Primary Care Attributes, Health Care System Hassles, and Chronic Illness

Administrative burden for patients in U.S. health care settings Post-Affordable Care Act: A scoping review

Administrative burdens are the costs associated with receiving a service or accessing a program. Based on the Herd & Moynihan framework, they occur in three subcategories: learning costs, compliance costs, and psychological costs. Administrative burdens manifest inequitably, more significantly impacting vulnerable populations. Administrative burdens may impact the health of those trying to access services, and in some cases block access to health-promoting services entirely. This scoping review examined studies focused on the impact on patients of administrative burden administrative burden in health care settings in the U.S. following the passage of the Affordable Care Act. We queried databases for empirical literature capturing patient administrative burden, retrieving 1578 records, with 31 articles ultimately eligible for inclusion. Of the 31 included studies, 18 used quantitative methods, nine used qualitative methods, three used mixed methods, and one was a case study. In terms of administrative burden subcategories, most patient outcomes reported were learning (22 studies) and compliance costs (26 studies). Psychological costs were the most rarely reported; all four studies describing psychological costs were qualitative in nature. Only twelve studies connected patient demographic data with administrative burden data, despite previous research suggesting an inequitable burden impact. Additionally, twenty-eight studies assessed administrative burden and only three attempted to reduce it via an intervention, resulting in a lack of data on intervention design and efficacy.

How do older adults with multimorbidity navigate healthcare?: a qualitative study in Singapore

BACKGROUND

Patients living with multimorbidity may require frequent visits to multiple healthcare institutions and to follow diverse medical regimens and advice. Older adults with multimorbidity could face additional challenges because of declining cognitive capability, frailty, increased complexity of diseases, as well as limited social and economic resources. Research on how this population navigates the healthcare system in Singapore also remains unknown. This study investigates the challenges older adults with multimorbidity face in navigating healthcare in Singapore.

METHODS

Twenty older adults with multimorbidity from a public primary care setting were purposively sampled. Interviews conducted inquired into their experiences of navigating the healthcare system with multiple conditions. Inductive thematic analysis was performed by independent coders who resolved differences through discussion.

RESULTS

Older adults with multimorbidity form a population with specific characteristics and challenges. Their ability to navigate the healthcare system well was influenced by these themes including patient-related factors (autonomy and physical mobility, literacy and technological literacy, social support network), healthcare system-related factors (communication and personal rapport, fragmented system, healthcare staff as advocate) and strategies for navigation (fitting in, asking for help, negotiating to achieve goals, managing the logistics of multimorbidity).

DISCUSSION

Older adults with multimorbidity should not be treated as a homogenous group but can be stratified according to those with less serious or disruptive conditions (less burden of illness and burden of treatment) and those with more severe conditions (more burden of illness and burden of treatment). Among the latter, some became navigational experts while others struggled to obtain the resources needed. The variations of navigational experiences of the healthcare system show the need for further study of the differential needs of older adults with multimorbidity. To be truly patient-centred, healthcare providers should consider factors such as the existence of family support networks, literacy, technological literacy and the age-related challenges older adults face as they interact with the healthcare system, as well as finding ways to improve healthcare systems through personal rapport and strategies for reducing unnecessary burden of treatment for patients with multimorbidity.

Patient perspectives on primary care for multimorbidity: An integrative review

INTRODUCTION

Improving healthcare for people with multiple chronic or ongoing conditions is receiving increased attention, particularly due to the growing number of people experiencing multimorbidity (MM) and concerns about the sustainability of the healthcare system. Primary care has been promoted as an important resource for supporting people with MM to live well with their conditions and to prevent unnecessary use of health care services. However, traditional primary care has been criticized for not centring the needs and preferences of people with MM themselves. Our aim was to conduct a review that centred on the perspective of people with MM in multiple ways, including having patient partners co-lead the design, conduct and reporting of findings, and focusing on literature that reported the perspective of people with MM, irrespective of it being experimental or nonexperimental.

METHODS

We searched for published literature in CINAHL with Full Text (EBSCOhost) and MEDLINE All (Ovid). Findings from experimental and nonexperimental studies were integrated into collaboration with patient partners.

RESULTS

Twenty-nine articles were included in the review. Findings are described in five categories: (1) Care that is tailored to my unique situation; (2) meaningful inclusion in the team; (3) a healthcare team that is ready and able to address my complex needs; (4) supportive relationships and (5) access when and where I need it.

CONCLUSION

This review supports a reorientation of primary care systems to better reflect the experiences and perspectives of people with MM. This can be accomplished by involving patient partners in the design and evaluation of primary care services and incentivizing collaboration among health and social supports and services for people with MM.

PATIENT OR PUBLIC CONTRIBUTION

Patient partners were involved in the design and conduct of this review, and in the preparation of the manuscript. Their involvement is further elucidated in the manuscript text.

Patient satisfaction with computer-assisted structured initial assessment facilitating patient streaming to emergency departments and primary care practices: results from a cross-sectional observational study accompanying the DEMAND intervention in Germany

Background

Patient numbers in emergency departments are on the rise. The DEMAND intervention aims to improve the efficacy of emergency services by computer-assisted structured initial assessment assigning patients to emergency departments or primary care practices. The aims of our study were to evaluate patient satisfaction with this intervention and to analyse if reduced patient satisfaction is predicted by sociodemographic data, health status or health literacy.

Methods

We conducted a cross-sectional patient survey in emergency departments and co-located primary care practices. Each intervention site was planned to participate for two observation periods, each with a duration of one full week. Study participants were recruited by the local staff. The patients filled out a written questionnaire during their waiting time. Patient satisfaction was assessed by agreement to four statements on a four point Likert scale. Predictors of patient satisfaction were identified by multilevel, multivariable logistic regression models adjusted for random effects at the intervention site level.

Results

The sample included 677 patients from 10 intervention sites. The patients had a mean age of 38.9 years and 59.0% were women. Between 67.5% and 55.0% were fully satisfied with aspects of the intervention. The most criticised aspect was that the staff showed too little interest in the patients’ personal situation. Full satisfaction (“clearly yes” to all items) was reported by 44.2%. Reduced patient satisfaction (at least one item rated as “rather yes”, “rather no”, “clearly no”) was predicted by lower age (odds ratio 0.79 for ten years difference, 95% confidence interval 0.67/0.95, p = 0.009), presenting with infections (3.08,1.18/8.05,p = 0.022) or injuries (3.46,1.01/11.82,p = 0.048), a higher natural logarithm of the symptom duration (1.23,1.07/1.30,p = 0.003) and a lower health literacy (0.71 for four points difference, 0.53/0.94,p = 0.019).

Conclusions

The patients were for the most part satisfied with the intervention. Assessment procedures should be evaluated a) regarding if all relevant patient-related aspects are included; and whether patient information can be improved b) for patients with strong opinions about cause, consequences and treatment options for their health problem; and c) for patients who have problems in the handling of information relevant to health and healthcare.

Trial registration

German Clinical Trials Register (https://www.drks.de/drks_web/setLocale_EN.do) no. DRKS00017014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01825-5.

Mechanisms of the Chinese Government's Efforts to Fight COVID-19: Integration of Top-down Interventions and Local Governance

The experiences and lessons of China's response to COVID-19 have been described in several studies, but the mechanisms of the Chinese government's efforts to fight COVID-19 have not been well characterized. Despite strong policy directives and orders from the central government, the response and handling of the epidemic also reflected distinctive characteristics of local governments in terms of their governance systems and capacities. In this article, the authors analyze public health policies and mechanisms of the Chinese government's response to COVID-19 based on the integration of top-down and local governance. A compendium of key events and measures provides the foundation for our analysis. Mechanisms related to leadership, emergency response, centralized mobilization, and accountability fully reflect the decisive measures for top-down interventions in the face of emergencies. China's policies and mechanisms to address the COVID-19 pandemic are consistent with its party-state bureaucracy and socioeconomic context. However, lower levels of government have used "repeated increments" and "one-size-fits-all" practices in the implementation of antiepidemic policies. Conservative local officials are more averse to social innovation and favor strict controls to manage the pandemic. Moreover, even under a unified system, there are substantial differences in the capacity and level of crisis management among local governments, especially in the mobilization of nonprofit organizations and volunteers. In this case study, we aim to expand the existing understanding of the tension between top-down interventions and local governance innovations.

The Coordination Toolkit and Coaching Project: Cluster-Randomized Quality Improvement Initiative to Improve Patient Experience of Care Coordination

BACKGROUND

Given persistent gaps in coordination of care for medically complex primary care patients, efficient strategies are needed to promote better care coordination.

OBJECTIVE

The Coordination Toolkit and Coaching project compared two toolkit-based strategies of differing intensity to improve care coordination at VA primary care clinics.

DESIGN

Multi-site, cluster-randomized QI initiative.

PARTICIPANTS

Twelve VA primary care clinics matched in 6 pairs.

INTERVENTIONS

We used a computer-generated allocation sequence to randomize clinics within each pair to two implementation strategies. Active control clinics received an online toolkit with evidence-based tools and QI coaching manual. Intervention clinics received the online toolkit plus weekly assistance from a distance coach for 12 months.

MAIN MEASURES

We quantified patient experience of general care coordination using the Health Care System Hassles Scale (primary outcome) mailed at baseline and 12-month follow-up to serial cross-sectional patient samples. We measured the difference-in-difference (DiD) in clinic-level-predicted mean counts of hassles between coached and non-coached clinics, adjusting for clustering and patient characteristics using zero-inflated negative binomial regression and bootstrapping to obtain 95% confidence intervals. Other measures included care coordination QI projects attempted, tools adopted, and patient-reported exposure to projects.

KEY RESULTS

N = 2,484 (49%) patients completed baseline surveys and 2,481 (48%) completed follow-ups. Six coached clinics versus five non-coached clinics attempted QI projects. All coached clinics versus two non-coached clinics attempted more than one project or projects that were multifaceted (i.e., involving multiple components addressing a common goal). Five coached versus three non-coached clinics used 1-2 toolkit tools. Both the coached and non-coached clinics experienced pre-post reductions in hassle counts over the study period (- 0.42 (- 0.76, - 0.08) non-coached; - 0.40 (- 0.75, - 0.06) coached). However, the DiD (0.02 (- 0.47, 0.50)) was not statistically significant; coaching did not improve patient experience of care coordination relative to the toolkit alone.

CONCLUSION

Although coached clinics attempted more or more complex QI projects and used more tools than non-coached clinics, coaching provided no additional benefit versus the online toolkit alone in patient-reported outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03063294.

Health care network model for older adults: a co-creation and participatory action research approach

Objective: To develop a collaborative, multidisciplinary care model for older adults that improves interdisciplinary teamwork and increases access to specialized services for frail patients, helping solve management problems in the Brazilian Unified Health System. In the state of Bahia, the health care network for older adults requires better interaction and integration with the Unified Health System and the Unified System of Social Assistance to improve patient flow in the network. Methods: We used a co-creation and participatory action research approach based on reflection, data collection, interaction, and feedback with participants and stakeholders. Data was collected from health professionals, representatives of health agencies, and older adults through collective and individual interviews, reflective diaries, and direct communication. Results: An action plan involving members of the older adult care network was developed to put the new model into practice. A pilot study with a multidisciplinary team allowed adjustments and implementation of the model at our institution. Conclusions: The new model improved both the internal management of the State Reference Center for Older Adult Health Care (Centro de Referência Estadual de Atenção à Saúde do Idoso - CREASI) and its interaction with primary care, optimizing patient flow and establishing rules for shared management between CREASI and primary care institutions. In view of this, restructuring the care model reorganized relations between the agencies, expanding CREASI’s role in the management and systematization of older adult health.

The impact of medical teleconsultations on general practitioner-patient communication during COVID- 19: A case study from Poland

According to the outbreak of the Covid-19 pandemic, medical teleconsultations using various technologies have become an important tool to mediate communication between general practitioners (GP) and the patients in primary health care in many countries. The quality of the GP-patient communication is an essential factor, which improves the results of treatment and patient satisfaction. The objective of this paper is to study patients' satisfaction from teleconsultation in primary care and the impact of teleconsultations on GP-patient communication through the Covid-19 pandemic in Poland. We analyse whether the teleconsultations performed without physical examinations have a positive impact on GP-patient communication. The quality of teleconsultation and GP-patient communication have been measured using a questionnaire regarding the quality of medical care in a remote care conditions. Among 36 items, nine questions have been related to the dimension of GP-patient communication and ten to system experience. Our results suggest that the quality of teleconsultations is not inferior to the quality of consultation during a face-to-face visit. The patients indicated a high level of satisfaction regarding communication with their GP during teleconsultation. We have also identified that the technical quality and the sense of comfort during teleconsultation positively impact the communication quality.

Cancer care reform in South Africa: A case for cancer care coordination: A narrative review

OBJECTIVE

This review provides an overview of the existing literature on the importance of care coordination for lung cancer care and other cancers in general. The review is inclusive of the burden of cancer, with a special reference to lung cancer, as well as challenges and achievements relating to cancer care coordination.

METHOD

We conducted a search of online databases of peer-reviewed studies published in the English language. The analysis for this review has been packaged into themes in order to generate results that can inform researchers and cancer health professionals, on the existing gaps necessary for developing appropriate intervention strategies and policy guidelines.

RESULTS

Cancer is a complex condition that often requires multiple interventions provided by a variety of health professionals within the healthcare continuum. This paper reviewed research studies that explored the supportive care needs of cancer patients. The results are presented in three superordinate themes, namely (a) cancer as a healthcare priority in South Africa (SA), (b) making a case for coordinated cancer care in SA, and (c) care coordination: a poorly defined, yet complex concept. One major need identified was the requirement of informational support. Other essential needs included referral, emotional, and financial support.

SIGNIFICANCE OF RESULTS

The identification of current obstacles has the potential to guide the development of a model to improve quality coordinated cancer health care. It remains that limited research exists around cancer services and cancer care in the South African region. This narrative review identified common elements and barriers to care for lung cancer patients and survivors, and offers recommendations for developing clinical care models.

Experiences of older primary care patients with multimorbidity and their caregivers in navigating the healthcare system: A qualitative study protocol

Background

Patients with multimorbidity must bear not just the burden of their illness, but also the burden of treatment which is, in part, induced by their interactions with the healthcare system. The need to shuttle between different healthcare institutions and multiple healthcare providers can make navigating the healthcare system challenging, and this may be even more so for older patients with limited resources and support.

Objectives

Few qualitative studies have explored the experiences of patients with multimorbidity in navigating the healthcare system. This study will explore the experiences of older patients with multimorbidity and their caregivers as they navigate through the healthcare system. We aim to arrive at a better understanding of patient experiences of possible gaps in the continuity of care and how the current system can be modified and adapted to better address the needs of older patients with multimorbidity.

Method

Semi-structured, in-depth interviews will be conducted with purposively sampled older patients with multimorbidity, aged 60 and above seen in primary care, together with their caregivers. Interviews will be transcribed verbatim and analysed by the study team using inductive thematic analysis.

Conclusions

Our study seeks to explore the navigational experiences within the healthcare system for older patients with multimorbidity in an Asian, multi-ethnic society. The findings will be shared with decision-makers in the healthcare setting in order to improve patient care for this population and ultimately maximise their positive health outcomes, and will add to better understanding how the burden of treatment arising from navigational challenges within the healthcare system may be reduced for older patients with multimorbidity.

Evaluation of China's public health system response to COVID-19

Background

The focus of the study is to assess the advantages and shortcomings of China's public health system in the process of the COVID-19 prevention and to discuss the future reform of China's public health system.

Methods

By searching literature and reports related to the COVID-19 prevention of China, we compared the prevention effectiveness with the prevention policies in the process of the COVID-19 prevention.

Results

China's public health system can effectively combine national power to maximize the effectiveness of pandemic prevention. It improved the pandemic prevention ability of communities continuously and promoted the fairness of prevention. Traditional Chinese Medicine has also been used in pandemic prevention, which reduces the drug resistance of the virus. At the same time, the combination of the disease diagnosis and the Internet has reduced the spread speed of the pandemic. China's public health system also has some problems in response to the COVID-19, such as the shortage of medical resources, insufficient alerts, the low efficiency of reporting to superior government and the shortage of reward and punishment system for pandemic prevention.

Conclusions

China's practice and efforts of the COVID-19 prevention can provide experience for other countries to improve their public health systems and accelerate the end of the COVID-19 pandemic.

Patient experience of health care system hassles: Dual-system vs single-system users

OBJECTIVE

To compare health care system problems or "hassles" experienced by Veterans receiving VA health care only versus those receiving dual care from both VA and non-VA community providers.

DATA SOURCES

We collected survey data in 2017-2018 from 2444 randomly selected Veterans with four or more primary care visits in the prior year at one of 12 VA primary care clinics located in four geographically diverse regions of the United States.

STUDY DESIGN

We used baseline surveys from the Coordination Toolkit and Coaching quality improvement project to explore Veterans' experience of hassles (dependent variable), source of health care, self-rated physical and mental health, and sociodemographics.

DATA COLLECTION

Participants responded to mailed surveys by mail, telephone, or online.

PRINCIPAL FINDINGS

The number of reported hassles ranged from 0 to 16; 79 percent of Veterans reported experiencing one or more hassles. Controlling for sociodemographic characteristics and self-rated physical and mental health, zero-inflated negative binominal regression indicated that dual care users experienced more hassles than VA-only users (adjusted predicted average 5.5 [CI: 5.2, 5.8] vs 4.3 [CI: 4.1, 4.6] hassles [P < .0001]).

CONCLUSIONS

Anticipated increases in Veterans accessing community-based care may require new strategies to help VA primary care teams optimize care coordination for dual care users.

"Patient centered care in medical disinformation era" among patients attending tertiary care hospital: A cross sectional study

BACKGROUND AND OBJECTIVES

Patient-centered care refers to the provision of care for patients' comprehensive needs, perspectives, and preferences. In health security, communication between patient and physician is the main key through which we plan and implement to threats that can affect huge population.

AIM

The aim of this study was to assess the patient-centered care in medical disinformation era among patients attending tertiary care teaching hospital, Rishikesh.

MATERIALS AND METHODS

A descriptive cross-sectional study was planned by enrolling 240 patients attending tertiary care teaching hospital. Total consecutive sampling technique was chosen to recruit the patients for the study.

TOOLS

Tools used were case reporting form and components of primary care index (CPCI).

RESULTS

The results show statistically significant association between chronic history of illness of patient (P = 0.02), education of patient (P = 0.008), and habitat of patient (P = 0.05) with interpersonal communication between patient and physician, and the results also show statistically significant association between accumulated knowledge (P = 0.000), coordination of care (P = 0.001), continuity belief (P = 0.000), comprehensiveness of care (P = 0.001), and first contact (P = 0.001) with interpersonal communication between patient and physician. The lowest mean percentage of patient-centered care score was observed for accumulated knowledge (65.70%) and the highest mean percentage (85.15%) score of patient-centered care was observed for interpersonal communication.

CONCLUSIONS

This study concluded that patient-centered care improves interpersonal communication between patient and physician. Threats arising due to present medical disinformation era can be combat by patient-centered care.

Difficulties that patients with chronic diseases face in the primary care setting in Singapore: a cross-sectional study

INTRODUCTION

Patients with chronic diseases face difficulties when navigating the healthcare system. Using the Healthcare System Hassles Questionnaire (HSHQ) developed by Parchman et al, this study aimed to explore the degree of hassles faced by primary care patients in Singapore and identify the characteristics associated with higher hassles.

METHODS

A cross-sectional study was conducted among patients with chronic disease at Hougang Polyclinic, Singapore, using interviewer-administered HSHQ. Mean HSHQ score was compared with Parchman et al's study. The associations between number of chronic diseases, demographic variables and healthcare hassles were assessed using multivariate linear logistic regression analysis.

RESULTS

217 outpatients aged 21 years and above were enrolled. Our overall mean HSHQ score (4.77 ± 6.18) was significantly lower than that in Parchman et al's study (15.94 ± 14.23, p < 0.001). Participants with five or more chronic diseases scored 3.38 (95% confidence interval [CI] 0.11-6.65, p = 0.043) points higher than those with one chronic disease. With each increasing year of age, mean HSHQ score decreased by 0.17 (95% CI -0.26 to -0.08, p = 0.001) points. Those with polytechnic/diploma/university education and higher scored 2.65 (95% CI 0.19-5.11, p = 0.035) points higher than those with primary education and lower.

CONCLUSION

Patients in our population reported lower hassles than those in Parchman et al's study. Increasing age and lower education level were associated with lower hassles. Further analysis of the types of chronic diseases may yield new information about the association of healthcare hassles with the number and types of chronic diseases.

The role of healthcare system hassles in delaying or forgoing care

BACKGROUND

Several factors besides appointment availability can influence access to care. Among these factors are the diverse challenges that patients may experience in navigating the healthcare system. However, the relationship between these challenges or "hassles" and delaying or forgoing care has not been assessed.

METHODS

We examined the relationship between healthcare system hassles and delaying or forgoing needed care. We used data from a 2016 Veterans Affairs (VA) survey of women veterans (N = 821) who were active users of primary care (3+ primary care visits in the past year) at any of 12 VA medical centers. The main independent variable was a measure of 16 healthcare system hassles, encompassing a wide range of clinically-relevant aspects of patient experience, such as uncertainty about when/how to take a medication or difficulty getting questions answered between appointments. The outcome was a self-reported measure of delaying or forgoing needed care. We used logistic regression to estimate this outcome as a function of hassles, adjusting for age, comorbidities, and health care utilization. Survey weights accounted for within-site clustering, nonproportional sampling, and nonresponse.

RESULTS

Overall, 26% of participants reported 0 hassles, and 39% reported 4 or more. Reporting 4 or more hassles (vs. 0) was associated with a roughly 5-fold increase in the predicted probability of delaying or forgoing care.

CONCLUSION

Addressing healthcare system hassles could yield unexpected benefits to realized access.

Eight Priorities for Improving Primary Care Access Management in Healthcare Organizations: Results of a Modified Delphi Stakeholder Panel

OBJECTIVE

To identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel.

BACKGROUND

Studies on healthcare access show its importance for ensuring population health. Few studies show how healthcare organizations can improve access.

METHODS

We conducted a modified Delphi stakeholder panel anchored by a systematic review. Panelists (N = 20) represented diverse stakeholder groups including patients, providers, policy makers, purchasers, and payers of healthcare services, predominantly from the Veterans Health Administration. A pre-panel survey addressed over 80 aspects of healthcare organization management of access, including defining access management. Panelists discussed survey-based ratings during a 2-day in-person meeting and re-voted afterward. A second panel process focused on each final priority and developed recommendations and suggestions for implementation.

RESULTS

The panel achieved consensus on definitions of optimal access and access management on eight urgent and important priorities for guiding access management improvement, and on 1-3 recommendations per priority. Each recommendation is supported by referenced, panel-approved suggestions for implementation. Priorities address two organizational structure targets (interdisciplinary primary care site leadership; clearly identified group practice management structure); four process improvements (patient telephone access management; contingency staffing; nurse management of demand through care coordination; proactive demand management by optimizing provider visit schedules), and two outcomes (quality of patients' experiences of access; provider and staff morale). Recommendations and suggestions for implementation, including literature references, are summarized in a panelist-approved, ready-to-use tool.

CONCLUSIONS

A stakeholder panel informed by a pre-panel systematic review identified eight action-oriented priorities for improving access and recommendations for implementing each priority. The resulting tool is suitable for guiding the VA and other integrated healthcare delivery organizations in assessing and initiating improvements in access management, and for supporting continued research.

Specific Measures of Quality of Life in Patients with Multimorbidity in Primary Healthcare: A Systematic Review on Patient-Reported Outcome Measures' Adequacy of Measurement

Purpose

The aim of this study is to search systematically for Patient Reported Outcome Measures (PROMs) used among patients with multimorbidity. Furthermore, the aim is to evaluate the adequacy and validity of the PROMs identified.

Design and setting

This systematic review follows the PRISMA guidelines. To assess the adequacy and validity of the identified PROMs the COSMIN Risk of Bias Checklist is used, more specifically a validation of the development, content validity, structural validity, and internal consistency of the PROMs.

Results

Four PROMs were identified in the primary search, and one was found from references. The sixth PROM was published after the primary search. None of the identified PROMs were aimed specifically at measuring the quality of life in patients with multimorbidity. According to the checklist, the development process and content validity were rated “adequate” in only one measure and “invalid”/“doubtful”/“inadequate” in the rest of the measures. The structural validity of the measures was rated “adequate” in four measures and “very good” in one. Regarding the internal consistency, two measures were rated doubtful and three “very good”. None of the six PROMs reported analyses about invariant measurement. The COSMIN Risk of Bias Checklist proved easy to use; however, there are some concerns in the rating of bias, that are discussed further.

Conclusion

All six PROMs developed for patients with multimorbidity identified possessed inadequacy in their measurement properties. Therefore, the aim for the future is to develop a valid and adequate measure of the quality of life among patients with multimorbidity.

Effect of multimorbidity on health service utilisation and health care experiences

INTRODUCTION Multimorbidity, the co-existence of two or more long-term conditions, is associated with poor quality of life, high health care costs and contributes to ethnic health inequality in New Zealand (NZ). Health care delivery remains largely focused on management of single diseases, creating major challenges for patients and clinicians. AIM To understand the experiences of people with multimorbidity in the NZ health care system. METHODS A questionnaire was sent to 758 people with multimorbidity from two primary health care organisations (PHOs). Outcomes were compared to general population estimates from the NZ Health Survey. RESULTS Participants (n = 234, 31% response rate) reported that their general practitioners (GPs) respected their opinions, involved them in decision-making and knew their medical history well. The main barriers to effective care were short GP appointments, availability and affordability of primary and secondary health care, and poor communication between clinicians. Access issues were higher than for the general population. DISCUSSION Participants generally had very positive opinions of primary care and their GP, but encountered structural issues with the health system that created barriers to effective care. These results support the value of ongoing changes to primary care models, with a focus on patient-centred care to address access and care coordination.

An Integrated Health-System Specialty Pharmacy Model for Coordinating Transitions of Care: Specialty Medication Challenges and Specialty Pharmacist Opportunities

Adherence and persistence to specialty medications are necessary to achieve successful outcomes of costly therapies. The increasing use of specialty medications has exposed several unique barriers to certain specialty treatments' continuation. Integrated specialty pharmacy teams facilitate transitions in sites of care, between different provider types, among prescribed specialty medications, and during financial coverage changes. We review obstacles encountered within these types of transitions and the role of the specialty pharmacist in overcoming these obstacles. Case examples for each type of specialty transition provide insight into the unique complexities faced by patients, and shed light on pharmacists' vital role in patient care. This insightful and real-world experience is needed to facilitate best practices in specialty care, particularly in the growing number of health-system specialty pharmacies.

Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial

BACKGROUND

Intensive primary care programs aim to coordinate care for patients with medical, behavioral, and social complexity, but little is known about their impact on patient experience when implemented in a medical home.

OBJECTIVE

Determine how augmenting the VA's medical home (Patient Aligned Care Team, PACT) with a PACT-Intensive Management (PIM) program influences patient experiences with care coordination, access, provider relationships, and satisfaction.

DESIGN

Cross-sectional analysis of patient survey data from a five-site randomized quality improvement study.

PARTICIPANTS

Two thousand five hundred sixty-six Veterans with hospitalization risk scores ≥ 90th percentile and recent acute care.

INTERVENTION

PIM offered patients intensive care coordination, including home visits, accompaniment to specialists, acute care follow-up, and case management from a team staffed by primary care providers, social workers, psychologists, nurses, and/or other support staff.

MAIN MEASURES

Patient-reported experiences with care coordination (e.g., health goal assessment, test and appointment follow-up, Patient Assessment of Chronic Illness Care (PACIC)), access to healthcare services, provider relationships, and satisfaction.

KEY RESULTS

Seven hundred fifty-nine PIM and 768 PACT patients responded to the survey (response rate 60%). Patients randomized to PIM were more likely than those in PACT to report that they were asked about their health goals (AOR = 1.26; P = 0.046) and that they have a VA provider whom they trust (AOR = 1.35; P = 0.005). PIM patients also had higher mean (SD) PACIC scores compared with PACT patients (2.91 (1.31) vs. 2.75 (1.25), respectively; P = 0.022) and were more likely to report 10 out of 10 on satisfaction with primary care (AOR = 1.25; P = 0.048). However, other effects on coordination, access, and satisfaction did not achieve statistical significance.

CONCLUSIONS

Augmenting VA's patient-centered medical home with intensive primary care had a modestly positive influence on high-risk patients' experiences with care coordination and provider relationships, but did not have a significant impact on most patient-reported access and satisfaction measures.

Universal health coverage and primary care, Thailand

Thailand’s policy on universal health coverage (UHC) has made good progress since its inception in 2002. Every Thai citizen is now entitled to essential preventive, curative and palliative health services at all life stages. Like its counterparts elsewhere, however, the policy faces challenges. A predominantly tax-financed system in a nation with a high proportion of people living in poverty will always strive to contain rising costs. Disparities exist among the different health insurance schemes that provide coverage for Thai citizens. National health expenditure is heavily borne by the government, primarily to reduce financial barriers to access for the poor. The population is ageing and the disease profiles of the population are changing alongside the modernization of Thai people’s lifestyles. Thailand is now aiming to enhance and sustain its UHC policy. We examine the merits of different policy options and aim to identify the most promising and feasible way to enhance and sustain UHC. We argue that developing the existing primary care system in Thailand has the greatest potential to provide more self-sustaining, efficient, equitable and effective UHC. Primary care needs to move from its traditional role of providing basic disease-based care, to being the first point of contact in an integrated, coordinated, community-oriented and person-focused care system, for which the national health budget should be prioritized.

Development of a web-based toolkit to support improvement of care coordination in primary care

Promising practices for the coordination of chronic care exist, but how to select and share these practices to support quality improvement within a healthcare system is uncertain. This study describes an approach for selecting high-quality tools for an online care coordination toolkit to be used in Veterans Health Administration (VA) primary care practices. We evaluated tools in three steps: (1) an initial screening to identify tools relevant to care coordination in VA primary care, (2) a two-clinician expert review process assessing tool characteristics (e.g. frequency of problem addressed, linkage to patients' experience of care, effect on practice workflow, and sustainability with existing resources) and assigning each tool a summary rating, and (3) semi-structured interviews with VA patients and frontline clinicians and staff. Of 300 potentially relevant tools identified by searching online resources, 65, 38, and 18 remained after steps one, two and three, respectively. The 18 tools cover five topics: managing referrals to specialty care, medication management, patient after-visit summary, patient activation materials, agenda setting, patient pre-visit packet, and provider contact information for patients. The final toolkit provides access to the 18 tools, as well as detailed information about tools' expected benefits, and resources required for tool implementation. Future care coordination efforts can benefit from systematically reviewing available tools to identify those that are high quality and relevant.

Pill for this and a pill for that: A cross-sectional survey of use and understanding of medication among adults with multimorbidity

OBJECTIVE

To understand the challenges managing medication use and knowledge of people living with multimorbidity.

METHODS

A cross-sectional survey of 234 adults with multimorbidity, identified using retrospective hospital discharge data. Participants were recruited from two primary health organisations in New Zealand.

RESULTS

Three quarters of participants (75%) were prescribed four or more medications, and one in four (27%) were prescribed eight or more medications. Participants reported knowing what their medications were for (88%, 95% CI 81.4-93.8) and when to take them (99%, 95% CI 97.5-99.9). However, over a fifth (22%, 95% CI 13.7-30.4) reported some problems managing multiple medications, and 40% (95% CI 30.2-50.2) reported a problem with side effects.

CONCLUSION

The results highlight the need to consider how prescribing can be adapted for people with multimorbidity and move beyond the application of multiple disease-specific guidelines.

Patient, Primary Care Provider, and Specialist Perspectives on Specialty Care Coordination in an Integrated Health Care System

Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists-that is, the specialty care "triad." This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and endocrinologists relied on interclinician relationships to coordinate care. Clinicians rarely included patients or other staff in their conceptualization of specialty care coordination. Patients often assumed responsibility for specialty care coordination but struggled to succeed. We identified several opportunities to improve coordination across the triad. In an integrated medical system, the shared organizational structure can facilitate these efforts.

Timely access to mental health care among women veterans

Using survey data on (N = 419) patients at Department of Veterans Affairs (VA) clinics we analyzed women veterans' reports of timely access to VA mental health care. We evaluated problems that patients might face in obtaining care, and examined subjective ratings of VA care as a function of timely access to mental health care. We found that 59% of participants reported "always" getting an appointment for mental health care as soon as needed. In adjusted analyses, two problems were negatively associated with timely access to mental health care: (a) medical appointments that interfere with other activities, and (b) difficulty getting questions answered between visits. Average subjective ratings of VA ranged from 8.2-8.6 out of 10, and 93% of participants would recommend VA care. Subjective ratings of VA were higher among women who reported timely access to mental health care. Findings suggest that overall experience of care is associated with timely access to mental health care, and that such access may be amenable to improvements related to clinic hours or mechanisms for answering patient questions between visits. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Care coordination and provider stress in primary care management of high-risk patients

BACKGROUND

Care coordination is a critical component of managing high-risk patients, who tend to have complex and multiple medical and psychosocial problems and are typically at high risk for increased hospitalization and incur high health care expenditures. Primary care models such as the patient-centered medical homes (PCMHs) are designed to improve care coordination and reduce care fragmentation. However, little is known about how the burden of care coordination for high-risk patients influences PCMH team members' stress.

OBJECTIVE

To evaluate the relationship between provider stress and care coordination time in high-risk patient care and whether availability of help is associated with reduced stress.

STUDY DESIGN

Multivariable regression analysis of a cross-sectional survey of PCMH primary care providers (PCPs) and nurses.

PARTICIPANTS

A total of 164 PCPs and 272 nurses in primary care practices at five geographically diverse Veteran Health Administration (VA) medical center health systems.

MAIN MEASURES

The main outcome variable was provider stress due to high-risk patient care. Independent variables were the reported proportion of high-risk patients in PCP/nurse patient panels, time spent coordinating care for these patients, and provider satisfaction with help received in caring for them.

KEY RESULTS

The response rate was 44%. Spending more than 8 h per week coordinating care was significantly associated with a 0.21-point increase in reported provider stress compared to spending 8 h or less per week (95% CI: 0.04-0.39; p = 0.015). The magnitude of the association between stress and care coordination time was diminished when provider satisfaction with help received was included in the model.

CONCLUSIONS

Perceived provider stress from care of high-risk patients may arise from challenges related to coordinating their care. Our findings suggest that the perception of receiving help for high-risk patient care may be valuable in reducing provider stress.

How Are Race, Cultural, and Psychosocial Factors Associated With Outcomes in Veterans With Spinal Cord Injury?

OBJECTIVE

To understand the role of cultural and psychosocial factors in the outcomes of veteran wheelchair users with spinal cord injury (SCI) to help clinicians identify unique factors faced by their patients and help researchers identify target variables for interventions to reduce disparities in outcomes.

DESIGN

Cross-sectional cohort study.

SETTING

Three urban Veterans Affairs medical centers affiliated with academic medical centers.

PARTICIPANTS

Of the patients (N=516) who were eligible to participate, 482 completed the interview and 439 had SCI. Because of small numbers in other race groups, analyses were restricted to white and African American participants, resulting in a final sample of 422.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Quality of life (QOL, Veterans RAND 12-Item Health Survey); satisfaction (Client Satisfaction Questionnaire); and participation (Craig Handicap Assessment and Reporting Technique Short Form).

RESULTS

African American Veterans reported poorer physical QOL but better mental QOL than did white Veterans. No other significant race differences were found in unadjusted analyses. Multivariable analyses showed that psychosocial factors were predominantly associated with patients' QOL outcomes and satisfaction with service, but demographic and medical factors were predominantly associated with participation outcomes. Interaction analyses showed that there was a stronger negative association between anxiety and mental QOL for African Americans than for whites, and a positive association between higher self-esteem and social integration for whites but not African Americans.

CONCLUSIONS

Findings suggest that attempts to improve the outcomes of Veterans with SCI should focus on a tailored approach that emphasizes patients' demographic, medical, and psychosocial assets (eg, building their sense of self-esteem or increasing their feelings of mastery), while providing services targeted to their specific limitations (eg, reducing depression and anxiety).

Quality and Equity in Wheelchairs Used by Veterans

OBJECTIVES

To assess in Veterans with spinal cord injury (SCI) or amputated limb (AL) the following: (1) patient demographics, medical factors, cultural and psychosocial characteristic by race; (2) wheelchair quality by race; and (3) the independent associations of patient race and the other factors with wheelchair quality.

DESIGN

Cross-sectional cohort study.

SETTING

Three Department of Veterans Affairs (VA) medical centers affiliated with academic medical centers.

PARTICIPANTS

Eligible participants were Veterans with SCI or ALs (N=516); 482 of them completed the interview. Analyses were restricted to white and African American participants. Because there was no variation in wheelchair quality among AL patients (n=42), they were excluded from all but descriptive analyses, leading to a final sample size of 421.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Wheelchair quality as defined by the Medicare Healthcare Common Procedure Coding System.

RESULTS

We found race differences in many of our variables, but not in quality for manual (odds ratio [OR]=.67; 95% confidence interval [CI], .33-1.36) or power (OR=.82; 95% CI, .51-1.34) wheelchairs. Several factors including age (OR=.96; 95% CI, .93-.99) and income (OR=3.78; 95% CI, 1.43-9.97) were associated with wheelchair quality. There were no significant associations of cultural or psychosocial factors with wheelchair quality.

CONCLUSIONS

Although there were no racial differences in wheelchair quality, we found a significant association of older age and lower income with poorer wheelchair quality among Veterans. Efforts are needed to raise awareness of such disparities among VA wheelchair providers and to take steps to eliminate these disparities in prescription practice across VA sites.

Patient prioritization of comorbid chronic conditions in the Veteran population: Implications for patient-centered care

Objective:

Patients with comorbid chronic conditions may prioritize some conditions over others; however, our understanding of factors influencing those prioritizations is limited. In this study, we sought to identify and elaborate a range of factors that influence how and why patients with comorbid chronic conditions prioritize their conditions.

Methods:

We conducted semi-structured, one-on-one interviews with 33 patients with comorbidities recruited from a single Veterans Health Administration Medical Center.

Findings:

The diverse factors influencing condition prioritization reflected three overarching themes: (1) the perceived role of a condition in the body, (2) self-management tasks, and (3) pain. In addition to these themes, participants described the rankings that they believed their healthcare providers would assign to their conditions as an influencing factor, although few reported having shared their priorities or explicitly talking with providers about the importance of their conditions.

Conclusion:

Studies that advance understanding of how and why patients prioritize their various conditions are essential to providing care that is patient-centered, reflecting what matters most to the individual while improving their health. This analysis informs guideline development efforts for the care of patients with comorbid chronic conditions as well as the creation of tools to promote patient–provider communication regarding the importance placed on different conditions.

Training Primary Care Physicians to Employ Self-Efficacy-Enhancing Interviewing Techniques: Randomized Controlled Trial of a Standardized Patient Intervention

BACKGROUND

Primary care providers (PCPs) have few tools for enhancing patient self-efficacy, a key mediator of myriad health-influencing behaviors.

OBJECTIVE

To examine whether brief standardized patient instructor (SPI)-delivered training increases PCPs' use of self-efficacy-enhancing interviewing techniques (SEE IT).

DESIGN

Randomized controlled trial.

PARTICIPANTS

Fifty-two family physicians and general internists from 12 primary care offices drawn from two health systems in Northern California.

INTERVENTIONS

Experimental arm PCPs received training in the use of SEE IT training during three outpatient SPI visits scheduled over a 1-month period. Control arm PCPs received a single SPI visit, during which they viewed a diabetes treatment video. All intervention visits (experimental and control) were timed to last 20 min. SPIs portrayed patients struggling with self-care of depression and diabetes in the first 7 min, then delivered the appropriate intervention content during the remaining 13 min.

MAIN MEASURES

The primary outcome was provider use of SEE IT (a count of ten behaviors), coded from three audio-recorded standardized patient visits at 1-3 months, again involving depression and diabetes self-care. Two five-point scales measured physician responses to training: Value (7 items: quality, helpfulness, understandability, relevance, feasibility, planned use, care impact), and Hassle (2 items: personal hassle, flow disruption).

KEY RESULTS

Pre-intervention, study PCPs used a mean of 0.7 behaviors/visit, with no significant between-arm difference (P = 0.23). Post-intervention, experimental arm PCPs used more of the behaviors than controls (mean 2.7 vs. 1.0 per visit; adjusted difference 1.7, 95 % CI 1.1-2.2; P < 0.001). Experimental arm PCPs had higher training Value scores than controls (mean difference 1.05, 95 % CI 0.68-1.42; P < 0.001), and similarly low Hassle scores.

CONCLUSIONS

Primary care physicians receiving brief SPI-delivered training increased their use of SEE IT and found the training to be of value. Whether patients visiting SEE IT-trained physicians experience improved health behaviors and outcomes warrants study. CLINICALTRIALS.

GOV IDENTIFIER

NCT01618552.

Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis

BACKGROUND

Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care.

METHODS

We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken.

RESULTS

Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low.

CONCLUSIONS

The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.

Disentangling the Linkage of Primary Care Features to Patient Outcomes: A Review of Current Literature, Data Sources, and Measurement Needs

Primary care plays a central role in the provision of health care, and is an organizing feature for health care delivery systems in most Western industrialized democracies. For a variety of reasons, however, the practice of primary care has been in decline in the U.S. This paper reviews key primary care concepts and their definitions, notes the increasingly complex interplay between primary care and the broader health care system, and offers research priorities to support future measurement, delivery and understanding of the role of primary care features on health care costs and quality.

Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review

The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing healthcare systems globally. It potentially threatens the coordination, continuity and safety of care. In this paper, we report the results of a scoping review examining the impact of multi-morbidity on the quality of healthcare. We used its results as a basis for a discussion of the challenges that research in this area is currently facing. In addition, we discuss its implications for health policy and clinical practice. The review identified 37 studies focussing on multi-morbidity but using conceptually different approaches. Studies focusing on 'comorbidity' (i.e. the 'index disease' approach) suggested that quality may be enhanced in the presence of synergistic conditions, and impaired by antagonistic or neutral conditions. Studies on 'multi-morbidity' (i.e. multiplicity of problems) and 'morbidity burden' (i.e. the total severity of conditions) suggested that increasing number of conditions and severity may be associated with better quality of healthcare when measured by process or intermediate outcome indicators, but with worse quality when patient-centred measures are used. However, issues related to the conceptualization and measurement of multi-morbidity (inconsistent across studies) and of healthcare quality (restricted to evaluations for each separate condition without incorporating considerations about multi-morbidity itself and its implications for management) compromised the generalizability of these observations. Until these issues are addressed and robust evidence becomes available, clinicians should apply minimally invasive and patient-centred medicine when delivering care for clinically complex patients. Health systems should focus on enhancing primary care centred coordination and continuity of care.

What are the core predictors of 'hassles' among patients with multimorbidity in primary care? A cross sectional study

Background

A limitation of service delivery in primary care in the United Kingdom is that services are often organised to manage discrete long-term conditions, using guidelines related to single conditions, and managed in clinics organised around single conditions. However, many older patients have more than one condition (so called multimorbidity). Qualitative research suggests that these patients experience ‘hassles’ in their care, including multiple appointments, poor co-ordination, and conflicting recommendations. However, there is limited quantitative evidence on the ‘hassles’ that patients with multimorbidity experience, or factors predicting ‘hassles’ in patients with multimorbidity.

Methods

We conducted a cross sectional study, mailing questionnaires to 1460 patients with multimorbidity identified from the disease registers of four general practices in the UK. Patients were asked to complete a range of self-report measures including measures of multimorbidity, measures of their experience of multimorbidity and service delivery. Data were analysed using regression modelling to assess the factors predicting ‘hassles’ in patients with multimorbidity.

Results

In total 33 % (n = 486) of patients responded to the baseline survey. The ‘hassles’ most often reported by patients related to lack of information about conditions and treatment options, poor communication among health professionals, and poor access to specialist care. There was a significant relationship between numbers of conditions, and reports of ‘hassles’. In multivariate analysis, 5 variables predicted more ‘hassles’: more long-term conditions, symptoms of anxiety and depression, younger age, being in paid employment, and not having a discussion with their GP in the last 12 months.

Conclusion

Hassles are frequently reported by patients with multimorbidity in primary care. A priority for future research should be on the development of new models of care that better cater for these patients. This research highlights core hassles that need to be addressed, and the patient groups that are most at risk, which may aid in the design of these new models.

Does patient experience of multimorbidity predict self-management and health outcomes in a prospective study in primary care?

BACKGROUND

There is a need to better understand the mechanisms which lead to poor outcomes in patients with multimorbidity, especially those factors that might be amenable to intervention.

OBJECTIVE

This research aims to explore what factors predict self-management behaviour and health outcomes in patients with multimorbidity in primary care in the UK.

METHODS

A prospective study design was used. Questionnaires were mailed out to 1460 patients with multimorbidity. Patients were asked to complete a range of self-report measures including measures of multimorbidity, measures of their experience of multimorbidity and service delivery and outcomes (three measures of self-management: behaviours, Self-monitoring and Insight and medication adherence; and a measure of self-reported health).

RESULTS

In total, 36% (n = 499) of patients responded to the baseline survey and 80% of those respondents completed follow-up. Self-management behaviour at 4 months was predicted by illness perceptions around the consequences of individual conditions. Self-monitoring and Insight at 4 months was predicted by patient experience of 'Hassles' in health services. Self-reported medication adherence at 4 months was predicted by health status, Self-monitoring and Insight and 'Hassles' in health services. Perceived health status at 4 months was predicted by age and patient experience of multimorbidity.

CONCLUSIONS

This research shows that different factors, particularly around patients' experiences of health care and control over their treatment, impact on various types of self-management. Patient experience of multimorbidity was not a critical predictor of self-management but did predict health status in the short term. The findings can help to develop and target interventions that might improve outcomes in patients with multimorbidity.

[Satisfaction with primary care nursing: use of measurement tools and explanatory factors]

OBJECTIVES

This study aims to assess the psychometric properties of two measurement tools for patient satisfaction with nursing care in Primary Care, the satisfaction level, and the personal and consultation characteristics associated with its variability.

METHODS

Subjects randomly selected in 23 Health Care centres in the Community of Madrid were included. Satisfaction was measured by means of the AMABLE and Baker questionnaires, in which the psychometric properties were evaluated. Sociodemographic characteristics of the consultations, variables related to health status, and other related to the consultation process were collected. An explanatory model using Generalized Estimating Equations was constructed.

RESULTS

The 662 subjects expressed a mean satisfaction of 4.95/5 (SD .25) with AMABLE, and 4.83/5 (SD .42) with the Baker questionnaire. AMABLE had a single dimension (Cronbach's alpha .85), and Baker three: professional care (mean 4.76, SD .48 Cronbach's alpha .74), depth of relationship (mean 3.76, SD 1.18, Cronbach's alpha .73), and perceived time (mean 4.42, SD .86, Cronbach's alpha .47). Ageing, a better perception of health status, and appointments arranged by nurses were associated with higher expressed satisfaction. Home care, hospital admissions, delayed consultation, extended family, or high family income were associated with lower satisfaction.

CONCLUSIONS

Satisfaction with nurse consultations in Primary Care was very high, and varied depending on personal characteristics and on the type of consultation. The assessed tools allowed this outcome to be measured properly.

What is care coordination?

Introduction

Care coordination is a high-priority area for improvement across healthcare systems, but no consensus definition of care coordination exists.

Methods

This article reviews published definitions of the term “care coordination,” identifies common themes among them, and presents a broad working definition of care coordination.

Results

The review identified 57 unique definitions of care coordination, ranging widely in the scope of participants, settings, and care processes included. Five major themes emerged from the definitions: care coordination involves numerous participants, is necessitated by interdependence among participants and activities, requires knowledge of others’ roles and resources, relies on information exchange, and aims to facilitate appropriate healthcare delivery. Only one definition identified included all five themes, and no one theme was found in a clear majority of definitions. The synthesized themes were incorporated into a broad working definition of care coordination, which has resulted in numerous uses (e.g. guide for systematic review of interventions, development of a measures repository, reference for this journal’s recast focus on the subject).

Discussion

Some ambiguity remains about the definition of care coordination, but the breadth of definitions in use underscores its widespread recognition as important for high-quality care. Even as understanding of care coordination continues to evolve, broad and flexible definitions can help guide the iterative process of developing conceptual models, testing them empirically, refining models, generating evidence about what works best, and ultimately improving the quality of care.

Public assessment of key performance indicators of healthcare in a Canadian province: the effect of age and chronic health problems

This study explores the effect of age and chronic conditions on public perceptions of the health system, as measured by the Key Performance Indicators (KPIs) of healthcare, in the province of Alberta in Canada. Drawing from data collected by Government of Alberta’s Department of Health and Wellness, this research examines two key questions: (1) Do people in the 65+ age group rate the KPIs of healthcare (i.e., availability, accessibility, quality, outcome, and satisfaction) more favorably compared to people in younger age groups in Alberta? (2) Does the rating of KPIs of healthcare in Alberta vary with different chronic conditions (i.e., no chronic problem, chronic illnesses without pain, and chronic pain)? The findings indicate that people in the older age group tend to rate the KPIs of healthcare more favorably compared to younger age groups in Alberta, net of socio-demographic factors, self-reported health status, and knowledge and utilization of health services. However, people experiencing chronic pain are less likely to rate the KPIs of healthcare favorably compared to people with no chronic health problem in Alberta. Discussion includes implications of the findings for the healthcare system in the province.

Interprofessional faculty development: integration of oral health into the geriatric diabetes curriculum, from theory to practice

Background

Health care workforce shortages and an increase demand for health care services by an older demographic challenged by oral–systemic conditions are being recognized across health care systems. Demands are placed on health care professionals to render coordinated delivery of services. Management of oral–systemic conditions requires a trained health care workforce to render interprofessional patient-centered and coordinated delivery of health care services. The purpose of this investigation was to evaluate the effectiveness of an interprofessional health care faculty training program.

Methods

A statewide comprehensive type 2 diabetes training program was developed and offered to multidisciplinary health care faculty using innovative educational methods. Video-recorded clinically simulated patient encounters concentrated on the oral–systemic interactions between type 2 diabetes and comorbidities. Post-encounter instructors facilitated debriefing focused on preconceptions, self-assessment, and peer discussions, to develop a joint interprofessional care plan. Furthermore, the health care faculty explored nonhierarchical opportunities to bridge common health care themes and concepts, as well as opportunities to translate information into classroom instruction and patient care.

Results

Thirty-six health care faculty from six disciplines completed the pre-research and post-research assessment survey to evaluate attitudes, knowledge, and perceptions following the interprofessional health care faculty training program. Post-training interprofessional team building knowledge improved significantly. The health care faculty post-training attitude scores improved significantly, with heightened awareness of the unique oral–systemic care needs of older adults with type 2 diabetes, supporting an interprofessional team approach to care management. In addition, the health care faculty viewed communication across disciplines as being essential and interprofessional training as being vital to the core curriculum of each discipline. Significant improvement occurred in the perception survey items for team accountability and use of uniform terminology to bridge communication gaps.

Conclusion

Attitude, knowledge, and perceptions of health care faculty regarding interprofessional team building and the team approach to management of the oral–systemic manifestations of chronic disease in older adults was improved. Uniform language to promote communication across health professionals, care settings, and caregivers/patients, was noted. Interprofessional team building/care planning should be integrated in core curricula.

Process indicators of quality clinical pharmacy services during transitions of care

The American College of Clinical Pharmacy charged the Public and Professional Relations Committee to develop a short white paper describing quality measures of clinical pharmacists' patient care services in transitional care settings. Transitional care describes patient movement from one health care setting or service to another. Care transitions are associated with an increased risk of adverse events for patients. Pharmacists play an important role in ensuring that medication errors and adverse events are minimized during these transitions, largely through the reconciliation of medications and assurance of continuity of care. Quality measures are often divided into three domains: structure, process, and outcome. Given the typical nature of the pharmacist's role, process indicators are best suited to evaluate quality clinical pharmacist services. However, process indicators relevant to pharmacists' activities are not yet fully described in the literature. The committee searched available literature describing quality measures that are directly influenced by the pharmacist during care transitions. This white paper describes these process indicators as quality measures of clinical pharmacists' services, identifies the transitional settings and activities to which they are most applicable, and provides the published sources from which indicators were derived. For process indicators that could not be found in published sources, we propose relevant measures that can be adapted for use in a given setting. As pharmacists become more involved in diverse and emerging patient care areas such as transitional care, it will be critical that they use these types of measures to document the quality of new services and reinforce the need for pharmacist participation during transitions of care.

Chronic illness and patient satisfaction

OBJECTIVE

To examine how the relationship between patient characteristics, patient experience with the health care system, and overall satisfaction with care varies with illness complexity.

DATA SOURCES/STUDY SETTING

Telephone survey in 14 U.S. geographical areas.

STUDY DESIGN

Structural equation modeling was used to examine how relationships among patient characteristics, three constructs representing patient experience with the health care system, and overall satisfaction with care vary across patients by number of chronic illnesses.

DATA COLLECTION/EXTRACTION METHODS

Random digital dial telephone survey of adults with one or more chronic illnesses.

PRINCIPAL FINDINGS

Patients with more chronic illnesses report higher overall satisfaction. The total effects of better patient-provider interaction and support for patient self-management are associated with higher satisfaction for all levels of chronic illness. The latter effect increases with illness burden. Older, female, or insured patients are more satisfied; highly educated patients are less satisfied.

CONCLUSIONS

Providers seeking to improve their patient satisfaction scores could do so by considering patient characteristics when accepting new patients or deciding who to refer to other providers for treatment. However, our findings suggest constructive actions that providers can take to improve their patient satisfaction scores without selection on patient characteristics.

Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012

As of 2005, the literature on the benefits of primary care oriented health systems was consistent in showing greater effectiveness, greater efficiency, and greater equity. In the ensuing five years, nothing changed that conclusion, but there is now greater understanding of the mechanisms by which the benefits of primary care are achieved. We now know that, within certain bounds, neither the wealth of a country nor the total number of health personnel are related to health levels. What counts is the existence of key features of health policy (Primary Health Care): universal financial coverage under government control or regulation, attempts to distribute resources equitably, comprehensiveness of services, and low or no copayments for primary care services. All of these, in combination, produce better primary care: greater first contact access and use, more person-focused care over time, greater range of services available and provided when needed, and coordination of care. The evidence is no longer confined mainly to industrialized countries, as new studies show it to be the case in middle and lower income countries. The endorsements of the World Health Organization (in the form of the reports of the Commission on Social Determinants of Health and the World Health Report of 2008, as well a number of other international commissions, reflect the widespread acceptance of the importance of primary health care. Primary health care can now be measured and assessed; all innovations and enhancements in it must serve its essential features in order to be useful.

Proposed model of integrated care to improve health outcomes for individuals with multimorbidities

Multimorbidity is defined as the coexistence of multiple chronic conditions. Individuals with multimorbidity typically present with complex needs and show significant changes in their functional health and quality of life. Multimorbidity in the aging population is well recognized, but there has been limited research on ways to manage the problem effectively. More recent studies have demonstrated a high prevalence of multimorbidity in the younger demographics aged under 65 years. There is a definite need to develop models of care that can manage these individuals effectively and mitigate the impact of illness on individuals and the financial burden to the health care system. An integrated model of care has been developed and implemented in a facility in Nova Scotia that routinely treats individuals with multiple chronic conditions. This care model is designed to address the specific needs of this complex patient population, with integrated and coordinated care modules that meet the needs of the person versus the disease. The results of a pilot evaluation of this care model are also discussed.

QUALICOPC, a multi-country study evaluating quality, costs and equity in primary care

Background

The QUALICOPC (Quality and Costs of Primary Care in Europe) study aims to evaluate the performance of primary care systems in Europe in terms of quality, equity and costs. The study will provide an answer to the question what strong primary care systems entail and which effects primary care systems have on the performance of health care systems. QUALICOPC is funded by the European Commission under the "Seventh Framework Programme". In this article the background and design of the QUALICOPC study is described.

Methods/design

QUALICOPC started in 2010 and will run until 2013. Data will be collected in 31 European countries (27 EU countries, Iceland, Norway, Switzerland and Turkey) and in Australia, Israel and New Zealand. This study uses a three level approach of data collection: the system, practice and patient. Surveys will be held among general practitioners (GPs) and their patients, providing evidence at the process and outcome level of primary care. These surveys aim to gain insight in the professional behaviour of GPs and the expectations and actions of their patients. An important aspect of this study is that each patient's questionnaire can be linked to their own GP's questionnaire. To gather data at the structure or national level, the study will use existing data sources such as the System of Health Accounts and the Primary Health Care Activity Monitor Europe (PHAMEU) database. Analyses of the data will be performed using multilevel models.

Discussion

By its design, in which different data sources are combined for comprehensive analyses, QUALICOPC will advance the state of the art in primary care research and contribute to the discussion on the merit of strengthening primary care systems and to evidence based health policy development.

Social but safe? Quality and safety of diabetes-related online social networks

OBJECTIVE

To foster informed decision-making about health social networking (SN) by patients and clinicians, the authors evaluated the quality/safety of SN sites' policies and practices.

DESIGN

Multisite structured observation of diabetes-focused SN sites. Measurements 28 indicators of quality and safety covering: (1) alignment of content with diabetes science and clinical practice recommendations; (2) safety practices for auditing content, supporting transparency and moderation; (3) accessibility of privacy policies and the communication and control of privacy risks; and (4) centralized sharing of member data and member control over sharing.

RESULTS

Quality was variable across n=10 sites: 50% were aligned with diabetes science/clinical practice recommendations with gaps in medical disclaimer use (30% have) and specification of relevant glycosylated hemoglobin levels (0% have). Safety was mixed with gaps in external review approaches (20% used audits and association links) and internal review approaches (70% use moderation). Internal safety review offers limited protection: misinformation about a diabetes 'cure' was found on four moderated sites. Of nine sites with advertising, transparency was missing on five; ads for unfounded 'cures' were present on three. Technological safety was poor with almost no use of procedures for secure data storage and transmission; only three sites support member controls over personal information. Privacy policies' poor readability impedes risk communication. Only three sites (30%) demonstrated better practice. Limitations English-language diabetes sites only.

CONCLUSION

The quality/safety of diabetes SN is variable. Observed better practice suggests improvement is feasible. Mechanisms for improvement are recommended that engage key stakeholders to balance autonomy, community ownership, conditions for innovation, and consumer protection.

Increasing Primary Care Comorbidity: A Conceptual Research and Practice Framework

Purpose: To present a “contrasting perspectives” conceptual framework reflecting the typically strained experiences of many comorbid adults now interacting with primary care clinicians across the world. Background: More comorbidity-related needs are presented to primary care clinicians during typically shorter office-based health care encounters. The overall perceptual differences between many comorbid consumers and health care clinicians and systems in many countries are likely to worsen. Conclusions: Conceptual implications are discussed for primary care researchers testing interventions and attempting to influence the outcomes of increasingly comorbid primary care adults. Implications for Nursing Research and Practice: Three strategies are offered for researchers and clinicians considering how to include elements of comorbidity into their prospective primary care study interventions and care delivery processes.

The breadth of primary care: a systematic literature review of its core dimensions

Background

Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level.

Methods

A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit.

Results

Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health.

Conclusions

A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.