IT-supported integrated care pathways for diabetes: A compilation and review of good practices

Using Measurement-Based Care as a Precision Medicine Strategy for Substance Use Disorders

PURPOSE OF REVIEW

Precision medicine prioritizes characterization of individual patient parameters to optimize care and this review evaluates measurement-based care (MBC) as a strategy for doing so in the treatment of substance use disorders (SUD). Measurement-based care refers to the systematic use of validated assessments to inform diagnosis and treatment planning, with varying frequency of assessments. Despite the seemingly obvious grounds for the use of MBC in treating SUD, systematic implementation to date has been limited. Thus, the goal of this review is to evaluate efforts to date and to stimulate greater consideration of MBC models in addictions programs.

RECENT FINDINGS

Data from two published randomized controlled trials and findings from pragmatic clinical research highlight the potential utility of MBC in the SUD treatment settings. Despite these findings, the existing literature indicates the high need for larger-scale clinical trials and quality improvement programs. Potential barriers to the implementation of MBC for SUD are outlined at the patient, provider, organization, and system levels, as well as the challenges associated with the use of MBC programs for clinical research. Critical thinking considerations and risk mitigation strategies are offered toward advancing MBC for SUD beyond the current nascent state. Collectively, the existing data confirm that MBC is a suitable and promising strategy for applying a precision medicine approach in SUD treatment, warranting further implementation efforts and scientific inquiry.

What is meant by 'integrated personalized diabetes management': A view into the future and what success should look like

Integrated personalized diabetes management (IPDM) has emerged as a promising approach to improving outcomes in patients with diabetes mellitus (DM). This care approach emphasizes the integration and coordination of different providers, including physicians, nurses, dietitians, social workers and pharmacists. The goal of IPDM is to provide patients with personalized care that is tailored to their needs. This review addresses the concept of integrated care and the use of technology (including data, software applications and artificial intelligence) as well as managerial, regulatory and financial aspects. The implementation and upscaling of digitally enabled IPDM are discussed, with elaboration of successful practices and related evidence. Finally, recommendations are made. It is concluded that the adoption of digitally enabled IPDM on a global level is inevitable, considering the challenges created by an increasing prevalence of patients with DM and the need for better outcomes and improvement of health system sustainability.

Toward Diabetes Device Development That Is Mindful to the Needs of Young People Living With Type 1 Diabetes: A Data- and Theory-Driven Qualitative Study

BACKGROUND

An important strategy to understand young people's needs regarding technologies for type 1 diabetes mellitus (T1DM) management is to examine their day-to-day experiences with these technologies.

OBJECTIVE

This study aimed to examine young people's and their caregivers' experiences with diabetes technologies in an exploratory way and relate the findings to the existing technology acceptance and technology design theories. On the basis of this procedure, we aimed to develop device characteristics that meet young people's needs.

METHODS

Overall, 16 in-person and web-based face-to-face interviews were conducted with 7 female and 9 male young people with T1DM (aged between 12 and 17 years) and their parents between December 2019 and July 2020. The participants were recruited through a pediatric diabetes clinic based at Canberra Hospital. Data-driven thematic analysis was performed before theory-driven analysis to incorporate empirical data results into the unified theory of acceptance and use of technology (UTAUT) and value-sensitive design (VSD). We used the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist for reporting our research procedure and findings. In this paper, we summarize the key device characteristics that meet young people's needs.

RESULTS

Summarized interview themes from the data-driven analysis included aspects of self-management, device use, technological characteristics, and feelings associated with device types. In the subsequent theory-driven analysis, the interview themes aligned with all UTAUT and VSD factors except for one (privacy). Privacy concerns or related aspects were not reported throughout the interviews, and none of the participants made any mention of data privacy. Discussions around ideal device characteristics focused on reliability, flexibility, and automated closed loop systems that enable young people with T1DM to lead an independent life and alleviate parental anxiety. However, in line with a previous systematic review by Brew-Sam et al, the analysis showed that reality deviated from these expectations, with inaccuracy problems reported in continuous glucose monitoring devices and technical failures occurring in both continuous glucose monitoring devices and insulin pumps.

CONCLUSIONS

Our research highlights the benefits of the transdisciplinary use of exploratory and theory-informed methods for designing improved technologies. Technologies for diabetes self-management require continual advancement to meet the needs and expectations of young people with T1DM and their caregivers. The UTAUT and VSD approaches were found useful as a combined foundation for structuring the findings of our study.

The ‘Service Transformation Outline’ toolkit to assist in the design, comparison and replication of integrated care programmes

Purpose

The author is introducing a toolkit that can assist stakeholders to design, compare and replicate integrated care programmes, by making explicit their view on the transformations of care and cure services, according to a structured template. The purpose of this paper is to address this issue.

Design/methodology/approach

The toolkit is made of two elements: a classification and a template. The author adopted a step-wise approach of semantic modelling to work out three layers of a classification in the domain of integration needs related to care and cure services. The third layer consists of 23 non-overlapping classes that fully cover that semantic domain. The classes are used to build a template to elicit the stakeholder's standpoint about the transformations involved in the deployment of a programme. The result is the «Outline» of the programme.

Findings

So far, in eight years the author applied the toolkit to 100+ programmes either to design, simulate or evaluate them, either to compare them to similar ones in the same or in different jurisdictions, and we refined the description of the classes according to that experience.

Research limitations/implications

The objective of the toolkit is not to provide solutions, but to stimulate reflections on the transformations involved in a programme and their practical consequences in a precise context. In fact, the Outlines cannot be generalized: they are conceived to reflect the perspective of the stakeholders and thus are intrinsically subjective; in addition, they must be contingent, as they must depend on the local context in the particular timeframe. In case of similar initiatives in other localities, the Outlines must be filled in again by the local stakeholders; however, a subsequent comparison could help to explore similarities and motivated differences.

Practical implications

Ideally the stakeholders should use the Outline of the actual transformations in a programme as a reference to mediate between the principles and the methodologies provided by the «Models» and «Conceptual Frameworks» in the literature (e.g. Chronic Care Model, Rainbow Model, Development Model of Integrated Care Patient-Centered Medical Home and Maturity Models) and the deeper studies using the specific tools developed in their disciplines (e.g. on information modelling, process modelling, cost–benefit analysis and health technology assessment). The toolkit could have its role also in a multi-annual roadmap made of a sequence of programmes to cope with the urgent challenges on ageing, social changes and technological evolution, in synergy with regulations, budget, context maturity, critical success factors and local priorities.

Originality/value

The author argues that the approach of the structured Outline is unique, as the scoring mechanism to assess the relevance of the transformation within each class on the overall change brought by the whole programme into the health systems.

Shaping Workflows in Digital and Remote Diabetes Care During the COVID-19 Pandemic via Service Design: Prospective, Longitudinal, Open-label Feasibility Trial

BACKGROUND

The COVID-19 pandemic poses new challenges to health care providers and the delivery of continuous care. Although many diabetes technologies, such as insulin pumps and continuous glucose monitors, have been established, the data from these devices are rarely assessed. Furthermore, telemedicine has not been sufficiently integrated into clinical workflows.

OBJECTIVE

We sought to remotely support children with type 1 diabetes and their caregivers, enhance the clinical outcomes and quality of life of children with diabetes, increase multiple stakeholders' engagement with digital care via a participatory approach, evaluate the feasibility of using an interoperable open-source platform in a university hospital setting, and analyze the success factors and barriers of transitioning from conventional care to digital care.

METHODS

Service design methods were used to adapt clinical workflows. Remote consultations were performed on a monthly and on-demand basis. Diabetes device data were uploaded from patients' homes to an open-source platform. Clinical and patient-reported outcomes were assessed before, during, and after the COVID-19 lockdown period in Germany.

RESULTS

A total of 28 children with type 1 diabetes and their caregivers enrolled in this study and completed 6 months of remote visits. Of these 28 participants, 16 (57%) also opted to attend at least one of their regular visits remotely. After 3 months of remote visits, participants' time in range (P=.001) and time in hyperglycemia (P=.004) significantly improved, and their time in hypoglycemia did not increase. These improvements were maintained during the COVID-19 lockdown period (ie, between months 3 and 6 of this study). Participants' psychosocial health improved after 6 months.

CONCLUSIONS

Remote consultations and commonly shared data access can improve the clinical outcomes and quality of life of children with type 1 diabetes, even during challenging circumstances. A service design approach helped with the delivery of comprehensive and holistic solutions that accounted for the needs of multiple stakeholders. Our findings can inform the future integration of digital tools into clinical care during and beyond the pandemic.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00016170; https://tinyurl.com/skz4wdk5.

Ischemic stroke: clinical pathway impact

PURPOSE

A clinical pathway for patients with acute ischemic stroke was implemented in 2014 by one Italian teaching hospital multidisciplinary team. The purpose of this paper is to determine whether this clinical pathway had a positive effect on patient management by comparing performance data.

DESIGN/METHODOLOGY/APPROACH

Volume, process and outcome indicators were analyzed in a pre-post retrospective observational study. Patients' (admitted in 2013 and 2015) medical records with International Classification of Diseases, ICD-9 code 433.x (precerebral artery occlusion and stenosis), 434.x (cerebral artery occlusion) and 435.x (transient cerebral ischemia) and registered correctly according to hospital guidelines were included.

FINDINGS

An increase context-sensitive in-patient numbers with more severe cerebrovascular events and an increase in patient transfers from the Stroke to Neurology Unit within three days (70 percent, p=0.25) were noted. Clinical pathway implementation led to an increase in patient flow from the Emergency Department to dedicated specialized wards such as the Stroke and Neurology Unit (23.7 percent, p<0.001). Results revealed no statistically significant decrease in readmission rates within 30 days (5.7 percent, p=0.85) and no statistically significant differences in 30-day mortality.

RESEARCH LIMITATIONS/IMPLICATIONS

The pre-post retrospective observational study design was considered suitable to evaluate likely changes in patient flow after clinical pathway implementation, even though this design comes with limitations, describing only associations between exposure and outcome.

ORIGINALITY/VALUE

Clinical pathway implementation showed an overall positive effect on patient management and service efficiency owing to the standardized application in time-dependent protocols and multidisciplinary/integrated care implementation, which improved all phases in acute ischemic stroke care.

Development of a Healthy Lifestyle Assessment Toolkit for the General Public

The prevalence of age-related non-communicable chronic diseases has increased worldwide, being the leading causes of morbidity and death in many world regions, including in Europe. Innovative models and strategies focused on preventive care, including early identification of risk factors underlying disease onset and progression, and proper modification of lifestyle habits and behaviors, might contribute to promote quality of life, healthy living and active aging. Healthy Lifestyle Innovative Quarters for Cities and Citizens (HeaLIQs4cities) is an EIT Health-funded project aiming to engage, empower and educate citizens toward healthy lifestyles. One of the major objectives of this project was to develop a toolkit for a rapid and informal assessment of healthy lifestyles, to be used at different levels of care pathways, including in informal public environments. In this paper, we describe the methodology underlying the development of the toolkit, which resulted from the collaboration of an interdisciplinary focus group of academic experts, from medicine, sport sciences, psychology, health economics, and innovative technologies applied to health. The following eight components were included in the toolkit: (1) anthropometric assessment and cardiometabolic parameters; (2) physical activity and exercise; (3) well-being, social cohesion, and functional independence; (4) nutrition; (5) mental health; (6) smoking, drinking, and use of illicit substances; (7) sleep habits and quality; and (8) health and disease. A traffic light rating system indicating the risk score was used (low: green; moderate: yellow; and relevant: orange) for each of the 8 components, together with recommendations for the toolkit users. After completing the reduced version of the toolkit, individuals showing moderate or relevant risk in one or more of the 8 dimensions, were invited to participate in a more detailed assessment (toolkit long version), based on deeper and scientifically validated tools. The toolkit was incorporated in eVida, a web-based platform that focuses on delivering services to personalized health and well-being. The validation of the current toolkit has been applied in wide-ranging public events in three different European Regions. Large scale deployment of the toolkit is expected to profit from the Reference Site Collaborative Network of the European Innovation Partnership on Active and Healthy Aging (EIP on AHA).

Effectiveness and cost-effectiveness of integrated care models for elderly, complex patients: A narrative review. Don’t we need a value-based approach?

Introduction

The management of patients with complex health and social needs is one of the main challenges for healthcare systems. Integrated care seems to respond to this issue, with collaborative working and integration efforts of the care system components professionals and service providers aimed at improving efficiency, appropriateness and person centeredness of care. We conducted a narrative review to analyse the available evidences published on effectiveness and cost-effectiveness of integrated care models targeted on the management of such elderly patients.

Methods

MEDLINE, Scopus and EBSCO were searched. We reported this narrative review according to the PRISMA Checklist. For studies to be included, they had to: (i) refer to integrated care models through implemented experimental or demonstration projects; (ii) focus on frail elderly ≥65 years old, with complex health and social needs, not disease-specific; (iii) evaluate effectiveness and/or cost and/or cost-effectiveness; (iv) report quantitative data (e.g. health outcomes, utilization outcomes, cost and cost-effectiveness).

Results

Thirty articles were included, identifying 13 integrated care models. Common features were identified in case management, geriatric assessment and multidisciplinary team. Favourable impacts on healthcare facilities utilization rates, though with mixed results on costs, were found. The development of community-based and cost-effective integrated systems of care for the elderly is possible, thanks to the cooperation across care professionals and providers, to achieving a relevant impact on healthcare and efficient resource management. The elements of success or failure are not always unique and identifiable, but the potential clearly exists for these models to be successful and generalized on a large scale.

Discussion

We found out a favourable impact of integrated care models/methods on health outcomes, care utilization and costs. The selected interventions are likely to be implemented at community level, focused on the patient management in terms of continuity of care. Thus, we propose a value-based framework for the evaluation of these services.

An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care

INTRODUCTION

In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance.

METHOD

This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care).

RESULTS

The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible.

CONCLUSION

Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.

Stem cells and heart disease - Brake or accelerator?

After two decades of intensive research and attempts of clinical translation, stem cell based therapies for cardiac diseases are not getting closer to clinical success. This review tries to unravel the obstacles and focuses on underlying mechanisms as the target for regenerative therapies. At present, the principal outcome in clinical therapy does not reflect experimental evidence. It seems that the scientific obstacle is a lack of integration of knowledge from tissue repair and disease mechanisms. Recent insights from clinical trials delineate mechanisms of stem cell dysfunction and gene defects in repair mechanisms as cause of atherosclerosis and heart disease. These findings require a redirection of current practice of stem cell therapy and a reset using more detailed analysis of stem cell function interfering with disease mechanisms. To accelerate scientific development the authors suggest intensifying unified computational data analysis and shared data knowledge by using open-access data platforms.