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Oddy C, Zhang J, Morley J, Ashrafian H. Promising algorithms to perilous applications: a systematic review of risk stratification tools for predicting healthcare utilisation. BMJ Health Care Inform 2024; 31:e101065. [PMID: 38901863 PMCID: PMC11191805 DOI: 10.1136/bmjhci-2024-101065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/14/2024] [Indexed: 06/22/2024] Open
Abstract
OBJECTIVES Risk stratification tools that predict healthcare utilisation are extensively integrated into primary care systems worldwide, forming a key component of anticipatory care pathways, where high-risk individuals are targeted by preventative interventions. Existing work broadly focuses on comparing model performance in retrospective cohorts with little attention paid to efficacy in reducing morbidity when deployed in different global contexts. We review the evidence supporting the use of such tools in real-world settings, from retrospective dataset performance to pathway evaluation. METHODS A systematic search was undertaken to identify studies reporting the development, validation and deployment of models that predict healthcare utilisation in unselected primary care cohorts, comparable to their current real-world application. RESULTS Among 3897 articles screened, 51 studies were identified evaluating 28 risk prediction models. Half underwent external validation yet only two were validated internationally. No association between validation context and model discrimination was observed. The majority of real-world evaluation studies reported no change, or indeed significant increases, in healthcare utilisation within targeted groups, with only one-third of reports demonstrating some benefit. DISCUSSION While model discrimination appears satisfactorily robust to application context there is little evidence to suggest that accurate identification of high-risk individuals can be reliably translated to improvements in service delivery or morbidity. CONCLUSIONS The evidence does not support further integration of care pathways with costly population-level interventions based on risk prediction in unselected primary care cohorts. There is an urgent need to independently appraise the safety, efficacy and cost-effectiveness of risk prediction systems that are already widely deployed within primary care.
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Affiliation(s)
- Christopher Oddy
- Department of Anaesthesia, Critical Care and Pain, Kingston Hospital NHS Foundation Trust, London, UK
| | - Joe Zhang
- Imperial College London Institute of Global Health Innovation, London, UK
- London AI Centre, Guy's and St. Thomas' Hospital, London, UK
| | - Jessica Morley
- Digital Ethics Center, Yale University, New Haven, Connecticut, USA
| | - Hutan Ashrafian
- Imperial College London Institute of Global Health Innovation, London, UK
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Sillero-Rejon C, Kirbyshire M, Thorpe R, Myring G, Evans C, Lloyd-Rees J, Bezer A, McLeod H. Supporting High-impAct useRs in Emergency Departments (SHarED) quality improvement: a mixed-method evaluation. BMJ Open Qual 2023; 12:e002496. [PMID: 38114246 DOI: 10.1136/bmjoq-2023-002496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 12/02/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND The need to better manage frequent attenders or high-impact users (HIUs) in hospital emergency departments (EDs) is widely recognised. These patients often have complex medical needs and are also frequent users of other health and care services. The West of England Academic Health Science Network launched its Supporting High impAct useRs in Emergency Departments (SHarED) quality improvement programme to spread a local HIU intervention across six other EDs in five Trusts. AIM SHarED aimed to reduce ED attendance and hospital admissions by 20% for enrolled HIUs. To evaluate the implementation of SHarED, we sought to learn about the experience of staff with HIU roles and their ED colleagues and assess the impact on HIU attendance and admissions. METHODS We analysed a range of data including semistructured interviews with 10 HIU staff; the number of ED staff trained in HIU management; an ED staff experience survey; and ED attendances and hospital admissions for 148 HIUs enrolled in SHarED. RESULTS Staff with HIU roles were unanimously positive about the benefits of SHarED for both staff and patients. SHarED contributed to supporting ED staff with patient-centred recommendations and provided the basis for more integrated case management across the health and care system. 55% of ED staff received training. There were improvements in staff views relating to confidence, support, training and HIUs receiving more appropriate care. The mean monthly ED attendance per HIU reduced over time. Follow-up data for 86% (127/148) of cases showed a mean monthly ED attendances per HIU reduced by 33%, from 2.1 to 1.4, between the 6 months pre-enrolment and post-enrolment (p<0.001). CONCLUSION SHarED illustrates the considerable potential for a quality improvement programme to promote more integrated case management by specialist teams across the health and care system for particularly vulnerable individuals and improve working arrangements for hard-pressed staff.
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Affiliation(s)
- Carlos Sillero-Rejon
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, UK, Bristol, UK
| | | | - Rebecca Thorpe
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Gareth Myring
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, UK, Bristol, UK
| | - Clare Evans
- Health Innovation West of England, Bristol, UK
| | - Johanna Lloyd-Rees
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Angela Bezer
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Hugh McLeod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, UK, Bristol, UK
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Blomgren J, Jäppinen S, Perhoniemi R. Identifying user profiles of healthcare, social and employment services in a working-age population: A cluster analysis with linked individual-level register data from Finland. PLoS One 2023; 18:e0293622. [PMID: 37910556 PMCID: PMC10619802 DOI: 10.1371/journal.pone.0293622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023] Open
Abstract
A thorough understanding of the use of services in the population is important in order to comprehend the varying service needs of different groups. This explorative study aimed to find distinct user profiles in a working-age population based on individuals' annual use of healthcare, social and employment services and to explore socio-demographic and morbidity-related predictors of the user groups. Administrative register data on the use of various services and individual-level covariates from year 2018 were linked for all residents aged 18-64 of the municipality of Oulu, Finland (N = 119,740). K-means cluster analysis was used to group the study subjects into clusters, based on their frequency of using 22 distinct healthcare, social and employment services during 2018. Multinomial logistic regression models were utilized to assess the associations of cluster assignment with socio-demographic and health-related covariates (sex, age, marital status, education, occupational class, income, days in employment, chronic disease and receipt of different social benefits). Five distinct clusters were identified in terms of service use, labelled low to moderate users of healthcare (82.0%), regular employment services users with moderate use of healthcare (9.6%), supported employment services users with moderate use of healthcare with an emphasis on preventive care (2.9%), frequent users of healthcare, social and employment services (2.9%), and rehabilitation, disability services and specialized healthcare users (2.6%). Each cluster not only showed different patterns of service use but were also differently associated with demographic, socio-economic and morbidity-related covariates, creating distinct service user types. Knowledge on the different user profiles and their determinants may help predict future need and use of services in a population, plan timely, coordinated and integrated services, and design early interventions and prevention measures. This is important in order to save costs and improve the effectiveness of services for groups with different care needs.
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Affiliation(s)
- Jenni Blomgren
- Research Unit, The Social Insurance Institution of Finland, Helsinki, Finland
| | - Sauli Jäppinen
- Analytics Unit, The Social Insurance Institution of Finland, Helsinki, Finland
| | - Riku Perhoniemi
- Research Unit, The Social Insurance Institution of Finland, Helsinki, Finland
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Evans BA, Khanom A, Edwards A, Edwards B, Farr A, Foster T, Fothergill R, Gripper P, Gunson I, Porter A, Rees N, Scott J, Snooks H, Watkins A. Experiences and views of people who frequently call emergency ambulance services: A qualitative study of UK service users. Health Expect 2023; 27:e13856. [PMID: 37578195 PMCID: PMC10726061 DOI: 10.1111/hex.13856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/01/2023] [Accepted: 08/09/2023] [Indexed: 08/15/2023] Open
Abstract
INTRODUCTION People who call emergency ambulances frequently are often vulnerable because of health and social circumstances, have unresolved problems or cannot access appropriate care. They have higher mortality rates. Case management by interdisciplinary teams can help reduce demand for emergency services and is available in some UK regions. We report results of interviews with people who use emergency ambulance services frequently to understand their experiences of calling and receiving treatment. METHODS We used a two-stage recruitment process. A UK ambulance service identified six people who were known to them as frequently calling emergency services. Through third-sector organisations, we also recruited nine individuals with healthcare experiences reflecting the characteristics of people who call frequently. We gained informed consent to record and transcribe all telephone interviews. We used thematic analysis to explore the results. RESULTS People said they make frequent calls to emergency ambulance services as a last resort when they perceive their care needs are urgent and other routes to help have failed. Those with the most complex health needs generally felt their immediate requirements were not resolved and underlying mental and physical problems led them to call again. A third of respondents were also attended to by police and were arrested for behaviour associated with their health needs. Those callers receiving case management did not know they were selected for this. Some respondents were concerned that case management could label frequent callers as troublemakers. CONCLUSION People who make frequent calls to emergency ambulance services feel their health and care needs are urgent and ongoing. They cannot see alternative ways to receive help and resolve problems. Communication between health professionals and service users appears inadequate. More research is needed to understand service users' motivations and requirements to inform design and delivery of accessible and effective services. PATIENT OR PUBLIC CONTRIBUTION People with relevant experience were involved in developing, undertaking and disseminating this research. Two public contributors helped design and deliver the study, including developing and analysing service user interviews and drafting this paper. Eight public members of a Lived Experience Advisory Panel contributed at key stages of study design, interpretation and dissemination. Two more public contributors were members of an independent Study Steering Committee.
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Affiliation(s)
- Bridie A. Evans
- Swansea University Medical SchoolSwanseaUK
- PRIME Centre Wales, Institute of Life ScienceSwansea University Medical SchoolSwanseaUK
| | - Ashra Khanom
- Swansea University Medical SchoolSwanseaUK
- PRIME Centre Wales, Institute of Life ScienceSwansea University Medical SchoolSwanseaUK
| | - Adrian Edwards
- School of Medicine, PRIME Centre Wales, Division of Population MedicineCardiff UniversityCardiffUK
| | - Bethan Edwards
- Public Contributor, c/o Swansea University Medical SchoolSwanseaUK
| | - Angela Farr
- Swansea Centre for Health EconomicsSwansea UniversitySwanseaUK
| | | | | | - Penny Gripper
- Public Contributor, c/o Swansea University Medical SchoolSwanseaUK
| | - Imogen Gunson
- West Midlands Ambulance Service University NHS Foundation TrustWest MidlandsUK
| | - Alison Porter
- Swansea University Medical SchoolSwanseaUK
- PRIME Centre Wales, Institute of Life ScienceSwansea University Medical SchoolSwanseaUK
| | - Nigel Rees
- Welsh Ambulance Services NHS TrustCwmbranUK
| | | | - Helen Snooks
- Swansea University Medical SchoolSwanseaUK
- PRIME Centre Wales, Institute of Life ScienceSwansea University Medical SchoolSwanseaUK
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Hudon C, Bisson M, Chouinard MC, Delahunty-Pike A, Lambert M, Howse D, Schwarz C, Dumont-Samson O, Aubrey-Bassler K, Burge F, Doucet S, Ramsden VR, Luke A, Macdonald M, Gaudreau A, Porter J, Rubenstein D, Scott C, Warren M, Wilhelm L. Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada. BMC Health Serv Res 2023; 23:377. [PMID: 37076851 PMCID: PMC10116737 DOI: 10.1186/s12913-023-09379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 04/08/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Case management is one of the most frequently performed interventions to mitigate the negative effects of high healthcare use on patients, primary care providers and the healthcare system. Reviews have addressed factors influencing case management interventions (CMI) implementation and reported common themes related to the case manager role and activities, collaboration with other primary care providers, CMI training and relationships with the patients. However, the heterogeneity of the settings in which CMI have been implemented may impair the transferability of the findings. Moreover, the underlying factors influencing the first steps of CMI implementation need to be further assessed. This study aimed to evaluate facilitators and barriers of the first implementation steps of a CMI by primary care nurses for people with complex care needs who frequently use healthcare services. METHODS A qualitative multiple case study was conducted including six primary care clinics across four provinces in Canada. In-depth interviews and focus groups with nurse case managers, health services managers, and other primary care providers were conducted. Field notes also formed part of the data. A mixed thematic analysis, deductive and inductive, was carried out. RESULTS Leadership of the primary care providers and managers facilitated the first steps of the of CMI implementation, as did the experience and skills of the nurse case managers and capacity development within the teams. The time required to establish CMI was a barrier at the beginning of the CMI implementation. Most nurse case managers expressed apprehension about developing an "individualized services plan" with multiple health professionals and the patient. Clinic team meetings and a nurse case managers community of practice created opportunities to address primary care providers' concerns. Participants generally perceived the CMI as a comprehensive, adaptable, and organized approach to care, providing more resources and support for patients and better coordination in primary care. CONCLUSION Results of this study will be useful for decision makers, care providers, patients and researchers who are considering the implementation of CMI in primary care. Providing knowledge about first steps of CMI implementation will also help inform policies and best practices.
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Affiliation(s)
- Catherine Hudon
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada.
- Centre Hospitalier Universitaire de Sherbrooke Research Centre, Sherbrooke, QC, Canada.
| | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | | | | | - Mireille Lambert
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Dana Howse
- Primary Healthcare Research Unit, Memorial University, St-John's, NL, Canada
| | - Charlotte Schwarz
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, NB, Canada
| | - Olivier Dumont-Samson
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University, St-John's, NL, Canada
| | - Fred Burge
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Shelley Doucet
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, NB, Canada
| | - Vivian R Ramsden
- Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Alison Luke
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, NB, Canada
| | - Marilyn Macdonald
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | | | - Judy Porter
- Nova Scotia Health Authority, Halifax, NS, Canada
| | | | - Cathy Scott
- Canadian Cancer Society, Toronto, ON, Canada
| | - Mike Warren
- Patient Advisory Council, Newfoundland and Labrador SPOR SUPPORT Unit, St. John's, NL, Canada
| | - Linda Wilhelm
- Canadian Arthritis Patient Alliance, Ottawa, ON, Canada
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Carter HE, Wallis S, McGowan K, Graves N, Pitt R, Coffey S, Phillips R, Parcell M. Economic evaluation of an integrated virtual care programme for people with chronic illness who are frequent users of health services in Australia. BMJ Open 2023; 13:e066016. [PMID: 37019493 PMCID: PMC10083818 DOI: 10.1136/bmjopen-2022-066016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
OBJECTIVE The MeCare programme is a tailored virtual care initiative targeted at frequent users of health services who have at least one chronic condition including cardiovascular disease, chronic respiratory disease, diabetes or chronic kidney disease. The programme aims to prevent unnecessary hospitalisations by helping patients to self-manage, improve their health literacy and engage in positive health behaviours. This study investigates the impact of the MeCare programme on healthcare resource use, costs and patient-reported outcomes. METHODS AND ANALYSIS A retrospective pre-post study design was adopted. Data on emergency department presentations, hospital admissions, outpatient appointments and their associated costs were obtained from administrative databases. Probabilistic sensitivity analysis using Monte Carlo simulation was used to model changes in resource use and costs prior to, and following, participant enrolment on the MeCare programme. Generalised linear models were used to investigate the observed changes in patient-reported outcomes. RESULTS The MeCare programme cost $A624 per participant month to deliver. Median monthly rates of ED presentations, hospital admissions and average length of stay post-MeCare reduced by 76%, 50% and 12%, respectively. This translated to a median net cost saving of $A982 per participant month (IQR: -1936; -152). A significant, positive trend in patient experience based on responses to the Patient Assessment of Care for Chronic Conditions Questionnaire was observed over the duration of programme enrolment. DISCUSSION The MeCare programme is likely to result in substantial cost savings to the health system, while maintaining or improving patient-reported outcomes. Further research in multisite randomised studies is needed to confirm the generalisability of these results.
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Affiliation(s)
- Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Shannon Wallis
- West Moreton Health, Community and Rural Services, Ipswich, Queensland, Australia
| | - Kelly McGowan
- West Moreton Health, Community and Rural Services, Ipswich, Queensland, Australia
| | - Nicholas Graves
- Health Systems and Services Research, Duke-NUS Medical School, Singapore
| | - Rachelle Pitt
- West Moreton Health, Community and Rural Services, Ipswich, Queensland, Australia
| | - Sue Coffey
- West Moreton Health, Community and Rural Services, Ipswich, Queensland, Australia
| | - Rachel Phillips
- Metro South Health, Queensland Health, Brisbane, Queensland, Australia
| | - Melinda Parcell
- West Moreton Health, Community and Rural Services, Ipswich, Queensland, Australia
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Hudon C, Chouinard MC, Dumont-Samson O, Gobeil-Lavoie AP, Morneau J, Paradis M, Couturier Y, Poitras ME, Poder T, Sabourin V, Lambert M. Integrated case management between primary care clinics and hospitals for people with complex needs who frequently use healthcare services: A multiple-case embedded study. Health Policy 2023; 132:104804. [PMID: 37028261 DOI: 10.1016/j.healthpol.2023.104804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Case management (CM) is recognized to improve care integration and outcomes of people with complex needs who frequently use healthcare services, but challenges remain regarding interaction between primary care clinics and hospitals. This study aimed to implement and evaluate an integrated CM program for this population where nurses in primary care clinics worked with a hospital case manager. METHODS A multiple embedded case study was conducted in the Saguenay-Lac-Saint-Jean region (Québec, Canada), in four dyads including a clinic and a hospital. Mixed data collection included, at baseline and 6 months, interviews and focus groups with stakeholders, patient questionnaires (patient experience of integrated care and self-management), and emergency department (ED) visits in the previous 6 months. RESULTS Integrated CM implementation was optimal when all stakeholders provided collective leadership, and were supportive of the program, particularly the physicians. The 6-month program enabled the observation of positive qualitative outcomes in most clinic-hospital dyads where implementation occurred. Full implementation was associated with improved care integration. DISCUSSION AND CONCLUSION Integrated CM between primary care clinics and hospitals is a promising innovation to improve care integration for people with complex needs who frequently use healthcare services. Collective leadership and physicians' buy-in to integrated CM are important to foster the implementation.
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Bujold M, Pluye P, Légaré F. Decision-making and related outcomes of patients with complex care needs in primary care settings: a systematic literature review with a case-based qualitative synthesis. BMC PRIMARY CARE 2022; 23:279. [PMID: 36352376 PMCID: PMC9644584 DOI: 10.1186/s12875-022-01879-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND In primary care, patients increasingly face difficult decisions related to complex care needs (multimorbidity, polypharmacy, mental health issues, social vulnerability and structural barriers). There is a need for a pragmatic conceptual model to understand decisional needs among patients with complex care needs and outcomes related to decision. We aimed to identify types of decisional needs among patients with complex care needs, and decision-making configurations of conditions associated with decision outcomes. METHODS We conducted a systematic mixed studies review. Two specialized librarians searched five bibliographic databases (Medline, Embase, PsycINFO, CINAHL and SSCI). The search strategy was conducted from inception to December 2017. A team of twenty crowd-reviewers selected empirical studies on: (1) patients with complex care needs; (2) decisional needs; (3) primary care. Two reviewers appraised the quality of included studies using the Mixed Methods Appraisal Tool. We conducted a 2-phase case-based qualitative synthesis framed by the Ottawa Decision Support Framework and Gregor's explicative-predictive theory type. A decisional need case involved: (a) a decision (what), (b) concerning a patient with complex care needs with bio-psycho-social characteristics (who), (c) made independently or in partnership (how), (d) in a specific place and time (where/when), (e) with communication and coordination barriers or facilitators (why), and that (f) influenced actions taken, health or well-being, or decision quality (outcomes). RESULTS We included 47 studies. Data sufficiency qualitative criterion was reached. We identified 69 cases (2997 participants across 13 countries) grouped into five types of decisional needs: 'prioritization' (n = 26), 'use of services' (n = 22), 'prescription' (n = 12), 'behavior change' (n = 4) and 'institutionalization' (n = 5). Many decisions were made between clinical encounters in situations of social vulnerability. Patterns of conditions associated with decision outcomes revealed four decision-making configurations: 'well-managed' (n = 13), 'asymmetric encounters' (n = 21), 'self-management by default' (n = 8), and 'chaotic' (n = 27). Shared decision-making was associated with positive outcomes. Negative outcomes were associated with independent decision-making. CONCLUSION Our results could extend decision-making models in primary care settings and inform subsequent user-centered design of decision support tools for heterogenous patients with complex care needs.
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Affiliation(s)
- Mathieu Bujold
- Department of Management, Evaluation and Health Policy, School of Public Health, Université de Montréal, Montreal, Canada.
- Department of Family Medicine, McGill University, Montreal, Canada.
| | - Pierre Pluye
- Department of Family Medicine, McGill University, Montreal, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Canada
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Shannon B, Eaton G, Lanos C, Leyenaar M, Nolan M, Bowles K, Williams B, O'Meara P, Wingrove G, Heffern JD, Batt A. The development of community paramedicine; a restricted review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e3547-e3561. [PMID: 36065522 PMCID: PMC10087318 DOI: 10.1111/hsc.13985] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/01/2022] [Accepted: 08/13/2022] [Indexed: 05/22/2023]
Abstract
Community paramedic roles are expanding internationally, and no review of the literature could be found to guide services in the formation of community paramedicine programmes. For this reason, the aim of this restricted review was to explore and better understand the successes and learnings of community paramedic programmes across five domains being; education requirements, models of delivery, clinical governance and supervision, scope of roles and outcomes. This restricted review was conducted by searching four databases (CENTRAL, ERIC, EMBASE, MEDLINE and Google Scholar) as well as grey literature search from 2001 until 28/12/2021. After screening, 98 articles were included in the narrative synthesis. Most studies were from the USA (n = 37), followed by Canada (n = 29). Most studies reported on outcomes of community paramedicine programmes (n = 50), followed by models of delivery (n = 28). The findings of this review demonstrate a lack of research and understanding in the areas of education and scope of the role for community paramedics. The findings highlight a need to develop common approaches to education and scope of role while maintaining flexibility in addressing community needs. There was an observable lack of standardisation in the implementation of governance and supervision models, which may prevent community paramedicine from realising its full potential. The outcome measures reported show that there is evidence to support the implementation of community paramedicine into healthcare system design. Community paramedicine programmes result in a net reduction in acute healthcare utilisation, appear to be economically viable and result in positive patient outcomes with high patient satisfaction with care. There is a developing pool of evidence to many aspects of community paramedicine programmes. However, at this time, gaps in the literature prevent a definitive recommendation on the impact of community paramedicine programmes on healthcare system functionality.
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Affiliation(s)
- Brendan Shannon
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
| | - Georgette Eaton
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | | | - Matthew Leyenaar
- Department of Health and Wellness, Emergency Health ServicesGovernment of Prince Edward IslandPrince Edward IslandCanada
| | - Mike Nolan
- County of Renfrew Paramedic ServicePembrokeCanada
| | - Kelly‐Ann Bowles
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
| | - Brett Williams
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
| | - Peter O'Meara
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
| | - Gary Wingrove
- International Roundtable on Community ParamedicineDuluthMNUSA
| | - JD Heffern
- Indigenous Services Canada, Government of CanadaOttawaOntarioCanada
| | - Alan Batt
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
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Gonçalves S, von Hafe F, Martins F, Menino C, Guimarães MJ, Mesquita A, Sampaio S, Londral AR. Case management intervention of high users of the emergency department of a Portuguese hospital: a before-after design analysis. BMC Emerg Med 2022; 22:159. [PMID: 36100864 PMCID: PMC9470068 DOI: 10.1186/s12873-022-00716-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background Emergency department (ED) High users (HU), defined as having more than ten visits to the ED per year, are a small group of patients that use a significant proportion of ED resources. The High Users Resolution Group (GRHU) identifies and provides care to HU to improve their health conditions and reduce the frequency of ED visits by delivering patient-centered case management integrated care. The main objective of this study was to measure the impact of the GRHU intervention in reducing ED visits, outpatient appointments, and hospitalizations. As secondary objectives, we aimed to compare the GRHU intervention costs against its potential savings or additional costs. Finally, we intend to study the impact of this intervention across different groups of patients. Methods We studied the changes triggered by the GRHU program in a retrospective, non-controlled before-after analysis of patients’ hospital utilization data on 6 and 12-month windows from the first appointment. Results A total of 238 ED HU were intervened. A sample of 152 and 88 patients was analyzed during the 6 and 12-month window, respectively. On the 12-month window, GRHU intervention was associated with a statistically significant reduction of 51% in ED visits and hospitalizations and a non-statistically significant increase in the total number of outpatient appointments. Overall costs were reduced by 43.56%. We estimated the intervention costs to be €79,935.34. The net cost saving was €104,305.25. The program’s Return on Investment (ROI) was estimated to be €2.3. Conclusion Patient-centered case management for ED HU seems to effectively reduce ED visits and hospitalizations, leading to better use of resources. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00716-3.
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Monthly Identification of High Frequency Emergency Presenters to Improve Care Delivery and Evaluation: A Unique Methodological Approach. Ochsner J 2022; 22:313-318. [PMID: 36561111 PMCID: PMC9753952 DOI: 10.31486/toj.22.0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Frequent presenters to emergency departments (EDs) pose many challenges around care delivery and health service management. The aim of this study was to investigate the presentation patterns of people with 5 or more ED visits in any calendar month (5+ frequent presenter [FP5+]) to develop a useful methodological framework on which the real impact of interventions may be assessed. Methods: This study is a retrospective analysis of de-identified frequent ED presentation data using segmented regression analysis of an interrupted time series (ITS). Results: A total of 82 FP5+ to this single ED were identified in a year. Of these presenters, 77% had 10 or more presentations in a year. The total FP5+ presentations in the 12 months preceding and after each participant's ≥5 presentations in 1 month (the trigger month for inclusion in the study) accounted for 1,064 and 1,606 visits, respectively. ITS analysis of frequent ED presentations did not show a significant level change or trend change during the data collection period. Monthly review of people who frequently present to a single ED showed that presentations typically occurred in bouts that may span calendar years. Presentation bouts then typically slow, potentially distorting evaluation of the effects of interventions. Conclusion: Rolling monthly examination of presentation data may facilitate timely case review and care delivery, as well as provide a holistic picture of the impacts of interventions targeting patient care needs. This unique analysis demands a reconsideration of the typical before-and-after analysis of interventions for this vulnerable and high-cost group of patients.
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Mayer V, Mijanovich T, Egorova N, Flory J, Mushlin A, Calvo M, Deshpande R, Siscovick D. Impact of New York State's Health Home program on access to care among patients with diabetes. BMJ Open Diabetes Res Care 2021; 9:9/Suppl_1/e002204. [PMID: 34933873 PMCID: PMC8679110 DOI: 10.1136/bmjdrc-2021-002204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/04/2021] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Access to care is essential for patients with diabetes to maintain health and prevent complications, and is important for health equity. New York State's Health Homes (HHs) provide care management services to Medicaid-insured patients with chronic conditions, including diabetes, and aim to improve quality of care and outcomes. There is inconsistent evidence on the impact of HHs, and care management programs more broadly, on access to care. RESEARCH DESIGN AND METHODS Using a cohort of patients with diabetes derived from electronic health records from the INSIGHT Clinical Research Network, we analyzed Medicaid data for HH enrollees and a matched comparison group of HH non-enrollees. We estimated HH impacts on several access measures using natural experiment methods. RESULTS We identified and matched 11 646 HH enrollees; patients were largely non-Hispanic Black (29.9%) and Hispanic (48.7%), and had high rates of dual eligibility (33.0%), Supplemental Security Income disability enrollment (49.1%), and multiple comorbidities. In the 12 months following HH enrollment, HH enrollees had one more month of Medicaid coverage (p<0.001) and 4.6 more outpatient visits than expected (p<0.001, evenly distributed between primary and specialty care). There were also positive impacts on the proportions of patients with follow-up visits within 7 days (4 percentage points (pp), p<0.001) and 30 days (6pp, p<0.001) after inpatient care, and on the proportion of patients with follow-up visits within 30 days after emergency department (ED) care (4pp, p<0.001). We did not find meaningful differences in continuity of care. We found small positive impacts on the proportion of patients with an inpatient visit and the proportion with an ED visit. CONCLUSIONS New York State's HH program improved access to care for Medicaid recipients with diabetes. These findings have implications for New York State Medicaid as well as other providers and care management programs.
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Affiliation(s)
- Victoria Mayer
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Tod Mijanovich
- Department of Applied Statistics, Social Sciences, and Humanities, Steinhardt School, New York University, New York City, New York, USA
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - James Flory
- Endocrinology Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Alvin Mushlin
- Departments of Population Health Sciences and Medicine, Weill Cornell Medicine, New York City, New York, USA
| | - Michele Calvo
- Research, Evaluation & Policy, New York Academy of Medicine, New York City, New York, USA
| | - Richa Deshpande
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Center for Biostatistics, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - David Siscovick
- Research, Evaluation & Policy, New York Academy of Medicine, New York City, New York, USA
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Kelley J. Stigma and Human Rights: Transgender Discrimination and Its Influence on Patient Health. Prof Case Manag 2021; 26:298-303. [PMID: 34609343 DOI: 10.1097/ncm.0000000000000506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/OBJECTIVES Transgender patients encounter barriers to accessing medical treatment. Although the medical field has made strides to improve transgender patients' health care experiences, programs that provide support in navigating existing obstacles are lacking. As integrated care becomes more prevalent, primary care settings have the potential to become medical havens for vulnerable patient populations. Enlisting support of professional case managers to connect transgender patients to services to meet their physical and behavioral health needs could increase health care utilization and decrease disparities. FINDINGS/CONCLUSIONS Because of their gender identities, transgender individuals experience high rates of discrimination within health care settings. There are also inequities that limit their access to quality treatment. These, combined with the fear of discrimination, contribute to an avoidance of medical care that negatively impacts the physical and mental health of transgender patients. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Transgender discrimination in health care settings is pervasive and has detrimental effects on patients' well-being. Future research should foster collaboration between health care administrators, professional case managers, primary care providers, behavioral health consultants, and transgender patients to remove existing barriers and increase access to care. Until these changes occur, programs need to be designed for case managers to assist transgender patients in navigating the health care system and connecting to affirming providers. PRIMARY PRACTICE SETTINGS Health care systems and integrated primary care settings.
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Affiliation(s)
- Jennifer Kelley
- Jennifer Kelley, MS, LPC , is a student of the Doctor of Behavioral Health program at the Cummings Graduate Institute. Currently, Jennifer works with patients within integrated care and hospital settings in Pennsylvania. She is most passionate about ensuring that all patients have access to quality treatment and finding interventions to reduce health disparities among patient populations
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McBrien KA, Nguyen V, Garcia-Jorda D, Rondeau K, Polachek A, Kamran H, Lang E, Ghali W, Barnabe C, Braun T, McLane P, Milaney K, Ronksley PE, Salvalaggio G, Spackman E, Tang KL, Williamson T, Fabreau G. Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol. Front Public Health 2021; 9:605695. [PMID: 34692614 PMCID: PMC8531265 DOI: 10.3389/fpubh.2021.605695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.
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Affiliation(s)
- Kerry A McBrien
- Department of Family Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Van Nguyen
- Calgary Urban Project Society, Calgary, AB, Canada
| | | | - Kimberly Rondeau
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alicia Polachek
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hasham Kamran
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - William Ghali
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cheryl Barnabe
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ted Braun
- Alberta Health Services, Calgary, AB, Canada
| | | | - Katrina Milaney
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Eldon Spackman
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Karen L Tang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tyler Williamson
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Gabriel Fabreau
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
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Sathyanarayanan S, Zhou B, Maxey M. Reducing Frequency of Emergency Department and Inpatient Visits Through Focused Case Management. Prof Case Manag 2021; 26:19-26. [PMID: 33214508 DOI: 10.1097/ncm.0000000000000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF STUDY To evaluate whether the Oklahoma State University (OSU) Health Access Network's (HAN's) case management program is effective in reducing the attendance of frequent users to the emergency department (ED) and inpatient department. PRIMARY PRACTICE SETTING This is a 2-year retrospective pre/post-case management analysis. Emergency department usage data from 2013 to 2016 of the OSU HAN contracted clinics are used in this study. This study involves case management interventions for high ED users and high-risk patients. The patients in the study must be enrolled in SoonerCare choice to be case managed. METHODOLOGY AND SAMPLE Patients who visited the ED 3 times or more in 12 months prior to their HAN enrollment and patients with 12 months of data preenrollment and postenrollment were included in the study. A historical control was used to compare ED and inpatient use per patient per month pre- and post-HAN case management. Chi-square and Wilcoxon's signed-rank tests were used to assess the data. RESULTS A total of 29 patients met the inclusion criteria. The number of ED and inpatient visits was reduced after HAN intervention (181 vs. 110, p < .001; 35 vs. 11, p < .001). The ED and inpatient use per patient per month reduced significantly from 0.52 to 0.31 (p < .001) and 0.10 to 0.03 (p < .01), respectively. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE This study suggests that continuous case management and implementation of various care plans with frequent follow-up are effective in reducing the cost of care and subsequent ED and inpatient visits.
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Affiliation(s)
- Shrieraam Sathyanarayanan
- Shrieraam Sathyanarayanan, MS, is a data analyst at the Oklahoma State University Health Access Network (OSU HAN). He manages the OSU HAN database that collects all the care management data. He has expertise in predictive modeling and machine learning
- Biting Zhou, MS, is a current PhD student in the Department of Statistics at the Oklahoma State University Sitllwater. She works on different mathematical models for sampling data
- Matthew Maxey, BSN, MAAL, RN, is the director of the Oklahoma State University (OSU) Health Access Network. He manages all the operations of the program. He designs the key components of the program, such as process improvement and quality assurance projects
| | - Biting Zhou
- Shrieraam Sathyanarayanan, MS, is a data analyst at the Oklahoma State University Health Access Network (OSU HAN). He manages the OSU HAN database that collects all the care management data. He has expertise in predictive modeling and machine learning
- Biting Zhou, MS, is a current PhD student in the Department of Statistics at the Oklahoma State University Sitllwater. She works on different mathematical models for sampling data
- Matthew Maxey, BSN, MAAL, RN, is the director of the Oklahoma State University (OSU) Health Access Network. He manages all the operations of the program. He designs the key components of the program, such as process improvement and quality assurance projects
| | - Matthew Maxey
- Shrieraam Sathyanarayanan, MS, is a data analyst at the Oklahoma State University Health Access Network (OSU HAN). He manages the OSU HAN database that collects all the care management data. He has expertise in predictive modeling and machine learning
- Biting Zhou, MS, is a current PhD student in the Department of Statistics at the Oklahoma State University Sitllwater. She works on different mathematical models for sampling data
- Matthew Maxey, BSN, MAAL, RN, is the director of the Oklahoma State University (OSU) Health Access Network. He manages all the operations of the program. He designs the key components of the program, such as process improvement and quality assurance projects
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16
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Karimi M, van der Zwaan L, Islam K, van Genabeek J, Mölken MRV. Evaluating Complex Health and Social Care Program Using Multi-Criteria Decision Analysis: A Case Study of "Better Together in Amsterdam North". VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:966-975. [PMID: 34243840 DOI: 10.1016/j.jval.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 01/04/2021] [Accepted: 02/12/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Multi-criteria decision analysis (MCDA) has been recommended to support policy making in healthcare. However, practical applications of MCDA are sparse. One potential use for MCDA is for the evaluation of programs for complex and vulnerable patients. These complex patients benefit from integrated care programs that span healthcare and social care and aim to improve more than just health outcomes. MCDA can evaluate programs that aim to improve broader outcomes because it allows the evaluation of multiple outcomes alongside each other. In this study, we evaluate an innovative integrated care program in the Netherlands using MCDA. METHODS We used an innovative MCDA framework with broad outcomes of health, well-being, and cost to evaluate the Better Together in Amsterdam North (BSiN) program using preferences of patients, partners, providers, payers, and policy makers in the Netherlands. BSiN provides case management support for a period of 6 months. Seven outcomes that previous research has deemed important to complex patients were measured, including physical functioning and social relationships and participation. RESULTS We find that the program improved the overall MCDA score marginally, and, thus, after 6 and after 12 months, BSiN was preferred to usual care by all stakeholders. BSiN was preferred to usual care, mostly owing to improvements in psychological well-being and social relationships and participation. CONCLUSIONS The integrated healthcare and social care program BSiN in the Netherlands was preferred to usual care according to an MCDA evaluation. MCDA seems a useful method to evaluate complex programs with benefits beyond health.
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Affiliation(s)
- Milad Karimi
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands.
| | - Lennart van der Zwaan
- Netherlands Organization for Applied Scientific Research TNO, Unit Healthy Living, Leiden, The Netherlands
| | - Kamrul Islam
- Department of Economics, University of Bergen, Bergen, Norway; NORCE Norwegian Research Centre, Bergen, Norway
| | - Joost van Genabeek
- Netherlands Organization for Applied Scientific Research TNO, Unit Healthy Living, Leiden, The Netherlands
| | - Maureen Rutten-van Mölken
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands; Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, The Netherlands
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Factors Associated with Readmission Among General Internal Medicine Patients Experiencing Homelessness. J Gen Intern Med 2021; 36:1944-1950. [PMID: 33515192 PMCID: PMC8298720 DOI: 10.1007/s11606-020-06483-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND People who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients. OBJECTIVE To identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness. DESIGN This prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals. PARTICIPANTS Adults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission. MAIN MEASURES Unplanned all-cause readmission to the study hospital within 90 days of discharge. KEY RESULTS Thirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13-0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08-0.78), and sending a copy of the patient's discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17-1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02-1.23). CONCLUSION Interventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.
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Brunner L, Canepa Allen M, Malebranche M, Hudon C, Senn N, Hugli O, Vu F, Akré C, Bodenmann P. Qualitative evaluation of primary care providers' experiences caring for frequent users of the emergency department. BMJ Open 2021; 11:e044326. [PMID: 34172545 PMCID: PMC8237725 DOI: 10.1136/bmjopen-2020-044326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Many interventions have been developed over the years to offer frequent users of the emergency department (FUEDs) better access to quality coordinated healthcare. Despite recognising the role primary care physicians (PCPs) play in FUEDs' care, to date their perceptions of case management, the most studied intervention, have rarely been assessed. Furthermore, a gap regarding PCPs' experience of caring for FUEDs persists. Thus, this study aimed to explore PCPs' perceptions of the care provided to FUEDs in emergency and primary care settings, their views on the local case management team (CMT), and their suggestions to improve FUEDs' care. DESIGN Qualitative study using in-depth semistructured interviews and inductive thematic analysis. SETTING Canton of Vaud, Switzerland. PARTICIPANTS Thirty PCPs participated, 16 in private practice (PP-PCPs) and 14 based at the Lausanne University Centre of General Medicine and Public Health (Unisanté-U-PCPs). RESULTS U-PCPs and PP-PCPs thought that most FUEDs' emergency department (ED) visits were legitimate, but questioned ED adequacy to meet FUEDs' needs. Yet, both PCP groups reported encountering many challenges in FUEDs' care themselves. In this context, PP-PCPs seemed more satisfied of the care they provided to FUEDs than U-PCPs. Generally, U-PCPs seemed to find more value in the CMT to help them care for FUEDs than PP-PCPs. To enhance FUEDs' care, U-PCPs and PP-PCPs suggested enhancing collaboration with other healthcare providers. U-PCPs also wished to increase their availability, and some PP-PCPs considered outpatient clinics, larger group practices or medical centres most appropriate to handle FUEDs' needs. CONCLUSIONS This study highlights the many challenges PCPs face in caring for FUEDs, that a CM intervention has the potential to mitigate, and provides ways forward in improving FUEDs' care, including reinforced communication with the CMT and ED physicians, and structural changes to their own way of delivering care to FUEDs.
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Affiliation(s)
- Laureline Brunner
- Department of Vulnerabilities and Social Medicine, Unisanté, Lausanne, Vaud, Switzerland
| | - Marina Canepa Allen
- Department of Vulnerabilities and Social Medicine, Unisanté, Lausanne, Vaud, Switzerland
| | - Mary Malebranche
- Department of Medicine, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Catherine Hudon
- Family Medicine and Emergency Medicine Department, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Nicolas Senn
- Department of Family Medicine, Unisanté, Lausanne, Vaud, Switzerland
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne, Lausanne, Vaud, Switzerland
| | - Francis Vu
- Department of Vulnerabilities and Social Medicine, Unisanté, Lausanne, Vaud, Switzerland
| | - Christina Akré
- Department of Epidemiology and Health Systems-University of Lausanne, Unisanté, Lausanne, Vaud, Switzerland
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Unisanté, Lausanne, Vaud, Switzerland
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Mbuya-Bienge C, Simard M, Gaulin M, Candas B, Sirois C. Does socio-economic status influence the effect of multimorbidity on the frequent use of ambulatory care services in a universal healthcare system? A population-based cohort study. BMC Health Serv Res 2021; 21:202. [PMID: 33676497 PMCID: PMC7937264 DOI: 10.1186/s12913-021-06194-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 02/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Frequent healthcare users place a significant burden on health systems. Factors such as multimorbidity and low socioeconomic status have been associated with high use of ambulatory care services (emergency rooms, general practitioners and specialist physicians). However, the combined effect of these two factors remains poorly understood. Our goal was to determine whether the risk of being a frequent user of ambulatory care is influenced by an interaction between multimorbidity and socioeconomic status, in an entire population covered by a universal health system. METHODS Using a linkage of administrative databases, we conducted a population-based cohort study of all adults in Quebec, Canada. Multimorbidity (defined as the number of different diseases) was assessed over a two-year period from April 1st 2012 to March 31st 2014 and socioeconomic status was estimated using a validated material deprivation index. Frequents users for a particular category of ambulatory services had a number of visits among the highest 5% in the total population during the 2014-15 fiscal year. We used ajusted logistic regressions to model the association between frequent use of health services and multimorbidity, depending on socioeconomic status. RESULTS Frequent users (5.1% of the population) were responsible for 25.2% of all ambulatory care visits. The lower the socioeconomic status, the higher the burden of chronic diseases, and the more frequent the visits to emergency departments and general practitioners. Socioeconomic status modified the association between multimorbidity and frequent visits to specialist physicians: those with low socioeconomic status visited specialist physicians less often. The difference in adjusted proportions of frequent use between the most deprived and the least deprived individuals varied from 0.1% for those without any chronic disease to 5.1% for those with four or more chronic diseases. No such differences in proportions were observed for frequent visits to an emergency room or frequent visits to a general practitioner. CONCLUSION Even in a universal healthcare system, the gap between socioeconomic groups widens as a function of multimorbidity with regard to visits to the specialist physicians. Further studies are needed to better understand the differential use of specialized care by the most deprived individuals.
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Affiliation(s)
- Cynthia Mbuya-Bienge
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, QC, Canada.
- Quebec National Institute of Public Health, Quebec, QC, Canada.
- Centre de Recherche Sur les Soins et les Services de Première Ligne de l'Université Laval, Québec, Canada.
| | - Marc Simard
- Quebec National Institute of Public Health, Quebec, QC, Canada
| | - Myles Gaulin
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, QC, Canada
- Quebec National Institute of Public Health, Quebec, QC, Canada
| | - Bernard Candas
- National Institute of Excellence in Health and Social Services, Quebec, QC, Canada
| | - Caroline Sirois
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, QC, Canada
- Quebec National Institute of Public Health, Quebec, QC, Canada
- Centre de Recherche Sur les Soins et les Services de Première Ligne de l'Université Laval, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec, Centre de recherche du CHU de Québec, Quebec, QC, Canada
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Malebranche M, Grazioli VS, Kasztura M, Hudon C, Bodenmann P. Case management for frequent emergency department users: no longer a question of if but when, where and how. CAN J EMERG MED 2020; 23:12-14. [PMID: 33683597 PMCID: PMC7726608 DOI: 10.1007/s43678-020-00024-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/06/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Mary Malebranche
- Department of Medicine, Cumming School of Medicine, University of Calgary, HSC 1410, 3330 Hospital Drive, Calgary, AB, T2N 4N1, Canada.
- Department of Vulnerabilities and Social Medicine, Center for General Medicine and Public Health (Unisanté), University of Lausanne, Canton of Vaud, Lausanne, Switzerland.
| | - Véronique S Grazioli
- Department of Vulnerabilities and Social Medicine, Center for General Medicine and Public Health (Unisanté), University of Lausanne, Canton of Vaud, Lausanne, Switzerland
| | - Miriam Kasztura
- Department of Vulnerabilities and Social Medicine, Center for General Medicine and Public Health (Unisanté), University of Lausanne, Canton of Vaud, Lausanne, Switzerland
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Center for General Medicine and Public Health (Unisanté), University of Lausanne, Canton of Vaud, Lausanne, Switzerland
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MacDonell R, Woods O, Whelan S, Cushen B, Carroll A, Brennan J, Kelly E, Bolger K, McNamara N, Lanigan A, McDonnell T, Prihodova L. Interventions to standardise hospital care at presentation, admission or discharge or to reduce unnecessary admissions or readmissions for patients with acute exacerbation of chronic obstructive pulmonary disease: a scoping review. BMJ Open Respir Res 2020; 7:7/1/e000733. [PMID: 33262103 PMCID: PMC7709517 DOI: 10.1136/bmjresp-2020-000733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/01/2020] [Accepted: 11/08/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that may be punctuated by episodes of worsening symptoms, called exacerbations. Acute exacerbations of COPD (AECOPD) are detrimental to clinical outcomes, reduce patient quality of life and often result in hospitalisation and cost for the health system. Improved diagnosis and management of COPD may reduce the incidence of hospitalisation and death among this population. This scoping review aims to identify improvement interventions designed to standardise the hospital care of patients with AECOPD at presentation, admission and discharge, and/or aim to reduce unnecessary admissions/readmissions. Methods The review followed a published protocol based on methodology set out by Arksey and O’Malley and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic database searches for peer-reviewed primary evidence were conducted in Web of Science, EMBASE (Elsevier) and PubMed. Abstract, full-text screening and data extraction were completed independently by a panel of expert reviewers. Data on type of intervention, implementation supports and clinical outcomes were extracted. Findings were grouped by theme and are presented descriptively. Results 21 articles met the inclusion criteria. Eight implemented a clinical intervention bundle at admission and/or discharge; six used a multidisciplinary care pathway; five used coordinated case management and two ran a health coaching intervention with patients. Conclusion The findings indicate that when executed reliably, improvement initiatives are associated with positive outcomes, such as reduction in length of stay, readmissions or use of health resources. Most of the studies reported an improvement in staff compliance with the initiatives and in the patient’s understanding of their disease. Implementation supports varied and included quality improvement methodology, multidisciplinary team engagement, staff education and development of written or in-person delivery of patient information. Consideration of the implementation strategy and methods of support will be necessary to enhance the likelihood of success in any future intervention.
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Affiliation(s)
- Rachel MacDonell
- Quality Improvement, Royal College of Physicians of Ireland, Dublin, Ireland
| | - Orla Woods
- Research Department, Royal College of Physicians of Ireland, Dublin, Ireland
| | - Stephanie Whelan
- Research Department, Royal College of Physicians of Ireland, Dublin, Ireland
| | - Breda Cushen
- Dept. of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Aine Carroll
- Healthcare Integration and Improvement, University College Dublin, Dublin, Ireland
| | - John Brennan
- Quality Improvement, Royal College of Physicians of Ireland, Dublin, Ireland
| | - Emer Kelly
- Acute Medicine & Respiratory Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Kenneth Bolger
- Dept. of Respiratory Medicine, South Tipperary General Hospital, Clonmel, Tipperary, Ireland
| | - Nora McNamara
- Dept. of Respiratory Medicine, South Tipperary General Hospital, Clonmel, Tipperary, Ireland
| | - Anne Lanigan
- Respiratory Physiotherapy, Midland Regional Hospital Portlaoise, Portlaoise, Laois, Ireland
| | - Timothy McDonnell
- National Clinical Programme Respiratory, Health Service Executive, Dublin, Ireland
| | - Lucia Prihodova
- Research Department, Royal College of Physicians of Ireland, Dublin, Ireland
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Poitras ME, Légaré F, Tremblay Vaillancourt V, Godbout I, Poirier A, Prévost K, Spence C, Chouinard MC, Zomahoun HTV, Khadhraoui L, Massougbodji J, Bujold M, Pluye P, Hudon C. High Users of Healthcare Services: Development and Alpha Testing of a Patient Decision Aid for Case Management. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 13:757-766. [PMID: 33083997 DOI: 10.1007/s40271-020-00465-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Some patients with complex healthcare needs become high users of healthcare services. Case management allows these patients and their interprofessional team to work together to evaluate their needs, priorities and available resources. High-user patients must make an informed decision when choosing whether to engage in case management and currently there is no tool to support them. OBJECTIVE The objective of this study was to develop and conduct a pilot alpha testing of a patient decision aid that supports high-user patients with complex needs and the teams who guide those patients in shared decision making when engaging in case management. METHODS We chose a user-centered design to co-develop a patient decision aid with stakeholders informed by the Ottawa Research Institute and International Patient Decision Aid Standards frameworks. Perceptions and preferences for the patient decision aid's content and format were assessed with patients and clinicians and were iteratively collected through interviews and focus groups. We developed a prototype and assessed its acceptability by using a think-aloud method and a questionnaire with three patient-partners, six clinicians and seven high-user patients with complex needs. RESULTS The three rounds of evaluation to assess the decision aid's acceptability highlighted comments related to simplicity, readability and visual aspect. A section presenting clinical vignettes including story telling was identified as the most helpful. CONCLUSIONS We created and evaluated a patient decision aid. Considering the positive comments, we believe that this aid has the potential to help high-user patients with complex care needs make better choices concerning case management.
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Affiliation(s)
- Marie-Eve Poitras
- Department of Family Medicine and Emergency Medicine/Nursing School, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Campus Saguenay, Saguenay, QC, Canada. .,Département de la recherche, Centre Intégré Universitaire de Santé et de Services Sociaux du Saguenay-Lac-Saint-Jean, Saguenay, QC, Canada. .,Centre de Recherche Charles-LeMoyne-Saguenay-Lac-Saint-Jean Sur Les Innovations en Santé, Saguenay, QC, Canada.
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada.,Population Health and Practice-Changing Research, CHU de Québec, Université Laval, Québec, QC, Canada
| | - Vanessa Tremblay Vaillancourt
- Department of Family Medicine and Emergency Medicine/Nursing School, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Campus Saguenay, Saguenay, QC, Canada.,Département de la recherche, Centre Intégré Universitaire de Santé et de Services Sociaux du Saguenay-Lac-Saint-Jean, Saguenay, QC, Canada.,Centre de Recherche Charles-LeMoyne-Saguenay-Lac-Saint-Jean Sur Les Innovations en Santé, Saguenay, QC, Canada
| | - Isabelle Godbout
- Québec SPOR Support Unit, Université du Québec à Montréal, Montréal, QC, Canada
| | | | - Karina Prévost
- Département de la recherche, Centre Intégré Universitaire de Santé et de Services Sociaux du Saguenay-Lac-Saint-Jean, Saguenay, QC, Canada
| | - Claude Spence
- Department of Family Medicine and Emergency Medicine/Nursing School, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Campus Saguenay, Saguenay, QC, Canada
| | | | - Hervé Tchala Vignon Zomahoun
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada.,Centre de Recherche sur ses Soins et les Services de Première Ligne, Université Laval, Québec, QC, Canada
| | | | | | - Mathieu Bujold
- Family Medicine Department, McGill University, Montréal, QC, Canada
| | - Pierre Pluye
- Family Medicine Department, McGill University, Montréal, QC, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine/Nursing School, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Campus Saguenay, Saguenay, QC, Canada.,Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC, Canada
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23
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Hedayioglu J, Whibley J, Bottle L, Sackree A. Managing the needs of frequent attenders of urgent care services: a case management approach. Emerg Nurse 2020; 28:16-23. [PMID: 32314562 DOI: 10.7748/en.2020.e1998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Frequent service users, frequent attenders and high intensity users comprise a small proportion of emergency department (ED) visits but have a significant effect on cost and workload and are often ineffectively managed in healthcare settings. A new frequent service user manager (FSUM) service was set up in west Kent. This service used a case management approach to address the issue of frequent ED attendance and to support the well-being of these patients. AIM To evaluate a pilot FSUM service designed to address the frequent use of urgent care services. METHOD Service data on demographics, loneliness, anxiety, quality of life and urgent care service use were obtained for 24 frequent service users in one west Kent ED. Interviews were also undertaken with a sample of these patients ( n =4) to capture their experiences of using the FSUM service. RESULTS The main presenting symptoms for attending the ED were pain and alcohol-related issues. After 12 months of the FSUM service, loneliness, anxiety and use of urgent care services had reduced. The participants' quality of life improved from baseline to four months, but then stabilised at 12 months. CONCLUSION This evaluation demonstrated the value of taking a case management approach to address the needs of frequent service users. Healthcare services must encourage the appropriate use of urgent care services to reduce system pressures, but also to improve the well-being of patients.
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Affiliation(s)
- Julie Hedayioglu
- Kent Community Health NHS Foundation Trust, Ashford, England and University of Kent, Canterbury, England
| | - Jill Whibley
- Kent Community Health NHS Foundation Trust, Ashford, England
| | - Laura Bottle
- NHS West Kent Clinical Commissioning Group, Tonbridge, England
| | - Amy Sackree
- Canterbury Christ Church University, Canterbury, England
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24
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Hudon C, Chouinard MC, Brousselle A, Bisson M, Danish A. Evaluating complex interventions in real context: Logic analysis of a case management program for frequent users of healthcare services. EVALUATION AND PROGRAM PLANNING 2020; 79:101753. [PMID: 31835149 DOI: 10.1016/j.evalprogplan.2019.101753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/25/2019] [Accepted: 11/20/2019] [Indexed: 06/10/2023]
Abstract
Case management programs for frequent users of healthcare services are complex interventions which implementation and application are challenging to evaluate. The aim of this article was to conduct a logic analysis to evaluate a case management program for frequent users of healthcare services. The study proceeded in three phases: 1) establishing causal links between the program's components by the construction of a logic model, 2) developing an integrated framework from a realistic synthesis, and 3) making a new reading of the case management program in regard of the integrated framework. The study demonstrated, on one hand, strengths and weaknesses of the actual case management program, and, on the other hand, how logic analysis can create a constructive dialogue between theory and practice. The evaluative process with decision-makers, clinicians and patients has helped to make connexions between theory, practice, experience and services organization.
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Affiliation(s)
- Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, QC Canada; Research Center of the University Hospital Center of Sherbrooke, Sherbrooke, QC Canada.
| | | | - Astrid Brousselle
- School of Public Administration, University of Victoria, Victoria, BC Canada.
| | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, QC Canada.
| | - Alya Danish
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, QC Canada.
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25
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Personalized Care Plans: Are They Effective in Decreasing ED Visits and Health Care Expenditure Among Adult Super-Utilizers? J Emerg Nurs 2020; 46:83-90. [DOI: 10.1016/j.jen.2019.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/02/2019] [Accepted: 09/01/2019] [Indexed: 11/24/2022]
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26
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Snooks HA, Khanom A, Cole R, Edwards A, Edwards BM, Evans BA, Foster T, Fothergill RT, Gripper CP, Hampton C, John A, Petterson R, Porter A, Rosser A, Scott J. What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom. BMC Emerg Med 2019; 19:82. [PMID: 31883535 PMCID: PMC6935477 DOI: 10.1186/s12873-019-0297-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/17/2019] [Indexed: 11/12/2022] Open
Abstract
Background Emergency ambulance services are integral to providing a service for those with unplanned urgent and life-threatening health conditions. However, high use of the service by a small minority of patients is a concern. Our objectives were to describe: service-wide and local policies or pathways for people classified as Frequent Caller; call volume; and results of any audit or evaluation. Method We conducted a national survey of current practice in ambulance services in relation to the management of people who call the emergency ambulance service frequently using a structured questionnaire for completion by email and telephone interview. We analysed responses using a descriptive and thematic approach. Results Twelve of 13 UK ambulance services responded. Most services used nationally agreed definitions for ‘Frequent Caller’, with 600–900 people meeting this classification each month. Service-wide policies were in place, with local variations. Models of care varied from within-service care where calls are flagged in the call centre; contact made with callers; and their General Practitioner (GP) with an aim of discouraging further calls, to case management through cross-service, multi-disciplinary team meetings aiming to resolve callers’ needs. Although data were available related to volume of calls and number of callers meeting the threshold for definition as Frequent Caller, no formal audits or evaluations were reported. Conclusions Ambulance services are under pressure to meet challenging response times for high acuity patients. Tensions are apparent in the provision of care to patients who have complex needs and call frequently. Multi-disciplinary case management approaches may help to provide appropriate care, and reduce demand on emergency services. However, there is currently inadequate evidence to inform commissioning, policy or practice development.
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Affiliation(s)
- Helen A Snooks
- Swansea University Medical School, Singleton Park, Swansea, SA1 8PP, UK
| | | | - Robert Cole
- West Midlands Ambulance Service, Trust Headquarters, Millennium Point, Waterfront Business Park, Waterfront Way, Brierley Hill, West Midlands, DY5 1LX, UK
| | - Adrian Edwards
- Division of Population Medicine School of Medicine, Cardiff University, Cardiff, CF10 3AT, UK
| | | | - Bridie A Evans
- Swansea University Medical School, Singleton Park, Swansea, SA1 8PP, UK
| | - Theresa Foster
- East of England Ambulance Service, Bury St Edmunds, Suffolk, UK
| | | | - Carol P Gripper
- Swansea University Medical School, Singleton Park, Swansea, SA1 8PP, UK
| | - Chelsey Hampton
- Swansea University Medical School, Singleton Park, Swansea, SA1 8PP, UK
| | - Ann John
- Swansea University Medical School, Singleton Park, Swansea, SA1 8PP, UK
| | - Robin Petterson
- Welsh Ambulance Services NHS Trust Headquarters, Ty Elwy, Unit 7, Ffordd Richard Davies, St Asaph Business Park, St Asaph, Denbighshire, LL17 0LJ, UK
| | - Alison Porter
- Swansea University Medical School, Singleton Park, Swansea, SA1 8PP, UK
| | - Andy Rosser
- West Midlands Ambulance Service, Trust Headquarters, Millennium Point, Waterfront Business Park, Waterfront Way, Brierley Hill, West Midlands, DY5 1LX, UK
| | - Jason Scott
- Northumbria University, Sutherland Building, Newcastle-upon-Tyne, NE1 8ST, England
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27
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Booth A, Preston L, Baxter S, Wong R, Chambers D, Turner J. Interventions to manage use of the emergency and urgent care system by people from vulnerable groups: a mapping review. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The NHS currently faces increasing demands on accident and emergency departments. Concern has been expressed regarding whether the needs of vulnerable groups are being handled appropriately or whether alternative methods of service delivery may provide more appropriate emergency and urgent care services for particular groups.
Objective
Our objective was to identify what interventions exist to manage use of the emergency and urgent care system by people from a prespecified list of vulnerable groups. We aimed to describe the characteristics of these interventions and examine service delivery outcomes (for patients and the health service) resulting from these interventions.
Review methods
We conducted an initial mapping review to assess the quantity and nature of the published research evidence relating to seven vulnerable groups (socioeconomically deprived people and families, migrants, ethnic minority groups, the long-term unemployed/inactive, people with unstable housing situations, people living in rural/isolated areas and people with substance abuse disorders). Databases, including MEDLINE and the Cumulative Index to Nursing and Allied Health Literature, and other sources were searched between 2008 and 2018. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. In addition, we searched for UK interventions and initiatives by examining press reports, commissioning plans and casebooks of ‘good practice’. We carried out a detailed intervention analysis, using an adapted version of the TIDieR (Template for Intervention Description and Replication) framework for describing interventions, and an analysis of current NHS practice initiatives.
Results
We identified nine different types of interventions: care navigators [three studies – moderate GRADE (Grading of Recommendations, Assessment, Development and Evaluations)], care planning (three studies – high), case finding (five studies – moderate), case management (four studies – high), front of accident and emergency general practice/front-door streaming model (one study – low), migrant support programme (one study – low), outreach services and teams (two studies – moderate), rapid access doctor/paramedic/urgent visiting services (one study – low) and urgent care clinics (one systematic review – moderate). Few interventions had been targeted at vulnerable populations; instead, they represented general population interventions or were targeted at frequent attenders (who may or may not be from vulnerable groups). Interventions supported by robust evidence (care navigators, care planning, case finding, case management, outreach services and teams, and urgent care clinics) demonstrated an effect on the general population, rather than specific population effects. Many programmes mixed intervention components (e.g. case finding, case management and care navigators), making it difficult to isolate the effect of any single component. Promising UK initiatives (front of accident and emergency general practice/front-door streaming model, migrant support programmes and rapid access doctor/paramedic/urgent visiting services) lacked rigorous evaluation. Evaluation should therefore focus on the clinical effectiveness and cost-effectiveness of these initiatives.
Conclusions
The review identified a limited number of intervention types that may be useful in addressing the needs of specific vulnerable populations, with little evidence specifically relating to these groups. The evidence highlights that vulnerable populations encompass different subgroups with potentially differing needs, and also that interventions seem particularly context sensitive. This indicates a need for a greater understanding of potential drivers for varying groups in specific localities.
Limitations
Resources did not allow exhaustive identification of all UK initiatives; the examples cited are indicative.
Future work
Research is required to examine how specific vulnerable populations differentially benefit from specific types of alternative service provision. Further exploration, using primary mixed-methods data and potentially realist evaluation, is required to explore what works for whom under what circumstances. Rigorous evaluation of UK initiatives is required, including a specific need for economic evaluations and for studies that incorporate effects on the wider emergency and urgent care system.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrew Booth
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Louise Preston
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Susan Baxter
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Janette Turner
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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28
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Majellano EC, Clark VL, Winter NA, Gibson PG, McDonald VM. Approaches to the assessment of severe asthma: barriers and strategies. J Asthma Allergy 2019; 12:235-251. [PMID: 31692528 PMCID: PMC6712210 DOI: 10.2147/jaa.s178927] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/25/2019] [Indexed: 12/12/2022] Open
Abstract
Asthma is a chronic condition with great variability. It is characterized by intermittent episodes of wheeze, cough, chest tightness, dyspnea and backed by variable airflow limitation, airway inflammation and airway hyper-responsiveness. Asthma severity varies uniquely between individuals and may change over time. Stratification of asthma severity is an integral part of asthma management linking appropriate treatment to establish asthma control. Precision assessment of severe asthma is crucial for monitoring the health of people with this disease. The literature suggests multiple factors that impede the assessment of severe asthma, these can be grouped into health care professional, patient and organizational related barriers. These barriers do not exist in isolation but interact and influence one another. Recognition of these barriers is necessary to promote precision in the assessment and management of severe asthma in the era of targeted therapy. In this review, we discuss the current knowledge of the barriers that impede assessment in severe asthma and recommend potential strategies for overcoming these barriers. We highlight the relevance of multidimensional assessment as an ideal approach to the assessment and management of severe asthma.
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Affiliation(s)
- Eleanor C Majellano
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
| | - Vanessa L Clark
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
| | - Natasha A Winter
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Peter G Gibson
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Vanessa M McDonald
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, NSW, Australia
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29
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Di Mauro R, Di Silvio V, Bosco P, Laquintana D, Galazzi A. Case management programs in emergency department to reduce frequent user visits: a systematic review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:34-40. [PMID: 31292413 PMCID: PMC6776176 DOI: 10.23750/abm.v90i6-s.8390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM Inappropriate visits to the Emergency Department (ED) by frequent users (FU) are a common phenomenon because this service is perceived as a rapid and concrete answer to any health and social issue not necessarily related to urgent matters. Could Case Management (CM) programs be a suitable solution to address the problem? The purpose is to examine how CM programs are implemented to reduce the number of FU visits to the ED. METHODS PubMed, CINAHL and EMBASE were consulted up to December 2018. This review follows PRISMA guidelines for systematic review, as first outcomes were considered the impact of CM interventions on ED utilization, costs and composition of teams. RESULTS Fourteen studies were included and they showed patients with common characteristics but the FU definition wasn't the same. Twelve studies provided a reduction of ED utilization and seven studies a cost reduction. The main tool used is the individual care plan with telephone contact, supportive group therapy, facilitated contacts with healthcare providers and informatics system for immediate identification. The CM team composition is heterogeneous, even if nurses are considered the most used professional figures. CONCLUSIONS In contrast with a standardized method, a customized approach of CM program helps frequent users in finding an appropriate answer to their needs, thus decreasing inappropriate visits to the ED.
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Ulrich LR, Petersen JJ, Mergenthal K, Berghold A, Pregartner G, Holle R, Siebenhofer A. Cost-effectiveness analysis of case management for optimized antithrombotic treatment in German general practices compared to usual care - results from the PICANT trial. HEALTH ECONOMICS REVIEW 2019; 9:4. [PMID: 30729350 PMCID: PMC6734317 DOI: 10.1186/s13561-019-0221-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/27/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND By performing case management, general practitioners and health care assistants can provide additional benefits to their chronically ill patients. However, the economic effects of such case management interventions often remain unclear although how to manage the burden of chronic disease is a key question for policy-makers. This analysis aimed to compare the cost-effectiveness of 24 months of primary care case management for patients with a long-term indication for oral anticoagulation therapy with usual care. METHODS This analysis is part of the cluster-randomized controlled Primary Care Management for Optimized Antithrombotic Treatment (PICANT) trial. A sample of 680 patients with German statutory health insurance was initially considered for the cost analysis (92% of all participants at baseline). Costs included all disease-related direct health care costs from the payer's perspective (German statutory health insurers) plus case management costs for the intervention group. A-Quality Adjusted Life Year (QALY) measurement (EQ-5D-3 L instrument) was used to evaluate utility, and incremental cost-effectiveness ratio (ICER) to assess cost-effectiveness. Mean differences were calculated and displayed with 95%-confidence intervals (CI) from non-parametric bootstrapping (1000 replicates). RESULTS N = 505 patients (505/680, 74%) were included in the cost analysis (complete case analysis with a follow-up after 12 and 24 months as well as information on cost and QALY). After two years, the mean difference of direct health care costs per patient (€115, 95% CI [- 201; 406]) and QALYs (0.03, 95% CI [- 0.04; 0.11]) in the two groups was small and not significant. The costs of case management in the intervention group caused mean total costs per patient in this group to rise significantly (mean difference €503, 95% CI [188; 794]). The ICER was €16,767 per QALY. Regardless of the willingness of insurers to pay per QALY, the probability of the intervention being cost-effective never rose above 70%. CONCLUSIONS A primary care case management for patients with a long-term indication for oral anticoagulation therapy improved QALYs compared to usual care, but was more costly. However, the results may help professionals and policy-makers allocate scarce health care resources in such a way that the overall quality of care is improved at moderate costs, particularly for chronically ill patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN41847489 .
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Affiliation(s)
- Lisa R. Ulrich
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt, Germany
| | - Juliana J. Petersen
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt, Germany
| | - Karola Mergenthal
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt, Germany
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Rolf Holle
- Helmholtz Zentrum München - German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Neuherberg, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Andrea Siebenhofer
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt, Germany
- Institute of General Practice and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria
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31
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Lloyd-Rees J. Supporting frequent attenders to reduce their visits to an emergency department. Emerg Nurse 2018; 27:21-27. [PMID: 31468757 DOI: 10.7748/en.2018.e1853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 11/09/2022]
Abstract
Frequent attenders to emergency departments (EDs) are a heterogeneous group who have traditionally been patched up and discharged with little support. This makes them vulnerable to over investigation and they often have a poor experience in EDs, which can cause frustration among the staff who work with them. This article reviews the literature on frequent ED attenders and explores the related issues. It also describes how a multidisciplinary team (MDT) was formed to identify people in this group, evaluate their attendances and notes to understand their individual needs and identify strategies to improve their options and care while in the ED. The rationale for the formation of the MDT, the process of selecting patients and the interventions commonly used are discussed, as well as the benefits to patients, staff and the trust.
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Affiliation(s)
- Johanna Lloyd-Rees
- University Hospitals Bristol NHS Foundation Trust, emergency department, Bristol, England
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Hudon C, Chouinard MC, Aubrey-Bassler K, Burge F, Doucet S, Ramsden VR, Brodeur M, Bush PL, Couturier Y, Dubois MF, Guénette L, Légare F, Morin P, Poder TG, Poitras MÈ, Roberge P, Valaitis R, Bighead S, Campbell C, Couture M, Davis B, Deschenes É, Edwards L, Gander S, Gauthier G, Gauthier P, Gibson RJ, Godbout J, Landry G, Longjohn C, Rabbitskin N, Roy DA, Roy J, Sabourin V, Sampalli T, Saulnier A, Spence C, Splane J, Warren M, Young J, Pluye P. Case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs: an implementation and realist evaluation protocol. BMJ Open 2018; 8:e026433. [PMID: 30478129 PMCID: PMC6254422 DOI: 10.1136/bmjopen-2018-026433] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Significant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. The three specific objectives of this study are to: (1) identify the facilitators and barriers of CM implementation in primary care clinics across Canada; (2) explain and understand the relationships between the actors, contextual factors, mechanisms and outcomes of the CM intervention; (3) identify the next steps towards CM spread in primary care across Canada. METHODS AND ANALYSIS We will conduct a multiple-case embedded mixed methods study. CM will be implemented in 10 primary care clinics in five Canadian provinces. Three different units of analysis will be embedded to obtain an in-depth understanding of each case: the healthcare system (macro level), the CM intervention in the clinics (meso level) and the individual/patient (micro level). For each objective, the following strategy will be performed: (1) an implementation analysis, (2) a realist evaluation and (3) consensus building among stakeholders using the Technique for Research of Information by Animation of a Group of Experts method. ETHICS AND DISSEMINATION This study, which received ethics approval, will provide innovative knowledge about facilitators and barriers to implementation of CM in different primary care jurisdictions and will explain how and why different mechanisms operate in different contexts to generate different outcomes among frequent users. Consensual and prioritised statements about next steps for spread of CM in primary care from the perspectives of all stakeholders will be provided. Our results will offer context-sensitive explanations that can better inform local practices and policies and contribute to improve the health of patients with complex healthcare needs who frequently use healthcare services. Ultimately, this will increase the performance of healthcare systems and specifically mitigate ineffective use and costs.
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Affiliation(s)
- Catherine Hudon
- Département de Médecine de Famille et Médecine d’urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Maud-Christine Chouinard
- Département des Sciences de la Santé, Université du Québec à Chicoutimi, Chicoutimi, Quebec, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University, St-John’s, Newfoundland and Labrador, Canada
| | - Frederick Burge
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shelley Doucet
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, New Brunswick, Canada
| | - Vivian R Ramsden
- Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Magaly Brodeur
- Département de Médecine de Famille et Médecine d’urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Paula L Bush
- Department of Family Medicine, Université McGill, Montréal, Quebec, Canada
| | - Yves Couturier
- School of Social Work, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marie-France Dubois
- Département des sciences de la santé communautaire, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - France Légare
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Canada
| | - Paul Morin
- School of Social Work, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Thomas G Poder
- Département de Médecine de Famille et Médecine d’urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- UETMIS and CRCHUS, CIUSSS de l’Estrie - CHUS, Sherbrooke, Quebec, Canada
| | - Marie-Ève Poitras
- Département des Sciences de la Santé, Université du Québec à Chicoutimi, Chicoutimi, Quebec, Canada
| | - Pasquale Roberge
- Département de Médecine de Famille et Médecine d’urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Ruta Valaitis
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Shirley Bighead
- Sturgeon Lake First Nation, Sturgeon Lake, Saskatchewan, Canada
| | - Cameron Campbell
- Department of Health and Community Services, St-John’s, Newfoundland and Labrador, Canada
| | - Martine Couture
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Chicoutimi, Quebec, Canada
| | - Breanna Davis
- Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Élaine Deschenes
- Centre de pédiatrie sociale Sud-Est (CPSSE), Memramcook, New Brunswick, Canada
| | - Lynn Edwards
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Sarah Gander
- Horizon Health Network, Miramichi, New Brunswick, Canada
| | | | - Patricia Gauthier
- Centre intégré universitaire de santé et services sociaux de l’Estrie – Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Julie Godbout
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Chicoutimi, Quebec, Canada
| | - Geneviève Landry
- Ministere de la Sante et des Services sociaux Quebec, Quebec, Quebec, Canada
| | | | | | - Denis A Roy
- Institut national d’excellence en santé et en services sociaux, Québec, Quebec, Canada
| | - Judy Roy
- Maritime SPOR SUPPORT Unit, Halifax, Nova Scotia, Canada
| | | | - Tara Sampalli
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | | | | | | | - Mike Warren
- NL SPOR SUPPORT Unit, St. John’s, Newfoundland and Labrador, Canada
| | - Joanne Young
- Chronic Disease Prevention and Management Health, Government of New Brunswick, Fredericton, New Brunswick, Canada
| | - Pierre Pluye
- Department of Family Medicine, Université McGill, Montréal, Quebec, Canada
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Kim JJ, Kwok ESH, Cook OG, Calder LA. Characterizing Highly Frequent Users of a Large Canadian Urban Emergency Department. West J Emerg Med 2018; 19:926-933. [PMID: 30429923 PMCID: PMC6225932 DOI: 10.5811/westjem.2018.9.39369] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction Highly frequent users (HFU) of the emergency department (ED) are a poorly defined population. This study describes patient and visit characteristics for Canadian ED HFU and patient subgroups with mental illness, substance misuse, or ≥ 30 yearly ED visits. Methods We reviewed health records from a random selection of adult patients whose visit frequency comprised the 99th percentile of yearly ED visits to The Ottawa Hospital. We excluded scheduled repeat ED assessments. We collected the following: 1) patient characteristics – age, sex, and comorbidities; and 2) ED visit characteristics – diagnosis category, length of stay, presentation time, consultation services, and final disposition. Two reviewers collected data, and we performed an inter-rater review to measure agreement. Results We analyzed 3,164 ED visits for 261 patients in all subgroups overall. Within the HFU random selection, mean age was 53.4 ± 1.3, and 55.6% were female. Most patients had a fixed address (88.9%), and family physician (87.2%). Top ED diagnoses included musculoskeletal pain (9.6%), alcohol intoxication (8.5%), and abdominal pain (8.4%). Allied health (social work, geriatric emergency medicine, or community care access centre) was consulted for 5.9% of visits. In 52.7% of these cases, allied health services were not available at the time of presentation. Conclusion HFU are a complex population who represent a marked proportion of annual ED visits. Our data indicate that there are opportunities to improve the current approaches to care. Future work examining ED-based screening and multi-disciplinary approaches for HFU may help reduce frequent ED presentations, and better serve this vulnerable population.
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Affiliation(s)
- Julie J Kim
- University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario, Canada
| | - Edmund S H Kwok
- University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Olivia G Cook
- University of Ottawa, Department of Undergraduate Medicine, Ottawa, Ontario, Canada
| | - Lisa A Calder
- University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Hudon C, Chouinard MC, Dubois MF, Roberge P, Loignon C, Tchouaket É, Lambert M, Hudon É, Diadiou F, Bouliane D. Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study. Ann Fam Med 2018; 16:232-239. [PMID: 29760027 PMCID: PMC5951252 DOI: 10.1370/afm.2233] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 12/20/2017] [Accepted: 01/19/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study aimed to evaluate the effects of the V1SAGES case management intervention (Vulnerable Patients in Primary Care: Nurse Case Management and Self-management Support) for frequent users of health care services with chronic disease and complex care needs on psychological distress and patient activation. METHODS We used a 2-phase sequential mixed methods design. The first phase was a pragmatic randomized controlled trial with intention-to-treat analysis that measured the effects of the intervention compared with usual care on psychological distress and patient activation before and after 6 months. The second phase had a qualitative descriptive design and entailed thematic analysis of in-depth interviews (25 patients, 6 case management nurses, 9 health managers) and focus groups (8 patients' spouses, 21 family physicians) to understand stakeholders' perceived effects of the intervention on patients. RESULTS A total of 247 patients were randomized into the intervention group (n = 126) or the control group (n = 121). Compared with usual care, the intervention reduced psychological distress (odds ratio = 0.43; 95% CI, 0.19-0.95, P = .04), but did not have any significant effect on patient activation (P = .43). Qualitative results suggested that patients and their spouses benefitted from the case management intervention, gaining a sense of security, and stakeholders noted better patient self-management of health. CONCLUSIONS Together, our study's quantitative and qualitative results suggest that case management reduces psychological distress, making patients and caregivers feel more secure, whereas impact on self-management is unclear. Case management is a promising avenue to improve outcomes among frequent users of health care with complex needs.
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Affiliation(s)
- Catherine Hudon
- Département de médecine de famille et de médecine d'urgence, Université de Sherbrooke, Québec, Canada .,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Québec, Canada
| | - Maud-Christine Chouinard
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Québec, Canada.,Département des sciences de la santé, Université du Québec à Chicoutimi, Québec, Canada.,Centre de recherche de l'Hôpital Charles-LeMoyne, Québec, Canada
| | - Marie-France Dubois
- Département des sciences de la santé communautaire, Université de Sherbrooke, Québec, Canada
| | - Pasquale Roberge
- Département de médecine de famille et de médecine d'urgence, Université de Sherbrooke, Québec, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Québec, Canada
| | - Christine Loignon
- Département de médecine de famille et de médecine d'urgence, Université de Sherbrooke, Québec, Canada
| | - Éric Tchouaket
- Département des sciences infirmières, Université du Québec en Outaouais, Québec, Canada
| | - Mireille Lambert
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Québec, Canada
| | - Émilie Hudon
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Québec, Canada.,Département des sciences de la santé, Université du Québec à Chicoutimi, Québec, Canada
| | - Fatoumata Diadiou
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Québec, Canada
| | - Danielle Bouliane
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Québec, Canada
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Grover CA, Sughair J, Stoopes S, Guillen F, Tellez L, Wilson TM, Gaccione C, Close RJH. Case Management Reduces Length of Stay, Charges, and Testing in Emergency Department Frequent Users. West J Emerg Med 2018; 19:238-244. [PMID: 29560049 PMCID: PMC5851494 DOI: 10.5811/westjem.2017.9.34710] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/04/2017] [Accepted: 09/14/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Case management is an effective, short-term means to reduce emergency department (ED) visits in frequent users of the ED. This study sought to determine the effectiveness of case management on frequent ED users, in terms of reducing ED and hospital length of stay (LOS), accrued costs, and utilization of diagnostic tests. Methods The study consisted of a retrospective chart review of ED and inpatient visits in our hospital's ED case management program, comparing patient visits made in the one year prior to enrollment in the program, to the visits made in the one year after enrollment in the program. We examined the LOS, use of diagnostic testing, and monetary charges incurred by these patients one year prior and one year after enrollment into case management. Results The study consisted of 158 patients in case management. Comparing the one year prior to enrollment to the one year after enrollment, ED visits decreased by 49%, inpatient admissions decreased by 39%, the use of computed tomography imaging decreased 41%, the use of ultrasound imaging decreased 52%, and the use of radiographs decreased 38%. LOS in the ED and for inpatient admissions decreased by 39%, reducing total LOS for these patients by 178 days. ED and hospital charges incurred by these patients decreased by 5.8 million dollars, a 41% reduction. All differences were statistically significant. Conclusion Case management for frequent users of the ED is an effective method to reduce patient visits, the use of diagnostic testing, length of stay, and cost within our institution.
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Affiliation(s)
- Casey A Grover
- Community Hospital of the Monterey Peninsula, Division of Emergency Medicine, Monterey, California
| | - Jameel Sughair
- Community Hospital of the Monterey Peninsula, Division of Emergency Medicine, Monterey, California
| | - Sydney Stoopes
- Community Hospital of the Monterey Peninsula, Division of Emergency Medicine, Monterey, California
| | - Felipe Guillen
- Community Hospital of the Monterey Peninsula, Division of Emergency Medicine, Monterey, California
| | - Leah Tellez
- Community Hospital of the Monterey Peninsula, Division of Emergency Medicine, Monterey, California
| | - Tierra M Wilson
- Community Hospital of the Monterey Peninsula, Division of Emergency Medicine, Monterey, California
| | - Charles Gaccione
- Community Hospital of the Monterey Peninsula, Division of Emergency Medicine, Monterey, California
| | - Reb J H Close
- Community Hospital of the Monterey Peninsula, Division of Emergency Medicine, Monterey, California
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Iglesias K, Baggio S, Moschetti K, Wasserfallen JB, Hugli O, Daeppen JB, Burnand B, Bodenmann P. Using case management in a universal health coverage system to improve quality of life of frequent Emergency Department users: a randomized controlled trial. Qual Life Res 2017; 27:503-513. [PMID: 29188481 PMCID: PMC5846993 DOI: 10.1007/s11136-017-1739-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2017] [Indexed: 11/30/2022]
Abstract
Purpose Frequent Emergency Department users are likely to experience poor quality of life (QOL). Case management interventions are efficient in responding to the complex needs of this population, but their effects on QOL have not been tested yet. Therefore, the aim of our study was to examine to what extent a case management intervention improved frequent Emergency Department users’ QOL in a universal health coverage system. Methods Data were part of a randomized controlled trial designed to improve frequent Emergency Department users’ QOL at the Lausanne University Hospital, Switzerland. A total of 250 frequent Emergency Department users (≥ 5 attendances during the previous 12 months) were randomly assigned to the control (n = 125) or the intervention group (n = 125). The latter benefited from case management intervention. QOL was evaluated using the WHOQOL-BREF at baseline, two, five and a half, nine, and twelve months later. It included four dimensions: physical health, psychological health, social relationship, and environment. Linear mixed-effects models were used to analyze the change in the patients’ QOL over time. Results Patients’ QOL improved significantly (p < 0.001) in both groups for all dimensions after two months. However, environment QOL dimension improved significantly more in the intervention group after 12 months. Conclusions Environment QOL dimension was the most responsive dimension for short-term interventions. This may have been due to case management’s assistance in obtaining income entitlements, health insurance coverage, stable housing, or finding general health care practitioners. Case management in general should be developed to enhance frequent users’ QOL. Trial registration: http://www.clinicaltrials.gov, Unique identifier: NCT01934322
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Affiliation(s)
- Katia Iglesias
- School of Health Sciences (HEdS-FR), University of Applied Sciences Western Switzerland (HES-SO), Route des Cliniques 15, 1700, Fribourg, Switzerland. .,Center for the Understanding of Social Processes, University of Neuchâtel, Neuchâtel, Switzerland.
| | - Stéphanie Baggio
- Life Course and Social Inequality Research Center, University of Lausanne, Lausanne, Switzerland
| | - Karine Moschetti
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Health Technology Assessment Unit, Lausanne University Hospital, Lausanne, Switzerland.,IEMS Plateforme interfacultaire en économie et management de la santé, University of Lausanne, Lausanne, Switzerland
| | | | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Patrick Bodenmann
- Vulnerable Population Unit, Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Lausanne, Switzerland
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Hudon C, Chouinard MC, Lambert M, Diadiou F, Bouliane D, Beaudin J. Key factors of case management interventions for frequent users of healthcare services: a thematic analysis review. BMJ Open 2017; 7:e017762. [PMID: 29061623 PMCID: PMC5665285 DOI: 10.1136/bmjopen-2017-017762] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of this paper was to identify the key factors of case management (CM) interventions among frequent users of healthcare services found in empirical studies of effectiveness. DESIGN Thematic analysis review of CM studies. METHODS We built on a previously published review that aimed to report the effectiveness of CM interventions for frequent users of healthcare services, using the Medline, Scopus and CINAHL databases covering the January 2004-December 2015 period, then updated to July 2017, with the keywords 'CM' and 'frequent use'. We extracted factors of successful (n=7) and unsuccessful (n=6) CM interventions and conducted a mixed thematic analysis to synthesise findings. Chaudoir's implementation of health innovations framework was used to organise results into four broad levels of factors: (1) ,environmental/organisational level, (2) practitioner level, (3) patient level and (4) programme level. RESULTS Access to, and close partnerships with, healthcare providers and community services resources were key factors of successful CM interventions that should target patients with the greatest needs and promote frequent contacts with the healthcare team. The selection and training of the case manager was also an important factor to foster patient engagement in CM. Coordination of care, self-management support and assistance with care navigation were key CM activities. The main issues reported by unsuccessful CM interventions were problems with case finding or lack of care integration. CONCLUSIONS CM interventions for frequent users of healthcare services should ensure adequate case finding processes, rigorous selection and training of the case manager, sufficient intensity of the intervention, as well as good care integration among all partners. Other studies could further evaluate the influence of contextual factors on intervention impacts.
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Affiliation(s)
- Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de recherche du Centre Hospitalier, Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Maud-Christine Chouinard
- Département des Sciences de la santé, Université du Québec à Chicoutimi, Chicoutimi, Quebec, Canada
- Centre integre universitaire de sante et de services sociaux du Saguenay-Lac-Saint-Jean, Chicoutimi, Quebec, Canada
| | - Mireille Lambert
- Centre integre universitaire de sante et de services sociaux du Saguenay-Lac-Saint-Jean, Chicoutimi, Quebec, Canada
| | - Fatoumata Diadiou
- Centre integre universitaire de sante et de services sociaux du Saguenay-Lac-Saint-Jean, Chicoutimi, Quebec, Canada
| | - Danielle Bouliane
- Centre integre universitaire de sante et de services sociaux du Saguenay-Lac-Saint-Jean, Chicoutimi, Quebec, Canada
| | - Jérémie Beaudin
- Département des Sciences de la santé, Université du Québec à Chicoutimi, Chicoutimi, Quebec, Canada
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Hensel JM, Taylor VH, Fung K, de Oliveira C, Vigod SN. Unique Characteristics of High-Cost Users of Medical Care With Comorbid Mental Illness or Addiction in a Population-Based Cohort. PSYCHOSOMATICS 2017; 59:135-143. [PMID: 29157683 DOI: 10.1016/j.psym.2017.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To understand whether high-cost users of medical care with and without comorbid mental illness or addiction differ in terms of their sociodemographic and health characteristics. Unique characteristics would warrant different considerations for interventions and service design aimed at reducing unnecessary health care utilization and associated costs. METHODS From the top 10% of Ontarians ranked by total medical care costs during fiscal year 2011/2012 (N = 314,936), prior 2-year mental illness or addiction diagnoses were determined from administrative data. Sociodemographics, medical illness characteristics, medical costs, and utilization were compared between those high-cost users of medical care with and without comorbid mental illness or addiction. Odds of being a frequent user of inpatient (≥3 admissions) and emergency (≥5 visits) services were compared between groups, adjusting for age, sex, socioeconomic status and medical illness characteristics. RESULTS High-cost users of medical care with comorbid mental illness or addiction were younger, had a lower socioeconomic status, had greater historical medical morbidity, and had higher total medical care costs (mean excess of $2,031/user) than those without. They were more likely to be frequent users of inpatient (12.8% vs 10.2%; adjusted OR, 1.14; 95% CI: 1.12-1.17) and emergency (8.4% vs 4.8%; adjusted OR, 1.55; 95% CI: 1.50-1.59) services. Effect sizes were larger in major mood, psychotic, and substance use disorder subgroups. CONCLUSIONS High-cost medical care users with mental illness or addiction have unique characteristics with respect to sociodemographics and service utilization patterns to consider in interventions and policies for this patient group.
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Affiliation(s)
- Jennifer M Hensel
- Department of Psychiatry, Women's College Hospital, Toronto, Canada; Women's College Research Institute, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada.
| | - Valerie H Taylor
- Department of Psychiatry, Women's College Hospital, Toronto, Canada; Women's College Research Institute, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Kinwah Fung
- Women's College Research Institute, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Claire de Oliveira
- Institute for Clinical Evaluative Sciences, Toronto, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Centre for Addiction and Mental Health, Toronto, Canada
| | - Simone N Vigod
- Department of Psychiatry, Women's College Hospital, Toronto, Canada; Women's College Research Institute, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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39
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Hudon C, Chouinard MC, Aubrey-Bassler K, Muhajarine N, Burge F, Pluye P, Bush PL, Ramsden VR, Legare F, Guenette L, Morin P, Lambert M, Groulx A, Couture M, Campbell C, Baker M, Edwards L, Sabourin V, Spence C, Gauthier G, Warren M, Godbout J, Davis B, Rabbitskin N. Case management in primary care among frequent users of healthcare services with chronic conditions: protocol of a realist synthesis. BMJ Open 2017; 7:e017701. [PMID: 28871027 PMCID: PMC5589014 DOI: 10.1136/bmjopen-2017-017701] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION A common reason for frequent use of healthcare services is the complex healthcare needs of individuals suffering from multiple chronic conditions, especially in combination with mental health comorbidities and/or social vulnerability. Frequent users (FUs) of healthcare services are more at risk for disability, loss of quality of life and mortality. Case management (CM) is a promising intervention to improve care integration for FU and to reduce healthcare costs. This review aims to develop a middle-range theory explaining how CM in primary care improves outcomes among FU with chronic conditions, for what types of FU and in what circumstances. METHODS AND ANALYSIS A realist synthesis (RS) will be conducted between March 2017 and March 2018 to explore the causal mechanisms that underlie CM and how contextual factors influence the link between these causal mechanisms and outcomes. According to RS methodology, five steps will be followed: (1) focusing the scope of the RS; (2) searching for the evidence; (3) appraising the quality of evidence; (4) extracting the data; and (5) synthesising the evidence. Patterns in context-mechanism-outcomes (CMOs) configurations will be identified, within and across identified studies. Analysis of CMO configurations will help confirm, refute, modify or add to the components of our initial rough theory and ultimately produce a refined theory explaining how and why CM interventions in primary care works, in which contexts and for which FU with chronic conditions. ETHICS AND DISSEMINATION Research ethics is not required for this review, but publication guidelines on RS will be followed. Based on the review findings, we will develop and disseminate messages tailored to various relevant stakeholder groups. These messages will allow the development of material that provides guidance on the design and the implementation of CM in health organisations. TRIAL REGISTRATION NUMBER Prospero CRD42017057753.
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Affiliation(s)
- Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University, St-John's, Newfoundland and Labrador, Canada
| | - Nazeem Muhajarine
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Pierre Pluye
- Department of Family Medicine, Université McGill, Montréal, Quebec, Canada
| | - Paula L Bush
- Department of Family Medicine, Université McGill, Montréal, Quebec, Canada
| | - Vivian R Ramsden
- Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - France Legare
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Canada
| | - Line Guenette
- Faculty of Pharmacy and CHU de Québec Research Center, Université Laval, Quebec, Canada
| | - Paul Morin
- School of Social Work, University de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mireille Lambert
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Chicoutimi, Quebec, Canada
| | - Antoine Groulx
- Ministère de la Santé et des Services Sociaux, Quebec, Canada
| | - Martine Couture
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, Chicoutimi, Quebec, Canada
| | - Cameron Campbell
- Department of Health and Community Services, St. John's, Newfoundland, Canada
| | - Margaret Baker
- Saskatchewan Government – Ministry of Health, Regina, Saskatchewan, Canada
| | - Lynn Edwards
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | | | | | | | - Mike Warren
- St. John’s, Newfoundland and Labrador, Canada
| | | | - Breanna Davis
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Norma Rabbitskin
- Sturgeon Lake Health Centre, Prince Albert, Saskatchewan, Canada
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