned admission rates, Nottingham Extended Activities of Daily Living (NEADL) scale, and QOL domain ratings from the brief version of the World Health Organization Quality of Life assessment tool. For the Netherlands sample (n = 3,141 aged 75+ years in 59 practices), we modeled 12-month unplanned admission rates, Groningen Activity Restriction Scale scores, and EuroQOL 5 dimensions (EQ-5D) summary index.

RESULTS

None of the GP or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample, but we found greater rates of admission in larger practices (incidence rate ratio [IRR], 1.45; 95% CI, 1.15-1.81) and practices staffed with a practice nurse (IRR, 1.74; 95% CI, 1.20-2.52) in the Netherlands sample. In both samples, differences were consistently small where there were significant associations with function (range, -0.26 to 0.19 NEADL points in the New Zealand sample; no associations in the Netherlands sample) and QOL (range, -1.64 to 0.97 QOL points in New Zealand; -0.01 EQ-5D points in the Netherlands).

CONCLUSIONS

In the absence of substantial differences in older people's function and QOL, it remains unclear whether intriguing GP- or practice-related variations in admission rates represent low- or high-quality practice.

Adolescent SBIRT Practices Among Pediatricians in Massachusetts

OBJECTIVES

Adolescent Screening, Brief Intervention, and Referral to Treatment (SBIRT) in primary care is a key strategy to prevent, identify, and respond to substance use problems and disorders, including opioid and other drug addictions. Despite substantial investment in recent years to increase its implementation, few studies have reported on recent levels of SBIRT implementation among pediatricians. We aimed to assess self-reported use of the SBIRT framework with adolescent patients among Massachusetts pediatricians, and describe trends since an earlier survey.

METHODS

We analyzed responses to a cross-sectional survey mailed in 2017 to a representative sample of pediatricians in Massachusetts. We computed response frequencies for all SBIRT practice questions. We used the chi-square test to compare current data to data collected in 2014, as we found no demographic differences between the 2 samples.

RESULTS

Nearly all pediatricians in the 2017 sample (n = 160) reported annual screening of their adolescent patients (99%). The majority reported giving positive reinforcement (87%), brief advice (92%), counseling (90%), and referral to treatment (66%) in response to screen results. Compared with 2014, a significantly higher proportion of pediatricians in 2017 referred patients who screened positively for problematic alcohol use, but perceived barriers to screening and follow-up remain, such as insufficient time to screen and patient refusal to return.

CONCLUSIONS

Among respondents to a Massachusetts pediatrician survey, we found high rates of delivering SBIRT in accordance with published guidelines, though barriers remain. Whether the content of the counseling adheres to guidelines is unknown.

Collaborative care for primary care treatment of late-life depression in Singapore: Randomized controlled trial

BACKGROUND

The effectiveness and portability of the collaborative care model in the primary care treatment of depression has not been demonstrated in many randomized controlled trials in healthcare settings across the world. We determined the effectiveness of collaborative care management of elderly depression in the primary care setting in Singapore.

METHOD

Eligible participants with depressive symptoms were randomized to 6-month duration usual care (UC, N = 112) or collaborative care (CC, N = 102). Outcome measures were HDRS-17, GDS, BDI and SF-12 MCS QOL measured at 3, 6, and 12-month, care satisfaction at 6-month, and also measured on 120 participants who refused referral (non-receipt of care, NC). Primary outcome was HDRS-17 measure of depression severity, response and remission at 6-month.

RESULTS

HDRS scores in CC group compared to UC group were reduced more at 6-month (1.5 points difference in change from baseline), and also at 3 and 12-month, with similar observations of differences for GDS and BDI. There was significantly greater improvement for both CC and UC groups compared to NC group. The CC group was about 1.5 times more likely to show HDRS treatment response and remission, and more than two times likely to show GDS treatment response and remission than the UC and NC groups, as well as better quality of life improvement (P < .001) and better care satisfaction (P < .001).

CONCLUSION

Collaborative care is effective for primary care treatment of older persons with depression and is portable in diverse health care settings.

Management of diabetes during fasting and COVID-19 - Challenges and solutions

Introduction:

Fasting is observed as a religious custom in various forms across the globe. Among them, the Ramadan fasting is very common and widely practiced. People with diabetes observe fasting with or without obtaining medical advice. Uncontrolled diabetes appears to be a risk factor for COVID-19 infection and its poorer outcomes. Fasting during Ramadan is challenging in people with diabetes. This year, the background of COVID-19 made it difficult for both the patients and health care workers to effectively manage diabetes and its complications during Ramadan. Because of a lack of sufficient evidence, clinicians were perplexed in handling this difficult situation.

Materials and Methods:

We accessed PubMed, Google Scholar, various guidelines and other evidence-based articles to review the available current literature which deals with diabetes, Ramadan, and COVID-19.

Results:

The importance of pre-Ramadan assessment, adequate nutrition, and hydration, choosing the right therapy has been emphasized. This review tries to address the common practical challenges and relevant possible solutions for the same. Due consideration has been given to various socio-cultural practices that can influence the management of diabetes patients in the setting of Ramadan and COVID-19 pandemic.

Conclusions:

Diabetes is associated with increased severity and susceptibility to COVID-19. People with diabetes should go through systemic and structure-based management during fasting. Family physicians who deliver personalized care play a vital role in managing diabetes during this crisis period. Telemedicine is emerging as an effective mode of managing various needs of individuals.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review

CONTEXT

Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined.

OBJECTIVE

Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit.

STUDY DESIGN

Systematic rapid realist review.

DATASET

Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation.

RESULTS

95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion.

CONCLUSIONS

Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.

Alternative care providers in rheumatoid arthritis patient care: a queueing and simulation analysis

Patients diagnosed with rheumatoid arthritis require lifelong monitoring by a rheumatologist. Initiation of the disease-modifying anti-rheumatic drug therapy within twelve weeks of the onset of symptoms is crucial to prevent joint damage and functional disability. We examine the impact of the engagement of alternate care providers (ACP) in alleviating delay due to limited rheumatologist capacity. Using queueing theory and discrete-event simulation, we model rheumatologist-only and rheumatologist-with-ACP system configurations as closed, multi-class queueing networks with class switching.Using summary data from an actual rheumatology clinic for illustration, we analyze various parameter conditions to aid clinic managers and policymakers in decisions concerning capacity allocations and feasible patient panel size that impact timeliness of care and resource utilization.Results not only confirm that a substantial increase in RA patient panel size with an ACP involved in the care of follow-up patients but also demonstrates the boundaries for feasible panel sizes and workload allocation.

Componentes do apoio matricial e cuidados colaborativos em saúde mental: uma revisão narrativa

Resumo Cuidados colaborativos entre saúde mental e atenção primária são efetivos em melhorar desfechos de saúde. O apoio matricial tem semelhanças com cuidados colaborativos pouco exploradas na literatura. Este artigo compara os dois modelos e analisa o apoio matricial a partir de evidências sobre cuidados colaborativos. Revisão narrativa. Componentes de cada modelo (atividades e dimensões) foram identificados e comparados. Evidências sobre cuidados colaborativos informaram análise de componentes semelhantes do apoio matricial. Foram identificadas dimensões do apoio matricial – suporte educacional, cuidado especializado, regulação, cogestão – e dos cuidados colaborativos – cuidado multiprofissional, comunicação sistemática, cuidado estruturado, suporte organizacional. A principal semelhança entre os modelos está nas atividades colaborativas diretas em torno de problemas clínicos, relacionadas a efetividade em estudos sobre cuidados colaborativos. Atividades colaborativas diretas são ponto positivo do apoio matricial. Cuidado estruturado e suporte em nível organizacional devem ser encorajados. Futuros estudos devem refinar as categorias propostas e explorar seu uso para desenvolvimento do apoio matricial.

Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care

OBJECTIVE

To examine whether nurse practitioner (NP)-assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)-assigned patients.

DATA SOURCES

Veterans Affairs (VA) administrative data capturing characteristics, outcomes, and provider assignments of 806 434 VA patients assigned to an MD primary care provider (PCP) who left VA practice between 2010 and 2012.

STUDY DESIGN

We applied a difference-in-difference approach comparing outcomes between patients reassigned to MD and NP PCPs, respectively. We examined measures of outpatient (primary care, specialty care, and mental health) and inpatient (total and ambulatory care sensitive hospitalizations) utilization, costs (outpatient, inpatient and total), and clinical outcomes (control of hemoglobin A1c, LDL, and blood pressure) in the year following reassignment.

PRINCIPAL FINDINGS

Compared to MD-assigned patients, NP-assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant.

CONCLUSIONS

Patients reassigned to NPs experienced similar outcomes and incurred less utilization at comparable cost relative to MD patients. NPs may offer a cost-effective approach to addressing anticipated shortages of primary care physicians.

Effectiveness of Shared Decision-making for Diabetes Prevention: 12-Month Results from the Prediabetes Informed Decision and Education (PRIDE) Trial

IMPORTANCE

Intensive lifestyle change (e.g., the Diabetes Prevention Program) and metformin reduce type 2 diabetes risk among patients with prediabetes. However, real-world uptake remains low. Shared decision-making (SDM) may increase awareness and help patients select and follow through with informed options for diabetes prevention that are aligned with their preferences.

OBJECTIVE

To test the effectiveness of a prediabetes SDM intervention.

DESIGN

Cluster randomized controlled trial.

SETTING

Twenty primary care clinics within a large regional health system.

PARTICIPANTS

Overweight/obese adults with prediabetes (BMI ≥ 24 kg/m2 and HbA1c 5.7-6.4%) were enrolled from 10 SDM intervention clinics. Propensity score matching was used to identify control patients from 10 usual care clinics.

INTERVENTION

Intervention clinic patients were invited to participate in a face-to-face SDM visit with a pharmacist who used a decision aid (DA) to describe prediabetes and four possible options for diabetes prevention: DPP, DPP ± metformin, metformin only, or usual care.

MAIN OUTCOMES AND MEASURES

Primary endpoint was uptake of DPP (≥ 9 sessions), metformin, or both strategies at 4 months. Secondary endpoint was weight change (lbs.) at 12 months.

RESULTS

Uptake of DPP and/or metformin was higher among SDM participants (n = 351) than controls receiving usual care (n = 1028; 38% vs. 2%, p < .001). At 12-month follow-up, adjusted weight loss (lbs.) was greater among SDM participants than controls (- 5.3 vs. - 0.2, p < .001).

LIMITATIONS

Absence of DPP supplier participation data for matched patients in usual care clinics.

CONCLUSIONS AND RELEVANCE

A prediabetes SDM intervention led by pharmacists increased patient engagement in evidence-based options for diabetes prevention and was associated with significantly greater uptake of DPP and/or metformin at 4 months and weight loss at 12 months. Prediabetes SDM may be a promising approach to enhance prevention efforts among patients at increased risk.

TRIAL REGISTRATION

This study was registered at clinicaltrails.gov (NCT02384109)).

Association of Specialist Physician Payment Model With Visit Frequency, Quality, and Costs of Care for People With Chronic Disease

IMPORTANCE

Specialist physicians are key members of chronic care management teams; to date, however, little is known about the association between specialist payment models and outcomes for patients with chronic diseases.

OBJECTIVE

To examine the association of payment model with visit frequency, quality of care, and costs for patients with chronic diseases seen by specialists.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study using propensity-score matching in patients seen by a specialist physician was conducted between April 1, 2011, and September 31, 2014. The study was completed on March 31, 2015, and data analysis was conducted from June 2017 to February 2018 and finalized in August 2019. In a population-based design, 109 839 adults with diabetes or chronic kidney disease newly referred to specialists were included. Because patients seen by independent salary-based and fee-for-service (FFS) specialists were significantly different in observed baseline characteristics, patients were matched 1:1 on demographic, illness, and physician characteristics.

EXPOSURES

Specialist physician payment model (salary-based or FFS).

MAIN OUTCOMES AND MEASURES

Follow-up outpatient visits, guideline-recommended care delivery, adverse events, and costs.

RESULTS

A total of 90 605 patients received care from FFS physicians and 19 234 received care from salary-based physicians. Before matching, the patients seen by salary-based physicians had more advanced chronic kidney disease (2630 of 14 414 [18.2%] vs 6627 of 54 489 [12.2%]), and a higher proportion had 5 or more comorbidities (5989 of 19 234 [31.3%] vs 23 326 of 90 605 [25.7%]). Propensity-score matching resulted in a cohort of 31 898 patients (15 949 FFS, 15 949 salary-based) seeing 489 specialists. In the matched cohort, patients were similar (mean [SD] age, 61.3 [18.2] years; 17 632 women [55.3%]; 29 251 residing in urban settings [91.7%]). Patients seen by salary-based specialists had a higher follow-up visit rate compared with those seen by FFS specialists (1.74 visits; 95% CI, 1.58-1.92 visits vs 1.54 visits; 95% CI, 1.41-1.68 visits), but the difference was not significant (rate ratio, 1.13; 95% CI, 0.99-1.28; P = .06). There was no statistical difference in guideline-recommended care delivery, hospital or emergency department visits for ambulatory care-sensitive conditions, or costs between patients seeing FFS and salary-based specialists. The median association of physician clustering with health care use and quality outcomes was consistently greater than the association with the physician payment, suggesting variation between physicians (eg, median rate ratio for follow-up outpatient visit rate was 1.74, which is greater than the rate ratio of 1.13).

CONCLUSIONS AND RELEVANCE

Specialist physician payment does not appear to be associated with variation in visits, quality, and costs for outpatients with chronic diseases; however, there is variation in outcomes between physicians. This finding suggests the need to consider other strategies to reduce physician variation to improve the value of care and outcomes for people with chronic diseases.

Mixed method evaluation of Relational Team Development (RELATED) to improve team-based care for complex patients with mental illness in primary care

BACKGROUND

Patients with mental illness are frequently treated in primary care, where Primary Care Providers (PCPs) report feeling ill-equipped to manage their care. Team-based models of care improve outcomes for patients with mental illness, but multiple barriers limit adoption. Barriers include practical issues and psychosocial factors associated with the reorganization of care. Practice facilitation can improve implementation, but does not directly address the psychosocial factors or gaps in PCP skills in managing mental illness. To address these gaps, we developed Relational Team Development (RELATED).

METHODS

RELATED is an implementation strategy combining practice facilitation and psychology clinical supervision methodologies to improve implementation of team-based care. It includes PCP-level clinical coaching and a team-level practice change activity. We performed a preliminary assessment of RELATED with a convergent parallel mixed method study in 2 primary care clinics in an urban Federally Qualified Health Center in Southwest, USA, 2017-2018. Study participants included PCPs, clinic staff, and patient representatives. Clinic staff and patients were recruited for the practice change activity only. Primary outcomes were feasibility and acceptability. Feasibility was assessed as ease of recruitment and implementation. Acceptability was measured in surveys of PCPs and staff and focus groups. We conducted semi-structured focus groups with 3 participant groups in each clinic: PCPs; staff and patients; and leadership. Secondary outcomes were change in pre- post- intervention PCP self-efficacy in mental illness management and team-based care. We conducted qualitative observations to better understand clinic climate.

RESULTS

We recruited 18 PCPs, 17 staff members, and 3 patient representatives. We ended recruitment early due to over recruitment. Both clinics developed and implemented practice change activities. The mean acceptability score was 3.7 (SD=0.3) on a 4-point Likert scale. PCPs had a statistically significant increase in their mental illness management self-efficacy [change = 0.9, p-value= <.01]. Focus group comments were largely positive, with PCPs requesting additional coaching.

CONCLUSIONS

RELATED was feasible and highly acceptable. It led to positive changes in PCP self-efficacy in Mental Illness Management. If confirmed as an effective implementation strategy, RELATED has the potential to significantly impact implementation of evidence-based interventions for patients with mental illness in primary care.

Designing the relational team development intervention to improve management of mental health in primary care using iterative stakeholder engagement

BACKGROUND

Team-based models of care are efficacious in improving outcomes for patients with mental and physical illnesses. However, primary care clinics have been slow to adopt these models. We used iterative stakeholder engagement to develop an intervention to improve the implementation of team-based care for this complex population.

METHODS

We developed the initial framework for Relational Team Development (RELATED) from a qualitative study of Primary Care Providers' (PCPs') experiences treating mental illness and a literature review of practice facilitation and psychology clinical supervision. Subsequently, we surveyed 900 Colorado PCPs to identify factors associated with PCP self-efficacy in management of mental illness and team-based care. We then conducted two focus groups for feedback on RELATED. Lastly, we convened an expert panel to refine the intervention.

RESULTS

We developed RELATED, a two-part intervention delivered by a practice facilitator with a background in clinical psychology. The facilitator observes PCPs during patient visits and provides individualized coaching. Next, the facilitator guides the primary care team through a practice change activity with a focus on relational team dynamics.

CONCLUSION

The iterative development of RELATED using stakeholder engagement offers a model for the development of interventions tailored to the needs of these stakeholders.

TRIAL REGISTRATION

Not applicable.

Barriers and facilitators to community-based psycho-oncology services: A qualitative study of health professionals' attitudes to the feasibility and acceptability of a shared care model

OBJECTIVE

Psychological therapies combined with medication are effective treatments for depression and anxiety in patients with cancer. However, the psycho-oncology workforce is insufficient to meet patient need and is hard to access outside of the major cities. To bridge this gap, innovative models of care are required. Implementation of a new model of care requires attention to the facilitators and barriers. The aim of this study was to explore stakeholders' attitudes to the feasibility and acceptability of a community-based, shared care model for the treatment of depression and anxiety.

METHODS

Semi-structured interviews were conducted with community-based clinical psychologists (n = 10), general practitioners (n = 6), and hospital-based psychologists working in psycho-oncology (n = 9). Framework analysis was conducted to identify key themes.

RESULTS

All stakeholders perceived the model as feasible and acceptable. Potential barriers/facilitators to implementation were summarised under six key themes: (a) initiative, ownership, and autonomy; (b) resources; (c) pathway establishment; (d) support; (e) skill acquisition; and (f) patient engagement. Facilitators included quality communication between health professionals across primary and tertiary care and appropriate education and support for community-based clinicians.

CONCLUSIONS

This in-depth exploration of Australian health professionals' perceptions of the feasibility and acceptability of a community-based model of psycho-oncology care revealed that most clinicians were willing to adopt the proposed changes into practice. An RCT of a shared care intervention for depressed patients with cancer is needed.

Barriers and Facilitators to the Implementation of Evidence-Based Lifestyle Management in Polycystic Ovary Syndrome: A Narrative Review

Polycystic ovary syndrome (PCOS) is a complex condition that involves metabolic, psychological and reproductive complications. Insulin resistance underlies much of the pathophysiology and symptomatology of the condition and contributes to long term complications including cardiovascular disease and diabetes. Women with PCOS are at increased risk of obesity which further compounds metabolic, reproductive and psychological risks. Lifestyle interventions including diet, exercise and behavioural management have been shown to improve PCOS presentations across the reproductive, metabolic and psychological spectrum and are recommended as first line treatment for any presentation of PCOS in women with excess weight by the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2018. However, there is a paucity of research on the implementation lifestyle management in women with PCOS by healthcare providers. Limited existing evidence indicates lifestyle management is not consistently provided and not meeting the needs of the patients. In this review, barriers and facilitators to the implementation of evidence-based lifestyle management in reference to PCOS are discussed in the context of a federally-funded health system. This review highlights the need for targeted research on the knowledge and practice of PCOS healthcare providers to best inform implementation strategies for the translation of the PCOS guidelines on lifestyle management in PCOS.

Physical Activity Health Communication for Adults With Mood Disorders in the United States

Using national representative data, this study sought to examine receipt of physical activity communication and counseling among adults with mood disorders in comparison to the general population in the United States. The sample consisted of adult primary-care visits in the National Hospital Ambulatory Medical Care and National Ambulatory Medical Care Surveys. Multivariable logistic regression was used to examine the relationship between mental health status and receipt of physical activity communication and counseling. Overall, less than 20% of visits included physical activity communication and counseling. Controlling for covariates, visits for adults with a mood disorder diagnosis were associated with an increased odds of including physical activity communication and counseling, odds ratio = 1.25, 95% confidence interval = [1.08, 1.45]. Although adults with mood disorders were more likely to receive physical activity communication and counseling, most primary-care visits for adults in the United States did not include physical activity communication and counseling.

Interprofessional collaboration in diabetes care: perceptions of family physicians practicing in or not in a primary health care team

BACKGROUND

In Canada, most patients with type 2 diabetes mellitus (T2DM) are cared for in the primary care setting in the practices of family physicians. This care is delivered through a variety of practice models ranging from a single practitioner to interprofessional team models of care. This study examined the extent to which family physicians collaborate with other health professionals in the care of patients with T2DM, comparing those who are part of an interprofessional health care team called a Primary Care Network (PCN) to those who are not part of a PCN.

METHODS

Family physicians in Alberta, Canada were surveyed to ascertain: which health professionals they refer to or have collaborative arrangements with when caring for T2DM patients; satisfaction and confidence with other professionals' involvement in diabetes care; and perceived effects of having other professionals involved in diabetes care. Chi-squared and Fishers Exact tests were used to test for differences between PCN and non-PCN physicians.

RESULTS

170 (34%) family physicians responded to the survey, of whom 127 were PCN physicians and 41 were non-PCN physicians (2 not recorded). A significantly greater proportion of PCN physicians vs non-PCN physicians referred patients to pharmacists (23.6% vs 2.6%) or had collaborative working arrangements with diabetes educators (55.3% vs 18.4%), dietitians (54.5% vs 21.1%), or pharmacists (43.1% vs 21.1%), respectively. Regardless of PCN status, family physicians expressed greater satisfaction and confidence in specialists than in other family physicians or health professionals in medication management of patients with T2DM. Physicians who were affiliated with a PCN perceived that interprofessional collaboration enabled them to delegate diabetes education and monitoring and/or adjustment of medications to other health professionals and resulted in improved patient care.

CONCLUSIONS

This study sheds new insight on the influence that being part of a primary care team has on physicians' practice. Specifically, supporting physicians' access to other health professionals in the primary care setting is perceived to facilitate interprofessional collaboration in the care of patients with T2DM and improve patient care.

The association between payment model and specialist physicians' selection of patients with diabetes: a descriptive study

BACKGROUND

As the number of people with chronic diseases increases, understanding the impact of payment model on the types of patients seen by specialists has implications for improving the quality and value of care. We sought to determine if there is an association between specialist physician payment model and the types of patients seen.

METHODS

In this descriptive study, we used administrative data to compare demographic characteristics, illness severity and visit indication of patients with diabetes seen by fee-for-service and salary-based internal medicine and diabetes specialists in Calgary and Edmonton between April 2011 and September 2014. The study cohort included all newly referred adults with diabetes (no appointment with a specialist in prior 4 yr). Diabetes was identified using a validated algorithm that excludes gestational diabetes.

RESULTS

Patients managed by salary-based physicians (n = 2736) were sicker than those managed by fee-for-service physicians (n = 21 218). Patients managed by salary-based specialists were more likely to have 5 or more comorbidities (23.0% [n = 628] v. 18.1% [n = 3843]) and to have been admitted to hospital or seen in an emergency department for an ambulatory care sensitive condition in the year before their index visit, probably reflecting poorer disease control or barriers to optimal outpatient care. A higher proportion of visits to salary-based physicians were for appropriate indications (65.2% [n = 744] v. 55.6% [n = 5553]; risk ratio 1.17, 95% confidence interval 1.09-1.27).

INTERPRETATION

Salary-based specialists were more likely to see patients with a clear indication for a specialist visit, while fee-for-service specialists were more likely to see healthier patients. Future research is needed to determine if the differences in types of patients are attributable to payment model or other provider- or system-level factors.

Prevalence, Comorbidity, and Correlates of Psychiatric and Substance Use Disorders and Associations with HIV Risk Behaviors in a Multisite Cohort of Women Living with HIV

We used the World Health Organization’s Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women’s race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.

Assessment and Management of Posttraumatic Stress Disorder

PURPOSE

The goal of this article is to increase clinicians' understanding of posttraumatic stress disorder (PTSD) and improve skills in assessing risk for and diagnosing PTSD. The importance and sequelae of lifetime trauma burden are discussed, with reference to trends in prevention, early intervention, and treatment.

RECENT FINDINGS

PTSD has different clinical phenotypes, which are reflected in the changes in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. PTSD is almost always complicated by comorbidity. Treatment requires a multimodal approach, usually including medication, different therapeutic techniques, and management of comorbidity. Interest is growing in the neurobiology of childhood survivors of trauma, intergenerational transmission of trauma, and long-term impact of trauma on physical health. Mitigation of the risk of PTSD pretrauma in the military and first responders is gaining momentum, given concerns about the cost and disability associated with PTSD. Interest is also growing in screening for PTSD in medical populations, with evidence of improved clinical outcomes. Preliminary research supports the treatment of PTSD with repetitive transcranial magnetic stimulation.

SUMMARY

PTSD is a trauma-related disorder with features of fear and negative thinking about the trauma and the future. Untreated, it leads to ongoing disruption of life due to avoidance, impaired vocational and social functioning, and other symptoms, depending on the phenotype. Despite a theoretical understanding of underlying mechanisms, PTSD remains challenging to treat, although evidence exists for benefit of pharmacologic agents and trauma-focused therapies. A need still remains for treatments that are more effective and efficient, with faster onset.

Stepped Care Interpersonal Psychotherapy Treatment for Depressed Adolescents: A Pilot Study in Pediatric Clinics

Adolescents with depression are at risk for negative long-term consequences and recurrence of depression. Many do not receive nor access treatment, especially Latino youth. New treatment approaches are needed. This study examined the feasibility and acceptability of a stepped collaborative care treatment model (SCIPT-A) for adolescents with depression utilizing interpersonal psychotherapy for adolescents (IPT-A) and antidepressant medication (if needed) compared to Enhanced Treatment as Usual (E-TAU) in urban pediatric primary care clinics serving primarily Latino youth. Results suggest the SCIPT-A model is feasible, acceptable and potentially beneficial for urban Latino adolescents. Clinicians delivered the SCIPT-A model with fidelity using supervision successfully implemented in a community setting.

The work and challenges of care managers in the implementation of collaborative care: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: In collaborative care models between psychiatry and general practice, mental health nurses are used as care managers who carry out the treatment of patients with anxiety or depression in general practice and establish a collaborating relationship with the general practitioner. Although the care manager is the key person in the collaborative care model, there is little knowledge about this role and the challenges involved in it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study shows that before the CMs could start treating patients in a routine collaborative relationship with GPs, they needed to carry out an extensive amount of implementation work. This included solving practical problems of location and logistics, engaging GPs in the intervention, and tailoring collaboration to meet the GP's particular preferences. Implementing the role requires high commitment and an enterprising approach on the part of the care managers. The very experienced mental health nurses of this study had these skills. However, the same expertise cannot be presumed in a disseminated model. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When introducing new collaborative care interventions, the care manager role should be well defined and be well prepared, especially as regards the arrival of the care manager in general practice, and supported during implementation by a coordinated leadership established in collaboration between hospital psychiatry and representatives from general practice.

ABSTRACT

Introduction In collaborative care models for anxiety and depression, the care manager (CM), often a mental health nurse, has a key role. However, the work and challenges related to this role remain poorly investigated. Aim To explore CMs' experiences of their work and the challenges they face when implementing their role in a collaborative care intervention in the Capital Region of Denmark. Methods Interviews with eight CMs, a group interview with five CMs and a recording of one supervision session were analysed by thematic analysis. Results The CM carried out considerable implementation work. This included finding suitable locations; initiating and sustaining communication with the GPs and maintaining their engagement in the model; adapting to the patient population in general practice; dealing with personal security issues, and developing supportive peer relations and meaningful supervision. Discussion We compare our findings to previous studies of collaborative care and advanced nursing roles in general practice. The importance of organizational leadership to support the CM's bridge-building role is emphasized. Implications for practice The planners of new collaborative care interventions should not only focus on the CM's clinical tasks but also on ensuring the sufficient organizational conditions for carrying out the role.

The role of the general practitioner in multidisciplinary teams: a qualitative study in elderly care

BACKGROUND

In the western world, a growing number of the older people live at home. In the Netherlands, GPs are expected to play a pivotal role in the organization of integrated care for this patient group. However, little is known about how GPs can play this role best. Our aim for this study was to unravel how GPs can play a successful role in elderly care, in particular in multidisciplinary teams, and to define key concepts for success.

METHODS

A mixed qualitative research model in four multidisciplinary teams for elderly care in the Netherlands was used. With these four teams, consisting of 46 health care and social service professionals, we carried out two rounds of focus-group interviews. Moreover, we performed semi-structured interviews with four GPs. We analysed data using a hybrid inductive/deductive thematic analysis.

RESULTS

According to the health care and social service professionals in our study, the role of GPs in multidisciplinary teams for elderly care was characterized by the ability to 'see the bigger picture'. We identified five key activities that constitute a successful GP role: networking, facilitating, team building, integrating care elements, and showing leadership. Practice setting and phase of multidisciplinary team development influenced the way in which GPs fulfilled their roles. According to team members, GPs were the central professionals in care services for older people. The opinions of GPs about their own roles were diverse.

CONCLUSIONS

GPs took an important role in successful care settings for older people. Five key concepts seemed to be important for best practices in care for frail older people: networking (community), facilitating (organization), team building (professional), integrating care elements (patient), and leadership (personal). Team members from primary care and social services indicated that GPs had an indispensable role in such teams. It would be advantageous for GPs to be aware of this attributed role. Attention to leadership competencies and to the diversity of roles in multidisciplinary teams in GP training programmes seems useful. The challenge is to convince GPs to take a lead, also when they are not inclined to take this role in organizing multidisciplinary teams for older people.

Applicability of acceptance and commitment therapy-based mobile app in depression nursing

Due to the high burden of depression, new models and methods of mental healthcare need to be developed. Prior research has shown the potential benefits of using technology tools such as mobile apps as self-help or combined with psychological treatment. Therefore, professionals should acquaint themselves with evidence-based apps to be able to use them with clients and guide the clients in their use. The purpose of this study was to explore how an acceptance and commitment therapy-based mobile app was perceived as a self-management tool among nurses, and how it could be applied in the prevention and treatment of depression and other mental health issues. Sixteen Finnish nurses undergoing depression nurse specialist education used the app for 5 weeks and participated in semistructured focus group interviews. Interviews were analyzed by qualitative content analysis. In general, the nurses found the app suitable as a self-management tool and identified three models of using it in clinical practice. Having used the app personally, the nurses were eager to take it into use with various client groups, especially in occupational health but also in the treatment of mental health problems. However, they also raised concerns about the effort needed in familiarizing oneself with the content and pointed out specific client groups for whom the benefits of the app should be carefully weighed against the potential risks. Despite the small sample size, the findings suggest that involving technology tools as part of the nurses' education could ease their adoption in clinical practice. The degree of professional support in the app use should be aligned to the severity of the mental health problems.

Improving kNowledge Transfer to Efficaciously RAise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF): Study protocol of a mixed methods study

Heart failure is a complex disease with poor outcome. This complexity may prevent care providers from covering all aspects of care. This could not only be relevant for individual patient care, but also for care organisation. Disease management programmes applying a multidisciplinary approach are recommended to improve heart failure care. However, there is a scarcity of research considering how disease management programme perform, in what form they should be offered, and what care and support patients and care providers would benefit most. Therefore, the Improving kNowledge Transfer to Efficaciously Raise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF) study aims to explore the current processes of heart failure care and to identify factors that may facilitate and factors that may hamper heart failure care and guideline adherence. Within a cross-sectional mixed method design in three regions of the North-West part of Europe, patients (n = 88) and their care providers (n = 59) were interviewed. Prior to the in-depth interviews, patients were asked to complete three questionnaires: The Dutch Heart Failure Knowledge scale, The European Heart Failure Self-care Behaviour Scale and The global health status and social economic status. In parallel, retrospective data based on records from these (n = 88) and additional patients (n = 82) are reviewed. All interviews were audiotaped and transcribed verbatim for analysis.

The benefits of co-location in primary care practices: the perspectives of general practitioners and patients in 34 countries

Background

There is no clear evidence as to whether the co-location of primary care professionals in the same facility positively influences their way of working and the quality of healthcare as perceived by patients. The aim of this study was to identify the relationships between general practitioner (GP) co-location with other GPs and/or other professionals and the GP outcomes and patients’ experiences.

Methods

We wanted to test whether GP co-location is related to a broader range of services provided, the use of clinical governance tools and inter-professional collaboration, and whether the patients of co-located GPs perceive a better quality of care in terms of accessibility, comprehensiveness and continuity of care with their GPs. The source of data was the QUALICOPC study (Quality and Costs of Primary Care in Europe), which involved surveys of GPs and their patients in 34 countries, mostly in Europe. In order to study the relationships between GP co-location and both GPs’ outcomes and patients’ experience, multilevel linear regression analysis was carried out.

Results

The GP questionnaire was filled in by 7183 GPs and the patient experience questionnaire by 61,931 patients. Being co-located with at least one other professional is the most common situation of the GPs involved in the study. Compared with single-handed GP practices, GP co-location are positively associated with the GP outcomes. Considering the patients’ perspective, comprehensiveness of care has the strongest negative relationship of GP co-location of all the dimensions of patient experiences analysed.

Conclusions

The paper highlights that GP mono- and multi-disciplinary co-location is related to positive outcomes at a GP level, such as a broader provision of technical procedures, increased collaboration among different providers and wider coordination with secondary care. However, GP co-location, particularly in a multidisciplinary setting, is related to less positive patient experiences, especially in countries with health systems characterised by a weak primary care structure.

The Impact of GP-Centered Healthcare

BACKGROUND

In Germany, enhanced primary care ('GP-centered health care') is being promoted in order to strengthen the role of GPs and improve the quality of primary care. The aim of this study was to evaluate the impact of a GPcentered healthcare program, established in 2011 in the German federal state of Thuringia, on healthcare costs, care coordination, and pharmacotherapy.

METHODS

We conducted a retrospective case-control study based on insurance claims data. Participants were followed from 18 months before the start of the program to 18 months after its introduction. The intervention and control groups were matched via propensity scores.

RESULTS

40 298 participants enrolled in the program for a minimum of 18 months (between July 2011 and December 2012) were included in the intervention arm of the study. The mean age was 64.8 years. There was no significant difference in total direct costs (primary outcome) between cases and controls. Turning to secondary outcomes, the number of GP consultations rose sharply (+47%; p<0.001), there were less patients who consulted more than one GP (-41.4%; p<0.001), and less specialist consultations without referral (-5.8%; p<0.001) among patients in the intervention group. The number of patients who participated in Disease Management Programs (DMPs) increased (+17.7%; p<0.001), as did the number of GP home visits (+5.0%; p<0.001), specialist consultations (+4.1%; p<0.01), and the number of hospitalizations (+4.3%; p=0.006). The costs for pharmaceuticals were lowered by 3.9% (p<0.001).

CONCLUSION

The study indicates that the GP-centered healthcare program does not lead to lower direct health care costs. However, it may lead to more intense and better coordinated healthcare in older, chronically ill patients with multiple conditions. Further studies are needed on long-term effects and clinical endpoints.

The impact of team-based primary care on health care services utilization and costs: Quebec's family medicine groups

We investigate the effects on health care costs and utilization of team-based primary care delivery: Quebec's Family Medicine Groups (FMGs). FMGs include extended hours, patient enrolment and multidisciplinary teams, but they maintain the same remuneration scheme (fee-for-service) as outside FMGs. In contrast to previous studies, we examine the impacts of organizational changes in primary care settings in the absence of changes to provider payment and outside integrated care systems. We built a panel of administrative data of the population of elderly and chronically ill patients, characterizing all individuals as FMG enrollees or not. Participation in FMGs is voluntary and we address potential selection bias by matching on GP propensity scores, using inverse probability of treatment weights at the patient level, and then estimating difference-in-differences models. We also use appropriate modelling strategies to account for the distributions of health care cost and utilization data. We find that FMGs significantly decrease patients' health care services utilization and costs in outpatient settings relative to patients not in FMGs. The number of primary care visits decreased by 11% per patient per year among FMG enrolees and specialist visits declined by 6%. The declines in costs were of roughly equal magnitude. We found no evidence of an effect on hospitalizations, their associated costs, or the costs of ED visits. These results provide support for the idea that primary care organizational reforms can have impacts on the health care system in the absence of changes to physician payment mechanisms. The extent to which the decline in GP visits represents substitution with other primary care providers warrants further investigation.

Caring for Patients With Chronic Physical and Mental Health Conditions: Lessons From TEAMcare and COMPASS

Depression is one of the leading causes of disability worldwide. It often coexists with other chronic conditions, contributing to poor self-management and subsequent poor health outcomes, increased service utilization and cost of care, and poor quality of life. Most patients with depression seek care in primary care settings. Patients given collaborative care for depression alone or for depression with commonly co-occurring general medical conditions have demonstrated improved outcomes. This article reviews findings from the TEAMcare (an integrated multicondition collaborative care program for chronic illnesses) and COMPASS (Care of Mental, Physical and Substance-Use Syndromes) programs to highlight the evidence supporting the effectiveness of the collaborative care model and its implementation in diverse settings.

Améliorer la santé mentale des populations par l’intégration des soins de santé mentale aux soins primaires

L’intégration des soins de santé mentale dans les soins primaires est une stratégie importante pour améliorer la santé mentale et le bien-être des populations. Dans la dernière décennie, le Québec a adopté plusieurs mesures pour renforcer les soins de santé mentale primaires, mais certains problèmes d’intégration persistent. Cette synthèse a été réalisée afin d’identifier et comparer les grandes initiatives internationales liées à l’intégration des soins de santé mentale aux soins primaires et de résumer les leçons tirées de ces initiatives qui sont pertinentes pour le Québec. Vingt initiatives ont été sélectionnées, décrites dans 153 articles et rapports. Trois initiatives portaient sur la santé mentale des jeunes, quatorze portaient principalement sur les adultes et trois autres initiatives portaient sur la santé mentale des aînés. La majorité des initiatives ont visé à implanter des modèles de soins de collaboration pour améliorer la gestion des troubles mentaux courants par les intervenants en soins primaires. Les initiatives ont été comparées sur les stratégies d’intégration adoptées, leurs effets, et les enjeux d’implantation rencontrés. Les leçons pour le Québec incluent le besoin de consolider davantage les soins en collaboration en santé mentale, de promouvoir des services informés par des processus d’amélioration continue de la qualité et de favoriser une plus grande utilisation des technologies qui soutiennent l’intégration.

Follow-up care of cancer survivors: challenges and solutions

Attention to survivors of adult cancers formally began more than 30 years ago with the founding of the National Coalition for Cancer Survivorship by representatives from 20 organisations who envisioned an organisation that would address survivorship issues and include friends, family, and caregivers. Since then, progress has been made in cancer care delivery, which has created challenges for and barriers to provision of optimal follow-up care to patients and survivors living with cancer as a chronic illness. Focus on post-treatment cancer care, including monitoring for long-term and late effects, and concerns regarding the effect of a cancer diagnosis and treatment on quality of life have gained momentum in the past 10 years. This impetus is largely a result of the 2005 Institute of Medicine Report From Cancer Patient to Cancer Survivor: Lost in Transition. Although the issues raised in the report were hardly novel, they gave a new and powerful voice to the cancer survivorship movement that demanded a call to action. In this Series paper, we provide an overview of the issues surrounding provision of cancer survivorship and follow-up care in the USA and discuss potential solutions to these challenges.

What are the barriers and facilitators to implementing Collaborative Care for depression? A systematic review

BACKGROUND

Collaborative Care is an evidence-based approach to the management of depression within primary care services recommended within NICE Guidance. However, uptake within the UK has been limited. This review aims to investigate the barriers and facilitators to implementing Collaborative Care.

METHODS

A systematic review of the literature was undertaken to uncover what barriers and facilitators have been reported by previous research into Collaborative Care for depression in primary care.

RESULTS

The review identified barriers and facilitators to successful implementation of Collaborative Care for depression in 18 studies across a range of settings. A framework analysis was applied using the Collaborative Care definition. The most commonly reported barriers related to the multi-professional approach, such as staff and organisational attitudes to integration, and poor inter-professional communication. Facilitators to successful implementation particularly focussed on improving inter-professional communication through standardised care pathways and case managers with clear role boundaries and key underpinning personal qualities.

LIMITATIONS

Not all papers were independent title and abstract screened by multiple reviewers thus limiting the reliability of the selected studies. There are many different frameworks for assessing the quality of qualitative research and little consensus as to which is most appropriate in what circumstances. The use of a quality threshold led to the exclusion of six papers that could have included further information on barriers and facilitators.

CONCLUSIONS

Although the evidence base for Collaborative Care is strong, and the population within primary care with depression is large, the preferred way to implement the approach has not been identified.

Anxiety Disorders and General Medical Conditions: Current Research and Future Directions

Evidence that anxiety disorders are associated with general medical conditions is growing. While it is known that medical and mental conditions are often comorbid, research demonstrates that there may be underlying causal mechanisms. Furthermore, comorbid anxiety and general medical conditions are associated with poorer patient outcomes than either condition alone. Comorbid general medical and mental disorders not only affect individual patient health but also strain existing medical systems. Growing health care expenditures and increasing time pressures on clinicians create a challenging environment for intensive therapy in traditional settings. Effective screening, diagnosis, and treatment of individuals with comorbid conditions require health systems that are based on interprofessional collaboration, including integrative and collaborative care services. These models encourage the provision of patient care within a network of health care professionals, working together and sharing expertise for more efficient and holistic care. Research on the design and implementation of these systems within the context of anxiety disorders and comorbid general medical conditions is in its infancy. Given the staggeringly high rates of anxiety disorders within the general population and the continued rise of many chronic medical conditions coinciding with the increasing lifespan, mental health and primary care providers should consider how they might implement integrative care methods within their own practice.

Collaborative Care model in mental health. Scope and experiences after three years of activity in Mexico City

Aim The aim of this study was to evaluate the experience of the Collaborative Care model with general practitioners (GPs) for diagnosis and treatment of depression and anxiety disorders in primary care centers (PCC).

BACKGROUND

For many years, different ways to address mental health problems in primary care settings have been evaluated. However, there is still debate over how to treat psychiatric conditions in such a context.

METHOD

A cross-sectional design was used. The study was conducted in two consecutive studies in six PCC that serve marginalized population in Mexico City. In the first study, cases were interviewed, diagnosed, and treated by a psychiatrist. In the second study, Collaborative Care model was used and GPs were trained; psychiatrists diagnosed and treated patients but GPs discussed the symptoms and treatment of the patients with the psychiatrist. Findings First study: 18 patients with depressive and/or anxiety disorders were interviewed; these cases were not discussed between the GPs and the psychiatrist. Second study: psychiatrists and GPs conducted joint interviews and cases were discussed. From the 399 evaluated individuals, 38.94% were diagnosed with a depressive disorder. After the Collaborative Care model was applied, GPs were more aware about mental health problems and they were more interested in the identification of these conditions in PCC. Replication studies will help confirm the effectiveness of this model.

[A computerised clinical decision-support system for the management of depression in Primary Care]

A pesar de su relevancia clínica y de su importancia como problema de salud pública existen importantes deficiencias en el abordaje de la depresión. Las guías clínicas basadas en la evidencia son útiles para mejorar los procesos y los resultados clínicos, y para facilitar su implementación se ha ensayado su transformación en sistemas informatizados de apoyo a las decisiones clínicas. En este artículo se describen los fundamentos y principales características de una nueva guía clínica informatizada para el manejo de la depresión mayor desarrollada en el sistema sanitario público de Cataluña. Esta herramienta ayuda al clínico a establecer diagnósticos de depresión fiables y precisos, a elegir el tratamiento idóneo a priori según las características de la enfermedad y del propio paciente, y enfatiza en la importancia de un seguimiento sistemático para evaluar la evolución clínica y adecuar las intervenciones terapéuticas a las necesidades del paciente en cada momento.

Collaborative care in real-world settings: barriers and opportunities for sustainability

Patient-centered care and self-management of chronic disease are optimally characterized by distinct adjunct services such as education, and support for the behavioral and psychosocial elements of managing disease. The collaborative care model for the treatment of depression and anxiety in primary care includes the integration of a behavioral health specialist, in collaboration with the primary care provider, and psychiatric consultation to effectively screen and treat common mental health problems. Dissemination and sustainability of the model have encountered numerous barriers across systems of care. This article represents a discussion of the key barriers to collaborative care and offers a discussion of opportunities for dissemination and sustainability of the model.

Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial

BACKGROUND

Collaborative care is effective for depression management in the USA. There is little UK evidence on its clinical effectiveness and cost-effectiveness.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of collaborative care compared with usual care in the management of patients with moderate to severe depression.

DESIGN

Cluster randomised controlled trial.

SETTING

UK primary care practices (n = 51) in three UK primary care districts.

PARTICIPANTS

A total of 581 adults aged ≥ 18 years in general practice with a current International Classification of Diseases, Tenth Edition depressive episode, excluding acutely suicidal people, those with psychosis, bipolar disorder or low mood associated with bereavement, those whose primary presentation was substance abuse and those receiving psychological treatment.

INTERVENTIONS

Collaborative care: 14 weeks of 6-12 telephone contacts by care managers; mental health specialist supervision, including depression education, medication management, behavioural activation, relapse prevention and primary care liaison. Usual care was general practitioner standard practice.

MAIN OUTCOME MEASURES

Blinded researchers collected depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety (General Anxiety Disorder-7) and quality of life (European Quality of Life-5 Dimensions three-level version), Short Form questionnaire-36 items) outcomes at 4, 12 and 36 months, satisfaction (Client Satisfaction Questionnaire-8) outcomes at 4 months and treatment and service use costs at 12 months.

RESULTS

In total, 276 and 305 participants were randomised to collaborative care and usual care respectively. Collaborative care participants had a mean depression score that was 1.33 PHQ-9 points lower [n = 230; 95% confidence interval (CI) 0.35 to 2.31; p = 0.009] than that of participants in usual care at 4 months and 1.36 PHQ-9 points lower (n = 275; 95% CI 0.07 to 2.64; p = 0.04) at 12 months after adjustment for baseline depression (effect size 0.28, 95% CI 0.01 to 0.52; odds ratio for recovery 1.88, 95% CI 1.28 to 2.75; number needed to treat 6.5). Quality of mental health but not physical health was significantly better for collaborative care at 4 months but not at 12 months. There was no difference for anxiety. Participants receiving collaborative care were significantly more satisfied with treatment. Differences between groups had disappeared at 36 months. Collaborative care had a mean cost of £272.50 per participant with similar health and social care service use between collaborative care and usual care. Collaborative care offered a mean incremental gain of 0.02 (95% CI -0.02 to 0.06) quality-adjusted life-years (QALYs) over 12 months at a mean incremental cost of £270.72 (95% CI -£202.98 to £886.04) and had an estimated mean cost per QALY of £14,248, which is below current UK willingness-to-pay thresholds. Sensitivity analyses including informal care costs indicated that collaborative care is expected to be less costly and more effective. The amount of participant behavioural activation was the only effect mediator.

CONCLUSIONS

Collaborative care improves depression up to 12 months after initiation of the intervention, is preferred by patients over usual care, offers health gains at a relatively low cost, is cost-effective compared with usual care and is mediated by patient activation. Supervision was by expert clinicians and of short duration and more intensive therapy may have improved outcomes. In addition, one participant requiring inpatient treatment incurred very significant costs and substantially inflated our cost per QALY estimate. Future work should test enhanced intervention content not collaborative care per se.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN32829227.

FUNDING

This project was funded by the Medical Research Council (MRC) (G0701013) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.