Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors

Quality of care for chronic conditions: identifying specificities of quality aims based on scoping review and Delphi survey

There is a growing need to implement high quality chronic care to address the global burden of chronic conditions. However, to our knowledge, there have been no systematic attempts to define and specify aims for chronic care quality. To address this gap, we conducted a scoping review and Delphi survey to establish and validate comprehensive specifications. The Institute of Medicine's (IOM) quality of care definition and aims were used as the foundation. We purposively selected articles from the scientific (n=48) and grey literature (n=26). We sought papers that acknowledged and unpacked the plurality of quality in chronic care and proposed or utilised frameworks, studied their implementation, or investigated at least two IOM quality care aims and implementation. Articles were analysed both deductively and inductively. The findings were validated through a Delphi survey involving 49 international chronic care experts with varied knowledge of, and experience in, low-and-middle-income countries. Considering the natural history of chronic conditions and the journey of a person with a chronic condition, we defined and identified the aims of chronic care quality. The six IOM aims apply with specific meanings. We identified a seventh aim, continuity, which relates to the issue of chronicity. The group endorsed our specifications and several participants gave contextualised interpretations and concrete examples. Chronic conditions pose specific challenges underscoring the relevance of tailoring quality of care aims. The next steps require a tailored definition and specific aims to improve, measure and assure the quality of chronic care.

Health Insurance Coverage and Access to Care by Sexual Orientation During the COVID-19 Pandemic: United States, January 2021-February 2022

Objectives. To compare health insurance coverage and access to care by sex and sexual minority status during the COVID-19 pandemic and assess whether lack of insurance hindered access to care by sexual minority status. Methods. Using Behavioral Risk Factor Surveillance System data (January 2021-February 2022), we examined differences by sex and sexual orientation among 158 722 adults aged 18 to 64 years living in 34 states. Outcomes were health insurance coverage type and 3 access to care measures. Results. Sexual minority women were significantly more likely to be uninsured than were heterosexual women, and lack of insurance widened the magnitude of disparity by sexual minority status in all measures of access. Compared with heterosexual men with health insurance, sexual minority men with health insurance were significantly more likely to report being unable to afford necessary care. Conclusions. During the pandemic, 1 in 8 sexual minority adults living in 34 study states were uninsured. Among sexual minority women, lack of insurance widened inequities in access to care. There were inequities among sexual minority men with health insurance. Public Health Implications. Sexual minority adults may be disproportionately affected by the unwinding of the COVID-19 public health emergency and may require tailored efforts to mitigate insurance coverage loss. (Am J Public Health. 2024;114(1):118-128. https://doi.org/10.2105/AJPH.2023.307446).

Creating and Activating an Implementation Community to Drive HPV Vaccine Uptake in Texas: The Role of an NCI-Designated Cancer Center

The University of Texas MD Anderson Cancer Center, a comprehensive cancer center designated by the National Cancer Institute (NCI), defines its service population area as the State of Texas (29.1 M), the second most populous state in the country and the state with the greatest number of uninsured residents in the United States. Consistent with a novel and formal commitment to prevention as part of its core mission, alongside clear opportunities in Texas to drive vaccine uptake, MD Anderson assembled a transdisciplinary team to develop an institutional Framework to increase adolescent HPV vaccination and reduce HPV-related cancer burden. The Framework was developed and activated through a four-phase approach aligned with the NCI Cancer Center Support Grant Community Outreach and Engagement component. MD Anderson identified collaborators through data-driven outreach and constructed a portfolio of collaborative multi-sector initiatives through review processes designed to assess readiness, impact and sustainability. The result is an implementation community of 78 institutions collaboratively implementing 12 initiatives within a shared measurement framework impacting 18 counties. This paper describes a structured and rigorous process to set up the implementation of a multi-year investment in evidence-based strategies to increase HPV vaccination that solves challenges preventing implementation of recommended strategies and to encourage similar initiative replication.

A Qualitative Approach to Explore Perceptions, Opinions and Beliefs of Communities who Experienced Health Disparities towards Chronic Health Conditions

The prevalence of chronic medical conditions is associated with biological, behavioral, and social factors. In Puerto Rico (PR), events such as budget cuts to essential services in recent years have contributed to deepening health disparities. This study aimed to explore community perceptions, opinions, and beliefs about chronic health conditions in the southern region of Puerto Rico. Framed by a Community-Based Participatory Research (CBPR) approach, this qualitative study developed eight focus groups (n = 59) with adults (age of 21 or older) from southern Puerto Rico, in person and remotely, during 2020 and 2021. Eight open-ended questions were used for discussions, which were recorded, transcribed, and analyzed via computer analysis. Content analysis revealed four main dimensions: knowledge, vulnerabilities, barriers, and identified resources. Relevant topics included: concerns about mental health-depression, anxiety, substance use, and suicide; individual vulnerabilities-risk behaviors, and unhealthy habits; economic factors-health access and commercialization of health. Resource identification was also explored, and participants discussed the importance of alliances between public and private sectors. These topics were addressed across all focus groups, with various recommendations. The results highlight the importance of prioritizing identified community needs, evaluating available resources, and promoting tailored-made interventions to reduce risk factors for chronic health conditions.

Patterns of healthcare utilization with placement changes for youth in foster care

BACKGROUND

Children in foster care experience poor health and high healthcare use. Child welfare agencies frequently require healthcare visits when children enter foster care; subsequent placement changes also disrupt healthcare. Studies of healthcare use have not accounted for placement changes.

OBJECTIVE

To understand patterns of healthcare use throughout the time a child enters foster care and with placement changes, accounting for mandated visits when children enter foster care or experience a placement change.

PARTICIPANTS AND SETTING

Children 4 and older in foster care between 2012 and 2017 (N = 2787) with linked child welfare administrative data from one county child welfare agency and one Midwest pediatric healthcare system.

METHODS

Negative binomial models predicted healthcare days per month that were planned (e.g., scheduled primary/specialty care), unplanned (e.g., emergency care), or missed.

RESULTS

Planned healthcare days increased as a function of placement changes (Incident Rate Ratio [IRR] =1.69, p < .05) and decreased with placement stability (IRR = 0.92, p < .01). Mandated visits that occurred later in a placement were associated with fewer planned (IRR = 0.81, p < .01) and unplanned (IRR = 0.82, p < .01) healthcare days during that placement.

CONCLUSIONS

Patterns of planned healthcare over the time children are in one placement and move between placements suggest more can be done to ensure youth remain connected to primary and specialty care throughout placements and placement transitions, s that children are seen as clinically appropriate rather than a function of placement disruption. Findings regarding the timing of mandated visits suggest that delays in mandated care may also reflect lower healthcare use overall.

The Brave Patient after 80-Satisfaction with Visit and Individual Determinants of Proactive Patient Attitude among the Oldest General Practice Users

Background. A patient’s adherence to a course of treatment depends on the individual’s activation, the quality of patient–clinician relations, attitudes, self-efficacy, or positive emotions. Patient proactive attitude (PAA) is seldom researched among the oldest healthcare users. This study was designed to identify predictors of PAA toward health and treatment among community-dwelling general practice patients aged 80+, and was based on a PRACTA (PRomoting ACTive Aging) project. Methods. Patients (n = 658), aged 80+ visiting a general practitioner (GP) filled in the PRACTA attitude toward treatment and health scale and the PRACTA self-efficacy scale questionnaires. Sociodemographic factors, self-reported health status, and satisfaction with the visit were analyzed as independent factors. Results. Attitudes toward treatment and health scores were predicted by marital status, living alone or not alone, hospitalization the prior year, level of impairment, and satisfaction with visit. However, some differences were observed depending on the device’s subscale. Self-efficacy score was determined by marital status, living alone or not alone, prior hospitalization, and satisfaction with visit. We did not find an effect of age or gender on PAA. Patient satisfaction with visit was the strongest predictor of all PAA dimensions. Conclusion. Higher visit satisfaction helps to retain a PAA among seniors 80+. Screening questions about living situation, marital and functional status, emotional state, and recent history of hospitalization might help GPs additionally anticipate PAA level and adjust their actions accordingly.

Effects of Child Protective Custody Status and Health Risk Behaviors on Health Care Use Among Adolescents

OBJECTIVE

To determine whether current protective custody status (ie, youth currently in the temporary or permanent custody of child protective services, eg, foster and kinship care) contributes to increased health care utilization compared to youth never in protective custody. Health characteristics (eg, mental health diagnoses) and behaviors (eg, substance use) were expected to account for differences in health care use among the two groups.

METHODS

Retrospective child welfare administrative data and linked electronic health records data were collected from a county's child welfare system and affiliated freestanding children's hospital between 2012 and 2017. Youth currently in protective custody (n = 2787) were identified and demographically matched to peers never in custody (n = 2787) who received health care from the same children's hospital. Health care use, health risk behaviors, and social, demographic, and diagnostic data were extracted and compared for both cohorts.

RESULTS

In baseline models, health care use was higher for youth in protective custody compared to peers. In adjusted models that included health risk behaviors and patient characteristics, protective custody status was associated with decreased primary and missed care, and no longer a significant predictor of other types of health care use.

CONCLUSIONS

Youth had significantly higher utilization while in protective custody than their demographically similar peers; however, health risk behaviors appear to account for most group differences. Identification of current custody status in pediatric settings and addressing health risk behaviors in this population may be important for health care systems interested in altering health care use and/or cost for this population.

Improving Quality Improvement Capacity and Clinical Performance in Small Primary Care Practices

PURPOSE

We undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease.

METHODS

A total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs-appropriate aspirin use, blood pressure (BP) control (<140/90 mm Hg), and smoking screening/cessation counseling-at baseline (2015) and follow-up (2017). Regression analyses with change in CQM as the dependent variable allowed for clustering by practice facilitator and adjusted for baseline CQM performance.

RESULTS

Practices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P <.001) from an average baseline of 6.45. All 3 CQMs also improved: aspirin use by 3.98% (average baseline = 66.8%; 95% CI for change, 1.17%-6.79%; P = .006); BP control by 3.36% (average baseline = 61.5%; 95% CI for change, 1.44%-5.27%; P = .001); and tobacco screening/cessation counseling by 7.49% (average baseline = 73.8%; 95% CI for change, 4.21%-10.77%; P <.001). Each 1-point increase in QICA score was associated with a 1.25% (95% CI, 0.41%-2.09%, P = .003) improvement in BP control; the estimated likelihood of reaching a 70% BP control performance goal was 1.24 times higher (95% CI, 1.09-1.40; P <.001) for each 1-point increase in QICA.

CONCLUSION

Improvements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months.

The association between GP organisational factors and the effectiveness of a prevention programme for cardiometabolic diseases: a prospective intervention study

Background

Owing to the rising disease burden of cardiometabolic diseases (CMD), prevention programmes for CMD are increasingly implemented in primary care. Organisational practice characteristics and availability of preventive services may be associated with a more effective programme.

Aim

To identify possible organisational success factors from general practices related to an effective primary prevention programme for CMD.

Design & setting

A prospective intervention study involving 37 Dutch general practices was undertaken.

Method

Patients aged 45–70 years without known CMD, hypertension, or hypercholesterolemia were invited for the prevention programme. The outcome measures were an improvement (yes/no) in four different CMD risk factors between baseline and 1-year follow-up on an individual level (body mass index [BMI], smoking, systolic blood pressure, and cholesterol ratio). Multivariate logistic regression analysis was used for assessing associations between practice organisational characteristics and outcomes.

Results

Just over half of the participants showed an improvement on one or more risk factors. Marginal differences were found in the four different outcomes between the practices with different organisational characteristics. None of the practice characteristics that were tested showed a significant association with an improvement in one of the outcome measures.

Conclusion

In this study, general practice organisational and preventive service characteristics showed no impact on the effectiveness of a CMD prevention programme. Possible explanations could be the effectiveness of protocolised pharmaceutical treatment and only limited contribution of lifestyle programmes on the improvement of CMD risk factors.

Evaluating the integration of chronic care elements in primary health care for people with mental illness: a longitudinal study in Nepal conducted among primary health care workers

Background

Despite many important developments in the global mental health arena in the past decade, many people with mental health problems still do not have access to good quality mental health care. The aim of this study was to evaluate the perceived impact of a mental health care package (MHCP) in integrating chronic care elements in primary health care for people with mental illness.

Methods

A controlled pre-post study design was used in 20 primary health care facilities in Chitwan, Nepal. We compared 10 health facilities that had implemented a MHCP (intervention group), with 10 health facilities that had not implemented the MHCP (comparative control group) but provided regular physical health services. We administered the Assessment of Chronic Illness Care (ACIC) tool on a group basis within all 20 health facilities among 37 health workers. Data was collected at three time points; at baseline, midline (at 13 months from baseline) and end line (at 25 months from baseline).

Results

From baseline to end line, we see a notable shift in the level of support reported by the intervention health facilities compared to those in the comparative control group. While at baseline 10% of the intervention health facilities had basic support for the implementation of chronic illness care, at the end line, 90% of the intervention group reported having reasonable support with the remaining 10% of the intervention facilities reporting that they had full support. In contrast, 20% of the health facilities in the comparative control group at end line still reported having limited support for the implementation of chronic illness care, with the remaining 80% only managing to shift to the next level which is basic support.

Conclusions

These findings suggest that training and supervision of primary health care workers in the implementation of MHCP interventions can lead to strengthening of the system to better address the needs of patients with chronic mental health problems. However, substantial financial and coordination inputs are needed to implement the MHCP. The comparative control group also demonstrated improvements, possibly due to the administration of the ACIC tool and components of counselling services for family planning and HIV/AIDS services.

Priority community engagement strategies for cardiovascular health: A checklist for community pharmacists

OBJECTIVE

The objective of this study was to identify essential strategies for use by community pharmacists seeking to establish community partnerships to prevent and manage cardiovascular disease (CVD) in their local communities.

METHODS

A multistep process was used to develop and refine the Community-Clinical Linkages for Cardiovascular Health (CCL-CVD) checklist. First, the authors reviewed the extant literature related to community pharmacists' community engagement and identified evidence-based recommendations for community pharmacists from the Centers for Disease Control and Prevention's guidance documents and linkage framework. Next, the authors developed a 9-item checklist of community engagement strategies for use by practicing community pharmacists with an interest in health promotion and partnership development. The authors then surveyed 15 content experts from across the United States and asked them to evaluate each of the 9 checklist items on a 3-point scale: (1) essential; (2) useful, but not essential; or (3) not necessary. On the basis of the survey results, the authors calculated a content validity ratio (CVR) for each of the 9 strategies and performed a content analysis of the qualitative responses provided by the content experts.

RESULTS

Eleven content experts completed the survey for a response rate of 73%. The CVR for 3 strategies from the initial CCL-CVD checklist reached statistical significance, and these 3 strategies were considered essential strategies for community pharmacists to use when working to develop community partnerships to improve CVD. The following strategies were considered essential: (1) gathering data to support the need for pharmacists' services, (2) identifying preferred communication strategies, and (3) creating mechanisms for documentation and establishing an evaluation plan. An additional strategy-develop goals and objectives for the partnership-neared statistical significance and was included as a second-tier strategy.

CONCLUSION

The multistep process resulted in a practical, 2-tiered checklist for use by community pharmacists who are interested in community engagement and developing sustainable CCLs to improve CVD health.

Enhancing self-resources in patients with chronic diseases: development and initial validation of the Disease and Care Management Score

Introduction:

Despite the importance of the assessment in the primary care of the self-resources among patients with chronic diseases, there is not available a measurement that allows this kind of comprehensive assessment. For this reason, the aim of this study was to develop a multi-dimensional score to determine the level of self-resources in chronic patients, describing its initial validation through face and content validity. The developed score was labelled as Disease and Care Management Score.

Methods:

We performed a methodological study, encompassing two main phases. The first phase was aimed to develop the Disease and Care Management score, choosing the most suitable measurement to assess each pre-identified determinant of wellbeing in chronic patients. The second phase was aimed to determine the Disease and Care Management score face and content validity through the views of 20 experts.

Results:

Disease and Care Management score shows evidence of face and content validity. All the obtained quantitative content validity indices (i.e. Content Validity Ratio, Content Validity Indices) were higher than 0,70, showing the pertinence and the adequacy of each pre-identified measure to compute Disease and Care Management score.

Conclusion:

Disease and Care Management score has the potential of addressing the health coaching interventions in primary care for chronic patients. Future research should show its predictive performance, as well as the cut-off to discriminate patients. (www.actabiomedica.it)

Impact of Physician Referral to Health Coaching on Patient Engagement and Health Risks: An Observational Study of UPMC's Prescription for Wellness

PURPOSE

Evaluate impact of physician referral to health coaching on patient engagement and health risk reduction.

DESIGN

Four-year retrospective, observational cohort study with propensity-matched pair comparisons.

SETTING

Integrated delivery and finance system in Pittsburgh, Pennsylvania.

SAMPLE

10 457 adult insured members referred to health coaching by their physician; 37 864 other members identified for health coaching through insurer-initiated outreach.

INTERVENTION

Practice-based, technology-supported workflow and process for physician prescribing of health coaching during regular office visit, with follow-up on patient's progress and implementation supports.

MEASURES

Patient engagement based on completion of pre-enrollment assessment, formal enrollment in health coaching, completion of required sessions, health risk levels, and number of health risks pre- and post-health coaching referral.

ANALYSIS

Difference-in-difference analysis to assess change in health risk levels and number of health risks pre- and post-health coaching and probability weighting to control for potential confounding between groups.

RESULTS

Members referred by a physician were significantly more likely to enroll in a health coaching program (21.0% vs 6.0%, P < .001) and complete the program requirements (8.5% vs 2.7%, P < .001) than when referred by insurer-initiated outreach; significant within group improvement in health risk levels from baseline (P < .001) was observed for both the groups.

CONCLUSIONS

Patients are significantly more likely to engage in health coaching when a referral is made by a physician; engagement in health coaching significantly improves health risk levels.

Engaging Patients in their Health Care: Lessons From a Qualitative Study on the Processes Health Coaches Use to Support an Active Learning Paradigm

Background

While recent health-care trends rely on activated patients, few studies report direct observations of how to engage and activate patients to be full participants in their own health care. The interpersonal processes and communication strategies used in integrative health coaching (IHC) may offer important insight into how clinicians can help patients step into a more active learning model rather than more typical passive roles.

Objective

This study uses verbatim transcripts of medical patients’ first few IHC sessions to identify the actual processes used to help patients embrace this more active learning role.

Methods

A thematic analysis was conducted of 72 verbatim transcripts from IHC sessions of 26 patients with severe dysfunction from tinnitus. The patients participated in 6 months of IHC as part of a larger integrative intervention in a randomized, controlled pilot designed to assess feasibility for a larger randomized, controlled trial on the clinical effectiveness of an integrative intervention.

Results

Four themes emerged: (1) Describing the Health Coaching Process to patients; (2) Using Key Procedures for Action Planning—optimal health future self-visualization, Wheel of Health, and exploration of the gap between current and desired states to help patients set goals for themselves; (3) Supporting Action and Building Momentum—the creation and support of action steps with frequent reinforcement of self-efficacy; and (4) Active Listening and Inviting the Patient to Articulate Learning—coaches’ active listening process included reflection, clarifying questions, turning patient questions back to the patients, highlighting values, identifying potential barriers and resources, and inviting patients to articulate what they were learning.

Conclusion

The processes identified in IHC incorporate key principles of adult learning theory and engage patients’ innate resources of goal orientation, self-direction, and intrinsic motivation. These interpersonal processes help patients embrace a more active learning role, with implications for patient engagement in other clinical contexts.

Care Experiences of Patients with Multiple Chronic Conditions in a Payer-Based Patient-Centered Medical Home

Individuals with multiple chronic health conditions require additional support and medical services, incur higher health care costs, and often have a higher risk of hospitalization. The goal of this study was to examine care experiences of patients with multiple chronic conditions in the CareFirst patient-centered medical home (PCMH). The study used a repeated cross-sectional research design and included 1308 adult CareFirst plan members with multiple chronic conditions. Patient care experiences were collected using a structured telephone survey in 2015 and 2017. Composite scores and individual question responses for patient-provider communication, coordination of care, access to care, and self-management support were analyzed to determine differences between survey years. Overall, patients reported positive care experiences with communication, self-management support, and care coordination. Access to care indicators received lower composite scores. Between 2015 and 2017, patients reported higher ratings for appointment reminders, communicating test results, providers listening carefully, and care plan effectiveness. Patients who completed their CareFirst PCMH care plan had higher care experience scores than patients who did not. A key finding of this study is that care plan completion is associated with positive care experiences, indicating the importance of the care plan to this PCMH model. Lower scores on access to care measures suggest a need for improved pathways for patients to obtain care during nontraditional office hours. Payer-based PCMH models that include enhanced care coordination and additional provider payments to support these activities may be beneficial to patients with multiple chronic conditions.

Implementing dementia risk reduction in primary care: a preliminary conceptual model based on a scoping review of practitioners' views

Primary care practitioners (PCPs) do not routinely promote dementia risk reduction. The purpose of this study was to map the published literature on the views of PCPs about dementia risk reduction, in order to identify implementation constructs and strategies crucial to the development of an implementation intervention to support dementia risk reduction in primary care. We undertook a scoping review of the PCPs' views about promoting brain health for reducing dementia risk. We searched MEDLINE, PsycINFO, CINAHL, and Embase for English-language articles published between 1995 and December 2017. We then applied the Consolidated Framework for Implementation Research (CFIR) and matched Expert Recommendations for Implementing Change to the scoping review findings in order to develop a preliminary implementation model. Eight articles reported views of PCPs about dementia prevention. Study findings were mapped to 5 of the 39 CFIR constructs: (i) knowledge and beliefs about dementia risk reduction, (ii) evidence strength and quality, (iii) relative priority, (iv) available resources, and (v) external policy and incentives. The findings suggest implementation strategies to consider in our preliminary model include (i) educational meetings, (ii) identifying and preparing champions, (iii) conducting local consensus discussions, (iv) altering incentive structures, and (v) capturing and sharing local knowledge. There have been few studies about the views of PCPs about dementia risk reduction. Implementation in the primary care setting is fundamental to early identification of risk and supporting preventive practices, but it needs to focus on more than just education for PCPs. We need more up-to-date and in-depth data on the views of PCPs about dementia risk reduction and context-specific analyses of implementation needs. Further research into effective primary care interventions to reduce dementia risk is expected to support implementation efforts.

Reducing cardiovascular disease in a rural community

In this case report, we describe the one-year formative phase of a five-year study to develop, implement, and test a community health worker (CHW)-delivered cardiovascular disease (CVD) prevention intervention. The purpose of the formative phase was to engage community partners in the adaptation of an existing evidence-based CVD prevention intervention to fit the needs and preferences of a rural, predominantly African-American community. The formative work was guided by a framework for adapting evidence-based interventions and involved engaging stakeholders in assessing the intervention's fit with the local context and then applying assessment findings to iteratively adapt the intervention's contents, materials, and delivery methods. Findings from the formative work were then applied to develop CHW position descriptions, workflow diagrams, and a training plan. Findings also were applied to adapt intervention materials and protocols to fit the needs of the community. This case report illustrates how community-engaged formative work can be applied to adapt an evidence-based intervention to fit community needs and resources.

Organizational culture and the adoption of anti-smoking initiatives at small to very small workplaces: An organizational level analysis

INTRODUCTION

Many workplaces have adopted anti-smoking initiatives to reduce smoking behavior, but small workplaces are less likely to adopt these initiatives. One factor that could influence adoption is organizational culture, defined as the values and assumptions shared by members of an organization. The aim of this study was to examine the types of organizational culture associated with smoking policy strength and adoption of smoking cessation activities at small (20–99 employees) and very small (<20 employees) workplaces. Two study hypotheses were made: An increase in clan culture (characterized by participation in decision-making and human resources development) will be associated with an increase in smoking policy strength (H1) and higher odds of having cessation activities in the workplace (H2).

METHODS

Between June and October 2017, executives and employees coming from small and very small workplaces participated in separate surveys. Executives answered questions about their workplace’s anti-smoking initiatives, while employees completed a 12-item questionnaire about organizational culture. We aggregated employee data to perform linear and logistic regression at the organizational level.

RESULTS

Organizational culture was not significantly associated with smoking policy strength, therefore H1 was not supported. Counter to H2, an increase in clan culture was associated with lower odds of offering smoking cessation activities (OR=0.06; 95% CI: 0.01–0.58).

CONCLUSIONS

We did not find support for the hypothesized relationships. External factors and additional cultural characteristics may explain study findings. Continued research on culture and ways to improve tobacco control within smaller workplaces is needed.

Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association

Growing scientific evidence of the benefits of heart-healthy dietary patterns and of the massive public health and economic burdens attributed to obesity and poor diet quality have triggered national calls to increase diet counseling in outpatients with atherosclerotic cardiovascular disease or risk factors. However, despite evidence that physicians are willing to undertake this task and are viewed as credible sources of diet information, they engage patients in diet counseling at less than desirable rates and cite insufficient knowledge and training as barriers. These data align with evidence of large and persistent gaps in medical nutrition education and training in the United States. Now, major reforms in undergraduate and graduate medical education designed to incorporate advances in the science of learning and to better prepare physicians for 21st century healthcare delivery are providing a new impetus and novel ways to expand medical nutrition education and training. This science advisory reviews gaps in undergraduate and graduate medical education in nutrition in the United States, summarizes reforms that support and facilitate more robust nutrition education and training, and outlines new opportunities for accomplishing this goal via multidimensional curricula, pedagogies, technologies, and competency-based assessments. Real-world examples of efforts to improve undergraduate and graduate medical education in nutrition by integrating formal learning with practical, experiential, inquiry-driven, interprofessional, and population health management activities are provided. The authors conclude that enhancing physician education and training in nutrition, as well as increasing collaborative nutrition care delivery by 21st century health systems, will reduce the health and economic burdens from atherosclerotic cardiovascular disease to a degree not previously realized.

Pushing chronic care forward in Abu Dhabi by identifying priorities and addressing barriers: a modified Delphi technique

OBJECTIVE

This study aimed to elucidate the top five key priorities and barriers to chronic care in the health system of Abu Dhabi, United Arab Emirates (UAE).

DESIGN

A modified Delphi study was performed to reach consensus on priority areas and barriers to the development of the Chronic Care Model in the health system of Abu Dhabi. Individual wireless audience response devices (keypads) linked to a computer were used to reduce 28 priorities and 20 barriers to the top five during three iterative rounds over three consecutive days.

SETTING

Chronic care services for patients with diabetes, cardiovascular diseases and cancer, in both private and publicly funded healthcare services in the emirate of Abu Dhabi.

PARTICIPANTS

A purposive sample of 20 health systems' experts were recruited. They were front-line healthcare workers from the public and private sector working in the delivery of care for patients with diabetes, cardiovascular diseases and cancer.

RESULTS

The 'overall organizational leadership in chronic illness care' was ranked as the most important priority to address (26.3%) and 'patient compliance' was ranked as the most important barrier (36.8%) to the development of the Chronic Care Model.

CONCLUSIONS

This study has identified the current priorities and barriers to improving chronic care within Abu Dhabi's healthcare system. Our paper addresses the UAE's 2021 Agenda of achieving a world-class healthcare system, and findings may help inform strategic changes required to achieve this mission.

Reducing major risk factors for chronic kidney disease

Chronic kidney disease (CKD) is a global public health concern and a key determinant of poor health outcomes. While the burden of CKD is reasonably well defined in developed countries, increasing evidence indicates that the CKD burden may be even greater in developing countries. Diabetes, hypertension, and obesity are major contributors to the global burden of the disease and are important traditional CKD risk factors; however, nontraditional CKD risk factors such as nephrotoxin exposure, kidney stones, fetal and maternal factors, infections, environmental factors, and acute kidney injury are also increasingly being recognized as major threats to global kidney health. A broad approach to CKD prevention begins with the identification of CKD risk factors in the population, followed by the development of appropriate mitigation strategies. Effective prevention policies rely on an accurate understanding of the incidence and prevalence of CKD in a given setting, as well as the distribution and burden of risk factors. Populations or individuals at CKD risk must be screened and treated early to prevent the onset of and delay the progression of the kidney disease. Systematically collected data should be analyzed at country, province, and district levels to identify regional disparities and CKD hotspots and develop targeted prevention strategies. Race-ethnicity, genetics, sex, socioeconomic status, and geography are likely modifiers of CKD risk. A comprehensive, informed approach to prevention that takes into account all of these factors is therefore required to successfully tackle the global CKD epidemic.

Homeless women's service use, barriers, and motivation for participating in substance use treatment

BACKGROUND

Homeless women are at high risk for substance use disorder (SUD), and are a growing proportion of the homeless population. However, homeless women experience barriers to engaging in substance use services.

OBJECTIVES

Among homeless women with SUD, to explore service use, motivation to change, service barriers, and willingness to have substance use and mental health problems addressed in primary health care.

METHODS

Women with SUD were sampled from 11 Health Care for the Homeless (HCH) primary care clinics in 9 states, yielding 241 with either an alcohol or drug use disorder who then completed questions about SUD services.

RESULTS

Over 60% of women with dual alcohol and drug use disorders used some type of SUD service in the past year, while 52% with a drug only disorder, and 44% with an alcohol only disorder used services. The most mentioned barrier to service use was depression, but cost, wait time, where to find treatment, and facilities located too far away, were also frequently noted. A large proportion across all groups indicated high motivation for treatment and willingness to discuss their SUD in a primary care setting.

CONCLUSION

There are continued barriers to SUD service use for homeless women despite high motivation for treatment, and willingness to be asked about SUD and mental health problems in primary care. HCH primary care sites should more systematically ask about SUD and mental health issues and address women's expressed need for support groups and alternative therapies to more holistically address their SUD needs.

Effect of Organizational Culture on Patient Access, Care Continuity, and Experience of Primary Care

This study examined relationships between organizational culture and patient-centered outcomes in primary care. Generalized least squares regression was used to analyze patient access, care continuity, and reported experiences of care among 357 physicians in 41 primary care departments. Compared with a "Group-oriented" culture, a "Rational" culture type was associated with longer appointment wait times, and both "Hierarchical" and "Developmental" culture types were associated with less care continuity, but better patient experiences with care. Understanding the unique effects of organizational culture can enhance the delivery of more patient-centered care.

Promoting integration within the public health domain of physical activity promotion

Purpose

The purpose of this paper is to report and critically reflect on the methodological processes involved in a formal attempt to promote health and social integration in the rarely reported public health domain of physical activity promotion.

Design/methodology/approach

A quality improvement (QI) methodology was deployed, comprising three elements: a diagnostic tool that assessed strategic and practice positions; a half-day workshop that brought senior leaders together for to reflect this evidence; and a structured process that sought to generate proposals for future integrated action. A mixed-method evaluative approach was used, capturing insights of the integration processes via quantitative and qualitative data collection pre-event, in-event, immediate post-event and at six-month follow-up.

Findings

Insights suggested that despite some critical concerns, this QI process can be considered as robust, offering pointers to elements required to successfully promote integration in this domain, including the significance of leadership, the preparatory contribution of a diagnostic tool and position paper, the opportunities for active exchange and planning within a workshop situation and the initiation of a process of integrated work via tangible “pledges”.

Originality/value

The paper offers originality in two respects. Generally, it describes and reflects on the relationship between theoretical and empirical dimensions of a model of integration promotion. Specifically, in offering an account of integrative public health work across health service, local authority and third sector partners, it addressed an area that has received relatively limited prior attention.

The COMPASS initiative: description of a nationwide collaborative approach to the care of patients with depression and diabetes and/or cardiovascular disease

OBJECTIVE

To describe a national effort to disseminate and implement an evidence-based collaborative care management model for patients with both depression and poorly controlled diabetes and/or cardiovascular disease across multiple, real-world diverse clinical practice sites.

METHODS

Goals for the initiative were as follows: (1) to improve depression symptoms in 40% of patients, (2) to improve diabetes and hypertension control rates by 20%, (3) to increase provider satisfaction by 20%, (4) to improve patient satisfaction with their care by 20% and (5) to demonstrate cost savings. A Care Management Tracking System was used for collecting clinical care information to create performance measures for quality improvement while also assessing the overall accomplishment of these goals.

RESULTS

The Care of Mental, Physical and Substance-use Syndromes (COMPASS) initiative spread an evidence-based collaborative care model among 18 medical groups and 172 clinics in eight states. We describe the initiative's evidence-base and methods for others to replicate our work.

CONCLUSIONS

The COMPASS initiative demonstrated that a diverse set of health care systems and other organizations can work together to rapidly implement an evidence-based care model for complex, hard-to-reach patients. We present this model as an example of how the time gap between research and practice can be reduced on a large scale.

Community to clinic navigation to improve diabetes outcomes

Rural residents experience rates of Type 2 Diabetes Mellitus (T2DM) that are considerably higher than their urban or suburban counterparts. Two primary modifiable factors, self-management and formal clinical management, have potential to greatly improve diabetes outcomes. “Community to Clinic Navigation to Improve Diabetes Outcomes,” is the first known randomized clinical trial pilot study to test a hybrid model of diabetes self-management education plus clinical navigation among rural residents with T2DM. Forty-one adults with T2DM were recruited from two federally qualified health centers in rural Appalachia from November 2014–January 2015. Community health workers provided navigation, including helping participants understand and implement a diabetes self-management program through six group sessions and, if needed, providing assistance in obtaining clinic visits (contacting providers' offices for appointments, making reminder calls, and facilitating transportation and dependent care). Pre and post-test data were collected on T2DM self-management, physical measures, demographics, psychosocial factors, and feasibility (cost, retention, and satisfaction). Although lacking statistical significance, some outcomes indicate trends in positive directions, including diet, foot care, glucose monitoring, and physical health, including decreased HbA1c and triglyceride levels. Process evaluations revealed high levels of satisfaction and feasibility. Due to the limited intervention dose, modest program expenditures (~$29,950), and a severely affected population most of whom had never received diabetes education, outcomes were not as robust as anticipated. Given high rates of satisfaction and retention, this culturally appropriate small group intervention holds promise for hard to reach rural populations. Modifications should include expanded recruitment venues, sample size, intervention dosage and longer term assessment.

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Community to clinic navigation combined diabetes self-management and navigation.

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CCN showed some positive trends in diet, triglycerides, self-care, and diabetes.

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CCN was feasible (low cost and high retention) and satisfactory.

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Increasing dose, length, and recruitment venues may improve the CCN intervention.

Is "disease management" the answer to our problems? No! Population health management and (disease) prevention require "management of overall well-being"

BACKGROUND

Disease management programs based on the chronic care model have achieved successful and long-term improvement in the quality of chronic care delivery and patients' health behaviors and physical quality of life. However, such programs have not been able to maintain or improve broader self-management abilities or social well-being, which decline over time in chronically ill patients. Disease management efforts, population health management initiatives and innovative primary care solutions are still mainly focused on clinical and functional outcomes and health behaviors (e.g., smoking cessation, exercise, and diet) failing to address individuals' overall quality of life and well-being. Individuals' ability to achieve well-being can be assessed with great specificity through the application of social production function (SPF) theory. This theory asserts that people produce their own well-being by trying to optimize the achievement of instrumental goals (stimulation, comfort, status, behavioral confirmation, affection) that provide the means to achieve the larger, universal goals of physical and social well-being.

DISCUSSION

A shift in focus from the management of physical function, disease limitations, and lifestyle behaviors alone to an approach that fosters self-management abilities such as self-efficacy and resource investment as well as overall quality of life, is urgently needed. Disease management interventions should be aimed at adequately addressing all difficulties chronically ill patients face in life, such as the effects of pain and fatigue on the ability to maintain a job and social life and to participate in activities promoting physical and social well-being. Patients' ability to maintain engagement in stimulating work and social activities with the people who are important to them may be even more important than aspects of disease self-management such as blood pressure or glycemic control. Interventions should aim to make chronically ill patients capable of managing their own well-being and adequately addressing their needs in a broader sense. So, is disease management the answer to our problems in the time of aging populations and increased prevalence of unhealthy lifestyles, chronic illnesses, and comorbidity? No! Effective (disease) prevention, disease management, patient-centered care, and high-quality chronic care and/or population health management calls for management of overall well-being.

Developing and implementing a social prescribing initiative in primary care: insights into the possibility of normalisation and sustainability from a UK case study

Aim To conduct a process-based evaluation of the inception and early implementation of a social prescribing initiative (Healthy Connections Stewartry) in two UK General Practices.

BACKGROUND

Prescribing a range of social, cultural, arts and educational activities to clients in primary care (known as 'social prescribing' or 'community linking schemes') as a means of addressing long-term physical health conditions and promoting mental health and well-being is becoming increasingly prominent and popular. However, concerns exist over a lack of evidence of effectiveness and formalised insights into how such initiatives may be optimally implemented.

METHODS

Within a case study design and using 1-1 semi-structured interviews, three related data sets were developed over a 12-month period from 30 purposively sampled informants: the project steering group; the wider primary care team; and various community groups. Data analysis drew on various theoretical resources, particularly those pertaining to nurturing sufficient capacity for the organisational 'normalisation' of this practice and understanding the dynamic flows and linkages between potential clients, 'prescribing' primary care staff and the available community resources. Findings The inception and implementation of the initiative had been broadly successful and that more generally, there were grounds to suggest that these practices were becoming 'normalised' into the day-to-day cultures and routines of the primary care organisations. A series of procedural features are considered significant in achieving such ends. Some specific barriers to change are identified and ultimately in the context of potential 'transferability', a wider reflection is undertaken of the potential for such innovative practice to become established in less advantageous organisational circumstances. Fundamental difficulties are recognised and thus the need for formally implemented 'change' processes. Furthermore, for social prescribing to become a pervasive feature of health-care provision, the need for necessary capacity and resources is stressed.

The Broken Thread of Health Promotion and Disease Prevention for Women During the Postpartum Period

Postpartum maternal health affects maternal functional status, future pregnancy outcomes, maternal chronic disease development, and infant health. After pregnancy, however, many mothers may find that they face gaps in care related to their health and caregiving roles. Research shows that they were unprepared, uninformed, and unsupported during the postpartum period as they struggle with physical and emotional symptoms, infant caregiving, breastfeeding concerns, and lifestyle adjustments. Limited follow-up after a diagnosis of gestational hypertension or gestational diabetes and screening for postpartum depression are additional gaps in preventive and supportive care. Integrative reviews revealed modest efficacy and limitations of recent postpartum health promotion and disease prevention interventions. System, clinical, and community strategies are identified to address these gaps in women's postpartum health services.

Implementing guidelines to routinely prevent chronic vascular disease in primary care: the Preventive Evidence into Practice cluster randomised controlled trial

OBJECTIVE

To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease.

SETTING

32 urban general practices in 4 Australian states.

RANDOMISATION

Stratified randomisation of practices.

PARTICIPANTS

122 general practitioners (GPs) and practice nurses (PNs) were recruited at baseline and 97 continued to 12 months. 21,848 patient records were audited for those aged 40-69 years who attended the practice in the previous 12 months without heart disease, stroke, diabetes, chronic renal disease, cognitive impairment or severe mental illness.

INTERVENTION

The practice level intervention over 6 months included small group training of practice staff, feedback on audited performance, practice facilitation visits and provision of patient education and referral information.

OUTCOME MEASURES

Primary: 1. Change in proportion of patients aged 40-69 years with smoking status, alcohol intake, body mass index (BMI), waist circumference (WC), blood pressure (BP) recorded and for those aged 45-69 years with lipids, fasting blood glucose and cardiovascular risk in the medical record. 2. Change in the level of risk for each factor.

SECONDARY

change in self-reported frequency and confidence of GPs and PNs in assessment.

RESULTS

Risk recording improved in the intervention but not the control group for WC (OR 2.52 (95% CI 1.30 to 4.91)), alcohol consumption (OR 2.19 (CI 1.04 to 4.64)), smoking status (OR 2.24 (1.17 to 4.29)) and cardiovascular risk (OR 1.50 (1.04 to 2.18)). There was no change in recording of BP, lipids, glucose or BMI and no significant change in the level of risk factors based on audit data. The confidence but not reported practices of GPs and PNs in the intervention group improved in the assessment of some risk factors.

CONCLUSIONS

This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000578808, results.

The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper

Behavioral health care includes care for patients around mental health and substance abuse conditions, health behavior change, life stresses and crises, and stress-related physical symptoms. Mental and substance use disorders alone are estimated to surpass all physical diseases as a major cause of worldwide disability by 2020. The literature recognizes the importance of the health care system effectively addressing behavioral health conditions. Recently, there has been a call for the use of the primary care delivery platform and the related patient-centered medical home model to effectively address these conditions. This position paper focuses on the issue of better integration of behavioral health into the primary care setting. It provides an environmental scan of the current state of conditions included in the concept of behavioral health and examines the arguments for and barriers to increased integration into primary care. It also examines various approaches of integrated care delivery and offers a series of policy recommendations that are based on the reviewed information and evidence to inform the actions of the American College of Physicians and its members regarding advocacy, research, and practice.

Implementation of integrated services networks in Quebec and nursing practice transformation: convergence or divergence?

BACKGROUND

Even though nurses are expected to play a key role in implementing integrated services networks, up to now their practice in this regard has received very little research attention. The aim of this study is to describe the extent to which the evolution of nursing practice in Quebec in recent years has converged with the requirements and efforts involved in services integration.

METHODS

This descriptive study was carried out with 107 nurses working an integrated network of healthcare services in Quebec in four different care pathways: chronic obstructive pulmonary disease, autonomy support for the elderly, palliative oncology care, and mental health. Development model for integrated care (DMIC) was used, first, to examine the prevalence in each pathway of integrative activities, grouped into nine practice dimensions, and then to position each pathway in relation to the four phases of development for any integration process, as defined by the DMIC.

RESULTS

Only one pathway had reached Phase 3, which involves expansion and monitoring of integration, whereas the others were still in the preliminary Phases 1 and 2 characterized by initiative and experimentation. Only two dimensions out of nine ('quality of care' and 'interprofessional teamwork') were prevalent in all the pathways; two others ('transparent entrepreneurship' and 'performance management') were in none of the pathways, and the remaining five ('patient-family centered care', 'result-focused learning', 'delivery system', 'commitment', 'roles and tasks') were present to varying degrees.

CONCLUSIONS

These results suggest that particular efforts should be made to bridge the significant gap between the pace of nursing practice transformation and the objectives of service integration. These efforts should focus, among other things, on the deployment of organizational, clinical, human, and material resources to support practice renewal and continuing education for nurses to prepare them for the requirements of integration.

Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

OBJECTIVES

To quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.

DESIGN

Longitudinal spatial study, at the level of the "lower layer super output area" (LSOA).

SETTING

32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012.

PARTICIPANTS

8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care.

INTERVENTION

National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators.

MAIN OUTCOME MEASURES

All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.

RESULTS

All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality.

CONCLUSIONS

Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.

Disease Management: The Need for a Focus on Broader Self-Management Abilities and Quality of Life

The study objective was to investigate long-term effects of disease management programs (DMPs) on (1) health behaviors (smoking, physical exercise); (2) self-management abilities (self-efficacy, investment behavior, initiative taking); and (3) physical and mental quality of life among chronically ill patients. The study also examined whether (changes in) health behaviors and self-management abilities predicted quality of life. Questionnaires were sent to all 5076 patients participating in 18 Dutch DMPs in 2010 (T0; 2676 [53%] respondents). Two years later (T1), questionnaires were sent to 4350 patients still participating in DMPs (1722 [40%] respondents). Structured interviews were held with the 18 DMP project leaders. DMP implementation improved patients' health behavior and physical quality of life, but mental quality of life and self-management abilities declined over time. Changes in patients' investment behavior predicted physical quality of life at T1 (P<.001); physical activity, investment behavior (both P<.05), and self-efficacy (P<.01) at T0, and changes in self-efficacy and investment behavior (both P<.001) predicted patients' mental quality of life at T1. The long-term benefits of these DMPs include successful improvement of chronically ill patients' health behaviors and physical quality of life. However, these programs were not able to improve or maintain broader self-management abilities or mental quality of life, highlighting the need to focus on these abilities and overall quality of life. As coproducers of care, patients should be stimulated and enabled to manage their health and quality of life.

Attitudes About and Practices of Health Promotion and Prevention Among Primary Care Providers

The Patient Protection and Affordable Care Act's emphasis on health promotion and prevention activities required an examination of the current practices of primary care providers in these areas. A total of 196 primary care providers completed a survey to assess current health promotion and prevention attitudes, practices, and barriers. Results of this study showed that family physicians in Pennsylvania recognize the importance of and their role in providing health promotion and prevention and offer advice in key behavioral and disease prevention areas. Results from the study suggest that their ability to provide these services is hindered by a lack of time and the heavy workload. Although most family physicians provided advice to patients in several health promotion and prevention areas, few participants reported that they referred patients to other health professionals. Finally, when it comes to preventive services, participants ranked blood pressure screening, tobacco use screening, and tobacco use cessation interventions as the most important services. Effective implementation of the Patient Protection and Affordable Care Act will require necessary resources and support of primary care providers to help patients achieve healthier lives.

What's in a setting?: Influence of organizational culture on provider adherence to clinical guidelines for treating tobacco use

BACKGROUND

Organizational culture is an important but underinvestigated feature of the work environment that can impact provider behavior, including adherence to clinical practice guidelines. There is substantial evidence that physician assistance to smokers can produce significant reductions in tobacco use. However, this evidence has not been well translated into practice, as only a small proportion of smokers receive recommended treatment during medical visits.

PURPOSE

This study examines organizational culture as a contextual feature of primary care clinics and its impact on adherence to evidence-based guidelines for treating tobacco use.

METHODOLOGY

Cross-sectional survey data were collected from 500 primary care providers in 60 community clinics located in New York City. Relationships between provider adherence to "5A" clinical guidelines, as recommended by the U.S. Public Health Service, and both provider and organizational covariates were described. We used hierarchical linear modeling to examine the associations between clinic culture and provider treatment patterns.

FINDINGS

Providers in clinics with stronger "group/clan," "hierarchical," and "rational" culture types, as compared with a "developmental" culture, reported greater adherence to 5A guidelines (p < .05). System-level structures and care processes were positively associated (p < .01), whereas number of ongoing quality initiatives was negatively associated with 5A delivery (p < .05). Provider familiarity with guidelines (p < .01), confidence with cessation counseling (p < .05), and perceived effectiveness in helping smokers quit were associated with more frequent 5A intervention (p < .01).

PRACTICE IMPLICATIONS

Findings suggest that organizational culture can influence provider adherence to cessation treatment guidelines, even when controlling for other factors known to affect practice patterns. Specifically, cultures that emphasize human resources and performance standards are conducive to integrating 5A guidelines into routine practice. Understanding the role of organizational culture enables healthcare managers and practitioners to be strategic when implementing, and also sustaining, use of evidence-based guidelines.

A randomized control trial of a chronic care intervention for homeless women with alcohol use problems

A clinician-randomized trial was conducted using the chronic care model for disease management for alcohol use problems among n = 82 women served in a health care for the homeless clinic. Women with problem alcohol use received either usual care or an intervention consisting of a primary care provider (PCP) brief intervention, referral to addiction services, and on-going support from a care manager (CM) for 6 months. Both groups significantly reduced their alcohol consumption, with a small effect size favoring intervention at 3 months, but there were no significant differences between groups in reductions in drinking or in housing stability, or mental or physical health. However, intervention women had significantly more frequent participation in substance use treatment services. Baseline differences and small sample size limit generalizability, although substantial reductions in drinking for both groups suggest that screening and PCP brief treatment are promising interventions for homeless women with alcohol use problems.

Coping with college and inflammatory bowel disease: implications for clinical guidance and support

BACKGROUND

Studies have shown that young adults with chronic diseases, including inflammatory bowel disease (IBD), experience greater difficulty during the transition to college, reaching lower levels of educational attainment and reporting greater levels of perceived stress than their otherwise-healthy peers. We performed a qualitative study to better understand how underlying illness shapes the college experience for patients with IBD and how the college experience, in turn, impacts disease management.

METHODS

Fifteen college students with IBD were recruited from the Boston Children's Hospital Center for IBD. We conducted an approximately 1 hour semistructured qualitative interview with each participant, and the interviews were thematically analyzed after an iterative and inductive process.

RESULTS

Four primary themes were identified: (1) The transition experience of college students with IBD is shaped by their health status, perceived readiness, and preparedness, (2) Elements of the college environment pose specific challenges to young adults with IBD that require adaptive strategies, (3) College students with IBD integrate their underlying illness with their individual and social identity, and (4) College students navigate health management by conceptualizing themselves, their families, and providers as serving particular roles.

CONCLUSIONS

For young adults with IBD, college is a proving ground for demonstrating self-care and disease management practices. Future initiatives aimed at this population should recognize the evolving roles of patients, parents, and providers in disease management. Increased attention should also be paid to the promotion of patient's self-management and the unique challenges of the structural and psychosocial college environment.

Psychiatric stigma and discrimination in South Africa: perspectives from key stakeholders

BACKGROUND

Stigma and discrimination against people with mental illness remain barriers to help seeking and full recovery for people in need of mental health services. Yet there is scarce research investigating the experiences of psychiatric stigma on mental health service users in low- and middle-income countries (LMICs). The aim of this study was therefore to explore the experiences of psychiatric stigma by service users in order to inform interventions to reduce such stigma and discrimination in one LMIC, namely South Africa.

METHODS

Participants comprised a total of 77 adults aged above 18 years, made up of service providers including professional nurses (10), lay counsellors (20), auxiliary social workers (2); and service users (45).

RESULTS

Psychiatric stigma was found to be perpetuated by family members, friends, employers, community members and health care providers. Causes of psychiatric stigma identified included misconceptions about mental illness often leading to delays in help-seeking. Experiencing psychiatric stigma was reported to worsen the health of service users and impede their capacity to lead and recover a normal life.

CONCLUSION

Media campaigns and interventions to reduce stigma should be designed to address specific stigmatizing behaviours among specific segments of the population. Counselling of families, caregivers and service users should include how to deal with experienced and internalized stigma.

The role of disease management programs in the health behavior of chronically ill patients

OBJECTIVE

Investigate the effects of disease management program (DMP) implementation on physical activity, smoking, and physical quality of life among chronically ill patients.

METHODS

This study used a mixed-methods approach involving qualitative (35 interviews with project managers) and quantitative (survey of patients from 18 DMPs) data collection. Questionnaire response rates were 51% (2010; 2619/5108) at T0 and 47% (2011; 2191/4693) at T1.

RESULTS

Physical activity and the percentage of smokers improved significantly over time, whereas physical quality of life declined. After adjusting for patients' physical quality of life at T0, age, educational level, marital status, and gender, physical activity at T0 (p<0.01), changes in physical activity (p<0.001), and percentage of smokers at T0 (p<0.05) predicted physical quality of life at T1. Project managers reported that DMPs improved patient-professional interaction. The ability to set more concrete targets improved patients' health behaviors.

CONCLUSIONS

DMPs appear to improve physical activity among chronically ill patients over time. Furthermore, (changes in) health behavior are important for the physical quality of life of chronically ill patients.

PRACTICE IMPLICATIONS

Redesigning care systems and implementing DMPs based on the chronic care model may improve health behavior among chronically ill patients.

Patient and provider perspectives on the relationship between multiple morbidity management and disease prevention

Despite competing demands of multiple morbidity (MM) management and disease prevention, our recent survey of 1,153 Appalachian residents aged 50 to 76 documented that individuals with MM were more likely to obtain colorectal cancer screening (CRCS) than those without MM. Nearly two thirds of respondents obtained CRCS, and the more MM, the greater the likelihood of screening. To gain insight into this relationship, we conducted nine focus groups, six with providers and three with patients. Three main explanations emerged: (a) patients' MM increases providers' vigilance for other health vulnerabilities; (b) having MM increases patients' own vigilance; and (c) patients' vigilance may stem from experiencing more symptoms, having a family history of cancer, and having successfully obtained health care. More frequent contact with health care providers appears to encourage preventive referral, especially in low-income populations that otherwise may not receive such counselling. We highlight participant recommendations to improve MM management and prevention.

Patient engagement as a risk factor in personalized health care: a systematic review of the literature on chronic disease

Background

The role of patient engagement as an important risk factor for healthcare outcomes has not been well established. The objective of this article was to systematically review the relationship between patient engagement and health outcomes in chronic disease to determine whether patient engagement should be quantified as an important risk factor in health risk appraisals to enhance the practice of personalized medicine.

Methods

A systematic review of prospective clinical trials conducted between January 1993 and December 2012 was performed. Articles were identified through a medical librarian-conducted multi-term search of Medline, Embase, and Cochrane databases. Additional studies were obtained from the references of meta-analyses and systematic reviews on hypertension, diabetes, and chronic care. Search terms included variations of the following: self-care, self-management, self-monitoring, (shared) decision-making, patient education, patient motivation, patient engagement, chronic disease, chronically ill, and randomized controlled trial. Studies were included only if they: (1) compared patient engagement interventions to an appropriate control among adults with chronic disease aged 18 years and older; (2) had minimum 3 months between pre- and post-intervention measurements; and (3) defined patient engagement as: (a) understanding the importance of taking an active role in one’s health and health care; (b) having the knowledge, skills, and confidence to manage health; and (c) using knowledge, skills and confidence to perform health-promoting behaviors. Three authors and two research assistants independently extracted data using predefined fields including quality metrics.

Results

We reviewed 543 abstracts to identify 10 trials that met full inclusion criteria, four of which had ‘high’ methodological quality (Jadad score ≥ 3). Diverse measurement of patient engagement prevented robust statistical analyses, so data were qualitatively described. Nine studies documented improvements in patient engagement. Five studies reported reduction in clinical markers of disease (for example HbA1C). All studies reported improvements in self-reported health status.

Conclusions

This review suggests patient engagement should be quantified as part of a comprehensive health risk appraisal given its apparent value in helping individuals to effectively self-manage chronic disease. Patient engagement measures should include assessment of the knowledge, confidence and skills to prevent and manage chronic disease, plus the behaviors to do so.

Development of an interprofessional program for cardiovascular prevention in primary care: A participatory research approach

BACKGROUND

The chronic care model provides a framework for improving the management of chronic diseases. Participatory research could be useful in developing a chronic care model-based program of interventions, but no one has as yet offered a description of precisely how to apply the approach.

OBJECTIVES

An innovative, structured, multi-step participatory process was applied to select and develop (1) chronic care model-based interventions program to improve cardiovascular disease prevention that can be adapted to a particular regional context and (2) a set of indicators to monitor its implementation.

METHODS

Primary care clinicians (n = 16), administrative staff (n = 2), patients and family members (n = 4), decision makers (n = 5), researchers, and a research coordinator (n = 7) took part in the process. Additional primary care actors (n = 26) validated the program.

RESULTS

The program targets multimorbid patients at high or moderate risk of cardiovascular disease with uncontrolled hypertension, dyslipidemia or diabetes. It comprises interprofessional follow-up coordinated by case-management nurses, in which motivated patients are referred in a timely fashion to appropriate clinical and community resources. The program is supported by clinical tools and includes training in motivational interviewing. A set of 89 process and clinical indicators were defined.

CONCLUSION

Through a participatory process, a contextualized interventions program to optimize cardiovascular disease prevention and a set of quality indicators to monitor its implementation were developed. Similar approach might be used to develop other health programs in primary care if program developers are open to building on community strengths and priorities.

Organization of Primary Care Practice for Providing Energy Balance Care

Purpose.

Primary care physicians (PCPs) may not adequately counsel or monitor patients regarding diet, physical activity, and weight control (i.e., provide energy balance care). We assessed the organization of PCPs' practices for providing this care.

Design.

The study design was a nationally representative survey conducted in 2008.

Setting.

The study setting was U.S. primary care practices.

Subjects.

A total of 1740 PCPs completed two sequential questionnaires (response rate, 55.5%).

Measures.

The study measured PCPs' reports of practice resources, and the frequency of body mass index assessment, counseling, referral for further evaluation/management, and monitoring of patients for energy balance care.

Analysis.

Descriptive statistics and logistic regression modeling were used.

Results.

More than 80% of PCPs reported having information resources on diet, physical activity, or weight control available in waiting/exam rooms, but fewer billed (45%), used reminder systems (< 30%), or received incentive payments (3%) for energy balance care. A total of 26% reported regularly assessing body mass index and always/often providing counseling as well as tracking patients for progress related to energy balance. In multivariate analyses, PCPs in practices with full electronic health records or those that bill for energy balance care provided this care more often and more comprehensively. There were strong specialty differences, with pediatricians more likely (odds ratio, 1.78; 95% confidence interval, 1.26–2.51) and obstetrician/gynecologists less likely (odds ratio, 0.28; 95% confidence interval, 0.17–0.44) than others to provide energy balance care.

Conclusion.

PCPs' practices are not well organized for providing energy balance care. Further research is needed to understand PCP care-related specialty differences.

Recruiting and engaging smokers in treatment in a primary care setting: developing a chronic care model implemented through a modified electronic health record

Almost 35 million U.S. smokers visit primary care clinics annually, creating a need and opportunity to identify such smokers and engage them in evidence-based smoking treatment. The purpose of this study is to examine the feasibility and effectiveness of a chronic care model of treating tobacco dependence when it is integrated into primary care systems using electronic health records (EHRs). The EHR prompted primary care clinic staff to invite patients who smoked to participate in a tobacco treatment program. Patients who accepted and were eligible were offered smoking reduction or cessation treatment. More than 65 % of smokers were invited to participate, and 12.4 % of all smokers enrolled in treatment-30 % in smoking reduction and 70 % in cessation treatment. The chronic care model developed for treating tobacco dependence, integrated into the primary care system through the EHR, has the potential to engage up to 4.3 million smokers in treatment a year.