Initial validation of an instrument to identify barriers to self-management for persons with co-morbidities

The association among cancer patients' collaboration with their healthcare providers, self-management and well-being during radiotherapy: An observational, cross-sectional survey

OBJECTIVES

Patients adapt to cancer through self-management, which requires collaboration between patients and their healthcare providers. We aimed to describe patterns of patient-provider collaboration during radiotherapy and examine associations among patient-provider collaboration, self-management and well-being.

METHODS

An observational, cross-sectional study was conducted at a cancer centre in the province of Ontario, Canada. Cancer patients (N = 130) completed a one-time questionnaire during their radiotherapy. The questionnaire assessed three variables: collaboration with healthcare providers, self-management and well-being. Patterns of collaboration were analysed using descriptive statistics. Associations among study variables were assessed through structural equation modelling (SEM). Separate models were tested for patient-nurse and patient-oncologist collaboration.

RESULTS

Participants reported greater collaboration with oncologists than with nurses or radiation therapists. Most participants reported no collaboration with other providers within healthcare teams (e.g. social workers, dietitians). SEM revealed different patterns for the patient-nurse and patient-oncologist collaboration models, where collaboration predicted one self-management aspect, and both physical and mental well-being.

CONCLUSION

During radiotherapy, patients collaborated mainly with doctors, nurses and radiation therapists. Collaborative relationships between patients and providers may enhance patient outcomes by fostering their self-management skills. Initiatives to strengthen patient-provider relationships and support self-management should be developed and applied to interprofessional-cancer-care teams.

IMPACT

This is the first known study to empirically support the links among patient-provider collaboration, self-management and patient outcomes. The study results can enhance practice, research and education.

Effect of multimorbidity on health service utilisation and health care experiences

INTRODUCTION Multimorbidity, the co-existence of two or more long-term conditions, is associated with poor quality of life, high health care costs and contributes to ethnic health inequality in New Zealand (NZ). Health care delivery remains largely focused on management of single diseases, creating major challenges for patients and clinicians. AIM To understand the experiences of people with multimorbidity in the NZ health care system. METHODS A questionnaire was sent to 758 people with multimorbidity from two primary health care organisations (PHOs). Outcomes were compared to general population estimates from the NZ Health Survey. RESULTS Participants (n = 234, 31% response rate) reported that their general practitioners (GPs) respected their opinions, involved them in decision-making and knew their medical history well. The main barriers to effective care were short GP appointments, availability and affordability of primary and secondary health care, and poor communication between clinicians. Access issues were higher than for the general population. DISCUSSION Participants generally had very positive opinions of primary care and their GP, but encountered structural issues with the health system that created barriers to effective care. These results support the value of ongoing changes to primary care models, with a focus on patient-centred care to address access and care coordination.

A systematic review of dimensions evaluating patient experience in chronic illness

Background

Living with a chronic disease often means experiencing chronic treatments and regular multidisciplinary monitoring as well as a profound life-changing experience which may impact all aspects of a patients life. The patient experience of chronic disease is frequently assessed by patient reported measures (PRMs) which incorporate patients perspectives to better understand how illness, treatment and care impact the entirety of a patient’s life. The purpose of this review was to collect and review different kinds of available PRM instruments validated for chronic patients, to produce an inventory of explored concepts in these questionnaires and to identify and classify all dimensions assessing chronic patients experience.

Methods

A systematic review of PRM instruments validated for chronic patients was conducted from three databases (Medline, the Cochrane library, and Psycinfo). Articles were selected after a double reading and questionnaires were classified according to their targeted concept. Then, all dimensions of the questionnaires were clustered into different categories.

Results

107 primary validation studies of PRM questionnaires were selected. Five kinds of instruments were recorded: 1) Questionnaires assessing health related quality of life or quality of life; 2) Instruments focusing on symptoms and functional status; 3) Instruments exploring patients’ feelings and attitude about illness; 4) Questionnaires related to patients’ experience of treatment or healthcare; 5) Instruments assessing patients attitudes about treatment or healthcare. Twelve categories of dimensions were obtained from these instruments.

Conclusions

This review provided an overview of some of the dimensions used to explore chronic patient experience. A large PRM diversity exists and none of the reviewed and selected questionnaires covered all identified categories of dimensions of patient experience of chronic disease. Furthermore, the definition of explored concepts varies widely among researchers and complex concepts often lack a clear definition in the reviewed articles. Before attempting to measure chronic patient experience, researchers should construct appropriate instruments focusing on well-defined concepts and dimensions encompassing patient’s personal experience, attitude and adaptation to illness, treatment or healthcare.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1084-2) contains supplementary material, which is available to authorized users.

Pill for this and a pill for that: A cross-sectional survey of use and understanding of medication among adults with multimorbidity

OBJECTIVE

To understand the challenges managing medication use and knowledge of people living with multimorbidity.

METHODS

A cross-sectional survey of 234 adults with multimorbidity, identified using retrospective hospital discharge data. Participants were recruited from two primary health organisations in New Zealand.

RESULTS

Three quarters of participants (75%) were prescribed four or more medications, and one in four (27%) were prescribed eight or more medications. Participants reported knowing what their medications were for (88%, 95% CI 81.4-93.8) and when to take them (99%, 95% CI 97.5-99.9). However, over a fifth (22%, 95% CI 13.7-30.4) reported some problems managing multiple medications, and 40% (95% CI 30.2-50.2) reported a problem with side effects.

CONCLUSION

The results highlight the need to consider how prescribing can be adapted for people with multimorbidity and move beyond the application of multiple disease-specific guidelines.

Development of a Self Report Stress Scale Using Item Response Theory-I: Item Selection, Formation of Factor Structure and Examination of Its Psychometric Properties

INTRODUCTION

Due to the absence of Turkish psychometric devices assessing stress, in the present study it was aimed to develop a stress scale, and examine its basic psychometric properties.

METHODS

Current study included two processes, formation of item pool and examination of psychometric properties of the selected items through three studies. In the first study, 611 individuals aged between 18 and 77 responded to 130 selected items. In the second study, 2223 individuals aged between 18 and 68 responded to 80 items. In the third study, 1969 individuals aged between 18 and 79 responded to the final form of 36 items. Further, in study 3 for criterion related validity 163 individuals completed the Coopersmith Self-Esteem Inventory, 113 individuals completed the Beck Anxiety Inventory, 104 individuals completed the Hospital Anxiety and Depression Scale, 107 individuals completed the Beck Depression Inventory, and 265 individuals completed the Perceived Stress Scale. Moreover, in the investigation of test-retest reliability, 119 individuals took the final form of the test after 2 weeks, and 111 individuals took the final form of the test after 3 weeks.

RESULTS

In the first study, out of 130 items, 54 that showed item-total score correlations below 0.30 were excluded from the scale. Fifty-seven items were preserved exactly, and 19 items' sentence structures were changed. Furthermore, by adding 4 new items, 80 were prepared for the second study. In the second study, two factors structure namely "Physiological Reactions/Strain" and "Psychological/Cognitive Appraisals" sub-dimensions were identified, and 36 items were selected via Item Response Theory representing these sub-dimensions. In study 3, exploratory factor analysis provided strong support for our hypothesized two factors structure. Confirmatory factor analysis indicated hypothesized model had a better fit to the data. Internal consistency coefficients were 0.94 for the entire scale, 0.90 for Physiological Reactions/Strain sub-dimension, and 0.91 for Psychological/Cognitive Appraisals sub-dimension. Correlation coefficients between the entire scale and other criterion scales ranged from 0.22 to 0.63. Test-retest correlation coefficients between the first administration of the scale, and the administrations at two and three week intervals were 0.88.

CONCLUSION

Results showed that the scale has basic psychometric requirements provided that the scale will be supported by validity studies.

Contributions of Children With Multiple Chronic Conditions to Pediatric Hospitalizations in the United States: A Retrospective Cohort Analysis

BACKGROUND

Children with multiple chronic conditions (CMCC) are increasingly using hospital care. We assessed how much of US pediatric inpatient care is used by CMCC and which chronic conditions are the key drivers of hospital use.

METHODS

A retrospective analysis of all 2.3 million US acute-care hospital discharges in 2012 for children age 0 to 18 years in the Kids' Inpatient Database. The ∼4.5 million US hospitalizations for pregnancy, childbirth, and newborn and neonatal care were not assessed. We adapted the Agency for Healthcare Research and Quality's Chronic Condition Indicators to classify hospitalizations for children with no, 1, or multiple chronic conditions, and to determine which specific chronic conditions of CMCC are associated with high hospital resource use.

RESULTS

Of all pediatric acute-care hospitalizations, 34.3% were of children with no chronic conditions, 36.5% were of those with 1 condition, and 29.3% were of CMCC. Of the $23.6 billion in total hospital costs, 19.7%, 27.4%, and 53.9% were for children with 0, 1, and multiple conditions, respectively, and similar proportions were observed for hospital days. The three populations accounted for the most hospital days were as follows: children with no chronic condition (20.9%), children with a mental health condition and at least 1 additional chronic condition (20.2%), and children with a mental health condition without an additional chronic condition (13.3%). The most common mental health conditions were substance abuse disorders and depression.

CONCLUSIONS

CMCC accounted for over one-fourth of acute-care hospitalizations and one-half of all hospital dollars for US pediatric care in 2012. Substantial CMCC hospital resource use involves children with mental health-related conditions.

Complexity of care and strategies of self-management in patients with colorectal cancer

PURPOSE

Given the inherent complexity of cancer care, in which personal, social, and clinical aspects accumulate and interact over time, self-management support need to become more comprehensive. This study has the following two aims: 1) to analyze and describe the complexity of individual patient situations and 2) to analyze and describe already established self-management strategies of patients to handle this complexity.

METHODS

A qualitative study was conducted. Ten focus groups were performed collecting perspectives of the following three user groups: patients with colorectal cancer (n=12) and representatives from support groups (n=2), physicians (n=17), and other health care professionals (HCPs; n=16). Data were analyzed using qualitative content analysis.

RESULTS

The results showed that cancer patients are struggling with the complexity of their individual situations characterized by the 1) "complexity of disease", 2) "complexity of care", and 3) "complexity of treatment-related data". To deal with these multifaceted situations, patients have established several individual strategies. These strategies are "proactive demanding" (eg, to get support and guidance or a meaningful dialog with the doctor), "proactive behavior" (eg, preparation of visits), and "proactive data management" (eg, in terms of merging treatment-related data and to disseminate these to their health care providers).

CONCLUSION

Patients with colorectal cancer have to handle a high complexity of individual situations within treatment and care of their disease. Private and social challenges have a culminating effect. This complexity increases as patients experience a longer duration of treatment and follow-up as patients have to handle a significantly higher amount of data over time. Self-management support should focus more on the individual complexity in a patient's life. This includes assisting patients with strategies that have already been established by themselves (like preparation of visits).

A qualitative study of older people's experience of living with neurogenic claudication to inform the development of a physiotherapy intervention

PURPOSE

The aim of this study was to explore older people's experiences of living with neurogenic claudication (NC), their preferences for physiotherapy treatment provision and associated outcomes in order to inform an intervention to be tested in a clinical trial.

METHOD

Patients with a diagnosis of NC and/or lumbar spinal stenosis were recruited through a UK NHS tertiary care center. Semi-structured interviews and self-report questionnaires were used to obtain data. A thematic analysis was conducted.

RESULTS

15 participants were recruited; half were classed as frail older adults. Pain and the threat of pain was a prominent feature of participants' experience of NC. This led to a loss of engagement in meaningful activities and sense of self. Discourses of ageing influenced experiences as well as treatment preferences, particularly the acceptability of walking aids. A combination of one-to-one and group setting for treatment was preferred. Outcome preferences related to re-engagement in meaningful activities and pain reduction. Limitations relate to generalisability of the findings for NC patients not under physiotherapy treatment.

CONCLUSION

We have obtained important findings about older people's experiences of living with NC and preferences for physiotherapy treatment and outcomes. These will be incorporated into an evidence-based intervention and evaluated in a randomized controlled trial. Implications for rehabilitation Older people living with NC want to get back to meaningful activities and learn how to live with the threat of pain. Allied health professionals (AHPs) should be sensitive to the complex and ambiguous ways in which older people live with ageing and age-related decline. AHPs are in a position to support patients' successful transition to the use of walking aids thereby reducing stigmatizing effects and increasing activity. AHPs should consider a mixture of one-to-one and group classes to enable rehabilitation for older NC patients.

The effectiveness and cost effectiveness of the PAtient-Centred Team (PACT) model: study protocol of a prospective matched control before-and-after study

BACKGROUND

The present study protocol describes the evaluation of a comprehensive integrated care model implemented at two hospital sites at the University Hospital of North Norway (UNN). The PAtient Centred Team (PACT) model includes proactive, patient-centred interdisciplinary teams that aim to improve the continuum and quality of care of frail elderly patients and reduce health care costs. The main objectives of the evaluation are to analyse the effectiveness and cost effectiveness of using patient-centred teams as part of routine service provision for this patient group. The evaluation will analyse the effect on patient health and functional status, patient experiences and hospital utilisation, and it will conduct an economic evaluation. This paper describes the PACT model and the rationale for and design of the planned effectiveness and cost-effectiveness study.

METHODS/DESIGN

This is a prospective, non-randomised matched control before-and-after intervention study. Patients in the intervention group will be recruited from the hospital sites that have implemented the PACT model. The controls will be recruited from two hospitals without the model. The control patients and the index patients will be matched according to sex, age and number of long-term conditions. The study aims to include 600 patients in each group, which will provide sufficient power to detect a clinical change in the primary outcome. The primary outcome is the physical dimension of the Short Form Health Survey (SF-36). Secondary outcomes are the Patient Generated Index (PGI), the Patient Activation Measure (PAM), the Patient Assessment of Chronic Illness Care (PACIC), hospitalisation and length of stay. The cost-effectiveness study takes a health provider perspective and calculates the cost per quality-adjusted life-years (QALYs) gained. The data will be collected at baseline, 6 and 12 months. The data will be analysed using techniques and models that recognise the lack of randomisation and the correlation of cost and effect data.

DISCUSSION

The study results will provide knowledge about whether the integrated care model implemented at UNN improves the quality of care for the frail elderly with multiple conditions. The study will establish whether the PAC. T model improves health and functional status and is cost effective compared to the usual care for this patient group.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02541474.

Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions

Background

Falls and chronic disease are both important health issues in older adults. The objectives of this study were to quantify the prevalence of falls and multi-morbidity (≥2 chronic conditions) in Canadian older adults; examine associations between falls and number of chronic conditions; and explore whether certain patterns of chronic disease were associated with a greater risk of falling.

Methods

Data were derived from the Canadian Community Health Survey- Healthy Aging. Primary outcomes from 16,357 community-dwelling adults aged 65 years and over were self-reported falls in the previous 12 months and presence of 13 chronic conditions. Prevalence estimates were calculated with normalized sampling weights, and hierarchical cluster analysis was used to identify clusters based on chronic condition patterns, and tested for association to falls with logistic regression.

Results

Overall prevalence of falling and multi-morbidity were 19.8% and 62.0% respectively. Fall risk was significantly greater in individuals with one, two, four, five and six or more chronic conditions relative to those with none (all p < 0.05). A seven-cluster model was selected, including groups with low prevalence of chronic disease, or high prevalence of hypertension and arthritis, visual impairment, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, or heart disease and hypertension. Only the hypertension cluster (Odds Ratio [OR] = 1.2) and COPD cluster (OR = 1.6) were significantly associated with increased falls relative to the low prevalence group.

Conclusions

Both the number and pattern of chronic conditions were related to falls. COPD emerged as a significant predictor of falls despite affecting a smaller proportion of respondents. Continued study is warranted to verify this association and determine how to incorporate consideration of chronic disease and multi-morbidity into fall risk assessments.

Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide

PURPOSE

Many patients consulting in primary care have multiple conditions (multimorbidity). Aims of this review were to identify measures of multimorbidity and morbidity burden suitable for use in research in primary care and community populations, and to investigate their validity in relation to anticipated associations with patient characteristics, process measures, and health outcomes.

METHODS

Studies were identified using searches in MEDLINE and EMBASE from inception to December 2009 and bibliographies.

RESULTS

Included were 194 articles describing 17 different measures. Commonly used measures included disease counts (n = 98), Chronic Disease Score (CDS)/RxRisk (n = 17), Adjusted Clinical Groups (ACG) System (n = 25), the Charlson index (n = 38), the Cumulative Index Illness Rating Scale (CIRS; n = 10) and the Duke Severity of Illness Checklist (DUSOI; n = 6). Studies that compared measures suggest their predictive validity for the same outcome differs only slightly. Evidence is strongest for the ACG System, Charlson index, or disease counts in relation to care utilization; for the ACG System in relation to costs; for Charlson index in relation to mortality; and for disease counts or Charlson index in relation to quality of life. Simple counts of diseases or medications perform almost as well as complex measures in predicting most outcomes. Combining measures can improve validity.

CONCLUSIONS

The measures most commonly used in primary care and community settings are disease counts, Charlson index, ACG System, CIRS, CDS, and DUSOI. Different measures are most appropriate according to the outcome of interest. Choice of measure will also depend on the type of data available. More research is needed to directly compare performance of different measures.

The roles of social support and self-efficacy in physical health's impact on depressive and anxiety symptoms in older adults

Physical illness may precipitate psychological distress among older adults. This study examines whether social support and self-efficacy moderate the associations between physical health and depression and anxiety. Predictions were tested in 222 individuals age 60 or older presenting for help with worry. Physical health was assessed through self-report (subjective) and physical diagnoses (objective). Objective physical health did not have a significant association with depression or anxiety. Worse subjective physical health was associated with increased somatic anxiety, but not with depression or worry. The relationship between subjective physical health and depressive symptoms was moderated by self-efficacy and social support. As predicted, when self-efficacy was low, physical health had its strongest negative association with depressive symptoms such that as physical health improved, depressive symptoms also improved. However, the moderation effect was not as expected for social support; at high levels of social support, worse physical health was associated with increased depressive affect.

Seniors' self-reported multimorbidity captured biopsychosocial factors not incorporated into two other data-based morbidity measures

OBJECTIVE

To explore the constructs underlying a self-report assessment of multimorbidity.

STUDY DESIGN AND SETTING

We conducted a cross-sectional survey of 352 HMO members aged 65 years or more with, at a minimum, diabetes, depression, and osteoarthritis. We assessed self-reported 'disease burden' (a severity-adjusted count of conditions) as a function of biopsychosocial factors, two data-based comorbidity indices, and demographic variables.

RESULTS

In multivariate regression, age, 'compound effects of conditions' (treatments and symptoms interfering with each other), self-efficacy, financial constraints, and physical functioning were significantly (p<or=0.05) associated with disease burden. An ICD-9-based morbidity index did not significantly contribute to disease burden, and a pharmacy-data-based morbidity index was minimally significant.

CONCLUSION

This measure of self-reported disease burden represents an amalgamation of functional capabilities, social considerations, and medical conditions that are not captured by two administrative data-based measures of morbidity. This suggests that (a) self-reported descriptions of multimorbidity incorporate biopsychosocial constructs that reflect the perceived burden of multimorbidity, (b) a simple count of diagnoses should be supplemented by an assessment of activity limitations imposed by these conditions, and (c) choice of the morbidity measurement instrument should be based on the outcome of interest rather than on the most convenient method of measurement.

Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities

PURPOSE

Persons with multiple chronic diseases must integrate self-management tasks for potentially interacting conditions to attain desired clinical outcomes. Our goal was to identify barriers to self-management that were associated with lower perceived health status and, secondarily, with lower reported physical functioning for a population of seniors with multimorbidities.

METHODS

We conducted a cross-sectional telephone survey of 352 health maintenance organization members aged 65 years or older with, at a minimum, coexisting diagnoses of diabetes, depression, and osteoarthritis. Validated questions were based on previous qualitative interviews that had elicited potential barriers to the self-management process for persons with multimorbidities. We analyzed associations between morbidity burden, potential barriers to self-management, and the 2 outcomes using multivariate linear regression modeling.

RESULTS

Our response rate was 47%. Sixty-six percent of respondents were female; 55% were aged 65 to 74 years, and 45% were aged 75 years or older. Fifty percent reported fair or poor health. On average they had 8.7 chronic diseases. In multivariate analysis, higher level of morbidity, lower level of physical functioning, less knowledge about medical conditions, less social activity, persistent depressive symptoms, greater financial constraints, and male sex were associated with lower perceived health status. Potential barriers to self-management significantly associated with lower levels of physical functioning were higher level of morbidity, greater financial constraints, greater number of compound effects of conditions, persistent depressive symptoms, higher level of patient-clinician communication, and lower income.

CONCLUSIONS

In addition to morbidity burden, specific psychosocial factors are independently associated with lower reported health status and lower reported physical functioning in seniors with multimorbidities. Many factors are amenable to intervention to improve health outcomes.

Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia

OBJECTIVES

To assess the importance of multiple chronic diseases (co-morbidities) to how people feel about their lives generally. To do this, we studied the associations between co-morbidities and indicators of quality of life and/or psychological distress.

METHODS

Analysis of unit record cross-sectional data from Australian national surveys for the population aged 20 years or more. Identification of an appropriate indicator of multiple chronic diseases (i.e. co-morbidities). Use of logistic regression techniques to study associations between: (1) co-morbidities and demographic, socio-economic and risk factor variables; and (2) quality of life (general and psychological distress) and demographic, socio-economic and health status indicators.

RESULTS

Older people, obese persons, women, persons with low socio-economic status and those living alone had significantly greater probability of having three or more chronic illnesses than did other people aged 20+ years (p<0.0001). Also, people with co-morbidities and/or with poor self-rated general health, those living alone, people with low educational qualifications and persons with low socio-economic status were more likely to feel dissatisfied, unhappy or terrible about their lives and to have moderate, high or very high psychological distress scores than the rest of the 20+-year-old population (p<0.0001).

CONCLUSIONS

Multiple chronic diseases were found to have a considerable negative impact on quality of life, not only in terms of how people felt about their lives generally, but also in terms of the extent of their psychological distress.