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Adelsjö I, Lehnbom EC, Hellström A, Nilsson L, Flink M, Ekstedt M. The impact of discharge letter content on unplanned hospital readmissions within 30 and 90 days in older adults with chronic illness - a mixed methods study. BMC Geriatr 2024; 24:591. [PMID: 38987669 PMCID: PMC11238400 DOI: 10.1186/s12877-024-05172-1] [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: 07/25/2023] [Accepted: 06/24/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Care transitions are high-risk processes, especially for people with complex or chronic illness. Discharge letters are an opportunity to provide written information to improve patients' self-management after discharge. The aim of this study is to determine the impact of discharge letter content on unplanned hospital readmissions and self-rated quality of care transitions among patients 60 years of age or older with chronic illness. METHODS The study had a convergent mixed methods design. Patients with chronic obstructive pulmonary disease or congestive heart failure were recruited from two hospitals in Region Stockholm if they were living at home and Swedish-speaking. Patients with dementia or cognitive impairment, or a "do not resuscitate" statement in their medical record were excluded. Discharge letters from 136 patients recruited to a randomised controlled trial were coded using an assessment matrix and deductive content analysis. The assessment matrix was based on a literature review performed to identify key elements in discharge letters that facilitate a safe care transition to home. The coded key elements were transformed into a quantitative variable of "SAFE-D score". Bivariate correlations between SAFE-D score and quality of care transition as well as unplanned readmissions within 30 and 90 days were calculated. Lastly, a multivariable Cox proportional hazards model was used to investigate associations between SAFE-D score and time to readmission. RESULTS All discharge letters contained at least five of eleven key elements. In less than two per cent of the discharge letters, all eleven key elements were present. Neither SAFE-D score, nor single key elements correlated with 30-day or 90-day readmission rate. SAFE-D score was not associated with time to readmission when adjusted for a range of patient characteristics and self-rated quality of care transitions. CONCLUSIONS While written summaries play a role, they may not be sufficient on their own to ensure safe care transitions and effective self-care management post-discharge. TRIAL REGISTRATION Clinical Trials. giv, NCT02823795, 01/09/2016.
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Affiliation(s)
- Igor Adelsjö
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, 39182, Kalmar, Sweden.
| | - Elin C Lehnbom
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, 39182, Kalmar, Sweden
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Amanda Hellström
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, 39182, Kalmar, Sweden
| | - Lina Nilsson
- Department of Medicine and Optometry, Faculty of Health and Life Sciences, eHealth Institute, Linnaeus University, Kalmar, Sweden
| | - Maria Flink
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Mirjam Ekstedt
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, 39182, Kalmar, Sweden
- Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
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Albanesi B, Piredda M, Dimonte V, De Marinis MG, Matarese M. Use of Motivational Interviewing in Older Patients with Multiple Chronic Conditions and Their Informal Caregivers: A Scoping Review. Healthcare (Basel) 2023; 11:1681. [PMID: 37372800 DOI: 10.3390/healthcare11121681] [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: 04/11/2023] [Revised: 06/03/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
The use of motivational interviewing is relatively new in multiple chronic conditions (MCCs). A scoping review was conducted according to JBI methodology to identify, map and synthesize existing evidence on the use of motivational interviewing to support self-care behavior changes in older patients with MCCs and to support their informal caregivers in promoting patient self-care changes. Seven databases were searched, from database inception to July 2022, for studies that used motivational interviewing in interventions for older patients with MCCs and their informal caregivers. We identified 12 studies, reported in 15 articles, using qualitative, quantitative, or mixed-method designs, conducted between 2012 and 2022, describing the use of motivational interviewing for patients with MCCs. We could not locate any study regarding its application for informal caregivers. The scoping review showed that the use of motivational interviewing is still limited in MCCs. It was used mainly to improve patient medication adherence. The studies provided scant information about how the method was applied. Future studies should provide more information about the application of motivational interviewing and should address self-care behavior changes relevant to patients and healthcare providers. Informal caregivers should also be targeted in motivational interviewing interventions, as they are essential for the care of older patients with MCCs.
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Affiliation(s)
- Beatrice Albanesi
- Department of Public Health and Pediatrics, University of Torino, 10126 Turin, Italy
| | - Michela Piredda
- Department of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Valerio Dimonte
- Department of Public Health and Pediatrics, University of Torino, 10126 Turin, Italy
| | - Maria Grazia De Marinis
- Department of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
- Palliative Care Centre 'Insieme nella Cura', Campus Bio-Medico University Hospital Foundation, 00128 Rome, Italy
| | - Maria Matarese
- Department of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
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Schrijver J, Lenferink A, Brusse-Keizer M, Zwerink M, van der Valk PD, van der Palen J, Effing TW. Self-management interventions for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2022; 1:CD002990. [PMID: 35001366 PMCID: PMC8743569 DOI: 10.1002/14651858.cd002990.pub4] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Self-management interventions help people with chronic obstructive pulmonary disease (COPD) to acquire and practise the skills they need to carry out disease-specific medical regimens, guide changes in health behaviour and provide emotional support to enable them to control their disease. Since the 2014 update of this review, several studies have been published. OBJECTIVES Primary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of health-related quality of life (HRQoL) and respiratory-related hospital admissions. To evaluate the safety of COPD self-management interventions compared to usual care in terms of respiratory-related mortality and all-cause mortality. Secondary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of other health outcomes and healthcare utilisation. To evaluate effective characteristics of COPD self-management interventions. SEARCH METHODS We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, EMBASE, trials registries and the reference lists of included studies up until January 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) and cluster-randomised trials (CRTs) published since 1995. To be eligible for inclusion, self-management interventions had to include at least two intervention components and include an iterative process between participant and healthcare provider(s) in which goals were formulated and feedback was given on self-management actions by the participant. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. We contacted study authors to obtain additional information and missing outcome data where possible. Primary outcomes were health-related quality of life (HRQoL), number of respiratory-related hospital admissions, respiratory-related mortality, and all-cause mortality. When appropriate, we pooled study results using random-effects modelling meta-analyses. MAIN RESULTS We included 27 studies involving 6008 participants with COPD. The follow-up time ranged from two-and-a-half to 24 months and the content of the interventions was diverse. Participants' mean age ranged from 57 to 74 years, and the proportion of male participants ranged from 33% to 98%. The post-bronchodilator forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of participants ranged from 33.6% to 57.0%. The FEV1/FVC ratio is a measure used to diagnose COPD and to determine the severity of the disease. Studies were conducted on four different continents (Europe (n = 15), North America (n = 8), Asia (n = 1), and Oceania (n = 4); with one study conducted in both Europe and Oceania). Self-management interventions likely improve HRQoL, as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (lower score represents better HRQoL) with a mean difference (MD) from usual care of -2.86 points (95% confidence interval (CI) -4.87 to -0.85; 14 studies, 2778 participants; low-quality evidence). The pooled MD of -2.86 did not reach the SGRQ minimal clinically important difference (MCID) of four points. Self-management intervention participants were also at a slightly lower risk for at least one respiratory-related hospital admission (odds ratio (OR) 0.75, 95% CI 0.57 to 0.98; 15 studies, 3263 participants; very low-quality evidence). The number needed to treat to prevent one respiratory-related hospital admission over a mean of 9.75 months' follow-up was 15 (95% CI 8 to 399) for participants with high baseline risk and 26 (95% CI 15 to 677) for participants with low baseline risk. No differences were observed in respiratory-related mortality (risk difference (RD) 0.01, 95% CI -0.02 to 0.04; 8 studies, 1572 participants ; low-quality evidence) and all-cause mortality (RD -0.01, 95% CI -0.03 to 0.01; 24 studies, 5719 participants; low-quality evidence). We graded the evidence to be of 'moderate' to 'very low' quality according to GRADE. All studies had a substantial risk of bias, because of lack of blinding of participants and personnel to the interventions, which is inherently impossible in a self-management intervention. In addition, risk of bias was noticeably increased because of insufficient information regarding a) non-protocol interventions, and b) analyses to estimate the effect of adhering to interventions. Consequently, the highest GRADE evidence score that could be obtained by studies was 'moderate'. AUTHORS' CONCLUSIONS Self-management interventions for people with COPD are associated with improvements in HRQoL, as measured with the SGRQ, and a lower probability of respiratory-related hospital admissions. No excess respiratory-related and all-cause mortality risks were observed, which strengthens the view that COPD self-management interventions are unlikely to cause harm. By using stricter inclusion criteria, we decreased heterogeneity in studies, but also reduced the number of included studies and therefore our capacity to conduct subgroup analyses. Data were therefore still insufficient to reach clear conclusions about effective (intervention) characteristics of COPD self-management interventions. As tailoring of COPD self-management interventions to individuals is desirable, heterogeneity is and will likely remain present in self-management interventions. For future studies, we would urge using only COPD self-management interventions that include iterative interactions between participants and healthcare professionals who are competent using behavioural change techniques (BCTs) to elicit participants' motivation, confidence and competence to positively adapt their health behaviour(s) and develop skills to better manage their disease. In addition, to inform further subgroup and meta-regression analyses and to provide stronger conclusions regarding effective COPD self-management interventions, there is a need for more homogeneity in outcome measures. More attention should be paid to behavioural outcome measures and to providing more detailed, uniform and transparently reported data on self-management intervention components and BCTs. Assessment of outcomes over the long term is also recommended to capture changes in people's behaviour. Finally, information regarding non-protocol interventions as well as analyses to estimate the effect of adhering to interventions should be included to increase the quality of evidence.
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Affiliation(s)
- Jade Schrijver
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, Netherlands
- Section Cognition, Data and Education, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, Netherlands
| | - Anke Lenferink
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, Netherlands
- Section Health Technology and Services Research, Faculty of Behavioural, Management and Social sciences, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - Marjolein Brusse-Keizer
- Section Health Technology and Services Research, Faculty of Behavioural, Management and Social sciences, Technical Medical Centre, University of Twente, Enschede, Netherlands
- Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands
| | - Marlies Zwerink
- Value-Based Health Care, Medisch Spectrum Twente, Enschede, Netherlands
| | | | - Job van der Palen
- Section Cognition, Data and Education, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, Netherlands
- Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands
| | - Tanja W Effing
- College of Medicine and Public Health, School of Medicine, Flinders University, Adelaide, Australia
- School of Psychology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
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Poot CC, Meijer E, Kruis AL, Smidt N, Chavannes NH, Honkoop PJ. Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2021; 9:CD009437. [PMID: 34495549 PMCID: PMC8425271 DOI: 10.1002/14651858.cd009437.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A multi-disciplinary and multi-component programme that addresses different elements of care could improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations. OBJECTIVES To compare the effectiveness of integrated disease management (IDM) programmes versus usual care for people with chronic obstructive pulmonary disease (COPD) in terms of health-related quality of life (QoL), exercise tolerance, and exacerbation-related outcomes. SEARCH METHODS We searched the Cochrane Airways Group Register of Trials, CENTRAL, MEDLINE, Embase, and CINAHL for potentially eligible studies. Searches were current as of September 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared IDM programmes for COPD versus usual care were included. Interventions consisted of multi-disciplinary (two or more healthcare providers) and multi-treatment (two or more components) IDM programmes of at least three months' duration. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. If required, we contacted study authors to request additional data. We performed meta-analyses using random-effects modelling. We carried out sensitivity analyses for the quality of included studies and performed subgroup analyses based on setting, study design, dominant intervention components, and region. MAIN RESULTS Along with 26 studies included in the 2013 Cochrane Review, we added 26 studies for this update, resulting in 52 studies involving 21,086 participants for inclusion in the meta-analysis. Follow-up periods ranged between 3 and 48 months and were classified as short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Studies were conducted in 19 different countries. The mean age of included participants was 67 years, and 66% were male. Participants were treated in all types of healthcare settings, including primary (n =15), secondary (n = 22), and tertiary care (n = 5), and combined primary and secondary care (n = 10). Overall, the level of certainty of evidence was moderate to high. We found that IDM probably improves health-related QoL as measured by St. George's Respiratory Questionnaire (SGRQ) total score at medium-term follow-up (mean difference (MD) -3.89, 95% confidence interval (CI) -6.16 to -1.63; 18 RCTs, 4321 participants; moderate-certainty evidence). A comparable effect was observed at short-term follow-up (MD -3.78, 95% CI -6.29 to -1.28; 16 RCTs, 1788 participants). However, the common effect did not exceed the minimum clinically important difference (MCID) of 4 points. There was no significant difference between IDM and control for long-term follow-up and for generic QoL. IDM probably also leads to a large improvement in maximum and functional exercise capacity, as measured by six-minute walking distance (6MWD), at medium-term follow-up (MD 44.69, 95% CI 24.01 to 65.37; 13 studies, 2071 participants; moderate-certainty evidence). The effect exceeded the MCID of 35 metres and was even greater at short-term (MD 52.26, 95% CI 32.39 to 72.74; 17 RCTs, 1390 participants) and long-term (MD 48.83, 95% CI 16.37 to 80.49; 6 RCTs, 7288 participants) follow-up. The number of participants with respiratory-related admissions was reduced from 324 per 1000 participants in the control group to 235 per 1000 participants in the IDM group (odds ratio (OR) 0.64, 95% CI 0.50 to 0.81; 15 RCTs, median follow-up 12 months, 4207 participants; high-certainty evidence). Likewise, IDM probably results in a reduction in emergency department (ED) visits (OR 0.69, 95%CI 0.50 to 0.93; 9 RCTs, median follow-up 12 months, 8791 participants; moderate-certainty evidence), a slight reduction in all-cause hospital admissions (OR 0.75, 95%CI 0.57 to 0.98; 10 RCTs, median follow-up 12 months, 9030 participants; moderate-certainty evidence), and fewer hospital days per person admitted (MD -2.27, 95% CI -3.98 to -0.56; 14 RCTs, median follow-up 12 months, 3563 participants; moderate-certainty evidence). Statistically significant improvement was noted on the Medical Research Council (MRC) Dyspnoea Scale at short- and medium-term follow-up but not at long-term follow-up. No differences between groups were reported for mortality, courses of antibiotics/prednisolone, dyspnoea, and depression and anxiety scores. Subgroup analysis of dominant intervention components and regions of study suggested context- and intervention-specific effects. However, some subgroup analyses were marked by considerable heterogeneity or included few studies. These results should therefore be interpreted with caution. AUTHORS' CONCLUSIONS This review shows that IDM probably results in improvement in disease-specific QoL, exercise capacity, hospital admissions, and hospital days per person. Future research should evaluate which combination of IDM components and which intervention duration are most effective for IDM programmes, and should consider contextual determinants of implementation and treatment effect, including process-related outcomes, long-term follow-up, and cost-effectiveness analyses.
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Affiliation(s)
- Charlotte C Poot
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Eline Meijer
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Annemarije L Kruis
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Nynke Smidt
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Persijn J Honkoop
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
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Brandberg C, Ekstedt M, Flink M. Self-management challenges following hospital discharge for patients with multimorbidity: a longitudinal qualitative study of a motivational interviewing intervention. BMJ Open 2021; 11:e046896. [PMID: 34330857 PMCID: PMC8327841 DOI: 10.1136/bmjopen-2020-046896] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe challenges in self-management activities among people with multimorbidity during a 4-week post-discharge period. DESIGN This is a longitudinal qualitative study using data from a randomised controlled trial (RCT) of motivational interviewing (MI) sessions. SETTING The RCT was conducted at six wards in two hospitals-one university hospital and one general hospital in Stockholm, Sweden, during 2016-2018. PARTICIPANTS Sixteen participants from the intervention group, diagnosed with heart failure or chronic obstructive pulmonary disease and at least one other chronic condition, were purposively selected for this study. INTERVENTIONS Each participant had four or five post-discharge MI sessions with a trained social worker during a period of approximately 4 weeks. The sessions were recorded digitally and analysed using content analysis. Altogether, 70 recorded sessions were analysed. RESULTS Self-management after hospital discharge was a dynamic process with several shifting features that evolved gradually over time. Patients with multimorbidity experienced two major challenges with self-management in the first 4 weeks following hospital discharge: 'Managing a system-centred care' and 'Handling the burden of living with multiple illnesses at home post-discharge'. CONCLUSIONS Self-management for patients with multimorbidity in the first post-discharge period does not equate to a fixed set of tasks, but varies over the post-discharge period. Self-management challenges include not only the burden of the disease itself, but also that of navigating and understanding the healthcare system. Hence, self-management support post-discharge involves both aiding patients with care coordination and meeting their gradually shifting disease-related needs. TRIAL REGISTRATION NUMBER NCT02823795.
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Affiliation(s)
- Carina Brandberg
- Department of Learning, Informatics, Managmenet and Ethics (LIME), Karolinska Institute, Stockholm, Sweden
| | - Mirjam Ekstedt
- Department of Learning, Informatics, Managmenet and Ethics (LIME), Karolinska Institute, Stockholm, Sweden
- School of Health and Caring Sciences, Linnaeus University Faculty of Health and Life Sciences, Kalmar, Sweden
| | - Maria Flink
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
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Wu J, Yu Y, Xu H. Influence of targeted motivational interviewing on self-care level and prognosis during nursing care of chronic heart failure. Am J Transl Res 2021; 13:6576-6583. [PMID: 34306399 PMCID: PMC8290814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/24/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To analyze the effects of targeted motivational interviewing (TMI) during the nursing care for chronic heart failure (CHF). METHODS A total of 93 patients with CHF admitted to our hospital were selected as study subjects, and were divided into Group A (n=47) and Group B (n=46) in accordance with a randomized double-blind method. Group A was treated with TMI, while Group B was treated with the conventional nursing care for heart failure (HF). The self-care levels (self-care of heart failure index), medication compliance (Morisky's medication compliance scale), quality of life (Minnesota Living with Heart Failure Questionnaire), and prognosis (the readmission and mortality rates) were compared between the 2 groups. RESULTS After nursing care, patients in Group A were higher than those in Group B in their scores of self-care maintenance, management and confidence, medication frequency, time, dose, and type as instructed by the physician, and drug withdrawal or discontinuation of drugs, and forgetting medication, and body, emotion, and other fields (P < 0.05). Group A was superior to Group B in the rates of medication compliance and medication non-compliance (61.70% and 6.38% vs. 41.30% and 23.91%, P < 0.05); rate of hospital readmission (6.38% vs. 23.91%, P < 0.05), and mortality rate (0% vs. 6.52%, P > 0.05). CONCLUSION TMI is conducive to improving the self-care level, medication compliance, quality of life, and prognosis in patients with CHF.
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Affiliation(s)
- Jianfei Wu
- Department of Cardiovascular Medicine, The First People’s Hospital of Fuyang HangzhouHangzhou 311400, Zhejiang Province, China
| | - Yilan Yu
- Department of Intensive Care Unit, The First People’s Hospital of Fuyang HangzhouHangzhou 311400, Zhejiang Province, China
| | - Huan Xu
- Department of Digestive Diseases, The First People’s Hospital of Fuyang HangzhouHangzhou 311400, Zhejiang Province, China
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Social work involvement in palliative care heart failure research: a review of recent literature. Curr Opin Support Palliat Care 2020; 14:3-8. [PMID: 31895064 DOI: 10.1097/spc.0000000000000482] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of the review is to examine the findings of empirical studies of palliative care interventions for patients with heart failure in which a social worker was identified as a key member of the interprofessional clinical team. RECENT FINDINGS Our systematic review of the empirical literature from January 2016 to August 2019 found five palliative care interventions with heart failure patients that cited involvement of a social worker as a key team member. The reviewed studies highlighted social workers' roles in the areas of psychosocial assessments and support, advance care planning, and patient-medical team communication. SUMMARY Palliative social workers possess the knowledge and skills to provide expertise in psychological, social, and cultural care within palliative care domains of practice. Given this primary and critical role, more studies that include the assessment of outcomes linked to the social worker's role should be pursued. Our review unearthed several important studies that highlight the role of the palliative social workers in heart failure models of care.
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Freilich J, Nilsson GH, Ekstedt M, Flink M. "Standing on common ground" - a qualitative study of self-management support for patients with multimorbidity in primary health care. BMC FAMILY PRACTICE 2020; 21:233. [PMID: 33203401 PMCID: PMC7670978 DOI: 10.1186/s12875-020-01290-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Multimorbidity, the co-existence of two or more chronic conditions in an individual, is present in most patients over 65 years. Primary health care (PHC) is uniquely positioned to provide the holistic and continual care recommended for this group of patients, including support for self-management. The aim of this study was to explore professionals', patients', and family caregivers' perspectives on how PHC professionals should support self-management in patients with multimorbidity. This study also includes experiences of using telemedicine to support self-management. METHODS A mixed qualitative method was used to explore regular self-management support and telemedicine as a tool to support self-management. A total of 42 participants (20 physicians, 3 registered nurses, 12 patients, and 7 family caregivers) were interviewed using focus group interviews (PHC professionals), pair interviews (patients and family caregivers), and individual interviews (registered nurses, patients, and family caregivers). The study was performed in urban areas in central Sweden and rural areas in southern Sweden between April 2018 and October 2019. Data were analyzed using content analysis. RESULTS The main theme that emerged was "Standing on common ground enables individualized support." To achieve such support, professionals needed to understand their own views on who bears the primary responsibility for patients' self-management, as well as patients' self-management abilities, needs, and perspectives. Personal continuity and trustful relationships facilitated this understanding. The findings also indicated that professionals should be accessible for patients with multimorbidity, function as knowledge translators (help patients understand their symptoms and how the symptoms correlated with diseases), and coordinate between levels of care. Telemedicine supported continual monitoring and facilitated patient access to PHC professionals. CONCLUSION Through personal continuity and patient-centered consultations, professionals could collaborate with patients to individualize self-management support. For some patients, this means that PHC professionals are in control and monitor symptoms. For others, PHC professionals play a less controlling role, empowering patients' self-management. Development and improvement of eHealth tools for patients with multimorbidity should focus on improving the ability to set mutual goals, strengthening patients' inner motivation, and including multiple caregivers to enhance information-sharing and care coordination.
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Affiliation(s)
- Joel Freilich
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 17177, Stockholm, Sweden.
| | - Gunnar H Nilsson
- Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden
| | - Mirjam Ekstedt
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 17177, Stockholm, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Kalmar/Växjö, Sweden
| | - Maria Flink
- Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden
- Department of Social work in healthcare, Karolinska University Hospital, Stockholm, Sweden
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Cross AJ, Elliott RA, Petrie K, Kuruvilla L, George J. Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications. Cochrane Database Syst Rev 2020; 5:CD012419. [PMID: 32383493 PMCID: PMC7207012 DOI: 10.1002/14651858.cd012419.pub2] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications. OBJECTIVES To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications. SEARCH METHODS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality. MAIN RESULTS We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes. AUTHORS' CONCLUSIONS Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Rohan A Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Austin Health, Heidelberg, Australia
| | - Kate Petrie
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Lisha Kuruvilla
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Barwon Health, North Geelong, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
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Why patients decline participation in an intervention to reduce re-hospitalization through patient activation: whom are we missing? Trials 2019; 20:82. [PMID: 30683140 PMCID: PMC6347805 DOI: 10.1186/s13063-019-3187-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 01/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite worldwide interest in reducing re-hospitalization, there is limited knowledge regarding characteristics of patients who chose to decline participation in such efforts and why. The aim is to explore reasons to decline participation in an intervention using motivational interviewing to reduce re-hospitalization through patient activation for persons with chronic obstructive pulmonary disease or heart failure. METHODS This study uses data from 385 patients who were asked about participating in a randomized controlled trial; of these, 232 declined participation. Data on age, gender, and diagnosis were collected for those who agreed to participate and those who declined. Reasons to decline participation were collected for those who were asked to participate but refused. The stated reasons to decline were analyzed using content analysis, and the categories identified were used for the statistical analysis. RESULTS The main reasons for declining participation were having sufficient support (17.5%), no need for support (16%), being too ill (14.6%), and lack of time for illness-related activities (14.2%). A statistically significant negative association between age and willingness to participate was found (odds ratio = - 0.03, 95% confidence interval 0.95-0.99). CONCLUSIONS Those who agreed to participate were younger than non-participants, and non-participants either lacked time for illness-related activities or did not have the energy needed to become involved in the intervention. TRIAL REGISTRATION ClinicalTrials.gov, NCT02823795 . Registered on 1 July 2016.
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11
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Sturt J, Dliwayo TR, Forjaz V, Hamilton K, Bryce C, Fraser J, Griffiths F. Eliciting the Impact of Digital Consulting for Young People Living With Long-Term Conditions (LYNC Study): Cognitive Interviews to Assess the Face and Content Validity of Two Patient-Reported Outcome Measures. J Med Internet Res 2018; 20:e268. [PMID: 30309832 PMCID: PMC6231804 DOI: 10.2196/jmir.9786] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/30/2018] [Accepted: 06/18/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Digital consulting, using email, text, and Skype, is increasingly offered to young people accessing specialist care for long-term conditions. No patient-reported outcome measures (PROMs) have been evaluated for assessing outcomes of digital consulting. Systematic and scoping reviews, alongside patient involvement, revealed 2 candidate PROMs for this purpose: the patient activation measure (PAM) and the physician's humanistic behaviors questionnaire (PHBQ). PAM measures knowledge, beliefs, and skills that enable people to manage their long-term conditions. PHBQ assesses the presence of behaviors that are important to patients in their physician-patient interactions. OBJECTIVE This study aimed to assess the face and content validity of PAM and PHBQ to explore whether they elicit important outcomes of digital consulting and whether the PROMs can isolate the digital consultation component of care. METHODS Participants were drawn from 5 clinics providing specialist National Health Service care to 16- to 24-year-olds with long-term health conditions participating in the wider LYNC (Long-Term Conditions, Young People, Networked Communications) study. Overall, 14 people undertook a cognitive interview in this substudy. Of these, 7 participants were young people with either inflammatory bowel disease, cystic fibrosis, or cancer. The remaining 7 participants were clinicians who were convenience sampled. These included a clinical psychologist, 2 nurses, 3 consultant physicians, and a community youth worker practicing in cancer, diabetes, cystic fibrosis, and liver disease. Cognitive interviews were transcribed and analyzed, and a spreadsheet recorded the participants' PROM item appraisals. Illustrative quotes were extracted verbatim from the interviews for all participants. RESULTS Young people found 11 of the PAM 13 items and 7 of the additional 8 PAM 22 items to be relevant to digital consulting. They were only able to provide spontaneous examples of digital consulting for 50% (11/22) of the items. Of the 7 clinicians, 4 appraised all PAM 13 items and 20 of the PAM 22 items to be relevant to evaluating digital consulting and articulated operationalization of the items with reference to their own digital consulting practice with greater ease than the young people. Appraising the PHBQ, in 14 of the 25 items, two-thirds of the young people's appraisals offered digital consulting examples with ease, suggesting that young people can detect and discern humanistic clinician behaviors via digital as well as face-to-face communication channels. Moreover, 17 of the 25 items were appraised as relevant by the young people. This finding was mirrored in the clinician appraisals. Both young people and the clinicians found the research task complex. Young participants required considerably more researcher prompting to elicit examples related to digital consulting rather than their face-to-face care. CONCLUSIONS PAM and PHBQ have satisfactory face and content validity for evaluating digital consulting to warrant proceeding to psychometric evaluation. Completion instructions require revision to differentiate between digital and face-to-face consultations.
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Affiliation(s)
- Jackie Sturt
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | | | - Vera Forjaz
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Kathryn Hamilton
- Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
| | - Carol Bryce
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | | | - Frances Griffiths
- Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
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