1
|
Kwon CS, Rafati A, Gandy M, Scott A, Newton CR, Jette N. Multipsychiatric Comorbidity in People With Epilepsy Compared With People Without Epilepsy: A Systematic Review and Meta-analysis. Neurology 2024; 103:e209622. [PMID: 39008805 DOI: 10.1212/wnl.0000000000209622] [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: 07/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Persons with epilepsy (PwE) have a higher risk of developing psychiatric comorbidities compared with the general population. There is limited knowledge about the prevalence of multiple psychiatric conditions in PwE. We summarize the current evidence on the prevalence of multipsychiatric comorbidities in PwE compared with persons without epilepsy. METHODS A systematic review of multipsychiatric comorbidities in PwE compared with persons without epilepsy was performed, and the results were reported using the Preferred Reporting Items of Systematic Reviews and Meta-analyses reporting standards. The search was conducted from January 1945 to June 2023 in Ovid MEDLINE. Embase, and PsycINFO, using the search terms related to "epilepsy," "psychiatric comorbidity," and "multimorbidity," combined with psychiatric disorders. Abstracts were reviewed in duplicate, and data were independently extracted using standard proforma. Data describing multipsychiatric comorbidities in PwE compared with persons without epilepsy were recorded. Descriptive statistics and, when feasible, meta-analyses are presented. The risk of bias of the studies was assessed using the Newcastle-Ottawa Scale and the International League Against Epilepsy tool. RESULTS A total of 12,841 records were identified from the systematic database search, and 15 studies met the eligibility criteria. All included studies were deemed high-quality in risk of bias according to both tools. The prevalence of multipsychiatric comorbidity was greater in persons with compared with those without epilepsy. The pooled prevalence of concomitant depression and anxiety disorder in PwE in 2 population-based studies was 15 of 163 (9.2%), which was significantly higher than 250 of 10,551 (2.4%) in patients without epilepsy (odds ratio [OR] 3.7, 95% CI 2.1-6.5, p-value <0.001, I2 = 0%, Cochran Q p-value for heterogeneity = 0.84). In 2 hospital-based studies, the prevalence of concomitant depression and attention-deficit/hyperactivity disorder in PwE (14/97, 14.4%) was significantly higher than in patients without epilepsy (5/126, 3.9%), with an OR 5.2 (95% CI 1.8-15.0, p-value = 0.002, I2 = 0%, Cochran Q p-value for heterogeneity = 0.79). DISCUSSION PwE experience elevated levels of multipsychiatric comorbidity compared with those without epilepsy. However, very few studies have empirically evaluated the extent of multipsychiatric comorbidity in PwE compared with persons without epilepsy nor their associations and consequences to prognosis in PwE.
Collapse
Affiliation(s)
- Churl-Su Kwon
- From the Departments of Neurology (C.-S.K.), Epidemiology (C.-S.K.), and Neurosurgery (C.-S.K.), Columbia University Irving Medical Center, New York; the Gertrude H. Sergievsky Center (C.-S.K.), New York, NY; School of Medicine (A.R.), Iran University of Medical Sciences, Tehran, Iran; Department of Psychiatry (C.-S.K., C.R.N.), University of Oxford, United Kingdom; School of Psychological Sciences (M.G., A.S.), Macquarie University, Sydney, Australia; and Department of Neurology (N.J.), University of Calgary, Alberta, Canada
| | - Ali Rafati
- From the Departments of Neurology (C.-S.K.), Epidemiology (C.-S.K.), and Neurosurgery (C.-S.K.), Columbia University Irving Medical Center, New York; the Gertrude H. Sergievsky Center (C.-S.K.), New York, NY; School of Medicine (A.R.), Iran University of Medical Sciences, Tehran, Iran; Department of Psychiatry (C.-S.K., C.R.N.), University of Oxford, United Kingdom; School of Psychological Sciences (M.G., A.S.), Macquarie University, Sydney, Australia; and Department of Neurology (N.J.), University of Calgary, Alberta, Canada
| | - Milena Gandy
- From the Departments of Neurology (C.-S.K.), Epidemiology (C.-S.K.), and Neurosurgery (C.-S.K.), Columbia University Irving Medical Center, New York; the Gertrude H. Sergievsky Center (C.-S.K.), New York, NY; School of Medicine (A.R.), Iran University of Medical Sciences, Tehran, Iran; Department of Psychiatry (C.-S.K., C.R.N.), University of Oxford, United Kingdom; School of Psychological Sciences (M.G., A.S.), Macquarie University, Sydney, Australia; and Department of Neurology (N.J.), University of Calgary, Alberta, Canada
| | - Amelia Scott
- From the Departments of Neurology (C.-S.K.), Epidemiology (C.-S.K.), and Neurosurgery (C.-S.K.), Columbia University Irving Medical Center, New York; the Gertrude H. Sergievsky Center (C.-S.K.), New York, NY; School of Medicine (A.R.), Iran University of Medical Sciences, Tehran, Iran; Department of Psychiatry (C.-S.K., C.R.N.), University of Oxford, United Kingdom; School of Psychological Sciences (M.G., A.S.), Macquarie University, Sydney, Australia; and Department of Neurology (N.J.), University of Calgary, Alberta, Canada
| | - Charles R Newton
- From the Departments of Neurology (C.-S.K.), Epidemiology (C.-S.K.), and Neurosurgery (C.-S.K.), Columbia University Irving Medical Center, New York; the Gertrude H. Sergievsky Center (C.-S.K.), New York, NY; School of Medicine (A.R.), Iran University of Medical Sciences, Tehran, Iran; Department of Psychiatry (C.-S.K., C.R.N.), University of Oxford, United Kingdom; School of Psychological Sciences (M.G., A.S.), Macquarie University, Sydney, Australia; and Department of Neurology (N.J.), University of Calgary, Alberta, Canada
| | - Nathalie Jette
- From the Departments of Neurology (C.-S.K.), Epidemiology (C.-S.K.), and Neurosurgery (C.-S.K.), Columbia University Irving Medical Center, New York; the Gertrude H. Sergievsky Center (C.-S.K.), New York, NY; School of Medicine (A.R.), Iran University of Medical Sciences, Tehran, Iran; Department of Psychiatry (C.-S.K., C.R.N.), University of Oxford, United Kingdom; School of Psychological Sciences (M.G., A.S.), Macquarie University, Sydney, Australia; and Department of Neurology (N.J.), University of Calgary, Alberta, Canada
| |
Collapse
|
2
|
Walløe S, Roikjær SG, Hansen SMB, Zangger G, Mortensen SR, Korfitsen CB, Simonÿ C, Lauridsen HH, Morsø L. Content validity of patient-reported measures evaluating experiences of the quality of transitions in healthcare settings-a scoping review. BMC Health Serv Res 2024; 24:828. [PMID: 39039533 PMCID: PMC11265152 DOI: 10.1186/s12913-024-11298-0] [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: 04/03/2024] [Accepted: 07/10/2024] [Indexed: 07/24/2024] Open
Abstract
No reviews so far have been conducted to define the constructs of patient-experienced quality in healthcare transitions or to identify existing generic measures of patients' experience of the quality within healthcare transitions. Our aim was to identify domains relevant for people experiencing healthcare transitions when evaluating the quality of care they have received, map the comprehensiveness of existing patient-reported experience measures (PREM), and evaluate the PREMs' content validity. The method was guided by the Joanna Briggs Institutes' guidance for scoping reviews. The search was performed on 07 December 2021 and updated 27 May 2024, in the electronic databases Medline (Ovid), Embase (Ovid), and Cinahl (EBSCO). The search identified 20,422 publications, and 190 studies were included for review. We identified 30 PREMs assessing at least one aspect of adults' experience of transitions in healthcare. Summarising the content, we consider a model with two domains, organisational and human-relational, likely to be adequate. However, a more comprehensive analysis and adequate definition of the construct is needed. None of the PREMs were considered content valid.
Collapse
Affiliation(s)
- Sisse Walløe
- Department of Clinical Research, Research Unit OPEN, University of Southern Denmark, Odense, Denmark.
- Department of Physio- and Occupational Therapy, Research- and Implmentation Unit PROgrez, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark.
| | - Stine Gundtoft Roikjær
- Department of Physio- and Occupational Therapy, Research- and Implmentation Unit PROgrez, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
- Department of Neurology, Center for Neurological Research, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
- Department of Health, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Sebrina Maj-Britt Hansen
- Department of Clinical Research, Research Unit OPEN, University of Southern Denmark, Odense, Denmark
| | - Graziella Zangger
- Department of Physio- and Occupational Therapy, Research- and Implmentation Unit PROgrez, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
- Department of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark
| | - Sofie Rath Mortensen
- Department of Physio- and Occupational Therapy, Research- and Implmentation Unit PROgrez, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
- Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise Epidemiology, University of Southern Denmark, Odense, Denmark
| | - Christoffer Bruun Korfitsen
- Department of Clinical Research, Research Unit OPEN, University of Southern Denmark, Odense, Denmark
- Department of Clinical Research, Cochrane Denmark & Centre for Evidence-Based Medicine Odense (CEBMO), University of Southern Denmark, Odense, Denmark
| | - Charlotte Simonÿ
- Department of Physio- and Occupational Therapy, Research- and Implmentation Unit PROgrez, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
- Department of Health, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Hein Lauridsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Lars Morsø
- Department of Clinical Research, Research Unit OPEN, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
3
|
Naik H, Murray TM, Khan M, Daly-Grafstein D, Liu G, Kassen BO, Onrot J, Sutherland JM, Staples JA. Population-Based Trends in Complexity of Hospital Inpatients. JAMA Intern Med 2024; 184:183-192. [PMID: 38190179 PMCID: PMC10775081 DOI: 10.1001/jamainternmed.2023.7410] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/11/2023] [Indexed: 01/09/2024]
Abstract
Importance Clinical experience suggests that hospital inpatients have become more complex over time, but few studies have evaluated this impression. Objective To assess whether there has been an increase in measures of hospital inpatient complexity over a 15-year period. Design, Setting and Participants This cohort study used population-based administrative health data from nonelective hospitalizations from April 1, 2002, to January 31, 2017, to describe trends in the complexity of inpatients in British Columbia, Canada. Hospitalizations were included for individuals 18 years and older and for which the most responsible diagnosis did not correspond to pregnancy, childbirth, the puerperal period, or the perinatal period. Data analysis was performed from July to November 2023. Exposure The passage of time (15-year study interval). Main Outcomes and Measures Measures of complexity included patient characteristics at the time of admission (eg, advanced age, multimorbidity, polypharmacy, recent hospitalization), features of the index hospitalization (eg, admission via the emergency department, multiple acute medical problems, use of intensive care, prolonged length of stay, in-hospital adverse events, in-hospital death), and 30-day outcomes after hospital discharge (eg, unplanned readmission, all-cause mortality). Logistic regression was used to estimate the relative change in each measure of complexity over the entire 15-year study interval. Results The final study cohort included 3 367 463 nonelective acute care hospital admissions occurring among 1 272 444 unique individuals (median [IQR] age, 66 [48-79] years; 49.1% female and 50.8% male individuals). Relative to the beginning of the study interval, inpatients at the end of the study interval were more likely to have been admitted via the emergency department (odds ratio [OR], 2.74; 95% CI, 2.71-2.77), to have multimorbidity (OR, 1.50; 95% CI, 1.47-1.53) and polypharmacy (OR, 1.82; 95% CI, 1.78-1.85) at presentation, to receive treatment for 5 or more acute medical issues (OR, 2.06; 95% CI, 2.02-2.09), and to experience an in-hospital adverse event (OR, 1.20; 95% CI, 1.19-1.22). The likelihood of an intensive care unit stay and of in-hospital death declined over the study interval (OR, 0.96; 95% CI, 0.95-0.97, and OR, 0.81; 95% CI, 0.80-0.83, respectively), but the risks of unplanned readmission and death in the 30 days after discharge increased (OR, 1.14; 95% CI, 1.12-1.16, and OR, 1.28; 95% CI, 1.25-1.31, respectively). Conclusions and Relevance By most measures, hospital inpatients have become more complex over time. Health system planning should account for these trends.
Collapse
Affiliation(s)
- Hiten Naik
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Tyler M. Murray
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayesha Khan
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel Daly-Grafstein
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Guiping Liu
- Center for Health Services and Policy Research (CHSPR), School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Barry O. Kassen
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jake Onrot
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason M. Sutherland
- Center for Health Services and Policy Research (CHSPR), School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - John A. Staples
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, British Columbia, Canada
| |
Collapse
|
4
|
Pati S, van den Akker M, Schellevis FFG, Sahoo KC, Burgers JS. Management of diabetes patients with comorbidity in primary care: a mixed-method study in Odisha, India. Fam Pract 2023; 40:714-721. [PMID: 36610706 DOI: 10.1093/fampra/cmac144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Diabetes patients with comorbidities need regular and comprehensive care for their disease management. Hence, it is essential to assess the primary care preparedness for managing diabetes patients and the perspectives of the diabetes patients on the care received at the primary care facilities. METHODS All 21 Urban Primary Health Centres (UPHCs) in Bhubaneswar city of Odisha, India, were assessed using the modified Primary Care Evaluation Tool and WHO Package of Essential Non-communicable disease interventions questionnaire. Additionally, 21 diabetes patients with comorbidities were interviewed in-depth to explore their perception of the care received at the primary care facilities. RESULTS All the UPHCs had provisions to meet the basic requirements for the management of diabetes and common comorbidities like hypertension. There were few provisions for chronic kidney illness, cardiovascular disease, mental health, and cancer. Diabetes patients felt that frequent change in primary care physicians at the primary care facilities affected their continuity of care. Easy accessibility, availability of free medicines, and provisions of basic laboratory tests at the facilities were felt to be necessary by the diabetes patients. CONCLUSION Our study highlights the existing gaps in India's healthcare system preparedness and the needs of diabetes patients with comorbidity. The government of India's Health and Wellness (HWC) scheme aims to deliver comprehensive healthcare to the population and provide holistic care at the primary care level for NCD patients. It is imperative that there is an early implementation of the various components of the HWC scheme to provide optimal care to diabetes patients.
Collapse
Affiliation(s)
- Sandipana Pati
- Department of Health and Family Welfare, Government of Odisha, Orissa State Institute of Health and Family Welfare, Bhubaneswar, India
| | - Marjan van den Akker
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Family Medicine, Goethe-Universität Frankfurt am Main Institut für Allgemeinmedizin, Frankfurt, Germany
- Katholieke Universiteit Leuven Academisch Centrum voor Huisartsgeneeskunde, Leuven, Belgium
- Department of General Practice & Elderly Care Medicine, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Department of General Practice & Elderly Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - F François G Schellevis
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Family Medicine, Goethe-Universität Frankfurt am Main Institut für Allgemeinmedizin, Frankfurt, Germany
- Katholieke Universiteit Leuven Academisch Centrum voor Huisartsgeneeskunde, Leuven, Belgium
- Department of General Practice & Elderly Care Medicine, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Department of General Practice & Elderly Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Krushna Chandra Sahoo
- Health Technology Assessment in India (HTAIn), ICMR-Regional Medical Research Centre, Bhubaneswar, India
| | - Jako S Burgers
- Department of Family Medicine, School CAPRI, Maastricht University, Maastricht, The Netherlands
- Dutch College of General Practitioners, Utrecht, The Netherlands
| |
Collapse
|
5
|
Lygre RB, Gjestad R, Norekvål TM, Mercer SW, Elgen IB. An interdisciplinary intervention for children and adolescents with multiple referrals and complex health complaints: a feasibility study. BMC Health Serv Res 2023; 23:1241. [PMID: 37951903 PMCID: PMC10638682 DOI: 10.1186/s12913-023-10250-y] [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: 06/21/2023] [Accepted: 10/30/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Children and adolescents with complex health complaints are often referred to several different healthcare specialists for assessments and treatment. This may result in fragmented care, higher risks of medical errors, and sub-optimal health outcomes. The aim of this non-controlled open label trial was to evaluate the feasibility of implementing a new interdisciplinary intervention for children and adolescents with multiple referrals and complex health complaints and to gather experiences from participating children, adolescents and parents. METHODS In all, 47 children and adolescents aged 6-16 years with multiple referrals at a tertiary hospital were invited to participate. The intervention was a half-day consultation based on a biopsychosocial model. The aim of the intervention was to clarify the child/adolescent's condition(s) and provide a joint understanding and treatment plan in collaboration with the family. A team consisting of a pediatrician, a physiotherapist and a psychologist delivered the intervention. Acceptance and completion rate was recorded, and child- and parent-experience measures were collected; the children and adolescents completed the Visual Consultation and Relational Empathy Scale (CARE) five questions and parents completed two de novo created measures about their experiences. RESULTS Almost all invited families consented to participate (96%) and ultimately received the interdisciplinary intervention (92%). Mean age of the children and adolescents was 12 years, and under half were boys (40%). Before the intervention, 39 (91%) parents completed a questionnaire about previous experiences with healthcare. After the consultation 39 children and adolescents (91%) and 40 (93%) parents completed the questionnaire regarding their experience with the interdisciplinary intervention. Of the children and adolescents, 18-30 (47-77%) rated relational empathy in the intervention as "Very good" or "Excellent". Of the parents, 35-39 (92-100%) rated their experience with the consultation using the more positive response options. The parents were significantly more content with the intervention compared to previously received healthcare (p < .001). CONCLUSIONS The present intervention was highly acceptable with positively reported experiences from parents of, and children and adolescents with, complex health complaints. A future randomized controlled trial is required to test the effectiveness of this intervention. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov NCT04652154 03.12.2020. Retrospectively registered.
Collapse
Affiliation(s)
- Ragnhild B Lygre
- Department of Clinical Medicine, University of Bergen, Postbox 7804, 5020, Bergen, Norway.
- Research Department, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.
- Department of Child and Adolescent Mental Health Services, Haukeland University Hospital, Bergen, Norway.
| | - Rolf Gjestad
- Research Department, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Tone M Norekvål
- Centre on Patient-Reported Outcomes, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Irene Bircow Elgen
- Department of Clinical Medicine, University of Bergen, Postbox 7804, 5020, Bergen, Norway
- Department of Child and Adolescent Mental Health Services, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
6
|
Tahsin F, Armas A, Kirakalaprathapan A, Cunningham H, Kadu M, Sritharan J, Steele Gray C. Information and Communication Technologies (ICTs) enabling integrated primary care for complex patients: a protocol for a scoping review. Syst Rev 2022; 11:193. [PMID: 36071450 PMCID: PMC9450266 DOI: 10.1186/s13643-022-02057-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION An increasing number of individuals are living with multiple chronic conditions, often combined with psychosocial complexities. For these patients with complex conditions, an integrated primary care model that provides care coordination and a team-based approach can help manage their multiple needs. Information and communication technologies (ICTs) are recognized as a critical enabler of integrated primary care. A better understanding of the use of ICTs in an integrated care setting and how ICTs are being leveraged would be beneficial to identify knowledge gaps and could lead to successful implementation for ICT-based interventions. OBJECTIVE This study will systematically scope the literature on the topic of ICT-enabled integrated healthcare delivery models for patients with complex care needs to identify which technologies have been used in integrated primary care settings. METHOD This study protocol outlines a scoping review of the peer-reviewed literature, using Arksey and O'Malley's (enhanced by Levac et al.) scoping review methodology. Peer-reviewed literature will be identified using a multi-database search strategy. The results of the search will be screened, abstracted, and charted in duplicate by six research team members. DISCUSSION The key findings of the study will be thematically analyzed to describe the implemented ICTs aimed for complex patients within the integrated primary care model. The finding will highlight what types of ICTs are being put in place to support these models, and how these ICTs are enabling care integration. This review will be the first step to formally identify how ICT is used to support integrated primary health care models. The results will be disseminated through peer-reviewed publications, conference presentations, and special interest groups.
Collapse
Affiliation(s)
- Farah Tahsin
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
| | - Alana Armas
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada
| | | | - Heather Cunningham
- Gerstein Science Information Centre, University of Toronto, Toronto, Canada
| | - Mudathira Kadu
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Jasvinei Sritharan
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Carolyn Steele Gray
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada
| |
Collapse
|
7
|
Schwarz T, Schmidt AE, Bobek J, Ladurner J. Barriers to accessing health care for people with chronic conditions: a qualitative interview study. BMC Health Serv Res 2022; 22:1037. [PMID: 35964086 PMCID: PMC9375930 DOI: 10.1186/s12913-022-08426-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 08/05/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is a growing interest in redesigning healthcare systems to increase access to and coordination across care settings for people with chronic conditions. We aim to gain a better understanding of the barriers faced by (1) children with chronic bronchial asthma, (2) adults with non-specific chronic back pain, and (3) older people with pre-existing mental illness/es in Austria's fragmented social health insurance system. METHODS Using a qualitative design, we conducted semi-structured interviews face-to-face and by telephone with health service providers, researchers, experts by experience (persons with lived/ personal experience, i.e., service users, patient advocates or family members/carers), and employees in public health administration between July and October 2019. The analysis and interpretation of data were guided by Levesque's model of access, a conceptual framework used to evaluate access broadly according to different dimensions of accessibility to care: approachability, acceptability, availability and accommodation, affordability, and appropriateness. RESULTS The findings from the 25 expert interviews were organised within Levesque's conceptual framework. They highlight a lack of coordination and defined patient pathways, particularly at the onset of the condition, when seeking a diagnosis, and throughout the care process. On the supply side, patterns of poor patient-provider communication, lack of a holistic therapeutic approach, an urban-rural divide, strict separation between social care and the healthcare system and limited consultation time were among the barriers identified. On the demand side, patients' ability to perceive a need and to subsequently seek and reach healthcare services was an important barrier, closely linked to a patient's socio-economic status, health literacy and ability to pay. CONCLUSIONS While studies on unmet needs suggest a very low level of barriers to accessing health care in the Austrian context, our study highlights potential 'invisible' barriers. Barriers to healthcare access are of concern for patients with chronic conditions, underlining existing findings about the need to improve health services according to patients' specific needs. Research on how to structure timely and integrated care independent of social and economic resources, continuity of care, and significant improvements in patient-centred communication and coordination of care would be paramount.
Collapse
Affiliation(s)
- Tanja Schwarz
- Austrian National Public Health Institute, Addiction Competence Centre, Stubenring 6, 1010, Vienna, Austria
| | - Andrea E Schmidt
- Austrian National Public Health Institute, Competence Centre on Climate and Health, Stubenring 6, 1010, Vienna, Austria.
| | - Julia Bobek
- Austrian National Public Health Institute, Health Economics and Health Systems Analysis, Stubenring 6, 1010, Vienna, Austria
| | - Joy Ladurner
- Austrian National Public Health Institute, Psychosocial Health, Stubenring 6, 1010, Vienna, Austria
| |
Collapse
|
8
|
Zhao Y, Ma Y, Zhao C, Lu J, Jiang H, Cao Y, Xu Y. The effect of integrated health care in patients with hypertension and diabetes: a systematic review and meta-analysis. BMC Health Serv Res 2022; 22:603. [PMID: 35513809 PMCID: PMC9074341 DOI: 10.1186/s12913-022-07838-1] [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: 04/28/2021] [Accepted: 03/23/2022] [Indexed: 11/18/2022] Open
Abstract
Background A growing number of studies show that integrated health care provides comprehensive and continuous care to patients with hypertension or diabetes. However, there is still no consensus about the effect of integrated health care on patients with hypertension or diabetes. The objective of this study was to verify the effectiveness of integrated health care for patients with hypertension or diabetes by using a systematic review and meta-analysis. Methods The study searched multiple English and Chinese electronic databases. The search period was from database inception to 31 October 2020. Systematic reviews and meta-analyses were conducted after assessing the risk of bias of each study. Results Sixteen studies that involved 5231 patients were included in this study. The results of the systematic review revealed that systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI) and glycosylated haemoglobin (HbA1c) are commonly used indicators for patients with hypertension or diabetes. Individual models and group- and disease-specific models are the most commonly used models of integrated health care. All the studies were from high-income and middle-income countries. Meta-analysis showed that integrated health care significantly improved SBP, DBP and HbA1c but not BMI. A comparison of interventions lasting 6 and 12 months for diabetes was conducted, and HbA1c was decreased after 12 months. The changes in SBP and DBP were statistically significant after using group- and disease-specific model but not individual models. HbA1c was significantly improved after using group- and disease-specific models and individual models. Conclusion Integrated health care is a useful tool for disease management, and individual models and group- and disease-specific models are the most commonly used models in integrated health care. Group- and disease-specific models are more effective than individual models in the disease management of hypertension patients. The duration of intervention should be considered in the disease management of patients with diabetes, and interventions longer than 12 months are recommended. The income level may affect the model of integrated health care in selecting which disease to intervene, but this point still needs support from more studies.
Collapse
Affiliation(s)
- Yan Zhao
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Yue Ma
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong Jiang
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Yanpei Cao
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China.
| | - Yafang Xu
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China. .,School of Nursing, Fudan University, Shanghai, China.
| |
Collapse
|
9
|
Miranda RN, Bhuiya AR, Thraya Z, Hancock-Howard R, Chan BC, Steele Gray C, Wodchis WP, Thavorn K. An Electronic Patient-Reported Outcomes Tool for Older Adults With Complex Chronic Conditions: Cost-Utility Analysis. JMIR Aging 2022; 5:e35075. [PMID: 35442194 PMCID: PMC9069297 DOI: 10.2196/35075] [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: 11/19/2021] [Revised: 02/21/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background eHealth technologies for self-management can improve quality of life, but little is known about whether the benefits gained outweigh their costs. The electronic patient-reported outcome (ePRO) mobile app and portal system supports patients with multiple chronic conditions to collaborate with primary health care providers to set and monitor health-related goals. Objective This study aims to estimate the cost of ePRO and the cost utility of the ePRO intervention compared with usual care provided to patients with multiple chronic conditions and complex needs living in the community, from the perspective of the publicly funded health care payer in Ontario, Canada. Methods We developed a decision tree model to estimate the incremental cost per quality-adjusted life year (QALY) gained for the ePRO tool versus usual care over a time horizon of 15 months. Resource utilization and effectiveness of the ePRO tool were drawn from a randomized clinical trial with 6 family health teams involving 45 participants. Unit costs associated with health care utilization (adjusted to 2020 Canadian dollars) were drawn from literature and publicly available sources. A series of sensitivity analyses were conducted to assess the robustness of the findings. Results The total cost of the ePRO tool was CAD $79,467 (~US $ 63,581; CAD $1733 [~US $1386] per person). Compared with standard care, the ePRO intervention was associated with higher costs (CAD $1710 [~US $1368]) and fewer QALYs (–0.03). The findings were consistent with the clinical evidence, suggesting no statistical difference in health-related quality of life between ePRO and usual care groups. However, the tool would be considered a cost-effective option if it could improve by at least 0.03 QALYs. The probability that the ePRO is cost-effective was 17.3% at a willingness-to-pay (WTP) threshold of CAD $50,000 (~US $40,000)/QALY. Conclusions The ePRO tool is not a cost-effective technology at the commonly used WTP value of CAD $50,000 (~US $40,000)/QALY, but long-term and the societal impacts of ePRO were not included in this analysis. Further research is needed to better understand its impact on long-term outcomes and in real-world settings. The present findings add to the growing evidence about eHealth interventions’ capacity to respond to complex aging populations within finite-resourced health systems. Trial Registration ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954
Collapse
Affiliation(s)
- Rafael N Miranda
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, ON, Canada
| | - Aunima R Bhuiya
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Zak Thraya
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Rebecca Hancock-Howard
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Brian Cf Chan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Carolyn Steele Gray
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
10
|
Verhoeff M, de Groot J, Burgers JS, van Munster BC. Development and internal validation of prediction models for future hospital care utilization by patients with multimorbidity using electronic health record data. PLoS One 2022; 17:e0260829. [PMID: 35298467 PMCID: PMC8929569 DOI: 10.1371/journal.pone.0260829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/17/2021] [Indexed: 12/05/2022] Open
Abstract
Objective To develop and internally validate prediction models for future hospital care utilization in patients with multiple chronic conditions. Design Retrospective cohort study. Setting A teaching hospital in the Netherlands (542 beds) Participants All adult patients (n = 18.180) who received care at the outpatient clinic in 2017 for two chronic diagnoses or more (including oncological diagnoses) and who returned for hospital care or outpatient clinical care in 2018. Development and validation using a stratified random split-sample (n = 12.120 for development, n = 6.060 for internal validation). Outcomes ≥2 emergency department visits in 2018, ≥1 hospitalization in 2018 and ≥12 outpatient visits in 2018. Statistical analysis Multivariable logistic regression with forward selection. Results Evaluation of the models’ performance showed c-statistics of 0.70 (95% CI 0.69–0.72) for the hospitalization model, 0.72 (95% CI 0.70–0.74) for the ED visits model and 0.76 (95% 0.74–0.77) for the outpatient visits model. With regard to calibration, there was agreement between lower predicted and observed probability for all models, but the models overestimated the probability for patients with higher predicted probabilities. Conclusions These models showed promising results for further development of prediction models for future healthcare utilization using data from local electronic health records. This could be the first step in developing automated alert systems in electronic health records for identifying patients with multimorbidity with higher risk for high healthcare utilization, who might benefit from a more integrated care approach.
Collapse
Affiliation(s)
- Marlies Verhoeff
- Department of Internal Medicine, University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Knowledge Institute of the Federation of Medical Specialists, Utrecht, the Netherlands
- * E-mail:
| | - Janke de Groot
- Knowledge Institute of the Federation of Medical Specialists, Utrecht, the Netherlands
| | - Jako S. Burgers
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Barbara C. van Munster
- Department of Internal Medicine, University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
11
|
Liao J, Zhou M, Zhong C, Liang C, Hu N, Kuang L. Effect of Family Practice Contract Services on the Perceived Quality of Primary Care among Patients with Multimorbidity: A Cross-Sectional Study in Guangdong, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:157. [PMID: 35010417 PMCID: PMC8751177 DOI: 10.3390/ijerph19010157] [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: 09/30/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Abstract
Family practice contract services, an important primary-care reform policy for improving primary healthcare quality in China, incorporate patients with multiple chronic conditions into the priority coverage groups and focus on their management. This study aims to explore the family practice contract services' effectiveness in improving the quality of primary care experienced by this population. A cross-sectional study using a three-stage sampling was conducted from January to March 2019 in Guangdong, China. A multivariable linear regression, including interaction terms, was applied to examine the associations between the contract services and primary care quality among people with different chronic conditions. The process quality of primary care was measured in six dimensions using the validated assessment survey of primary care (ASPC) scale. People with contract services scored higher in terms of quality of primary care than those without contract services. Contract services moderated the association between chronic condition status and primary care quality. Significantly positive interactions were observed in the patient-centred care dimension and negative interactions were reflected in the accessibility dimension. Our findings suggest that family practice contract services play a crucial role in improving patient-perceived primary care quality and provide emerging evidence that patients with multimorbidity tend to benefit more from the services, especially in patient-centred care.
Collapse
Affiliation(s)
- Jingyi Liao
- Department of Health Administration, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; (J.L.); (M.Z.)
| | - Mengping Zhou
- Department of Health Administration, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; (J.L.); (M.Z.)
| | - Chenwen Zhong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong 999077, China;
| | - Cuiying Liang
- Science Education Department, Dongguan People’s Hospital, Dongguan 523000, China;
| | - Nan Hu
- Department of Biostatistics, FIU Robert Stempel College of Public Health and Social Work, Miami, FL 33199, USA
- Department of Family and Preventive Medicine and Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Li Kuang
- Department of Health Administration, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; (J.L.); (M.Z.)
| |
Collapse
|
12
|
The Cost Consequences of the Gold Coast Integrated Care Programme. Int J Integr Care 2021; 21:9. [PMID: 34611459 PMCID: PMC8447978 DOI: 10.5334/ijic.5542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/02/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial. Methods A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost. Results A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group. Conclusion The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in health-related quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program.
Collapse
|
13
|
Kim J, Keshavjee S, Atun R. Trends, patterns and health consequences of multimorbidity among South Korea adults: Analysis of nationally representative survey data 2007-2016. J Glob Health 2021; 10:020426. [PMID: 33274065 PMCID: PMC7698588 DOI: 10.7189/jogh.10.020426] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Multimorbidity is a global challenge. It is more common in the elderly and deprived populations. Health systems are not providing appropriate care for people with multimorbidity as they are focused on managing single diseases and are not oriented to effectively manage complexity of care-coordination for multimorbidity. This study aims to examine trends, disparities and consequences of multimorbidity over a 10-year period. It also aims to analyze different multimorbidity clusters and their association with quality of life. Methods This study analyzes Korea National Health and Nutrition Examination Survey – a cross-sectional survey repeated each year of 100 000 individuals aged one or more in 192 regions of South Korea – for the 10-year period 2007-2016. This is a population-based study based on nationally representative survey data for 10 years in Korea. Our study included 68 590 adults aged 19 or more who answered questions on presence of diseases. 39 chronic conditions were included. Disease clustering by frequency, composition and number of diseases from the top 10 most common chronic conditions were used to establish patterns of multimorbidity clusters. We performed regression analyses to analyze annual trend and the prevalence of multimorbidity across socioeconomic strata. Regressions were performed to measure association between multimorbidity and unmet need, health care service utilization, sickness days, perceived health status, and EQ-5D. Results Multimorbidity increased in the study period and was more prevalent in the elderly, females, and people with lower household income and education level. Multimorbidity was associated with increased unmet need, health care utilization and sickness days and reduced perceived health status and quality of life. Hypertension was the most common condition in individuals with multimorbidity. Reduced quality of life was associated with increasing number of chronic diseases and multimorbidity clusters which included stroke and arthritis. Conclusions The prevalence of multimorbidity varied across socioeconomic strata, with higher levels and health consequences observed in individuals in lower socio-economic income groups. Different multimorbidity clusters had differential effect on the quality of life. Health system designs incorporating integrated care strategies for complex conditions are required to effectively manage multimorbidity and different multimorbidity clusters.
Collapse
Affiliation(s)
- Jungyeon Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
14
|
Lalloo D, Gallagher J, Macdonald E, McDonnell C. Clinical Case Complexity in Occupational Health: Contributing Factors and a Proposed Conceptual Framework Model. J Occup Environ Med 2021; 63:e352-e361. [PMID: 33950037 DOI: 10.1097/jom.0000000000002215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Clinical case complexity is an inherent factor in occupational health (OH), yet it is poorly defined and understood. Our aim was to identify the multiple sources of complexity in OH and propose a conceptual complexity framework model for clinical OH practice. METHODS Through a scoping review, expert panel consensus, and content analysis of OH clinical case reports, we identified relevant complexity-contributing factors (CCFs) specifically tailored to the OH setting, which we defined and validated. RESULTS The proposed model consists of three primary domains (PDs); health factors, workplace factors and biopsychosocial factors. Twenty-seven CCFs are described and defined within these PDs. CONCLUSIONS This work lays the foundation for improved understanding, identification, and assessment of complexity in OH. This is imperative for ensuring high quality clinical practice standards, identifying training needs and appropriate triaging/resource allocation.
Collapse
Affiliation(s)
- Drushca Lalloo
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8RZ, UK (Dr Lalloo and Dr Macdonald); School of Public Health, University College Cork, Cork T12 YN60, Ireland (Dr Gallagher); Mid-West Region, Limerick V94 7X9, Ireland (Dr McDonnell)
| | | | | | | |
Collapse
|
15
|
Heggestad T, Greve G, Skilbrei B, Elgen I. Complex care pathways for children with multiple referrals demonstrated in a retrospective population-based study. Acta Paediatr 2020; 109:2641-2647. [PMID: 32159873 DOI: 10.1111/apa.15250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/05/2020] [Accepted: 03/09/2020] [Indexed: 11/29/2022]
Abstract
AIM To identify children with complex medical needs by examining their patterns of hospital care. METHODS We conducted a retrospective population-based study on 18 577 patients aged 6-12 years from the Haukeland University Hospital register over a 3-year period (from 2013 to 2015). Data were structured to examine the temporal patterns and sequences of referrals, care episodes and diagnoses, including flow across medical specialties. RESULTS Over a third of patients had repeated referrals, and 14.9% of all had three or more. Furthermore, 9.3% of patients were referred to both somatic and mental healthcare services. Patients with such combined referrals had a higher number of referrals as well as a higher number of different diagnoses. Overall, there was a high frequency of non-specific diagnoses, and 34.8% of patients still had a non-specific main diagnosis at the end of their hospital contact. CONCLUSION This study demonstrates an increased risk for complex care pathways in children with multiple referrals. Interdisciplinary patterns of referrals were relatively common, particularly for patients in mental health care. These findings highlight the importance of developing interdisciplinary-based approaches for patients with complex complaints.
Collapse
Affiliation(s)
- Torhild Heggestad
- Department of Research and Development Haukeland University Hospital Bergen Norway
| | - Gottfried Greve
- Department of Heart Disease Haukeland University Hospital Bergen Norway
- Department of Clinical Science University of Bergen Bergen Norway
| | - Birger Skilbrei
- Department of Research and Development Haukeland University Hospital Bergen Norway
| | - Irene Elgen
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Child and Adolescent Psychiatry Division of Mental Health Haukeland University Hospital Bergen Norway
| |
Collapse
|
16
|
Czypionka T, Kraus M, Reiss M, Baltaxe E, Roca J, Ruths S, Stokes J, Struckmann V, Haček RT, Zemplényi A, Hoedemakers M, Rutten-van Mölken M. The patient at the centre: evidence from 17 European integrated care programmes for persons with complex needs. BMC Health Serv Res 2020; 20:1102. [PMID: 33256723 PMCID: PMC7706259 DOI: 10.1186/s12913-020-05917-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 11/12/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND As the prevalence of multi-morbidity increases in ageing societies, health and social care systems face the challenge of providing adequate care to persons with complex needs. Approaches that integrate care across sectors and disciplines have been increasingly developed and implemented in European countries in order to tackle this challenge. The aim of the article is to identify success factors and crucial elements in the process of integrated care delivery for persons with complex needs as seen from the practical perspective of the involved stakeholders (patients, professionals, informal caregivers, managers, initiators, payers). METHODS Seventeen integrated care programmes for persons with complex needs in 8 European countries were investigated using a qualitative approach, namely thick description, based on semi-structured interviews and document analysis. In total, 233 face-to-face interviews were conducted with stakeholders of the programmes between March and September 2016. Meta-analysis of the individual thick description reports was performed with a focus on the process of care delivery. RESULTS Four categories that emerged from the overarching analysis are discussed in the article: (1) a holistic view of the patient, considering both mental health and the social situation in addition to physical health, (2) continuity of care in the form of single contact points, alignment of services and good relationships between patients and professionals, (3) relationships between professionals built on trust and facilitated by continuous communication, and (4) patient involvement in goal-setting and decision-making, allowing patients to adapt to reorganised service delivery. CONCLUSIONS We were able to identify several key aspects for a well-functioning integrated care process for complex patients and how these are put into actual practice. The article sets itself apart from the existing literature by specifically focussing on the growing share of the population with complex care needs and by providing an analysis of actual processes and interpersonal relationships that shape integrated care in practice, incorporating evidence from a variety of programmes in several countries.
Collapse
Affiliation(s)
- Thomas Czypionka
- Institute for Advanced Studies, Josefstädter Straße 39, 1080, Vienna, Austria.,London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Markus Kraus
- Institute for Advanced Studies, Josefstädter Straße 39, 1080, Vienna, Austria.
| | - Miriam Reiss
- Institute for Advanced Studies, Josefstädter Straße 39, 1080, Vienna, Austria
| | - Erik Baltaxe
- Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Villarroel 170, Barcelona,, 08036,, Catalonia, Spain
| | - Josep Roca
- Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Villarroel 170, Barcelona,, 08036,, Catalonia, Spain
| | - Sabine Ruths
- University of Bergen, Postboks 7804, 5020, Bergen, Norway
| | - Jonathan Stokes
- University of Manchester, 7th Floor, Williamson Building, Oxford Road, Manchester, M13 9P, UK
| | - Verena Struckmann
- Berlin University of Technology, Strasse des 17. Juni 135 (H80), 10623, Berlin, Germany
| | | | - Antal Zemplényi
- Syreon Research Institute, Mexikoi str. 65/A, 1142, Budapest, Hungary
| | - Maaike Hoedemakers
- Erasmus University Rotterdam, P.O.Box 1738, 3000, DR, Rotterdam, The Netherlands
| | | |
Collapse
|
17
|
District nurses' use of a decision support and assessment tool to improve the quality and safety of medication use in older adults: a feasibility study. Prim Health Care Res Dev 2020; 21:e15. [PMID: 32495732 PMCID: PMC7303788 DOI: 10.1017/s1463423620000092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aim: To investigate whether district nurses (DNs) can identify factors related to the quality and safety of medication use among older patients via a clinical decision support system (CDSS) for medication and an instrument for assessing the safety of drug use [the Safe Medication Assessment tool (SMA)]. A secondary aim was to describe patients’ experiences of the assessment. Background: DNs in Stockholm County have the opportunity to establish special units at primary health care centers (PHCCs) for patients aged 75 years and older. The units conduct drug utilization reviews and create care plans for older adults. Methods: Nine DNs at 7 PHCCs in Stockholm County used the tools with 45 patients aged 75 years and older who used one or more drugs. Outcome measures were the number of drugs, potential drug-related problems, nursing interventions, and patient satisfaction. Prevalences of drug-related problems and nursing interventions were calculated. Eleven patients answered a telephone questionnaire on their experiences of the assessment. Findings: DNs identified factors indicative of drug-related problems, including polypharmacy (9.8 drugs per person), potential drug–drug interactions (prevalence 40%), potential adverse drug reactions (2.7 per person), and prescribers from more than two medical units (60%). DNs used several nursing interventions to improve the safety of medication use (e.g., patient education, initiating a pharmaceutical review). The patients thought it was meaningful to receive information about their drug use and important to identify potential drug-related problems. With the support of the CDSS and the SMA tool, the DNs could identify several factors related to inappropriate or unsafe medication and initiated a number of interventions to improve medication use. The patients were positive toward the assessments. Using these tools, the DNs may help promote safe medication use in older patients.
Collapse
|
18
|
Ha NT, Wright C, Youens D, Preen DB, Moorin R. Effect Modification of Multimorbidity on the Association Between Regularity of General Practitioner Contacts and Potentially Avoidable Hospitalisations. J Gen Intern Med 2020; 35:1504-1515. [PMID: 32096082 PMCID: PMC7210343 DOI: 10.1007/s11606-020-05699-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 12/18/2019] [Accepted: 02/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Scheduled regular contact with the general practitioner (GP) may lower the risk of potentially avoidable hospitalisations (PAHs). Despite the high prevalence of multimorbidity, little is known about its effect on the relationship between regularity of GP contact and PAHs. OBJECTIVE To investigate potential effect modification of multimorbidity on the relationship between regularity of GP contact and probability of PAHs. DESIGN A retrospective, cross-sectional study. PARTICIPANTS 229,964 individuals aged 45 years and older from the 45 and Up Study in New South Wales, Australia, from 2009 to 2015. MAIN MEASURES The main exposure was regularity of GP contact (capturing dispersion of GP contacts); the outcomes were PAHs evaluated by unplanned hospitalisations, chronic ambulatory care sensitive condition (ACSC) hospitalisations and unplanned chronic ACSC hospitalisations. Multivariable logistic regression models and population attributable fractions (PAF) were conducted to identify effect modification of multimorbidity, assessed by Rx-Risk comorbidity score. KEY RESULTS Compared with the lowest quintile of regularity, the highest quintile had significantly lower predicted probability of unplanned admission (- 79.9 per 1000 people at risk, 95% confidence interval (CI) - 85.6; - 74.2), chronic ACSC (- 6.07 per 1000 people at risk, 95%CI - 8.07; - 4.08) and unplanned chronic ACSC hospitalisation (- 4.68 per 1000 people at risk, 95%CI - 6.11; - 3.26). Effect modification of multimorbidity was observed. Specifically, the PAF among people with no multimorbidity indicated that 31.7% (95%CI 28.7-34.4%) of unplanned, 36.4% (95%CI 25.1-45.9%) of chronic ACSC and 48.9% (95%CI 32.9-61.1%) of unplanned chronic ACSC hospitalisation would be reduced by a shift to the highest quintile of regularity. However, among people with 10+ morbidities, the proportional reduction was only 5.2% (95%CI 3.8-6.5%), 9.0% (95%CI 0.5-16.8%) and 17.8% (95%CI 5.4-28.5%), respectively. CONCLUSIONS Weakening of the association between regularity and PAHs with increasing levels of multimorbidity suggests a need to improve primary care support to prevent PAHs for patients with multimorbidity.
Collapse
Affiliation(s)
- Ninh Thi Ha
- Health Systems and Health Economics, School of Public Health, Curtin University, Perth, Western Australia, Australia.
| | - Cameron Wright
- Health Systems and Health Economics, School of Public Health, Curtin University, Perth, Western Australia, Australia.,School of Medicine, College of Health & Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - David Youens
- Health Systems and Health Economics, School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - David B Preen
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Crawley, WA, Australia
| | - Rachael Moorin
- Health Systems and Health Economics, School of Public Health, Curtin University, Perth, Western Australia, Australia.,School of Population and Global Health, The University of Western Australia, Crawley, WA, Australia
| |
Collapse
|
19
|
Zhang T, Ren J, Zhang X, Max W. Medical and socio-demographic characteristics associated with patient-perceived continuity of primary care: A cross-sectional survey in Hangzhou, China. Int J Health Plann Manage 2019; 35:569-580. [PMID: 31736143 DOI: 10.1002/hpm.2967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This study measured the perceived continuity of general practitioner (GP) care from the patient's perspective and identified the associated factors. METHODS A cross-sectional survey was carried out on 624 patients in community health care centres in Hangzhou, China. A self-designed Likert scale was used to measure patients' perceptions on informational, managerial, and relational continuity of GP care. An average score for three types of continuity ranging from 0 to 100 was calculated. Linear regression models were developed to determine the factors influencing continuity. RESULTS Average rating scores of 57.73 (±15.31), 50.74 (±17.18), 61.61 (±18.07), and 63.57 (±17.40) were found for total, informational, managerial, and relational continuity of care, respectively. Older patients reported a more positive rating on all types of continuity. Income was negatively associated with managerial continuity. The factors affecting informational, relational, and total continuities included chronic diseases, walking distance to nearest community health centres, signing a contract with a GP, and knowing the names of contracted GPs. CONCLUSION Patients' perception of continuity of GP care remains at a low level, especially for informational continuity. The varied association between continuity of care and identified factors suggests that targeted actions should be considered for improving the quality of GP services.
Collapse
Affiliation(s)
- Tao Zhang
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,School of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Jianping Ren
- School of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Xinyu Zhang
- School of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Wendy Max
- Institute for Health and Aging, School of Nursing, University of California, California, USA
| |
Collapse
|
20
|
González-González AI, Schmucker C, Blom J, van den Akker M, Nguyen TS, Nothacker J, Meerpohl JJ, Röttger K, Wegwarth O, Hoffmann T, Straus SE, Gerlach FM, Muth C. Health-related preferences of older patients with multimorbidity: the protocol for an evidence map. BMJ Open 2019; 9:e029724. [PMID: 31481558 PMCID: PMC6731896 DOI: 10.1136/bmjopen-2019-029724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/21/2019] [Accepted: 08/06/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Interaction of conditions and treatments, complicated care needs and substantial treatment burden make patient-physician encounters involving multimorbid older patients highly complex. To optimally integrate patients' preferences, define and prioritise realistic treatment goals and individualise care, a patient-centred approach is recommended. However, the preferences of older patients, who are especially vulnerable and frequently multimorbid, have not been systematically investigated with regard to their health status. The purpose of this evidence map is to explore current research addressing health-related preferences of older patients with multimorbidity, and to identify the knowledge clusters and research gaps. METHODS AND ANALYSIS To identify relevant research, we will conduct searches in the electronic databases MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL, Social Science Citation Index, Social Science Citation Index Expanded and the Cochrane library from their inception. We will check reference lists of relevant articles and carry out cited reference research (forward citation tracking). Two independent reviewers will screen titles and abstracts, check full texts for eligibility and extract the data. Any disagreement will be resolved and consensus reached with the help of a third reviewer. We will include both qualitative and quantitative studies, and address preferences from the patients' perspectives in a multimorbid population of 60 years or older. There will be no restrictions on the publication language. Data extraction tables will present study and patient characteristics, aim of study, methods used to identify preferences and outcomes (ie, type of preferences). We will summarise the data using tables and figures (ie, bubble plot) to present the research landscape and to describe clusters and gaps. ETHICS AND DISSEMINATION Due to the nature of the proposed evidence map, ethics approval will not be required. Results from our research will be disseminated by means of specifically prepared materials for patients, at relevant (inter)national conferences and via publication in peer-reviewed journals.
Collapse
Affiliation(s)
- Ana Isabel González-González
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jeanet Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Truc Sophia Nguyen
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Julia Nothacker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kristian Röttger
- Patient Representative, Federal Joint Committee "Gemeinsamer Bundesausschuss", Berlin, Germany
| | - Odette Wegwarth
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Sharon E Straus
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ferdinand M Gerlach
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| |
Collapse
|
21
|
Spring B, Stump T, Penedo F, Pfammatter AF, Robinson JK. Toward a health-promoting system for cancer survivors: Patient and provider multiple behavior change. Health Psychol 2019; 38:840-850. [PMID: 31436465 PMCID: PMC6709684 DOI: 10.1037/hea0000760] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This paper examines how and why to improve care systems for disease management and health promotion for the growing population of cancer survivors with cardiovascular multi-morbidities. METHOD We reviewed research characterizing cancer survivors' and their multiple providers' common sense cognitive models of survivors' main health threats, preventable causes of adverse health events, and optimal coping strategies. RESULTS Findings indicate that no entity in the health care system self-identifies as claiming primary responsibility to address longstanding unhealthy lifestyle behaviors that heighten survivors' susceptibility to both cancer and cardiovascular disease (CVD) and whose improvement could enhance quality of life. CONCLUSIONS To address this gap, we propose systems-level changes that integrate health promotion into existing survivorship services by including behavioral risk factor vital signs in the electronic medical record, with default proactive referral to a health promotionist (a paraprofessional coach adept with mobile technologies and supervised by a professional expert in health behavior change). By using the patient's digital tracking data to coach remotely and periodically report progress to providers, the health promotionist closes a gap, creating a connected care system that supports, reinforces, and maintains accountability for healthy lifestyle improvement. No comparable resource solely dedicated to treatment of chronic disease risk behaviors (smoking, obesity, physical inactivity, treatment nonadherence) exists in current models of integrated care. Integrating health promotionists into care delivery channels would remove burden from overtaxed PCPs and instantiate a comprehensive, actionable systems-level schema of health risks and coping strategies needed to have preventive impact with minimal interference to clinical work flow. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
Collapse
Affiliation(s)
- Bonnie Spring
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Tammy Stump
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Frank Penedo
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine
| | | | - June K. Robinson
- Department of Dermatology, Northwestern University Feinberg School of Medicine
| |
Collapse
|
22
|
Pariser P, Pham TNT, Brown JB, Stewart M, Charles J. Connecting People With Multimorbidity to Interprofessional Teams Using Telemedicine. Ann Fam Med 2019; 17:S57-S62. [PMID: 31405877 PMCID: PMC6827667 DOI: 10.1370/afm.2379] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/12/2018] [Accepted: 12/27/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Most models for managing chronic disease focus on single diseases. Managing patients with multimorbidity is an increasing challenge in family medicine. We evaluated the feasibility of a novel approach to caring for patients with multimorbidity, performing a case study of TIP-Telemedicine IMPACT (Interprofessional Model of Practice for Aging and Complex Treatments) Plus-a 1-time interprofessional consultation with primary care physicians (PCPs) and their patients in Toronto, Canada. METHODS We assessed feasibility of the TIP model from the number of referrals from PCPs and emergency departments in Toronto, Canada; the intervention cost; and the satisfaction of patients, PCPs, and team members with the new model. One patient and PCP story highlights the model's impact. We also performed thematic analysis of written feedback. RESULTS A total of 76 patients were referred from 53 PCPs and 4 emergency departments, and 65 PCPs participated in TIP. All 74 patient survey respondents indicated TIP improved their access to interdisciplinary resources, and 97% reported feeling hopeful their conditions would improve as a result. Of 21 PCP survey respondents, 100% reported they would use TIP again, and 90% reported improved confidence in managing their patient's care. Of 87 team member survey respondents, 97% rated TIP as effective. Qualitative findings indicated benefits to both patients and health professionals. The cost was about 22% less than that of a 1-day hospital admission through the emergency department (C$854 vs C$1,088). CONCLUSIONS TIP is a feasible intervention in multiple primary care settings that gives patients an active role in their health management, supported by their team. The model effectively addresses the needs of the most complex patients and their PCPs.
Collapse
Affiliation(s)
- Pauline Pariser
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto-Central Local Health Integration Network Toronto, Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada
| | - Thuy-Nga Tia Pham
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,South East Toronto Family Health Team, Toronto, Ontario, Canada
| | - Judith B Brown
- Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
| | - Moira Stewart
- Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
| | - Jocelyn Charles
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada .,Toronto-Central Local Health Integration Network Toronto, Toronto, Ontario, Canada.,Veterans Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
23
|
What is Important to Older People with Multimorbidity and Their Caregivers? Identifying Attributes of Person Centered Care from the User Perspective. Int J Integr Care 2019; 19:4. [PMID: 31367203 PMCID: PMC6659759 DOI: 10.5334/ijic.4655] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Introduction: Health systems are striving to design and deliver care that is ‘person
centred’—aligned with the needs and preferences of those
receiving it; however, it is unclear what older people and their caregivers
value in their care. This paper captures attributes of care that are
important to older people and their caregivers. Methods: This qualitative descriptive study entailed 1–1 interviews with older
adults with multimorbidity receiving community based primary health care in
Canada and New Zealand and caregivers. Data were analyzed to identify core
attributes of care, important to participants. Findings: Feeling heard, appreciated and comfortable; having someone to count on;
easily accessing health and social care; knowing how to manage health and
what to expect; feeling safe; and being independent were valued. Each
attribute had several characteristics including: being treated like a
friend; having contact information of a responsive provider; being
accompanied to medical and social activities; being given clear treatment
options including what to expect; having homes adapted to support
limitations and having the opportunity to participate in meaningful
hobbies. Conclusions: Attributes of good care extend beyond disease management. While our findings
include activities that characterize these attributes, further research on
implementation barriers and facilitators is required.
Collapse
|
24
|
Care Plans in Community Mental Health: an Audit Focusing on People with Recent Hospital Admissions. J Behav Health Serv Res 2019; 44:474-482. [PMID: 26940207 DOI: 10.1007/s11414-016-9504-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
25
|
Salisbury C, Man MS, Chaplin K, Mann C, Bower P, Brookes S, Duncan P, Fitzpatrick B, Gardner C, Gaunt DM, Guthrie B, Hollinghurst S, Kadir B, Lee V, McLeod J, Mercer SW, Moffat KR, Moody E, Rafi I, Robinson R, Shaw A, Thorn J. A patient-centred intervention to improve the management of multimorbidity in general practice: the 3D RCT. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
People with multimorbidity experience impaired quality of life, poor health and a burden from treatment. Their care is often disease-focused rather than patient-centred and tailored to their individual needs.
Objective
To implement and evaluate a patient-centred intervention to improve the management of patients with multimorbidity in general practice.
Design
Pragmatic, cluster randomised controlled trial with parallel process and economic evaluations. Practices were centrally randomised by a statistician blind to practice identifiers, using a computer-generated algorithm.
Setting
Thirty-three general practices in three areas of England and Scotland.
Participants
Practices had at least 4500 patients and two general practitioners (GPs) and used the EMIS (Egton Medical Information Systems) computer system. Patients were aged ≥ 18 years with three or more long-term conditions.
Interventions
The 3D (Dimensions of health, Depression and Drugs) intervention was designed to offer patients continuity of care with a named GP, replacing separate reviews of each long-term condition with comprehensive reviews every 6 months. These focused on individualising care to address patients’ main problems, attention to quality of life, depression and polypharmacy and on disease control and agreeing treatment plans. Control practices provided usual care.
Outcome measures
Primary outcome – health-related quality of life (assessed using the EuroQol-5 Dimensions, five-level version) after 15 months. Secondary outcomes – measures of illness burden, treatment burden and patient-centred care. We assessed cost-effectiveness from a NHS and a social care perspective.
Results
Thirty-three practices (1546 patients) were randomised from May to December 2015 [16 practices (797 patients) to the 3D intervention, 17 practices (749 patients) to usual care]. All participants were included in the primary outcome analysis by imputing missing data. There was no evidence of difference between trial arms in health-related quality of life {adjusted difference in means 0.00 [95% confidence interval (CI) –0.02 to 0.02]; p = 0.93}, illness burden or treatment burden. However, patients reported significant benefits from the 3D intervention in all measures of patient-centred care. Qualitative data suggested that both patients and staff welcomed having more time, continuity of care and the patient-centred approach. The economic analysis found no meaningful differences between the intervention and usual care in either quality-adjusted life-years [(QALYs) adjusted mean QALY difference 0.007, 95% CI –0.009 to 0.023] or costs (adjusted mean difference £126, 95% CI –£739 to £991), with wide uncertainty around point estimates. The cost-effectiveness acceptability curve suggested that the intervention was unlikely to be either more or less cost-effective than usual care. Seventy-eight patients died (46 in the intervention arm and 32 in the usual-care arm), with no evidence of difference between trial arms; no deaths appeared to be associated with the intervention.
Limitations
In this pragmatic trial, the implementation of the intervention was incomplete: 49% of patients received two 3D reviews over 15 months, whereas 75% received at least one review.
Conclusions
The 3D approach reflected international consensus about how to improve care for multimorbidity. Although it achieved the aim of providing more patient-centred care, this was not associated with benefits in quality of life, illness burden or treatment burden. The intervention was no more or less cost-effective than usual care. Modifications to the 3D approach might improve its effectiveness. Evaluation is needed based on whole-system change over a longer period of time.
Trial registration
Current Controlled Trials ISRCTN06180958.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 5. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Chris Salisbury
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mei-See Man
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cindy Mann
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Sara Brookes
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Polly Duncan
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Caroline Gardner
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Daisy M Gaunt
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bruce Guthrie
- Population Health Sciences Division, School of Medicine, University of Dundee, Dundee, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bryar Kadir
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Victoria Lee
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - John McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Stewart W Mercer
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Keith R Moffat
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Emma Moody
- Bristol Clinical Commissioning Group, Bristol, UK
| | - Imran Rafi
- Royal College of General Practitioners, London, UK
| | | | - Alison Shaw
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joanna Thorn
- Centre for Academic Primary Care, National Institute for Health Research School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
26
|
Clarke JM, Warren LR, Arora S, Barahona M, Darzi AW. Guiding interoperable electronic health records through patient-sharing networks. NPJ Digit Med 2018; 1:65. [PMID: 31304342 PMCID: PMC6550264 DOI: 10.1038/s41746-018-0072-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/09/2018] [Indexed: 01/01/2023] Open
Abstract
Effective sharing of clinical information between care providers is a critical component of a safe, efficient health system. National data-sharing systems may be costly, politically contentious and do not reflect local patterns of care delivery. This study examines hospital attendances in England from 2013 to 2015 to identify instances of patient sharing between hospitals. Of 19.6 million patients receiving care from 155 hospital care providers, 130 million presentations were identified. On 14.7 million occasions (12%), patients attended a different hospital to the one they attended on their previous interaction. A network of hospitals was constructed based on the frequency of patient sharing between hospitals which was partitioned using the Louvain algorithm into ten distinct data-sharing communities, improving the continuity of data sharing in such instances from 0 to 65-95%. Locally implemented data-sharing communities of hospitals may achieve effective accessibility of clinical information without a large-scale national interoperable information system.
Collapse
Affiliation(s)
- Jonathan M. Clarke
- NIHR Patient Safety Translational Research Centre, Imperial College London, London, W2 1NY UK
- EPSRC Centre for Mathematics of Precision Healthcare, Imperial College London, London, SW7 2AZ UK
- Centre for Health Policy, Imperial College London, London, W2 1NY UK
| | - Leigh R. Warren
- NIHR Patient Safety Translational Research Centre, Imperial College London, London, W2 1NY UK
| | - Sonal Arora
- NIHR Patient Safety Translational Research Centre, Imperial College London, London, W2 1NY UK
| | - Mauricio Barahona
- EPSRC Centre for Mathematics of Precision Healthcare, Imperial College London, London, SW7 2AZ UK
- Department of Mathematics, Imperial College London, London, SW7 2AZ UK
| | - Ara W. Darzi
- NIHR Patient Safety Translational Research Centre, Imperial College London, London, W2 1NY UK
- Centre for Health Policy, Imperial College London, London, W2 1NY UK
| |
Collapse
|
27
|
Abstract
BACKGROUND Claims-based algorithms based on administrative claims data are frequently used to identify an individual's primary care physician (PCP). The validity of these algorithms in the US Medicare population has not been assessed. OBJECTIVE To determine the agreement of the PCP identified by claims algorithms with the PCP of record in electronic health record data. DATA Electronic health record and Medicare claims data from older adults with diabetes. SUBJECTS Medicare fee-for-service beneficiaries with diabetes (N=3658) ages 65 years and older as of January 1, 2008, and medically housed at a large academic health system. MEASURES Assignment algorithms based on the plurality and majority of visits and tie breakers determined by either last visit, cost, or time from first to last visit. RESULTS The study sample included 15,624 patient-years from 3658 older adults with diabetes. Agreement was higher for algorithms based on primary care visits (range, 78.0% for majority match without a tie breaker to 85.9% for majority match with the longest time from first to last visit) than for claims to all visits (range, 25.4% for majority match without a tie breaker to 63.3% for majority match with the amount billed tie breaker). Percent agreement was lower for nonwhite individuals, those enrolled in Medicaid, individuals experiencing a PCP change, and those with >10 physician visits. CONCLUSIONS Researchers may be more likely to identify a patient's PCP when focusing on primary care visits only; however, these algorithms perform less well among vulnerable populations and those experiencing fragmented care.
Collapse
|
28
|
Pouplier S, Olsen MÅ, Willadsen TG, Sandholdt H, Siersma V, Andersen CL, Olivarius NDF. The development of multimorbidity during 16 years after diagnosis of type 2 diabetes. JOURNAL OF COMORBIDITY 2018; 8:2235042X18801658. [PMID: 30363325 PMCID: PMC6169975 DOI: 10.1177/2235042x18801658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 08/14/2018] [Indexed: 12/21/2022]
Abstract
Objective: The aims of this study were to (1) quantify the development and composition
of multimorbidity (MM) during 16 years following the diagnosis of type 2
diabetes and (2) evaluate whether the effectiveness of structured personal
diabetes care differed between patients with and without MM. Research design and methods: One thousand three hundred eighty-one patients with newly diagnosed type 2
diabetes were randomized to receive either structured personal diabetes care
or routine diabetes care. Patients were followed up for 19 years in Danish
nationwide registries for the occurrence of outcomes. We analyzed the
prevalence and degree of MM based on 10 well-defined disease groups. The
effect of structured personal care in diabetes patients with and without MM
was analyzed with Cox regression models. Results: The proportion of patients with MM increased from 31.6% at diabetes diagnosis
to 80.4% after 16 years. The proportion of cardiovascular and
gastrointestinal diseases in surviving patients decreased, while, for
example, musculoskeletal, eye, and neurological diseases increased. The
effect of the intervention was not different between type 2 diabetes
patients with or without coexisting chronic disease. Conclusions: In general, the proportion of patients with MM increased after diabetes
diagnosis, but the composition of chronic disease changed during the 16
years. We found cardiovascular and musculoskeletal disease to be the most
prevalent disease groups during all 16 years of follow-up. The post hoc
analysis of the intervention showed that its effectiveness was not different
among patients who developed MM compared to those who continued to have
diabetes alone.
Collapse
Affiliation(s)
- Sandra Pouplier
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Maria Åhlander Olsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Tora Grauers Willadsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Håkon Sandholdt
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Christen Lykkegaard Andersen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Niels de Fine Olivarius
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
29
|
Berntsen G, Høyem A, Lettrem I, Ruland C, Rumpsfeld M, Gammon D. A person-centered integrated care quality framework, based on a qualitative study of patients' evaluation of care in light of chronic care ideals. BMC Health Serv Res 2018; 18:479. [PMID: 29925357 PMCID: PMC6011266 DOI: 10.1186/s12913-018-3246-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 05/29/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Person-Centered Integrated Care (PC-IC) is believed to improve outcomes and experience for persons with multiple long-term and complex conditions. No broad consensus exists regarding how to capture the patient-experienced quality of PC-IC. Most PC-IC evaluation tools focus on care events or care in general. Building on others' and our previous work, we outlined a 4-stage goal-oriented PC-IC process ideal: 1) Personalized goal setting 2) Care planning aligned with goals 3) Care delivery according to plan, and 4) Evaluation of goal attainment. We aimed to explore, apply, refine and operationalize this quality of care framework. METHODS This paper is a qualitative evaluative review of the individual Patient Pathways (iPP) experiences of 19 strategically chosen persons with multimorbidity in light of ideals for chronic care. The iPP includes all care events, addressing the persons collected health issues, organized by time. We constructed iPPs based on the electronic health record (from general practice, nursing services, and hospital) with patient follow-up interviews. The application of the framework and its refinement were parallel processes. Both were based on analysis of salient themes in the empirical material in light of the PC-IC process ideal and progressively more informed applications of themes and questions. RESULTS The informants consistently reviewed care quality by how care supported/ threatened their long-term goals. Personal goals were either implicit or identified by "What matters to you?" Informants expected care to address their long-term goals and placed responsibility for care quality and delivery at the system level. The PC-IC process framework exposed system failure in identifying long-term goals, provision of shared long-term multimorbidity care plans, monitoring of care delivery and goal evaluation. The PC-IC framework includes descriptions of ideal care, key questions and literature references for each stage of the PC-IC process. This first version of a PC-IC process framework needs further validation in other settings. CONCLUSION Gaps in care that are invisible with event-based quality of care frameworks become apparent when evaluated by a long-term goal-driven PC-IC process framework. The framework appears meaningful to persons with multimorbidity.
Collapse
Affiliation(s)
- Gro Berntsen
- Norwegian center for eHealth research, University Hospital of Northern Norway, PB. 35, 9038 Tromsø, Norway
- Department of primary care, Institute of community medicine, UIT – The Arctic University of Norway, PB 6050, Langnes, 9037 Tromsø, Norway
| | - Audhild Høyem
- Department of Integrated Care, University Hospital of Northern Norway, PB. 35, 9038 Tromsø, Norway
| | - Idar Lettrem
- General Practice Health Centre, 9050, Storsteinnes, Norway
| | - Cornelia Ruland
- Department of Integrated Care, University Hospital of Northern Norway, PB. 35, 9038 Tromsø, Norway
| | - Markus Rumpsfeld
- Department of primary care, Institute of community medicine, UIT – The Arctic University of Norway, PB 6050, Langnes, 9037 Tromsø, Norway
- Department for Internal Medicine, University Hospital of Northern Norway, PB 101, 9038 Tromsø, Norway
| | - Deede Gammon
- Norwegian center for eHealth research, University Hospital of Northern Norway, PB. 35, 9038 Tromsø, Norway
- Center for Shared Decision Making and Collaborative Care Research, Oslo University Hospital, Sogn Arena, Pb 4950 Nydalen, N-0424 Oslo, Norway
| |
Collapse
|
30
|
Willadsen TG, Siersma V, Nicolaisdóttir DR, Køster-Rasmussen R, Jarbøl DE, Reventlow S, Mercer SW, Olivarius NDF. Multimorbidity and mortality: A 15-year longitudinal registry-based nationwide Danish population study. JOURNAL OF COMORBIDITY 2018; 8:2235042X18804063. [PMID: 30364387 PMCID: PMC6194940 DOI: 10.1177/2235042x18804063] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/09/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Knowledge about prevalent and deadly combinations of multimorbidity is needed. OBJECTIVE To determine the nationwide prevalence of multimorbidity and estimate mortality for the most prevalent combinations of one to five diagnosis groups. Furthermore, to assess the excess mortality of the combination of two groups compared to the product of mortality associated with the single groups. DESIGN A prospective cohort study using Danish registries and including 3.986.209 people aged ≥18 years on 1 January, 2000. Multimorbidity was defined as having diagnoses from at least 2 of 10 diagnosis groups: lung, musculoskeletal, endocrine, mental, cancer, neurological, gastrointestinal, cardiovascular, kidney, and sensory organs. Logistic regression (odds ratios, ORs) and ratio of ORs (ROR) were used to study mortality and excess mortality. RESULTS Prevalence of multimorbidity was 7.1% in the Danish population. The most prevalent combination was the musculoskeletal-cardiovascular (0.4%), which had double the mortality (OR, 2.03) compared to persons not belonging to any of the diagnosis groups but showed no excess mortality (ROR, 0.97). The neurological-cancer combination had the highest mortality (OR, 6.35), was less prevalent (0.07%), and had no excess mortality (ROR, 0.94). Cardiovascular-lung was moderately prevalent (0.2%), had high mortality (OR, 5.75), and had excess mortality (ROR, 1.18). Endocrine-kidney had high excess mortality (ROR, 1.81) and cancer-mental had low excess mortality (ROR, 0.66). Mortality increased with the number of groups. CONCLUSIONS All combinations had increased mortality risk with some of them having up to a six-fold increased risk. Mortality increased with the number of diagnosis groups. Most combinations did not increase mortality above that expected, that is, were additive rather than synergistic.
Collapse
Affiliation(s)
- TG Willadsen
- The Research Unit for General Practice and Section of General
Practice, Institute of Public Health, University of Copenhagen, Copenhagen,
Denmark
| | - V Siersma
- The Research Unit for General Practice and Section of General
Practice, Institute of Public Health, University of Copenhagen, Copenhagen,
Denmark
| | - DR Nicolaisdóttir
- The Research Unit for General Practice and Section of General
Practice, Institute of Public Health, University of Copenhagen, Copenhagen,
Denmark
| | - R Køster-Rasmussen
- The Research Unit for General Practice and Section of General
Practice, Institute of Public Health, University of Copenhagen, Copenhagen,
Denmark
| | - DE Jarbøl
- Department of Public Health, The Research Unit of General Practice,
University of Southern Denmark, Odense, Denmark
| | - S Reventlow
- The Research Unit for General Practice and Section of General
Practice, Institute of Public Health, University of Copenhagen, Copenhagen,
Denmark
| | - SW Mercer
- General Practice and Primary Care, Institute of Health and
Wellbeing, University of Glasgow, Glasgow, Scotland
| | - N de Fine Olivarius
- The Research Unit for General Practice and Section of General
Practice, Institute of Public Health, University of Copenhagen, Copenhagen,
Denmark
| |
Collapse
|
31
|
Hansen RA, Hohmann N, Maciejewski ML, Domino ME, Ray N, Mahendraratnam N, Farley JF. Continuity of Medication Management among Adults with Schizophrenia and Comorbid Cardiometabolic Conditions. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2017; 9:13-20. [PMID: 29552104 DOI: 10.1111/jphs.12201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objectives Adults with schizophrenia and cardiometabolic conditions may be good candidates for co-management by primary care prescribers and specialists. Associated risks for discontinuity in medication management have not been well-studied. This study examines whether medication adherence, inpatient admissions, and emergency department (ED) visits vary by the number and types of prescribers seen by adults with schizophrenia and cardiometabolic conditions. Methods This study used a retrospective cohort of 4,223 adult Medicaid enrollees with schizophrenia and hypertension, hyperlipidemia, and/or diabetes from three states in 2009-2010. Logistic regression models were run on outcome variables reflecting medication adherence, ED utilization, and inpatient admissions as a function of the number and types of prescribers. Key findings Increases in number of psychiatric specialists were associated with better antipsychotic adherence, but decreasing statin adherence. Increases in number of psychiatric specialists were also associated with a higher probability of inpatient admission and ED visits, while increases in number of primary care prescribers were associated with increases in the probability of ED visits. Conclusion Greater antipsychotic adherence for adults receiving prescriptions from multiple psychiatric specialists was counteracted by lower statin adherence and greater risk of ED and inpatient utilization. This may help inform optimal care models for these complex individuals.
Collapse
Affiliation(s)
| | | | - Matthew L Maciejewski
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center
| | - Marisa E Domino
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Neepa Ray
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
- Center for Medication Optimization through Practice and Policy, UNC Eshelman School of Pharmacy
| | | | - Joel F Farley
- College of Pharmacy, University of Minnesota, Department of Pharmaceutical Care & Health Systems, Minneapolis, USA
| |
Collapse
|
32
|
Vargas I, Garcia-Subirats I, Mogollón-Pérez AS, De Paepe P, da Silva MRF, Unger JP, Aller MB, Vázquez ML. Patient perceptions of continuity of health care and associated factors. Cross-sectional study in municipalities of central Colombia and north-eastern Brazil. Health Policy Plan 2017; 32:549-562. [PMID: 28104694 DOI: 10.1093/heapol/czw168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2016] [Indexed: 12/11/2022] Open
Abstract
Despite the fragmentation of healthcare provision being considered one of the main obstacles to attaining effective health care in Latin America, very little is known about patients' perceptions. This paper analyses the level of continuity of health care perceived by users and explores influencing factors in two municipalities of Colombia and Brazil, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had suffered at least one health problem within the previous three months (2163 in Colombia; 2167 in Brazil). An adapted and validated version of the CCAENA© (Questionnaire of care continuity across levels of health care) was applied. Logistic regression models were generated to assess the relationship between perceptions of the different types of health care continuity and sociodemographic characteristics, health needs, and organizational factors. The results show lower levels of continuity across care levels in information transfer and care coherence and higher levels for the ongoing patient-doctor relationship, albeit with differences between the two countries. They also show greater consistency of doctors in the Brazilian study areas, especially in primary care. Consistency of doctors was not only positively associated with the patient-doctor ongoing relationship in the study areas of both countries, but also with information transfer and care coherence across care levels. The study area and health needs (the latter negatively for patients with poor self-rated health and positively for those with at least one chronic condition) were associated with all types of continuity of care. The influence of the sex or income varied depending on the country. The influence of the insurance scheme in the Colombian sample was not statistically significant. Both countries should implement policies to improve coordination between care levels, especially regarding information transfer and job stability for primary care doctors, both key factors to guarantee quality of care.
Collapse
Affiliation(s)
- Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, Barcelona, Spain
| | - Irene Garcia-Subirats
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, Barcelona, Spain
| | - Amparo Susana Mogollón-Pérez
- Escuela de Medicina y Ciencias de la Salud. Universidad del Rosario, Carrera 24, Número 63C-69, Bogotá, Colombia
| | - Pierre De Paepe
- The Prince Leopold Institute of Tropical Medicine, Nationalestraat 15, Antwerpen, Belgium
| | | | - Jean-Pierre Unger
- The Prince Leopold Institute of Tropical Medicine, Nationalestraat 15, Antwerpen, Belgium
| | - M B Aller
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, Barcelona, Spain
| | - María Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, Barcelona, Spain
| |
Collapse
|
33
|
Lawson C, Pati S, Green J, Messina G, Strömberg A, Nante N, Golinelli D, Verzuri A, White S, Jaarsma T, Walsh P, Lonsdale P, Kadam UT. Development of an international comorbidity education framework. NURSE EDUCATION TODAY 2017; 55:82-89. [PMID: 28535380 DOI: 10.1016/j.nedt.2017.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 04/27/2017] [Accepted: 05/08/2017] [Indexed: 06/07/2023]
Abstract
CONTEXT The increasing number of people living with multiple chronic conditions in addition to an index condition has become an international healthcare priority. Health education curricula have been developed alongside single condition frameworks in health service policy and practice and need redesigning to incorporate optimal management of multiple conditions. AIM Our aims were to evaluate current teaching and learning about comorbidity care amongst the global population of healthcare students from different disciplines and to develop an International Comorbidity Education Framework (ICEF) for incorporating comorbidity concepts into health education. METHODS We surveyed nursing, medical and pharmacy students from England, India, Italy and Sweden to evaluate their understanding of comorbidity care. A list of core comorbidity content was constructed by an international group of higher education academics and clinicians from the same disciplines, by searching current curricula and analysing clinical frameworks and the student survey data. This list was used to develop the International Comorbidity Education Framework. RESULTS The survey sample consisted of 917 students from England (42%), India (48%), Italy (8%) and Sweden (2%). The majority of students across all disciplines said that they lacked knowledge, training and confidence in comorbidity care and were unable to identify specific teaching on comorbidities. All student groups wanted further comorbidity training. The health education institution representatives found no specific references to comorbidity in current health education curricula. Current clinical frameworks were used to develop an agreed list of core comorbidity content and hence an International Comorbidity Education Framework. CONCLUSIONS Based on consultation with academics and clinicians and on student feedback we developed an International Comorbidity Education Framework to promote the integration of comorbidity concepts into current healthcare curricula.
Collapse
Affiliation(s)
- C Lawson
- Keele University, Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, UK.
| | - S Pati
- Public Health Foundation of India, Indian Institute of Public Health-Bhubaneswar, India
| | - J Green
- Keele University, Department of Nursing and Midwifery, UK
| | - G Messina
- University of Siena, Department of Public Health, Italy
| | - A Strömberg
- Linkoping University, Medical and Health Sciences, Sweden
| | - N Nante
- University of Siena, Department of Public Health, Italy
| | - D Golinelli
- University of Siena, Department of Public Health, Italy
| | - A Verzuri
- University of Siena, Department of Public Health, Italy
| | - S White
- Keele University, Department of Pharmacy, UK
| | - T Jaarsma
- Linkoping University, Social and Welfare Studies, Sweden
| | - P Walsh
- Keele University, Department of Nursing and Midwifery, UK
| | - P Lonsdale
- Keele University, Department of Nursing and Midwifery, UK
| | - U T Kadam
- Keele University, Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, UK
| |
Collapse
|
34
|
|
35
|
Mc Namara KP, Breken BD, Alzubaidi HT, Bell JS, Dunbar JA, Walker C, Hernan A. Health professional perspectives on the management of multimorbidity and polypharmacy for older patients in Australia. Age Ageing 2017; 46:291-299. [PMID: 27836856 DOI: 10.1093/ageing/afw200] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 09/28/2016] [Indexed: 12/31/2022] Open
Abstract
Background delivering appropriate care for patients with multimorbidity and polypharmacy is increasingly challenging. Challenges for individual healthcare professions are known, but only little is known about overall healthcare team implementation of best practice for these patients. Objective to explore current approaches to multimorbidity management, and perceived barriers and enablers to deliver appropriate medications management for community-dwelling patients with multimorbidity and polypharmacy, from a broad range of healthcare professional (HCP) perspectives in Australia. Methods this qualitative study used semi-structured interviews to gain in-depth understanding of HCPs' perspectives on the management of multimorbidity and polypharmacy. The interview guide was based on established principles for the management of multimorbidity in older patients. HCPs in rural and metropolitan Victoria and South Australia were purposefully selected to obtain a maximum variation sample. Twenty-six HCPs, from relevant medical, dentistry, nursing, pharmacy and allied health backgrounds, were interviewed between October 2013 and February 2014. Fourteen were prescribers and 12 practiced in primary care. Interviews were digitally audio-taped, transcribed verbatim and analysed using a constant comparison approach. Results most participants did not routinely use structured approaches to incorporate patients' preferences in clinical decision-making, address conflicting prescriber advice, assess patients' adherence to treatment plans or seek to optimise care plans. Most HCPs were either unaware of medical decision aids and measurements tools to support these processes or disregarded them as not being user-friendly. Challenges with coordination and continuity of care, pressures of workload and poorly defined individual responsibilities for care, all contributed to participants' avoiding ownership of multimorbidity management. Potential facilitators of improved care related to improved culture, implementation of electronic health records, greater engagement of pharmacists, nurses and patients, families in care provision, and the use of care coordinators. Conclusion extensive shortcomings exist in team-based care for the management of multimorbidity. Delegating coordination and review responsibilities to specified HCPs may support improved overall care.
Collapse
Affiliation(s)
- Kevin Peter Mc Namara
- Deakin Rural Health, School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia
- School of Health and Social Development, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | | | - Hamzah Tariq Alzubaidi
- Sharjah Institute for Medical Research and College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - James A Dunbar
- Faculty of Health, Deakin University,Burwood, Victoria, Australia
| | | | - Andrea Hernan
- Deakin Rural Health, Deakin University, Warrnambool, Victoria, Australia
| |
Collapse
|
36
|
Duthie K, Strohschein FJ, Loiselle CG. Living with cancer and other chronic conditions: Patients' perceptions of their healthcare experience. Can Oncol Nurs J 2017; 27:43-48. [PMID: 31148776 DOI: 10.5737/236880762714348] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Multimorbidity is known to contribute to the complexity of care for patients with cancer. This qualitative study begins to explore cancer patients' experience with multimodal treatments, that is, treatments for multiple chronic conditions, as well as issues related to navigating the healthcare system. Participants (n=10) were recruited from an ambulatory cancer centre in a large, university-affiliated hospital in Montreal, Quebec. Important challenges were reported in terms of striking a fine balance between acute health needs and underlying ongoing chronic condition(s), experiencing unforeseen treatment complications, and negotiating silos across medical specialties. Participants also wished to be better known by the healthcare team. When reporting a positive care coordination experience, participants often attributed it to the intervention by a nurse navigator. Lastly, participants expected a more personalized care approach and would have liked to be included in multidisciplinary board meetings. Study results underscore the impetus to better integrate care across diseases, enhance person-centred care, and support patients who strive to balance competing needs when facing multimorbidity.
Collapse
Affiliation(s)
- Kia Duthie
- Staff Nurse, BC Cancer Agency, 401 - 122, Walter Hardwick Ave, Vancouver, BC V5Y 0C9, 514-726-3902;
| | - Fay J Strohschein
- Ingram School of Nursing, McGill University, Nursing Counsellor, Segal Cancer Centre, Jewish General Hospital, 3755 Côte-Sainte-Catherine, Rd, Pav. H-304.4, Montreal, QC H3T 1E2, 514-340-8222 ext. 3864;
| | - Carmen G Loiselle
- Associate Professor, Department of Oncology and Ingram School of Nursing, McGill University, Co-Director (Academic) and Senior Investigator, Segal Cancer Centre, Jewish General Hospital, 3755 Côte-Sainte-Catherine Rd, Pav. E-748, Montreal, QC H3T 1E2, 514-340-8222 ext. 3940;
| |
Collapse
|
37
|
Patients with multimorbidity and their experiences with the healthcare process: a scoping review. JOURNAL OF COMORBIDITY 2017; 7:11-21. [PMID: 29090185 PMCID: PMC5556434 DOI: 10.15256/joc.2017.7.97] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/09/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND The number of patients with multimorbidity (two or more conditions) is increasing. Observational research has shown that having multiple health problems is associated with poorer outcomes in terms of health, quality of care, and costs. Thus, it is imperative to understand how patients with multimorbidity experience their healthcare process. Insight into patient experiences can be used to tailor healthcare provision specifically to the needs of patients with multimorbidity. OBJECTIVE To synthesize self-reported experiences with the healthcare process of patients with multimorbidity, and identify overarching themes. DESIGN A scoping literature review that evaluates both qualitative and quantitative studies published in PubMed, Embase, MEDLINE, and PsycINFO. No restrictions were applied to healthcare setting or year of publication. Studies were included if they reported experiences with the healthcare process of patients with multimorbidity. Patient experiences were extracted and subjected to thematic analysis (interpretative), which revealed overarching themes by mapping their interrelatedness. RESULTS Overall, 22 empirical studies reported experiences of patients with multimorbidity. Thematic analysis identified 12 themes within these studies. The key overarching theme was the experience of a lack of holistic care. Patients also experienced insufficient guidance from healthcare providers. Patients also perceived system-related issues such as problems stemming from poor professional-to-professional communication. CONCLUSIONS Patients with multimorbidity experience a range of system- and professional-related issues with healthcare delivery. This overview illustrates the diversity of aspects that should be considered in designing healthcare services for patients with multimorbidity.
Collapse
|
38
|
Jeffs L, Kuluski K, Law M, Saragosa M, Espin S, Ferris E, Merkley J, Dusek B, Kastner M, Bell CM. Identifying Effective Nurse-Led Care Transition Interventions for Older Adults With Complex Needs Using a Structured Expert Panel. Worldviews Evid Based Nurs 2017; 14:136-144. [DOI: 10.1111/wvn.12196] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Lianne Jeffs
- St. Michael's Hospital Volunteer Association Chair in Nursing Research Scientist, Keenan Research Centre of the Li Ka Shing Knowledge Institute St. Michael's Hospital, Associate Professor, Lawrence S. Bloomberg Faculty of Nursing and Institute of Health, Policy, Management and Evaluation; University of Toronto; Toronto ON Canada
| | - Kerry Kuluski
- Research Scientist, Sinai Health System; Lunenfeld-Tanenbaum Research Institute; Toronto ON Canada
| | - Madelyn Law
- Associate Professor; Brock University; St. Catherines ON Canada
| | | | - Sherry Espin
- Associate Professor; Ryerson University; Toronto ON Canada
| | - Ella Ferris
- Former Executive Vice-President-Programs; Chief Nursing Executive, and Chief Health Disciplines Executive; St. Michael's Hospital Toronto ON Canada
| | - Jane Merkley
- Executive Vice President Patient Care; Quality and Chief Nurse Executive Sinai Health System; Toronto ON Canada
| | - Brenda Dusek
- Former Program Manager; Registered Nurses’ Association of Ontario; Toronto ON Canada
| | - Monika Kastner
- Scientist, Keenan Research Centre of the Li Ka Shing Knowledge Institute; St. Michael's Hospital; Toronto ON Canada
| | - Chaim M. Bell
- Clinician Scientist; Sinai Health System; Toronto ON Canada
| |
Collapse
|
39
|
Steele Gray C, Wodchis WP, Upshur R, Cott C, McKinstry B, Mercer S, Palen TE, Ramsay T, Thavorn K. Supporting Goal-Oriented Primary Health Care for Seniors with Complex Care Needs Using Mobile Technology: Evaluation and Implementation of the Health System Performance Research Network, Bridgepoint Electronic Patient Reported Outcome Tool. JMIR Res Protoc 2016; 5:e126. [PMID: 27341765 PMCID: PMC4938886 DOI: 10.2196/resprot.5756] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Older adults experiencing multiple chronic illnesses are at high risk of hospitalization and health decline if they are unable to manage the significant challenges posed by their health conditions. Goal-oriented care approaches can provide better care for these complex patients, but clinicians find the process of ascertaining goals "too complex and too-time consuming," and goals are often not agreed upon between complex patients and their providers. The electronic patient reported outcomes (ePRO) mobile app and portal offers an innovative approach to creating and monitoring goal-oriented patient-care plans to improve patient self-management and shared decision-making between patients and health care providers. The ePRO tool also supports proactive patient monitoring by the patient, caregiver(s), and health care provider. It was developed with and for older adults with complex care needs as a means to improve their quality of life. OBJECTIVE Our proposed project will evaluate the use, effectiveness, and value for money of the ePRO tool in a 12-month multicenter, randomized controlled trial in Ontario; targeting individuals 65 or over with two or more chronic conditions that require frequent health care visits to manage their health conditions. METHODS Intervention groups using the ePRO tool will be compared with control groups on measures of quality of life, patient experience, and cost-effectiveness. We will also evaluate the implementation of the tool. RESULTS The proposed project presented in this paper will be funded through the Canadian Institute for Health Research (CIHR) eHealth Innovation Partnerships Program (eHIPP) program (CIHR-348362). The expected completion date of the study is November, 2019. CONCLUSIONS We anticipate our program of work will support improved quality of life and patient self-management, improved patient-centered primary care delivery, and will encourage the adoption of goal-oriented care approaches across primary health care systems. We have partnered with family health teams and quality improvement organizations in Ontario to ensure that our research is practical and that findings are shared widely. We will work with our established international network to develop an implementation framework to support continued adaptation and adoption across Canada and internationally.
Collapse
Affiliation(s)
- Carolyn Steele Gray
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Willadsen TG, Bebe A, Køster-Rasmussen R, Jarbøl DE, Guassora AD, Waldorff FB, Reventlow S, Olivarius NDF. The role of diseases, risk factors and symptoms in the definition of multimorbidity - a systematic review. Scand J Prim Health Care 2016; 34:112-21. [PMID: 26954365 PMCID: PMC4977932 DOI: 10.3109/02813432.2016.1153242] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 01/30/2016] [Indexed: 01/23/2023] Open
Abstract
UNLABELLED Objective is to explore how multimorbidity is defined in the scientific literature, with a focus on the roles of diseases, risk factors, and symptoms in the definitions. DESIGN Systematic review. METHODS MEDLINE (PubMed), Embase, and The Cochrane Library were searched for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diagnoses, risk factors, and symptoms. We reviewed 163 articles. In 61 articles (37%), the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions, with diabetes as the most frequent. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways. The definition of multimorbidity is heterogeneous and risk factors are more often included than symptoms. The severity of conditions is seldom included. Since the number of people living with multimorbidity is increasing there is a need to develop a concept of multimorbidity that is more useful in daily clinical work. Key points The increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice. Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4-147 different conditions. Diseases are included in all definitions of multimorbidity. Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included.
Collapse
Affiliation(s)
- Tora Grauers Willadsen
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Lolland Falster Population Study (LOFUS), Nykøbing F, Denmark;
| | - Anna Bebe
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Lolland Falster Population Study (LOFUS), Nykøbing F, Denmark;
| | - Rasmus Køster-Rasmussen
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
| | - Dorte Ejg Jarbøl
- The Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ann Dorrit Guassora
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
| | - Frans Boch Waldorff
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Susanne Reventlow
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Lolland Falster Population Study (LOFUS), Nykøbing F, Denmark;
| | - Niels de Fine Olivarius
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Lolland Falster Population Study (LOFUS), Nykøbing F, Denmark;
| |
Collapse
|
41
|
Malik N, Alvaro C, Kuluski K, Wilkinson AJ. Measuring patient satisfaction in complex continuing care/rehabilitation care. Int J Health Care Qual Assur 2016; 29:324-36. [DOI: 10.1108/ijhcqa-07-2015-0084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
To develop a psychometrically validated survey to assess satisfaction in complex continuing care/rehabilitation patients.
Design/methodology/approach
A paper or computer-based survey was administered to 252 complex continuing care/ rehabilitation patients (i.e., post-acute hospital care setting for people who require ongoing care before returning home) across two hospitals in Toronto, Ontario, Canada.
Findings
Using factor analysis, five domains were identified with loadings above 0.4 for all but one item. Behavioral intention and information/communication showed the lowest patient satisfaction, while patient centredness the highest. Each domain correlated positively and significantly predicted overall satisfaction, with quality and safety showing the strongest predictive power and the healing environment the weakest. Gender made a significant contribution to predicting overall satisfaction, but age did not.
Research limitations/implications
Results provide evidence of the survey’s psychometric properties. Owing to a small sample, supplemental testing with a larger patient-group is required to confirm the five-factor structure and to assess test-retest reliability.
Originality/value
Improving the health system requires integrating patient perspectives. The patient experience, however, will vary depending on the population being served. This is the first psychometrically validated survey specific to a smaller speciality patient group receiving care at a complex continuing care/rehabilitation facility in Canada.
Collapse
|
42
|
Linnenkamp R, Drenkard K. Coordinating Care: Shifts in Perspective. Nurs Adm Q 2016; 40:122-129. [PMID: 26938184 DOI: 10.1097/naq.0000000000000152] [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: 06/05/2023]
Abstract
Effective coordination of care has consistently been a challenge for clinicians, care providers, and systems of health care. The health care system is inherently fraught with unorganized and disparate parts including multiple points of entry. A review of the current issues and the leadership implications is explored in this article with an emphasis on patients becoming more actively engaged in managing their care journey across the continuum. A case study of a primary care clinic in Annapolis, Maryland, is described to illustrate the application of evidence-based leadership skills, knowledge, and a framework to transform health care to more effectively engage patients in their care. As the constant on the continuum of care, the engaged patient is in the unique position to manage coordination, thus ensuring continuity.
Collapse
Affiliation(s)
- Rita Linnenkamp
- Anne Arundel Medical Center, Annapolis, Maryland (Ms Linnenkamp); and GetWellNetwork, Bethesda, Maryland (Dr Drenkard)
| | | |
Collapse
|
43
|
How Does Sex Influence Multimorbidity? Secondary Analysis of a Large Nationally Representative Dataset. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:391. [PMID: 27043599 PMCID: PMC4847053 DOI: 10.3390/ijerph13040391] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/11/2016] [Accepted: 03/23/2016] [Indexed: 11/24/2022]
Abstract
Multimorbidity increases with age and is generally more common in women, but little is known about sex effects on the “typology” of multimorbidity. We have characterized multimorbidity in a large nationally representative primary care dataset in terms of sex in ten year age groups from 25 years to 75 years and over, in a cross-sectional analysis of multimorbidity type (physical-only, mental-only, mixed physical and mental; and commonest conditions) for 1,272,685 adults in Scotland. Our results show that women had more multimorbidity overall in every age group, which was most pronounced in the 45–54 years age group (women 26.5% vs. men 19.6%; difference 6.9 (95% CI 6.5 to 7.2). From the age of 45, physical-only multimorbidity was consistently more common in men, and physical-mental multimorbidity more common in women. The biggest difference in physical-mental multimorbidity was found in the 75 years and over group (women 30.9% vs. men 21.2%; difference 9.7 (95% CI 9.1 to 10.2). The commonest condition in women was depression until the age of 55 years, thereafter hypertension. In men, drugs misuse had the highest prevalence in those aged 25–34 years, depression for those aged 35–44 years, and hypertension for 45 years and over. Depression, pain, irritable bowel syndrome and thyroid disorders were more common in women than men across all age groups. We conclude that the higher overall prevalence of multimorbidity in women is mainly due to more mixed physical and mental health problems. The marked difference between the sexes over 75 years especially warrants further investigation.
Collapse
|
44
|
Adriaanse MC, Drewes HW, van der Heide I, Struijs JN, Baan CA. The impact of comorbid chronic conditions on quality of life in type 2 diabetes patients. Qual Life Res 2015; 25:175-82. [PMID: 26267523 PMCID: PMC4706581 DOI: 10.1007/s11136-015-1061-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2015] [Indexed: 12/13/2022]
Abstract
Objective To study the prevalence, impact and dose–response relationship of comorbid chronic conditions on quality of life of type 2 diabetes patients. Research design and methods Cross-sectional data of 1676 type 2 diabetes patients, aged 31–96 years, and treated in primary care, were analyzed. Quality of life (QoL) was measured using the mental component summary (MCS) and the physical component summary (PCS) scores of the Short Form-12. Diagnosis of type 2 diabetes was obtained from medical records and comorbidities from self-reports. Results Only 361 (21.5 %) of the patients reported no comorbidities. Diabetes patients with comorbidities showed significantly lower mean difference in PCS [−8.5; 95 % confidence interval (CI) −9.8 to −7.3] and MCS scores (−1.9; 95 % CI −3.0 to −0.9), compared to diabetes patients without. Additional adjustments did not substantially change these associations. Both MCS and PCS scores decrease significantly with the number of comorbid conditions, yet most pronounced regarding physical QoL. Comorbidities that reduced physical QoL most significantly were retinopathy, heart diseases, atherosclerosis in abdomen or legs, lung diseases, incontinence, back, neck and shoulder disorder, osteoarthritis and chronic rheumatoid arthritis, using the backwards stepwise regression procedure. Conclusion Comorbidities are highly prevalent among type 2 diabetes patients and have a negative impact on the patient’s QoL. A strong dose–response relationship between comorbidities and physical QoL was found. Reduced physical QoL is mainly determined by musculoskeletal and cardiovascular disorders.
Collapse
Affiliation(s)
- Marcel C Adriaanse
- Department of Health Sciences and EMGO Institute for Health and Care Research, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
| | - Hanneke W Drewes
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Iris van der Heide
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Jeroen N Struijs
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Caroline A Baan
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| |
Collapse
|
45
|
Ricci-Cabello I, Violán C, Foguet-Boreu Q, Mounce LTA, Valderas JM. Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review. Eur J Gen Pract 2015; 21:192-202. [PMID: 26232238 DOI: 10.3109/13814788.2015.1046046] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing healthcare systems globally. It potentially threatens the coordination, continuity and safety of care. In this paper, we report the results of a scoping review examining the impact of multi-morbidity on the quality of healthcare. We used its results as a basis for a discussion of the challenges that research in this area is currently facing. In addition, we discuss its implications for health policy and clinical practice. The review identified 37 studies focussing on multi-morbidity but using conceptually different approaches. Studies focusing on 'comorbidity' (i.e. the 'index disease' approach) suggested that quality may be enhanced in the presence of synergistic conditions, and impaired by antagonistic or neutral conditions. Studies on 'multi-morbidity' (i.e. multiplicity of problems) and 'morbidity burden' (i.e. the total severity of conditions) suggested that increasing number of conditions and severity may be associated with better quality of healthcare when measured by process or intermediate outcome indicators, but with worse quality when patient-centred measures are used. However, issues related to the conceptualization and measurement of multi-morbidity (inconsistent across studies) and of healthcare quality (restricted to evaluations for each separate condition without incorporating considerations about multi-morbidity itself and its implications for management) compromised the generalizability of these observations. Until these issues are addressed and robust evidence becomes available, clinicians should apply minimally invasive and patient-centred medicine when delivering care for clinically complex patients. Health systems should focus on enhancing primary care centred coordination and continuity of care.
Collapse
Affiliation(s)
- Ignacio Ricci-Cabello
- a Nuffield Department of Primary Care Health Sciences , University of Oxford , Oxford , UK
| | - Concepció Violán
- b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.,c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain
| | - Quinti Foguet-Boreu
- b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.,c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain.,d Department of Medical Sciences , School of Medicine, University of Girona , Girona , Spain
| | - Luke T A Mounce
- e Institute for Health Research, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter , Exeter , UK
| | - Jose M Valderas
- a Nuffield Department of Primary Care Health Sciences , University of Oxford , Oxford , UK.,b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.,c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain.,e Institute for Health Research, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter , Exeter , UK.,f CIBER en Epidemiologia y Salud P blica (CIBERESP) , Barcelona , Spain
| |
Collapse
|
46
|
The performance of integrated health care networks in continuity of care: a qualitative multiple case study of COPD patients. Int J Integr Care 2015. [PMID: 26213524 PMCID: PMC4512888 DOI: 10.5334/ijic.1527] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Integrated health care networks (IHN) are promoted in numerous countries as a response to fragmented care delivery by providing a coordinated continuum of services to a defined population. However, evidence on their effectiveness and outcome is scarce, particularly considering continuity across levels of care; that is the patient's experience of connected and coherent care received from professionals of the different care levels over time. The objective was to analyse the chronic obstructive pulmonary disease (COPD) patients’ perceptions of continuity of clinical management and information across care levels and continuity of relation in IHN of the public health care system of Catalonia. Methods A qualitative multiple case study was conducted, where the cases are COPD patients. A theoretical sample was selected in two stages: (1) study contexts: IHN and (2) study cases consisting of COPD patients. Data were collected by means of individual, semi-structured interviews to the patients, their general practitioners and pulmonologists and review of records. A thematic content analysis segmented by IHN and cases with a triangulation of sources and analysists was carried out. Results COPD patients of all networks perceived that continuity of clinical management was existent due to clear distribution of roles for COPD care across levels, rapid access to care during exacerbations and referrals to secondary care when needed; nevertheless, patients of some networks highlighted too long waiting times to non-urgent secondary care. Physicians generally agreed with patients, however, also indicated unclear distribution of roles, some inadequate referrals and long waiting times to primary care in some networks. Concerning continuity of information, patients across networks considered that their clinical information was transferred across levels via computer and that physicians also used informal communication mechanisms (e-mail, telephone); whereas physicians highlighted numerous problems of the information system, thus the need to use informal communication channels. Finally, regarding continuity of relation, patients of some networks pointed out high turnover of personnel - being frequently seen by locum doctors or assigned to new physicians - which hindered the development of a trusting relationship. Conclusion Study findings suggest a generally perceived adequate performance of IHN in continuity of care but also the existence of a series of difficulties related to all continuity types. Results can provide opportunities to improving the care process of COPD patients but also of patients with other conditions who receive care across the primary and secondary care level.
Collapse
|
47
|
Hujala A, Rijken M, Laulainen S, Taskinen H, Rissanen S. People with multimorbidity: forgotten outsiders or dynamic self-managers? J Health Organ Manag 2015; 28:696-712. [PMID: 25735425 DOI: 10.1108/jhom-10-2013-0221] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE The purpose of this paper is to draw attention to the discursive construction of multimorbidity. The study illustrates how the social reality of multimorbidity and the agency of patients are discursively constructed in scientific articles addressing care for people with multiple chronic conditions. DESIGN/METHODOLOGY/APPROACH The study is based on the postmodern assumptions about the power of talk and language in the construction of reality. Totally 20, scientific articles were analysed by critically oriented discourse analysis. The interpretations of the findings draw on the agency theories and principals of critical management studies. FINDINGS Four discourses were identified: medical, technical, collaborative and individual. The individual discourse challenges patients to become self-managers of their health. It may, however, go too far in the pursuit of patients' active agency. The potential restrictions and consequences of a "business-like" orientation must be paid careful attention when dealing with patients with multimorbidity. RESEARCH LIMITATIONS/IMPLICATIONS The data consisted solely of scientific texts and findings therefore serve as limited illustrations of the discursive construction of multimorbidity. In future, research focusing for example on political documents and practice talk of professionals and patients is needed. Social implications - The findings highlight the power of talk and importance of ethical considerations in the development of care for challenging patient groups. ORIGINALITY/VALUE By identifying the prevailing discourses the study attempts to cast doubt on the taken-for-granted understandings about the agency of patients with multimorbidity.
Collapse
|
48
|
Care coordination of multimorbidity: a scoping study. JOURNAL OF COMORBIDITY 2015; 5:15-28. [PMID: 29090157 PMCID: PMC5636034 DOI: 10.15256/joc.2015.5.39] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 03/05/2015] [Indexed: 11/05/2022]
Abstract
BACKGROUND A key challenge in healthcare systems worldwide is the large number of patients who suffer from multimorbidity; despite this, most systems are organized within a single-disease framework. OBJECTIVE The present study addresses two issues: the characteristics and preconditions of care coordination for patients with multimorbidity; and the factors that promote or inhibit care coordination at the levels of provider organizations and healthcare professionals. DESIGN The analysis is based on a scoping study, which combines a systematic literature search with a qualitative thematic analysis. The search was conducted in November 2013 and included the PubMed, CINAHL, and Web of Science databases, as well as the Cochrane Library, websites of relevant organizations and a hand-search of reference lists. The analysis included studies with a wide range of designs, from industrialized countries, in English, German and the Scandinavian languages, which focused on both multimorbidity/comorbidity and coordination of integrated care. RESULTS The analysis included 47 of the 226 identified studies. The central theme emerging was complexity. This related to both specific medical conditions of patients with multimorbidity (case complexity) and the organization of care delivery at the levels of provider organizations and healthcare professionals (care complexity). CONCLUSIONS In terms of how to approach care coordination, one approach is to reduce complexity and the other is to embrace complexity. Either way, future research must take a more explicit stance on complexity and also gain a better understanding of the role of professionals as a prerequisite for the development of new care coordination interventions.
Collapse
|
49
|
Yardley S, Cottrell E, Rees E, Protheroe J. Modelling successful primary care for multimorbidity: a realist synthesis of successes and failures in concurrent learning and healthcare delivery. BMC FAMILY PRACTICE 2015; 16:23. [PMID: 25886592 PMCID: PMC4343192 DOI: 10.1186/s12875-015-0234-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/29/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND People are increasingly living for longer with multimorbidity. Medical education and healthcare delivery must be re-orientated to meet the societal and individual patient needs that multimorbidity confers. The impact of multimorbidity on the educational needs of doctors is little understood. There has been little critique of how learning alongside healthcare provision is negotiated by patients, general practitioners and trainee doctors. This study asked 'what is known about how and why concurrent healthcare delivery and professional experiential learning interact to generate outcomes, valued by patients, general practitioners and trainees, for patients with multimorbidity in primary care?' METHODS This realist synthesis is reported using RAMESES standards. Relationship-centred negotiation of needs-based learning and care was the primary outcome of interest. Healthcare, social science and educational literature were sought as evidence. Data extraction focused on context, mechanism and outcome configurations within studies and on data which might assist understanding and explain; i) these configurations; ii) the relationships between them and; iii) their role and place in evolving programme theories arising from data synthesis. Mind-mapping software and team meetings were used to aid interpretative analysis. RESULTS The final synthesis included 141 papers of which 34 contained models for workplace-based experiential learning and/or patient care. Models of experiential learning for practitioners and for patient engagement were congruent, frequently referencing theories of transformation and socio-cultural processes as mechanisms for improving clinical care. Key issues included the perceived impossibility of reconciling personalised concepts of success with measurability of clinical markers or adherence to guidelines, and the need for greater recognition of social dynamics between patients, GPs and trainees including the complexities of shared responsibilities. A model for considering the implications of concurrency for learning and healthcare delivery in the context of multimorbidity in primary care is proposed and supporting evidence is presented. CONCLUSIONS This study is novel in considering empirical evidence from patients, GPs and trainees engaged in concurrent learning and healthcare delivery. The findings should inform future interventions designed to produce a medical workforce equipped to provide multimorbidity care. TRIAL REGISTRATION PROSPERO International prospective register of systematic reviews CRD42013003862.
Collapse
Affiliation(s)
- Sarah Yardley
- Primary Care and Health Sciences, Keele University, Keele, Staffs, ST5 5BG, UK.
| | - Elizabeth Cottrell
- Primary Care and Health Sciences, Keele University, Keele, Staffs, ST5 5BG, UK.
| | - Eliot Rees
- Primary Care and Health Sciences, Keele University, Keele, Staffs, ST5 5BG, UK.
| | - Joanne Protheroe
- Primary Care and Health Sciences, Keele University, Keele, Staffs, ST5 5BG, UK.
| |
Collapse
|
50
|
Steele Gray C, Miller D, Kuluski K, Cott C. Tying eHealth Tools to Patient Needs: Exploring the Use of eHealth for Community-Dwelling Patients With Complex Chronic Disease and Disability. JMIR Res Protoc 2014; 3:e67. [PMID: 25428028 PMCID: PMC4260075 DOI: 10.2196/resprot.3500] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 09/30/2014] [Accepted: 10/19/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Health policy makers have recently shifted attention towards examining high users of health care, in particular patients with complex chronic disease and disability (CCDD) characterized as having multimorbidities and care needs that require ongoing use of services. The adoption of eHealth technologies may be a key strategy in supporting and providing care for these patients; however, these technologies need to address the specific needs of patients with CCDD. This paper describes the first phase of a multiphased patient-centered research project aimed at developing eHealth technology for patients with CCDD. OBJECTIVE As part of the development of new eHealth technologies to support patients with CCDD in primary care settings, we sought to determine the perceived needs of these patients with respect to (1) the kinds of health and health service issues that are important to them, (2) the information that should be collected and how it could be collected in order to help meet their needs, and (3) their views on the challenges/barriers to using eHealth mobile apps to collect the information. METHODS Focus groups were conducted with community-dwelling patients with CCDD and caregivers. An interpretive description research design was used to identify the perceived needs of participants and the information sharing and eHealth technologies that could support those needs. Analysis was conducted concurrently with data collection. Coding of transcripts from four focus groups was conducted by 3 authors. QSR NVivo 10 software was used to manage coding. RESULTS There were 14 total participants in the focus groups. The average age of participants was 64.4 years; 9 participants were female, and 11 were born in Canada. Participants identified a need for open two-way communication and dialogue between themselves and their providers, and better information sharing between providers in order to support continuity and coordination of care. Access issues were mainly around wait times for appointments, challenges with transportation, and costs. A visual depiction of these perceived needs and their relation to each other is included as part of the discussion, which will be used to guide development of our eHealth technologies. Participants recognized the potential for eHealth technologies to support and improve their care but also expressed common concerns regarding their adoption. Specifically, they mentioned privacy and data security, accessibility, the loss of necessary visits, increased social isolation, provider burden, downloading responsibility onto patients for care management, entry errors, training requirements, and potentially confusing interfaces. CONCLUSIONS From the perspective of our participants, there is a significant potential for eHealth tools to support patients with CCDD in community and primary care settings, but we need to be wary of the potential downfalls of adopting eHealth technologies and pay special attention to patient-identified needs and concerns. eHealth tools that support ongoing patient-provider interaction, patient self-management (such as telemonitoring), and provider-provider interactions (through electronic health record integration) could be of most benefit to patients similar to those in our study.
Collapse
Affiliation(s)
- Carolyn Steele Gray
- Bridgepoint Collaboratory for Research and Innovation, Bridgepoint Active Healthcare, Toronto, ON, Canada.
| | | | | | | |
Collapse
|