A matched-group study protocol to evaluate the implementation of an Integrated Care Pathway programme for chronic obstructive pulmonary disease in Singapore

Identifying Key Themes of Care Coordination for Patients with Chronic Conditions in Singapore: A Scoping Review

A projected rise in patients with complex health needs and a rapidly ageing population will place an increased burden on the healthcare system. Care coordination can bridge potential gaps during care transitions and across the care continuum to facilitate care integration and the delivery of personalised care. Despite having a national strategic vision of improving care integration across different levels of care and community partners, there is no consolidation of evidence specifically on the salient dimensions of care coordination in the Singapore healthcare context. Hence, this scoping review aims to uncover the key themes that facilitate care coordination for patients with chronic conditions in Singapore to be managed in the community while illuminating under-researched areas in care coordination requiring further exploration. The databases searched were PubMed, CINAHL, Scopus, Embase, and Cochrane Library. Results from Google Scholar were also included. Two independent reviewers screened articles in a two-stage screening process based on the Cochrane scoping review guidelines. Recommendation for inclusion was indicated on a three-point scale and rating conflicts were resolved through discussion. Of the 5792 articles identified, 28 were included in the final review. Key cross-cutting themes such as having standards and guidelines for care programmes, forging stronger partnerships across providers, an interoperable information system across care interfaces, strong programme leadership, financial and technical resource availabilities and patient and provider-specific factors emerged. This review also recommends leveraging these themes to align with Singapore's national healthcare vision to contain rising healthcare costs.

The Voice of Patients Really Matters: Using Patient-Reported Outcomes and Experiences Measures to Assess Effectiveness of Home-Based Integrated Care-A Scoping Review of Practice

Background: The aim of the study is to analyze the prevalence of using patients’ reported outcomes measures and experiences (PROMs and PREMs) in relation to integrated care (IC). Material and methods: To select eligible studies (<10 years, full-text), PubMed was used. The general subject of the articles referring to the type of disease was indicated on the basis of a review of all full-text publications discussing the effectiveness of IC (N = 6518). The final search included MeSH headings related to outcomes measures and IC. Full-text screening resulted in including 73 articles (23 on COPD, 40 on diabetes/obesity and 10 on depression) with 93.391 participants. Results: Analysis indicated that authors used multiple outcome measures, with 54.8% of studies including at least one patient reported. PROMs were more often used than PREMs. Specific (disease or condition/dimension) outcome measures were reported more often than general, especially those dedicated to self-assessment of health in COPD and depression. PROMs and PREMs were most commonly used in studies from the USA and Netherlands. Conclusion: Using PROMS/PREMS is becoming more popular, although it is varied, both due to the place of research and type of disease.

Elements and Performance Indicators of Integrated Healthcare Programmes on Chronic Diseases in Six Countries in the Asia-Pacific Region: A Scoping Review

Background and Aims:

Globally, hospital-based healthcare models targeting acute care, are not effective in addressing chronic conditions. Integrated care programmes for chronic diseases have been widely developed and implemented in Europe and North America and to a much lesser extent in the Asia-Pacific region to meet such challenges. We completed a scoping review aiming to examine the elements of programmes identified in the literature from select study countries in the Asia-Pacific, and discuss important facilitators and barriers for design and implementation.

Methods:

The study design adopted a scoping review approach. Integrated care programmes in the study countries were searched in electronic databases using a developed search strategy and key words. Elements of care integration, barriers and facilitators were identified and charted following the Chronic Care Model (CCM).

Results:

Overall the study found a total of 87 integrated care programmes for chronic diseases in all countries, with 44 in China, 21 in Singapore, 12 in India, 5 in Vietnam, 4 in the Philippines and 1 in Fiji. Financial incentives were found to play a crucial role in facilitating integrated care and ensuring the sustainability of programmes. In many cases, the performance of programmes was found not to have been adequately assessed.

Conclusion:

Integrated care is important for addressing the challenges surrounding the delivery of long-term care and there is an increasing trend of integrated care programmes for chronic diseases in the Asia-Pacific. Evaluating the performance of integrated care programmes is crucial for developing strategies for implementing future programmes and improving already existing programmes.

How Views of the Organization of Primary Care Among Patients with Hypertension Vary by Race or Ethnicity

INTRODUCTION

We assessed potential racial or ethnic differences in the degree to which veterans with pharmaceutically treated hypertension report experiences with their primary care system that are consistent with optimal chronic illness care as suggested by Wagner's Chronic Care Model (CCM).

MATERIALS AND METHODS

A cross-sectional analysis of the results of the Patient Assessment of Chronic Illness Care (PACIC), which measured components of the care system suggested by the CCM and was completed at baseline by participants in a hypertension disease management clinical trial. Participants had a recent history of uncontrolled systolic blood pressure.

RESULTS

Among 377 patients, non-Hispanic African American veterans had almost twice the odds of indicating that their primary care experience is consistent with CCM features when compared with non-Hispanic White patients (odds ratio (OR) = 1.86; 95% confidence interval (CI) = 1.16-2.98). Similar statistically significant associations were observed for follow-up care (OR = 2.59; 95% CI = 1.49-4.50), patient activation (OR = 1.80; 95% CI = 1.13-2.87), goal setting (OR = 1.65; 95% CI = 1.03-2.64), and help with problem solving (OR = 1.62; 95% CI = 1.00-2.60).

CONCLUSIONS

Non-Hispanic African Americans with pharmaceutically treated hypertension report that the primary care system more closely approximates the Wagner CCM than non-Hispanic White patients.

Effectiveness of a chronic obstructive pulmonary disease integrated care pathway in a regional health system: a propensity score matched cohort study

OBJECTIVE

The chronic obstructive pulmonary disease (COPD) integrated care pathway (ICP) programme was designed and implemented to ensure that the care for patients with COPD is comprehensive and integrated across different care settings from primary care to acute hospital and home. We evaluated the effectiveness of the ICP programme for patients with COPD.

DESIGN, SETTING AND PARTICIPANTS

A retrospective propensity score matched cohort study was conducted comparing differences between programme enrolees and propensity-matched non-enrolees in a Regional Health System in Singapore. Data on patients diagnosed with COPD who enrolled in the programme (n=95) and patients who did not enrol (n=6330) were extracted from the COPD registry and hospital administrative databases. Enrolees and non-enrolees were propensity score matched.

OUTCOME MEASURES

The risk of COPD hospitalisations and COPD hospital bed days savings were compared between the groups using a difference-in-difference strategy and generalised estimating equation approach. Adherence with recommended care elements for the COPD-ICP group was measured quarterly at baseline and during a 2-year follow-up period.

RESULTS

Compared with non-enrolees, COPD hospitalisation risk for ICP programme enrolees was significantly lower in year 2 (incidence rate ratio (IRR): 0.73; 95% CI 0.54 to 1.00). Similarly, COPD hospital bed days was significantly lower for enrolees in year 2 (IRR: 0.78; 95% CI 0.64 to 0.95). ICP programme patients had sustained improvements in compliance with all recommended care elements for patients with COPD. The overall all-or-none care bundle compliance rate had improved from 28% to 54%.

CONCLUSION

The study concluded that the COPD-ICP programme was associated with reductions in COPD hospitalisation risk and COPD health utilisation in a 2-year follow-up period.

Process evaluation of an integrated care pathway in geriatric rehabilitation for people with complex health problems

Background

An integrated care pathway in geriatric rehabilitation was developed to improve coordination and continuity of care for community-living older adults in the Netherlands, who go through the process of hospital admission, admission to a geriatric rehabilitation facility and discharge back to the home situation. This pathway is a complex intervention and is focused on improving communication, triage and transfers of patients between the hospital, geriatric rehabilitation facility and primary care organisations. A process evaluation was performed to assess the feasibility of this pathway.

Methods

The study design incorporated mixed methods. Feasibility was assessed thru if the pathway was implemented according to plan (fidelity and dose delivered), (b) if patients, informal caregivers and professionals were satisfied with the pathway (dose received) and (c) which barriers and facilitators influenced implementation (context). These components were derived from the theoretical framework of Saunders and colleagues. Data were collected using three structured face-to-face interviews with patients, self-administered questionnaires among informal caregivers, and group interviews with professionals. Furthermore, data were collected from the information transfer system in the hospital, patient files of the geriatric rehabilitation facility and minutes of evaluation meetings.

Results

In total, 113 patients, 37 informal caregivers and 19 healthcare professionals participated in this process evaluation. The pathway was considered largely feasible as two components were fully implemented according to plan and two components were largely implemented according to plan. The timing and quality of medical discharge summaries were not sufficiently implemented according to plan and professionals indicated that the triage instrument needed refinement. Healthcare professionals were satisfied with the implementation of the pathway and they indicated that due to improved collaboration, the quality of care provision improved. Although patients and informal caregivers were also satisfied with the care provision in the pathway, they indicated that the care organisations involved should pay more attention towards providing information about their treatment.

Conclusions

This process evaluation showed that patients, informal caregivers and professionals are fairly satisfied with the care provision in the pathway and professionals reported that collaboration improved. Extra attention should be paid to the components in the pathway that were not implemented according to plan.

Trial registration

ISRCTN90000867 Registered 7 April 2016.

Comprehensive Diagnostic Assessment of Health Status of Patients with Asthma or COPD: A Delphi Panel Study among Dutch Experts

A comprehensive diagnostic assessment is needed to improve understanding of the health status of patients with chronic obstructive pulmonary disease (COPD) or asthma. Therefore, this study investigated which components and subsequent instruments should be part of a holistic assessment in secondary care. We also explored which data need to be exchanged for an adequate transfer of patients between primary and secondary care, and vice versa. A cross-sectional Web-based survey was conducted among Dutch healthcare professionals using a Delphi-like procedure; these included professionals working in primary or secondary care, medical advisors of health insurance companies and patients' representatives. The national guidelines were used as a starting point, resulting in a questionnaire addressing 55 components related to a comprehensive diagnostic assessment, covering the domains physiological impairments, symptoms, functional limitations and quality of life. Of the 151 experts and stakeholders invited, 92 (60.9%) completed the first round and 79 (52.3%) the second round; most respondents were pulmonologists. There was a high level of agreement between respondents from primary versus secondary care regarding which components should be measured during a comprehensive assessment of patients with asthma or COPD in secondary care and the instruments to measure these components. Regarding the exchange of information, upon referral, pulmonologists required little information from the general practitioners, whereas general practitioners required more extensive information after referral. An overview is provided of what should be part of a holistic assessment of health status in asthma and COPD. This information can be used as input for integrated care pathways.

Clinical pathway for video-assisted thoracic surgery: the Hong Kong story

A clinical pathway provides a scheduled, objective protocol for the multi-disciplinary, evidence-based management of patients with a specific condition or undergoing a specific procedure. In implementing a clinical pathway for the care of patients receiving video-assisted thoracic surgery (VATS) in Hong Kong, many insights were gained into what makes a clinical pathway work: meticulous preparation and team-building are keys to success; the pathway must be constantly reviewed and revisions made in response to evolving clinical need; and data collection is a key element to allow auditing and clinical research. If these can be achieved, a clinical pathway delivers not only measurable improvements in patient outcomes, but also fundamentally complements clinical advances such as VATS. This article narrates the story of how the clinical pathway for VATS in Hong Kong was created and evolved, highlighting how the above lessons were learned.