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Schneberk T, Bolshakova M, Sloan K, Chang E, Stal J, Dinalo J, Jimenez E, Motala A, Hempel S. Quality Indicators for High-Need Patients: a Systematic Review. J Gen Intern Med 2022; 37:3147-3161. [PMID: 35260956 PMCID: PMC9485370 DOI: 10.1007/s11606-022-07454-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/03/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Healthcare systems are increasingly implementing programs for high-need patients, who often have multiple chronic conditions and complex social situations. Little, however, is known about quality indicators that might guide healthcare organizations and providers in improving care for high-need patients. We sought to conduct a systematic review to identify potential quality indicators for high-need patients. METHODS This systematic review (CRD42020215917) searched PubMed, CINAHL, and EMBASE; guideline clearing houses ECRI and GIN; and Google scholar. We included publications suggesting, evaluating, and utilizing indicators to assess quality of care for high-need patients. Critical appraisal of the indicators addressed the development process, endorsement and adoption, and characteristics, such as feasibility. We standardized indicators by patient population subgroups to facilitate comparisons across different indicator groups. RESULTS The search identified 6964 citations. Of these, 1382 publications were obtained as full text, and 53 studies met inclusion criteria. We identified over 1700 quality indicators across studies. Quality indicator characteristics varied widely. The scope of the selected indicators ranged from detailed criterion (e.g., "annual eye exam") to very broad categories (e.g., "care coordination"). Some publications suggested disease condition-specific indicators (e.g., diabetes), some used condition-independent criteria (e.g., "documentation of the medication list in the medical record available to all care agencies"), and some publications used a mixture of indicator types. DISCUSSION We identified and evaluated existing quality indicators for a complex, heterogeneous patient group. Although some quality indicators were not disease-specific, we found very few that accounted for social determinants of health and behavioral factors. More research is needed to develop quality indicators that address patient risk factors.
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Affiliation(s)
- Todd Schneberk
- Gehr Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, GNH 1011, 1200 N State Street Rm 1011, Los Angeles, CA, 90033, USA.
| | - Maria Bolshakova
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kylie Sloan
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Evelyn Chang
- VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Julia Stal
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jennifer Dinalo
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Elvira Jimenez
- VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Aneesa Motala
- Gehr Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, GNH 1011, 1200 N State Street Rm 1011, Los Angeles, CA, 90033, USA
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Susanne Hempel
- Gehr Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, GNH 1011, 1200 N State Street Rm 1011, Los Angeles, CA, 90033, USA
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Bayliss EA, Albers K, Gleason K, Pieper LE, Boyd CM, Campbell NL, Ensrud KE, Gray SL, Linsky AM, Mangin D, Min L, Rich MW, Steinman MA, Turner J, Vasilevskis EE, Dublin S. Recommendations for outcome measurement for deprescribing intervention studies. J Am Geriatr Soc 2022; 70:2487-2497. [PMID: 35648465 PMCID: PMC9489620 DOI: 10.1111/jgs.17894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/21/2022] [Accepted: 05/03/2022] [Indexed: 01/03/2023]
Abstract
Interpreting results from deprescribing interventions to generate actionable evidence is challenging owing to inconsistent and heterogeneous outcome definitions between studies. We sought to characterize deprescribing intervention outcomes and recommend approaches to measure outcomes for future studies. A scoping literature review focused on deprescribing interventions for polypharmacy and informed a series of expert panel discussions and recommendations. Twelve experts in deprescribing research, policy, and clinical practice interventions participating in the Measures Workgroup of the US Deprescribing Research Network sought to characterize deprescribing outcomes and recommend approaches to measure outcomes for future studies. The scoping review identified 125 papers reflecting 107 deprescribing studies. Common outcomes included medication discontinuation, medication appropriateness, and a broad range of clinical outcomes potentially resulting from medication reduction. Panel recommendations included clearly defining clinically meaningful medication outcomes (e.g., number of chronic medications, dose reductions), ensuring adequate sample size and follow-up time to capture clinical outcomes resulting from medication discontinuation (e.g., quality of life [QOL]), and selecting appropriate and feasible data sources. A new conceptual model illustrates how downstream clinical outcomes (e.g., reduction in falls) should be interpreted in the context of initial changes in medication measures (e.g., reduction in mean total medications). Areas needing further development include implementation outcomes specific to deprescribing interventions and measures of adverse drug withdrawal events. Generating evidence to guide deprescribing is essential to address patient, caregiver, and clinician concerns about the benefits and harms of medication discontinuation. This article provides recommendations and an initial conceptual framework for selecting and applying appropriate intervention outcomes to support deprescribing research.
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Affiliation(s)
- Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kathleen Albers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Kathy Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Lisa E Pieper
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Noll L Campbell
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana, USA
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, Indiana, USA
| | - Kristine E Ensrud
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
- Center for Care Delivery and Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Shelly L Gray
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Amy M Linsky
- Section of General Internal Medicine and Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Derelie Mangin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Lillian Min
- Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Ann Arbor VA Medical Center, Geriatric Education Research and Clinical Center, Ann Arbor, Michigan, USA
| | - Michael W Rich
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Division of Geriatraics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Justin Turner
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eduard E Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
- Epidemiology Department, University of Washington, Seattle, Washington, USA
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Chang ET, Newberry S, Rubenstein LV, Motala A, Booth MJ, Shekelle PG. Quality Measures for Patients at Risk of Adverse Outcomes in the Veterans Health Administration: Expert Panel Recommendations. JAMA Netw Open 2022; 5:e2224938. [PMID: 35917129 DOI: 10.1001/jamanetworkopen.2022.24938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite longstanding efforts to improve health care quality for patients with complex needs who are at highest risk for hospitalization or death, to our knowledge, no guidance exists on what constitutes measurable high-quality care for this heterogeneous population. Identifying quality measures that are cross-cutting (ie, relevant to multiple chronic conditions and disease states) may enable health care professionals and health care systems to better design and report on quality improvement efforts for this patient population. OBJECTIVE To identify quality measures of care and prioritize quality-of-care concepts in the ambulatory primary care setting for patients in the Veterans Health Administration (VHA) who have complex care needs and are at high risk for adverse outcomes, such as hospitalization or death. EVIDENCE REVIEW In this expert panel assessment and prioritization, relevant measure concepts for future quality measure development in 3 care categories (assessment, management, and other features of health care) were extracted from a systematic review, conducted from June 2020 to June 2021, of published studies that suggested, evaluated, or used indicators of quality care for patients at high risk of adverse outcomes. Measure concepts associated with single conditions, surgical or other specialty care settings, and inpatient care were excluded. A panel of 14 experts (10 VHA leaders and staff, 2 non-VHA physician investigators, and 2 veterans) discussed and rated the importance of the remaining set of potentially relevant measure concepts using a modified RAND/UCLA Appropriateness Method on January 15, 2021. Measure concepts were rated on a scale of 1 to 9, with 9 being the highest priority. A median rating of 7.5 or greater was used as the cutoff to identify the highest-priority items. FINDINGS The systematic review identified 519 measure concepts, from which 15 domains and 49 measure concepts were proposed for expert panel consideration. After panel discussions and changes to measure concepts, the expert panel rated 63 measure concepts in 13 domains. The measure concepts with the highest median ratings focused on caregiver availability and support, COVID-19 vaccination, and pneumonia vaccination (all rated 9.0); housing instability (rated 8.5); and physical function, depression symptoms, cognitive impairment, prescription regimen, primary care follow-up after an emergency department visit or hospitalization, and timely transmission of discharge information to primary care (all rated 8.0). Recommendations to improve care included timely assessment of housing instability, caregiver support, physical function, depression symptoms, and cognitive impairment; annual prescription regimen review; coordinated transitions in care; and preventive care including vaccinations. CONCLUSIONS AND RELEVANCE The expert panelists identified a parsimonious set of high-priority, evidence-based, cross-cutting quality measure concepts for improving care of patients at high risk for adverse health outcomes in the VHA. These quality measures may inform both future research for patients at high risk and health care system quality improvement.
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Affiliation(s)
- Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at UCLA, Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles
| | | | | | - Aneesa Motala
- RAND Corporation, Santa Monica, California
- University of Southern California, Los Angeles
| | | | - Paul G Shekelle
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at UCLA, Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles
- RAND Corporation, Santa Monica, California
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Skou ST, Mair FS, Fortin M, Guthrie B, Nunes BP, Miranda JJ, Boyd CM, Pati S, Mtenga S, Smith SM. Multimorbidity. Nat Rev Dis Primers 2022; 8:48. [PMID: 35835758 PMCID: PMC7613517 DOI: 10.1038/s41572-022-00376-4] [Citation(s) in RCA: 245] [Impact Index Per Article: 122.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 02/06/2023]
Abstract
Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.
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Affiliation(s)
- Søren T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Slagelse, Denmark.
| | - Frances S Mair
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Quebec, Canada
| | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Bruno P Nunes
- Postgraduate Program in Nursing, Faculty of Nursing, Universidade Federal de Pelotas, Pelotas, Brazil
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Epidemiology and Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
| | - Sanghamitra Pati
- ICMR Regional Medical Research Centre, Bhubaneswar, Odisha, India
| | - Sally Mtenga
- Department of Health System Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
| | - Susan M Smith
- Discipline of Public Health and Primary Care, Institute of Population Health, Trinity College Dublin, Russell Building, Tallaght Cross, Dublin, Ireland
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Suls J, Bayliss EA, Berry J, Bierman AS, Chrischilles EA, Farhat T, Fortin M, Koroukian SM, Quinones A, Silber JH, Ward BW, Wei M, Young-Hyman D, Klabunde CN. Measuring Multimorbidity: Selecting the Right Instrument for the Purpose and the Data Source. Med Care 2021; 59:743-756. [PMID: 33974576 PMCID: PMC8263466 DOI: 10.1097/mlr.0000000000001566] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adults have a higher prevalence of multimorbidity-or having multiple chronic health conditions-than having a single condition in isolation. Researchers, health care providers, and health policymakers find it challenging to decide upon the most appropriate assessment tool from the many available multimorbidity measures. OBJECTIVE The objective of this study was to describe a broad range of instruments and data sources available to assess multimorbidity and offer guidance about selecting appropriate measures. DESIGN Instruments were reviewed and guidance developed during a special expert workshop sponsored by the National Institutes of Health on September 25-26, 2018. RESULTS Workshop participants identified 4 common purposes for multimorbidity measurement as well as the advantages and disadvantages of 5 major data sources: medical records/clinical assessments, administrative claims, public health surveys, patient reports, and electronic health records. Participants surveyed 15 instruments and 2 public health data systems and described characteristics of the measures, validity, and other features that inform tool selection. Guidance on instrument selection includes recommendations to match the purpose of multimorbidity measurement to the measurement approach and instrument, review available data sources, and consider contextual and other related constructs to enhance the overall measurement of multimorbidity. CONCLUSIONS The accuracy of multimorbidity measurement can be enhanced with appropriate measurement selection, combining data sources and special considerations for fully capturing multimorbidity burden in underrepresented racial/ethnic populations, children, individuals with multiple Adverse Childhood Events and older adults experiencing functional limitations, and other geriatric syndromes. The increased availability of comprehensive electronic health record systems offers new opportunities not available through other data sources.
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Affiliation(s)
- Jerry Suls
- Behavioral Research Program, National Cancer Institute, Bethesda, MD
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jay Berry
- Complex Care Services, Division of General Pediatrics, Boston Children's Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Arlene S Bierman
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD
| | | | - Tilda Farhat
- Office of Science Policy, Strategic Planning, Reporting, and Data, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Chicoutimi, Quebec, QC, Canada
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Ana Quinones
- Department of Family Medicine, Oregon Health and Science University, Portland, OR
| | - Jeffrey H Silber
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Brian W Ward
- Division of Health Care Statistics, National Center for Health Statistics, Hyattsville, MD
| | - Melissa Wei
- Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Deborah Young-Hyman
- Office of Behavioral and Social Sciences Research, National Institutes of Health
| | - Carrie N Klabunde
- Office of Disease Prevention, National Institutes of Health, Bethesda, MD
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Dennett EJ, Janjua S, Stovold E, Harrison SL, McDonnell MJ, Holland AE. Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review. Cochrane Database Syst Rev 2021; 7:CD013384. [PMID: 34309831 PMCID: PMC8407330 DOI: 10.1002/14651858.cd013384.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality. OBJECTIVES To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data). SEARCH METHODS We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021. SELECTION CRITERIA Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed-methods studies to identify themes. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed-methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations. MAIN RESULTS Quantitative studies We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land-based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type. Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates. Intervention versus usual care Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) -10.85, 95% confidence interval (CI) -12.66 to -9.04; 1 study, 70 participants; low-certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.60; 1 study, 70 participants, moderate-certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD -6.90, 95% CI -9.56 to -4.24; moderate-certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low-certainty evidence). For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent interventions at 38 to 52 weeks (low-certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality. Intervention versus active comparator We included one study comparing water-based and land-based exercise (30 participants). We found no evidence for quality of life or exacerbations. There may be little to no difference between water- and land-based exercise for 6MWD (MD 5 metres, 95% CI -22 to 32; 38 participants; very low-certainty evidence). Qualitative studies One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long-term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment. Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall. AUTHORS' CONCLUSIONS Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take-home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities. Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.
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Affiliation(s)
- Emma J Dennett
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Sadia Janjua
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Elizabeth Stovold
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | | | - Melissa J McDonnell
- Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland
| | - Anne E Holland
- Physiotherapy, Alfred Health, Melbourne, Australia
- Discipline of Physiotherapy, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
- Institute for Breathing and Sleep, Melbourne, Australia
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Feldman DE, Carlesso LC, Nahin RL. Management of Patients with a Musculoskeletal Pain Condition that is Likely Chronic: Results from a National Cross Sectional Survey. THE JOURNAL OF PAIN 2020; 21:869-880. [DOI: 10.1016/j.jpain.2019.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/03/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
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Whiffen T, Akbari A, Paget T, Lowe S, Lyons R. How effective are population health surveys for estimating prevalence of chronic conditions compared to anonymised clinical data? Int J Popul Data Sci 2020; 5:1151. [PMID: 34232969 PMCID: PMC7473295 DOI: 10.23889/ijpds.v5i1.1151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Population health surveys are used to record person-reported outcome measures for chronic health conditions and provide a useful source of data when evaluating potential disease burdens. The reliability of survey-based prevalence estimates for chronic diseases is unclear nonetheless. This study applied methodological triangulation via a data linkage method to validate prevalence of selected chronic conditions (angina, myocardial infarction, heart failure, and asthma). METHODS Linked healthcare records were used for a combined cohort of 11,323 adults from the 2013 and 2014 sweeps of the Welsh Health Survey (WHS). The approach utilised consented survey data linked to primary and secondary care electronic health record (EHR) data back to 2002 within the Secure Anonymised Information Linkage (SAIL) Databank. RESULTS This descriptive study demonstrates validation of survey and clinical data using data linkage for selected chronic cardiovascular conditions and asthma with varied success. The results indicate that identifying cases for separate cardiovascular conditions was limited without specific medication codes for each condition, but more straightforward for asthma, where there was an extensive list of medications available. For asthma there was better agreement between prevalence estimates based on survey and clinical data as a result. CONCLUSION Whilst the results provide external validity for the WHS as an instrument for estimating the burden of chronic disease, they also indicate that a data linkage appproach can be used to produce comparable prevalence estimates using clinical data if a defined condition-specific set of clinical codes are available.
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Affiliation(s)
| | - A Akbari
- Health Data Research UK, Swansea University
- Administrative Data Research Wales
| | | | - S Lowe
- Welsh Government
- Administrative Data Research Wales
| | - R Lyons
- Health Data Research UK, Swansea University
- Administrative Data Research Wales
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Ozavci G, Bucknall T, Woodward-Kron R, Hughes C, Jorm C, Joseph K, Manias E. A systematic review of older patients' experiences and perceptions of communication about managing medication across transitions of care. Res Social Adm Pharm 2020; 17:273-291. [PMID: 32299684 DOI: 10.1016/j.sapharm.2020.03.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/26/2020] [Accepted: 03/28/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Communication about managing medications may be difficult when older people move across transitions of care. Communication breakdowns may result in medication discrepancies or incidents. OBJECTIVE The aim of this systematic review was to explore older patients' experiences and perceptions of communication about managing medications across transitions of care. DESIGN A systematic review. METHODS A comprehensive review was conducted of qualitative, quantitative and mixed method studies using CINAHL Complete, MEDLINE, Embase and PsycINFO, Web of Science, INFORMIT and Scopus. These databases were searched from inception to 14.12.2018. Key article cross-checking and hand searching of reference lists of included papers were also undertaken. INCLUSION CRITERIA studies of the medication management perspectives of people aged 65 or older who transferred between care settings. These settings comprised patients' homes, residential aged care and acute and subacute care. Only English language studies were included. Comments, case reports, systematic reviews, letters, editorials were excluded. Thematic analysis was undertaken by synthesising qualitative data, whereas quantitative data were summarised descriptively. Methodological quality was assessed with the Mixed Methods Appraisal Tool. RESULTS The final review comprised 33 studies: 12 qualitative, 17 quantitative and 4 mixed methods studies. Twenty studies addressed the link between communication and medication discrepancies; ten studies identified facilitators of self-care through older patient engagement; 18 studies included older patients' experiences with health professionals about their medication regimen; and, 13 studies included strategies for communication about medications with older patients. Poor communication between primary and secondary care settings was reported as a reason for medication discrepancy before discharge. Older patients expected ongoing and tailored communication with providers and timely, accurate and written information about their medications before discharge or available for the post-discharge period. CONCLUSIONS Communication about medications was often found to be ineffective. Most emphasis was placed on older patients' perspectives at discharge and in the post-discharge period. There was little exploration of older patients' views of communication about medication management on admission, during hospitalisation, or transfer between settings.
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Affiliation(s)
- Guncag Ozavci
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Tracey Bucknall
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 221 Burwood Highway, Burwood, Victoria, 3125, Australia; Deakin-Alfred Health Nursing Research Centre, Alfred Health, 55 Commercial Rd, Melbourne, VIC 3004 Australia.
| | - Robyn Woodward-Kron
- Department of Medical Education, Melbourne Medical School, The University of Melbourne, Grattan Street Parkville, 3052, Victoria, Australia.
| | - Carmel Hughes
- Queen's University Belfast, School of Pharmacy, 97 Lisburn Road Belfast BT9 7BL, UK, Northern Ireland, UK.
| | - Christine Jorm
- NSW Regional Health Partners, Wisteria House, James Fletcher Hospital, 72 Watt St, Newcastle, 2300, NSW, Australia.
| | - Kathryn Joseph
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Elizabeth Manias
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
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10
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Damluji AA, Forman DE, van Diepen S, Alexander KP, Page RL, Hummel SL, Menon V, Katz JN, Albert NM, Afilalo J, Cohen MG. Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e6-e32. [DOI: 10.1161/cir.0000000000000741] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.
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11
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Wagner E, Patrick DL, Khandelwal N, Brumback L, Starks H, Fausto J, Dunlap BS, Lober W, Sibley J, Loggers ET, Curtis JR, Engelberg RA. The Influence of Multimorbidity on Health Care Utilization at the End of Life for Patients with Chronic Conditions. J Palliat Med 2019; 22:1260-1265. [DOI: 10.1089/jpm.2018.0349] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Elizabeth Wagner
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
| | - Donald L. Patrick
- Department of Health Services, University of Washington, Seattle, Washington
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Lyndia Brumback
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Helene Starks
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
- Department of Bioethics and Humanities, and University of Washington, Seattle, Washington
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - James Fausto
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Benjamin S. Dunlap
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - William Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington
| | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington
| | - Elizabeth T. Loggers
- Seattle Cancer Care Alliance, Seattle, Washington
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
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12
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Zulman DM, Chang ET, Wong A, Yoon J, Stockdale SE, Ong MK, Rubenstein LV, Asch SM. Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial. J Gen Intern Med 2019; 34:75-81. [PMID: 31098977 PMCID: PMC6542922 DOI: 10.1007/s11606-019-04965-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA. .,Division of Primary Care and Population Health, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA.
| | - Evelyn T Chang
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.,Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Ava Wong
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Jean Yoon
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,VA Health Economics Resource Center, Menlo Park, CA, USA
| | - Susan E Stockdale
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael K Ong
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.,Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,RAND, Santa Monica, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA
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13
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Szanton SL, Xue QL, Leff B, Guralnik J, Wolff JL, Tanner EK, Boyd C, Thorpe RJ, Bishai D, Gitlin LN. Effect of a Biobehavioral Environmental Approach on Disability Among Low-Income Older Adults: A Randomized Clinical Trial. JAMA Intern Med 2019; 179:204-211. [PMID: 30615024 PMCID: PMC6439640 DOI: 10.1001/jamainternmed.2018.6026] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Disability among older adults is a strong predictor of health outcomes, health service use, and health care costs. Few interventions have reduced disability among older adults. OBJECTIVE To determine whether a 10-session, home-based, multidisciplinary program reduces disability. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial of 300 low-income community-dwelling adults with a disability in Baltimore, Maryland, between March 18, 2012, and April 29, 2016, 65 years or older, cognitively intact, and with self-reported difficulty with 1 or more activities of daily living (ADLs) or 2 or more instrumental ADLs (IADLs), participants were interviewed in their home at baseline, 5 months (end point), and 12 months (follow-up) by trained research assistants who were masked to the group allocation. Participants were randomized to either the intervention (CAPABLE) group (n = 152) or the attention control group (n = 148) through a computer-based assignment scheme, stratified by sex in randomized blocks. Intention-to-treat analysis was used to assess the intervention. Data were analyzed from September 2017 through August 2018. INTERVENTIONS The CAPABLE group received up to 10 home visits over 5 months by occupational therapists, registered nurses, and home modifiers to address self-identified functional goals by enhancing individual capacity and the home environment. The control group received 10 social home visits by a research assistant. MAIN OUTCOMES AND MEASURES Disability with ADLs or IADLs at 5 months. Each ADL and IADL task was self-scored from 0 to 2 according to whether in the previous month the person did not have difficulty and did not need help (0), did not need help but had difficulty (1), or needed help regardless of difficulty (2). The overall score ranged from 0 to 16 points. RESULTS Of the 300 people randomized to either the CAPABLE group (n = 152) or the control group (n = 148), 133 of the CAPABLE participants (87.5%) were women with a mean (SD) age of 75.7 (7.6) years; 126 (82.9%) self-identified as black. Of the controls, 129 (87.2%) were women with a mean (SD) age of 75.4 (7.4) years; 133 (89.9%) self-identified as black. CAPABLE participation resulted in 30% reduction in ADL disability scores at 5 months (relative risk [RR], 0.70; 95% CI, 0.54-0.93; P = .01) vs control participation. CAPABLE participation resulted in a statistically nonsignificant 17% reduction in IADL disability scores (RR, 0.83; 95% CI, 0.65-1.06; P = .13) vs control participation. Participants in the CAPABLE group vs those in the control group were more likely to report that the program made their life easier (82.3% vs 43.1%; P < .001), helped them take care of themselves (79.8% vs 35.5%; P < .001), and helped them gain confidence in managing daily challenges (79.9% vs 37.7%; P < .001). CONCLUSIONS AND RELEVANCE Low-income community-dwelling older adults who received the CAPABLE intervention experienced substantial decrease in disability; disability may be modifiable through addressing both the person and the environment. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01576133.
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Affiliation(s)
- Sarah L Szanton
- Johns Hopkins University School of Nursing, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Qian-Li Xue
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Bruce Leff
- Johns Hopkins University School of Nursing, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jack Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Jennifer L Wolff
- Johns Hopkins University School of Nursing, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Roland J Thorpe
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David Bishai
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Laura N Gitlin
- Johns Hopkins University School of Nursing, Baltimore, Maryland.,College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania
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14
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Bayliss EA, Tabano HA, Gill TM, Anzuoni K, Tai-Seale M, Allore HG, Ganz DA, Dublin S, Gruber-Baldini AL, Adams AL, Mazor KM. Data Management for Applications of Patient Reported Outcomes. EGEMS (WASHINGTON, DC) 2018; 6:5. [PMID: 29881763 PMCID: PMC5983068 DOI: 10.5334/egems.201] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 02/01/2018] [Indexed: 11/20/2022]
Abstract
CONTEXT Patient reported outcomes (PROs) are one means of systematically gathering meaningful subjective information for patient care, population health, and patient centered outcomes research. However, optimal data management for effective PRO applications is unclear. CASE DESCRIPTION Delivery systems associated with the Health Care Systems Research Network (HCSRN) have implemented PRO data collection as part of the Medicare annual Health Risk Assessment (HRA). A questionnaire assessed data content, collection, storage, and extractability in HCSRN delivery systems. FINDINGS Responses were received from 15 (83.3 percent) of 18 sites. The proportion of Medicare beneficiaries completing an HRA ranged from less than 10 to 42 percent. Most sites collected core HRA elements and 10 collected information on additional domains such as social support. Measures for core domains varied across sites. Data were collected at and prior to visits. Modes included paper, clinician entry, patient portals, and interactive voice response. Data were stored in the electronic health record (EHR) in scanned documents, free text, and discrete fields, and in summary databases. MAJOR THEMES PRO implementation requires effectively collecting, storing, extracting, and applying patient-reported data. Standardizing PRO measures and storing data in extractable formats can facilitate multi-site uses for PRO data, while access to individual PROs in the EHR may be sufficient for use at the point of care. CONCLUSION Collecting comparable PRO data elements, storing data in extractable fields, and collecting data from a higher proportion of eligible respondents represents an optimal approach to support multi-site applications of PRO information.
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Affiliation(s)
- E. A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, US
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, US
| | - H. A. Tabano
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, US
| | - T. M. Gill
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US
| | - K. Anzuoni
- Meyers Primary Care Institute, a joint endeavor of the University of Massachusetts Medical School, Reliant Medical Group and Fallon Health, Worcester, MA, US
| | - M. Tai-Seale
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, US
| | - H. G. Allore
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US
| | - D. A. Ganz
- Division of Geriatrics, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, US
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, US
| | - S. Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle WA, US
| | - A. L. Gruber-Baldini
- Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, US
| | - A. L. Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, US
| | - K. M. Mazor
- Meyers Primary Care Institute, a joint endeavor of the University of Massachusetts Medical School, Reliant Medical Group and Fallon Health, Worcester, MA, US
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15
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Smith SM, Wallace E, Salisbury C, Sasseville M, Bayliss E, Fortin M. A Core Outcome Set for Multimorbidity Research (COSmm). Ann Fam Med 2018; 16. [PMID: 29531104 PMCID: PMC5847351 DOI: 10.1370/afm.2178] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE We aimed to develop a consensus-based set of core outcomes specifically for studies in multimorbidity. METHODS We undertook a consensus study following the COS-STAR (Core Outcome Set-STAndards for Reporting) guidelines for the design and reporting of core outcome sets. A Delphi panel of experts completed a web-based survey with 2 rounds. Panelists were presented with a range of outcomes that had been identified in previous workshops and a related systematic review. They indicated their level of agreement on whether each outcome should be included in the core set using a 5-point Likert scale, and outcomes reaching a prespecified consensus level were included. RESULTS Of 30 individuals invited to be panelists, 26 from 13 countries agreed. All 26 completed both rounds of the survey. The Delphi panel reached consensus on 17 outcomes for inclusion in a core outcome set for multimorbidity (COSmm). The highest-ranked outcomes were health-related quality of life, mental health outcomes, and mortality. Other outcomes were grouped into overarching themes of patient-reported impacts and behaviors (treatment burden, self-rated health, self-management behavior, self-efficacy, adherence); physical activity and function (activities of daily living, physical function, physical activity); consultation related (communication, shared decision making, prioritization); and health systems (health care use, costs, quality of health care). CONCLUSIONS This consensus study involved a wide range of international experts who identified a large number of outcomes for multimorbidity intervention studies. Our results suggest that quality of life, mental health outcomes, and mortality should be regarded as essential core outcomes. Researchers should, however, also consider the full range of outcomes when designing studies to capture important domains in multimorbidity depending on individual study aims and interventions.
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Affiliation(s)
- Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Chris Salisbury
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Maxime Sasseville
- Department of Health Sciences Research, Research Chair on Chronic Diseases in Primary Care, Chicoutimi (Quebec), Canada
| | - Elizabeth Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, University of Colorado School of Medicine, Denver, Colorado
| | - Martin Fortin
- Département de médecine de famille, Université de Sherbrooke, Sherbrooke (Québec), Canada
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16
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Schiøtz ML, Høst D, Christensen MB, Domínguez H, Hamid Y, Almind M, Sørensen KL, Saxild T, Holm RH, Frølich A. Quality of care for people with multimorbidity - a case series. BMC Health Serv Res 2017; 17:745. [PMID: 29151022 PMCID: PMC5694163 DOI: 10.1186/s12913-017-2724-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 11/13/2017] [Indexed: 12/16/2022] Open
Abstract
Background Multimorbidity is becoming increasingly prevalent and presents challenges for healthcare providers and systems. Studies examining the relationship between multimorbidity and quality of care report mixed findings. The purpose of this study was to investigate quality of care for people with multimorbidity in the publicly funded healthcare system in Denmark. Methods To investigate the quality of care for people with multimorbidity different groups of clinicians from the hospital, general practice and the municipality reviewed records from 23 persons with multimorbidity and discussed them in three focus groups. Before each focus group, clinicians were asked to review patients’ medical records and assess their care by responding to a questionnaire. Medical records from 2013 from hospitals, general practice, and health centers in the local municipality were collected and linked for the 23 patients. Further, two clinical pharmacologists reviewed the appropriateness of medications listed in patient records. Results The review of the patients’ records conducted by three groups of clinicians revealed that around half of the patients received adequate care for the single condition which prompted the episode of care such as a hospitalization, a visit to an outpatient clinic or the general practitioner. Further, the care provided to approximately two-thirds of the patients did not take comorbidities into account and insufficiently addressed more diffuse symptoms or problems. The review of the medication lists revealed that the majority of the medication lists contained inappropriate medications and that there were incongruity in medication listed in the primary and secondary care sector. Several barriers for providing high quality care were identified. These included relative short consultation times in general practice and outpatient clinics, lack of care coordinators, and lack of shared IT-system proving an overview of the treatment. Conclusions Our findings reveal quality of care deficiencies for people with multimorbidity. Suggestions for care improvement for people with multimorbidity includes formally assigned responsibility for care coordination, a change in the financial incentive structure towards a system rewarding high quality care and care focusing on prevention of disease exacerbation, as well as implementing shared medical record systems.
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Affiliation(s)
- Michaela L Schiøtz
- Cross-sectoral Research Unit, The Danish Capital Region, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark. .,Research Unit for Chronic Conditions, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark.
| | - Dorte Høst
- Cross-sectoral Research Unit, The Danish Capital Region, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Research Unit for Chronic Conditions, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel B Christensen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | - Helena Domínguez
- Department of Cardiology, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | - Yasmin Hamid
- Department of Endocrinology, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | - Merete Almind
- Department of Respiratory Medicine, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Rikke Høgsbro Holm
- Health Prevention Center, Municipality of Copenhagen, Copenhagen, Denmark
| | - Anne Frølich
- Research Unit for Chronic Conditions, Department of Clinical Epidemiology, Bispebjerg and Frederiksberg Hospitals, University of Copenhagen, Copenhagen, Denmark
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17
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Affiliation(s)
- Danelle Cayea
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, 5500 Eastern Avenue, Mason F. Lord Building, Center Tower, Suite 2200, Room 208, Baltimore, MD 21224, USA.
| | - Samuel C Durso
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, 5200 Eastern Avenue, Mason F. Lord Building, Center Tower, Floor 3, DOM Suite, Room 317, Baltimore, MD 21224, USA.
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18
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Tisminetzky M, Bayliss EA, Magaziner JS, Allore HG, Anzuoni K, Boyd CM, Gill TM, Go AS, Greenspan SL, Hanson LR, Hornbrook MC, Kitzman DW, Larson EB, Naylor MD, Shirley BE, Tai-Seale M, Teri L, Tinetti ME, Whitson HE, Gurwitz JH. Research Priorities to Advance the Health and Health Care of Older Adults with Multiple Chronic Conditions. J Am Geriatr Soc 2017; 65:1549-1553. [PMID: 28555750 PMCID: PMC5507733 DOI: 10.1111/jgs.14943] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To prioritize research topics relevant to the care of the growing population of older adults with multiple chronic conditions (MCCs). DESIGN Survey of experts in MCC practice, research, and policy. Topics were derived from white papers, funding announcements, or funded research projects relating to older adults with MCCs. SETTING Survey conducted through the Health Care Systems Research Network (HCSRN) and Claude D. Pepper Older Americans Independence Centers (OAICs) Advancing Geriatrics Infrastructure and Network Growth Initiative, a joint endeavor of the HCSRN and OAICs. PARTICIPANTS Individuals affiliated with the HCSRN or OAICs and national MCC experts, including individuals affiliated with funding agencies having MCC-related grant portfolios. MEASUREMENTS A "top box" methodology was used, counting the number of respondents selecting the top response on a 5-point Likert scale and dividing by the total number of responses to calculate a top box percentage for each of 37 topics. RESULTS The highest-ranked research topics relevant to the health and healthcare of older adults with MCCs were health-related quality of life in older adults with MCCs; development of assessment tools (to assess, e.g., symptom burden, quality of life, function); interactions between medications, disease processes, and health outcomes; disability; implementation of novel (and scalable) models of care; association between clusters of chronic conditions and clinical, financial, and social outcomes; role of caregivers; symptom burden; shared decision-making to enhance care planning; and tools to improve clinical decision-making. CONCLUSION Study findings serve to inform the development of a comprehensive research agenda to address the challenges relating to the care of this "high-need, high-cost" population and the healthcare delivery systems responsible for serving it.
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Affiliation(s)
- Mayra Tisminetzky
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jay S. Magaziner
- University of Maryland School of Medicine, Dept. of Epidemiology & Public Health, Baltimore, Maryland
| | | | - Kathryn Anzuoni
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
| | - Cynthia M. Boyd
- Division of Geriatric Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Thomas M. Gill
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Susan L. Greenspan
- New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | | | - Mark C. Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | | | - Mary D. Naylor
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Benjamin E. Shirley
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
| | - Linda Teri
- School of Nursing, University of Washington, Seattle
| | - Mary E. Tinetti
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Heather E. Whitson
- Duke University Aging Center, Duke University, Durham, North Carolina
- Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina
| | - Jerry H. Gurwitz
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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Association between Continuity of Care and Health-Related Quality of Life. J Am Board Fam Med 2017; 30:205-212. [PMID: 28379827 PMCID: PMC8565337 DOI: 10.3122/jabfm.2017.02.160225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/25/2016] [Accepted: 11/01/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Patient-reported outcomes (PROs) are considered potential quality metrics for patients with multiple chronic medical conditions (MCC). Although continuity of care (COC) is an essential MCC care process, the association between common PROs and COC is unknown. METHODS We assessed baseline and two-year follow-up self-reported health status, physical, and emotional well-being, and COC in seniors with MCC. Using mixed effects models with repeated measures adjusting for age, gender, and morbidity, we assessed each outcome as a function of COC. RESULTS Of 2,078 seniors, 961 completed the initial survey and 806 completed follow-up. On a 0-100 scale, mean (sd) baseline self-reported health status, physical well-being, and emotional well-being were 48.7 (22.0), 36.4 (11.4), and 54.8 (9.0). On a 0 to 1 scale, mean baseline and 2-year COC were 0.24 (sd 0.22) and 0.22 (0.18). Follow-up self-reported health status, physical well-being, and emotional well-being were 48.8 (23.1), 36.5 (11.5), and 55.3 (8.8). In adjusted primary and secondary analyses using all available data, there were no associations between any outcomes and COC. CONCLUSION Given the measurement burden of quality assessment, negative associations between potential quality metrics and care processes are informative. Systematic assessment of PROs can inform patient-centered MCC care. However, PRO scores should be used with caution as quality measures.
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