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van Grootel JWM, Collet RJ, van Dongen JM, van der Leeden M, Geleijn E, Ostelo R, van der Schaaf M, Wiertsema S, Major ME. Experiences with hospital-to-home transitions: perspectives from patients, family members and healthcare professionals. A systematic review and meta-synthesis of qualitative studies. Disabil Rehabil 2024:1-14. [PMID: 39101687 DOI: 10.1080/09638288.2024.2384624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/18/2024] [Accepted: 07/20/2024] [Indexed: 08/06/2024]
Abstract
PURPOSE Multiple studies have explored the needs and experiences of patients, family members, and healthcare professionals regarding hospital-to-home transitions. Our study aimed to identify, critically appraise, and summarize these studies in a qualitative meta-synthesis. MATERIALS AND METHODS Medline, CINAHL and Embase were systematically searched to identify eligible articles from inception to June 2024. Qualitative studies were included and critically appraised using the Critical Appraisal Skills Program. Insufficient-quality papers were excluded. We performed a meta-synthesis following (1) open coding by two independent researchers and (2) discussing codes during reflexivity meetings. RESULTS Ninety-eight studies were appraised, of which 53 were included. We reached thematic saturation, four themes were constructed: (1) care coordination and continuity, (2) communication, (3) patient and family involvement, and (4) individualized support and information exchange. For patients and families, tailored information and support are prerequisites for a seamless transition and an optimal recovery trajectory after hospital discharge. It is imperative that healthcare professionals communicate effectively within and across care settings to ensure multidisciplinary collaboration and care continuity. CONCLUSIONS This study identifies essential elements of optimal transitional care. These findings could be supportive to researchers and healthcare professionals when (re)designing transitional care interventions to ensure care continuity after hospital discharge.
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Affiliation(s)
- J W M van Grootel
- Department of Rehabilitation Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Ageing and Vitality, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - R J Collet
- Department of Rehabilitation Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Musculoskeletal Health, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Department of Health Sciences, Faculty of Science, Vrije University Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J M van Dongen
- Musculoskeletal Health, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Department of Health Sciences, Faculty of Science, Vrije University Amsterdam, Amsterdam, The Netherlands
| | - M van der Leeden
- Department of Rehabilitation Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Ageing and Vitality, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - E Geleijn
- Department of Rehabilitation Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - R Ostelo
- Musculoskeletal Health, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Department of Health Sciences, Faculty of Science, Vrije University Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M van der Schaaf
- Department of Rehabilitation Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Ageing and Vitality, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - S Wiertsema
- Department of Rehabilitation Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - M E Major
- Department of Rehabilitation Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Ageing and Vitality, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Faculty of Health, Department of Physical Therapy, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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Romeo GR, Caputo T, Stanescu IW, Alkhaddo JB. The Arduous Path Toward Equitable Access to Endocrinology Care. J Endocr Soc 2024; 8:bvae134. [PMID: 39071475 PMCID: PMC11273240 DOI: 10.1210/jendso/bvae134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Indexed: 07/30/2024] Open
Abstract
Multiple factors contribute to the widening gap between supply and demand of endocrinology services. In addition to the inadequate growth of the workforce, the inefficient utilization of endocrinologists' expertise coupled with the rising prevalence of endocrine conditions has generated a crisis in access to specialty care. This mismatch is magnified in underserved communities and among certain racial/ethnic groups that carry a disproportionate burden of chronic diseases, like diabetes and osteoporosis, thus perpetuating the cycle of health disparities in vulnerable populations. Reorienting the framework of endocrine care toward more effective and equitable access will require comprehensive changes in operational processes, system-based policies, and in the diversity of our workforce. Specifically, the progressive transition to outcome-driven, team-based models of care can extend endocrinology services beyond the traditional boundaries of in-office referrals and promote job satisfaction. Further, the implementation of policies that directly tackle structural determinants of health is a prerequisite to a more precise and equitable deployment of specialty care. In this view, the recruitment and professional growth of clinicians underrepresented in medicine along the career ladder, including leadership roles, is a key conduit to revitalize our field and to innovate the delivery of endocrine care across all communities.
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Affiliation(s)
- Giulio R Romeo
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - Tiziana Caputo
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
| | - Izabela W Stanescu
- Ambulatory Operation Services, Mass General Brigham, Harvard Medical School, Boston, MA 02215, USA
| | - Jamil B Alkhaddo
- Division of Endocrinology, Department of Medicine, Allegheny Health Network, Pittsburgh, PA 15212, USA
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Kim B, Benzer JK, Afable MK, Fletcher TL, Yusuf Z, Smith TL. Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care. J Eval Clin Pract 2023; 29:1338-1353. [PMID: 36938857 DOI: 10.1111/jep.13832] [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] [Received: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND, AIMS AND OBJECTIVES This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care. METHODS Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations. RESULTS Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions. CONCLUSIONS Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.
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Affiliation(s)
- Bo Kim
- U.S. Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin K Benzer
- U.S. Department of Veterans Affairs, Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans, Central Texas Veterans Healthcare System, Department of Psychiatry and Behavioral Sciences, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | | | - Terri L Fletcher
- U.S. Department of Veterans Affairs, South Central Mental Illness Research, Education and Clinical Center, Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Zenab Yusuf
- U.S. Department of Veterans Affairs, Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Tracey L Smith
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
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Pilla SJ, Meza KA, Schoenborn NL, Boyd CM, Maruthur NM, Chander G. A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications. J Gen Intern Med 2023; 38:1008-1015. [PMID: 36175758 PMCID: PMC10039184 DOI: 10.1007/s11606-022-07828-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs. OBJECTIVE To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications. DESIGN This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated. PARTICIPANTS Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty. APPROACH Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous. KEY RESULTS Participants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively. CONCLUSIONS Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Kayla A Meza
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Geetanjali Chander
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Provider-To-Provider Communication About Care Transitions: Considering Different Health Technology Tools. J Healthc Qual 2023; 45:133-139. [PMID: 36848603 DOI: 10.1097/jhq.0000000000000375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
ABSTRACT Transitions in patient care require exchanges of information between providers. This period of transition presents a range of challenges, and inadequate transitions can have serious consequences for patients. Our objective was to understand providers' perspectives about patient care transitions, especially around communication between providers and the role of health information technology in provider-to-provider communication. Semi-structured interviews were conducted. Deductive-dominant thematic analysis was used to allow categorization of data based on general themes derived from the interview guides, as well as identification of emergent themes. We characterized three main themes involving providers' perspectives about care transitions. Themes included communication challenges, communication preferences, and suggestions for improving the care transition processes. With respect to challenges around communication, providers highlighted four main concerns. These concerns included the existence of too many methods of communication, high volume of communication, challenges with involvement of multiple providers delivering longitudinal care, and difficulty communicating with providers outside the health system. Providers noted opportunities to improve transitions including improving standardization, enhancing the specialty to primary care transition process, and increasing communication back to the referring provider. Implementation and evaluation of these improvements could be considered by health systems to enhance care transitions.
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Yao M, Zhang DY, Fan JT, Lin K, Haroon S, Jackson D, Li H, Chen W, Lehman R, Cheng KK. The experiences of Chinese general practitioners in communicating with people with type 2 diabetes-a focus group study. BMC FAMILY PRACTICE 2021; 22:156. [PMID: 34275440 PMCID: PMC8287665 DOI: 10.1186/s12875-021-01506-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/05/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND China has more ascertained cases of diabetes than any other country. Much of the care of people with type 2 diabetes (T2DM) in China is managed by GPs and this will increase with the implementation of health care reforms aimed at strengthening China's primary health care system. Diabetes care requires effective communication between physicians and patients, yet little is known about this area in China. We aimed to explore the experiences of Chinese GPs in communicating with diabetes patients and how this may relate to communication skills training. METHODS Focus groups with Chinese GPs were undertaken. Purposive sampling was used to recruit 15 GPs from Guangzhou city in China. All data were audio-recorded and transcribed. A thematic analysis using the Framework Method was applied to code the data and identify themes. RESULTS Seven males and 8 females from 12 general practices attended 4 focus groups with a mean age of 37.6 years and 7.5 years' work experience. Four major themes were identified: diversity in diabetic patients, communication with patients, patient-doctor relationship, and communication skills training. GPs reported facing a wide variety of diabetes patients in their daily practice. They believed insufficient knowledge and misunderstanding of diabetes was common among patients. They highlighted several challenges in communicating with diabetes patients, such as insufficient consultation time, poor communication regarding blood glucose monitoring and misunderstanding the risk of complications. They used terms such as "blind spot" or "not on the same channel" to describe gaps in their patients' understanding of diabetes and its management, and cited this as a cause of ineffective patient-doctor communication. Mutual understanding of diabetes was perceived to be an important factor towards building positive patient-doctor relationships. Although GPs believed communication skills training was necessary, they reported rarely received this. CONCLUSIONS Chinese GPs reported facing challenges in communicating with diabetes patients. Some of these were perceived as being due to the patients themselves, others were attributed to system constraints, and some were seen as related to a lack of clinician training. The study identified key issues for the development of primary care-based management of diabetes in China, and for developing appropriate communication skills training programs for the primary care workforce.
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Affiliation(s)
- Mi Yao
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Dong-Ying Zhang
- Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jie-Ting Fan
- Department of Endocrinology, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Kai Lin
- Family Medicine Center, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Shamil Haroon
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Dawn Jackson
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Hai Li
- Department of Endocrinology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510 080, China.
| | - Richard Lehman
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Kar Keung Cheng
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
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Gray W, Dorriz P, Kim H, Partain L, Benekos E, Carpinelli A, Zupanc M, Grant K, Weiss M. Adult Provider Perspectives on Transition and Transfer to Adult Care: A Multi-Specialty, Multi-Institutional Exploration. J Pediatr Nurs 2021; 59:173-180. [PMID: 33932647 DOI: 10.1016/j.pedn.2021.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE To identify barriers that transcend multiple adult care specialties and identify potential solutions. DESIGN AND METHODS Twenty-one adult care providers practicing in the specialty areas of internal medicine, family medicine, gastroenterology, endocrinology, and neurology participated in one of six semi-structured focus group interviews. Data were coded and analyzed according to the Socio-ecological Model of Adolescent/Young Adult Readiness for Transition (SMART). RESULTS Three themes and one subtheme emerged from the data. These fell within the beliefs/expectations, knowledge, access/insurance, and relationships (subtheme) domains of the SMART model. Family beliefs/expectations regarding the provider role, difficulty accessing reliable information, and limited access to mental health and behavioral providers reportedly affect providers' ability to provide optimal health care. CONCLUSIONS Adult providers identified several barriers affecting their ability to care for newly transferred patients. Increased education of families and improved methods of communication between providers were recommended. Barriers related to access and insurance are common and require larger systems-level collaborations between health care systems and payor sources. PRACTICAL IMPLICATIONS Some recommendations (e.g., educating families on the distinct roles of the PCP vs. specialist, highlighting new treatment opportunities in adult care, conveying trust and endorsing the new provider), represent concrete steps pediatric providers can immediately take to improve transfer. Other steps will require forging bridges across the pediatric and adult care world to expand patient access to medical, mental health, and behavioral services.
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Affiliation(s)
- Wendy Gray
- Children's Health of Orange County, Orange, CA, United States of America.
| | - Parasto Dorriz
- Children's Health of Orange County, Orange, CA, United States of America
| | - Hanae Kim
- Children's Health of Orange County, Orange, CA, United States of America
| | - Lauren Partain
- Children's Health of Orange County, Orange, CA, United States of America
| | - Erin Benekos
- Children's Health of Orange County, Orange, CA, United States of America
| | - Anne Carpinelli
- Children's Health of Orange County, Orange, CA, United States of America
| | - Mary Zupanc
- Children's Health of Orange County, Orange, CA, United States of America
| | - Kenneth Grant
- Children's Health of Orange County, Orange, CA, United States of America
| | - Michael Weiss
- Children's Health of Orange County, Orange, CA, United States of America
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Wray J, Sugarman H, Davis L, Butler C, McIntyre D, Hewitt R. Improving community-based care for children with a rare condition: The example of long-segment congenital tracheal stenosis and perceptions of health professionals, parents and teachers. Int J Pediatr Otorhinolaryngol 2021; 143:110651. [PMID: 33662711 DOI: 10.1016/j.ijporl.2021.110651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/08/2021] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Long segment congenital tracheal stenosis (LSCTS) is a rare, complex condition which is often poorly understood by community-based health professionals (HPs). Anecdotally, such HPs often lack confidence providing care for children, resulting in children being brought to the tertiary centre more frequently than necessary. We wanted to identify the information and support needs of HPs in primary and secondary care looking after a child with LSCTS, the views of those providing education to these children, and elicit parents' perceptions about community-based services, to improve overall care for children and families. METHOD Questionnaires were sent to 175 community-based HPs and 34 teachers involved in the care of children with LSCTS. Face-to-face or telephone interviews were conducted with 12 parents of patients with LSCTS to establish their perceptions of community-based services. RESULTS Ninety (51%) completed questionnaires were returned from HPs and 18 (53%) from teachers. Responses indicated low levels of knowledge of LSCTS. Physical, practical and communication information needs were identified by all respondent groups, together with general and condition-specific concerns. Interviews with parents indicated that they thought the level of knowledge about LSCTS in the community was low, which had a negative impact on their willingness to consult local services. Better information provision for HPs, teachers and parents was identified as a means of improving outcomes. CONCLUSION Professionals caring for children with LSCTS in the community and in schools have unmet information and support needs, with consequences for children, families, HCPs in both the community and tertiary hospital, and teachers.
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Affiliation(s)
- Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street, London, WC1N 3JH, UK.
| | - Hannah Sugarman
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street, London, WC1N 3JH, UK
| | - Laura Davis
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street, London, WC1N 3JH, UK
| | - Colin Butler
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street, London, WC1N 3JH, UK
| | - Denise McIntyre
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street, London, WC1N 3JH, UK
| | - Richard Hewitt
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street, London, WC1N 3JH, UK
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Dankoly US, Vissers D, El Farkouch Z, Kolasa E, Ziyyat A, Rompaey BV, Maamri A. Perceived Barriers, Benefits, Facilitators, and Attitudes of Health Professionals Towards Multidisciplinary Team Care in Type 2 Diabetes Management: A Systematic Review. Curr Diabetes Rev 2021; 17:e111020187812. [PMID: 33176659 DOI: 10.2174/1573399816999201110200126] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/01/2020] [Accepted: 10/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The need for a multidisciplinary team approach to provide physical exercise, diet, behavioral change, and insulin therapy in type 2 diabetes mellitus (T2DM) treatment has long been recognized. However, often patients with T2DM do not have access to a multidisciplinary team. INTRODUCTION In developing countries, most patients with T2DM receive their diabetes care in the office of an internist or family practice physician or in a primary level health center with a general practitioner. Knowledge of healthcare professionals regarding the perceived barriers, attitudes, facilitators, and benefits of a multidisciplinary team approach in T2DM treatment can help facilitate the implementation of multidisciplinary care in T2DM. METHODS A systematic search strategy was performed in six databases (PubMed, Web of Science, CINAHL, EMBASE, MEDLINE, and Cochrane) using different keyword combinations to identify studies describing the healthcare professionals' views of multidisciplinary team care in T2DM. A textual narrative synthesis was used to analyze data. The Critical Appraisals Skills Programme (CASP) tool for qualitative studies was used to assess the risk of bias and transferability. RESULTS The views of health professionals about multidisciplinary team care in T2DM were categorized into six major factors, namely working collaboratively to foster supportive relationships; strong committed organizational and team leadership; diversity in expertise, with team members tailored to local circumstances; shared goals and approaches to ensure consistency of message; clear and open communication with the team and with patients; and the patient at the center of decision- making. CONCLUSION There is a huge gap in shared roles among health professionals in T2DM therapy. Hence, there is a need for allied health professionals such as physiotherapists, dieticians, and psychologists with expertise in diabetes to explore primary healthcare, barriers and facilitators to the successful integration of multidisciplinary team, seamlessly distributedinto three hierarchal levels, namely health management, health professionals, and diabetic patients.
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Affiliation(s)
- Usman Sani Dankoly
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Dirk Vissers
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Zainab El Farkouch
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Esther Kolasa
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Abderrahim Ziyyat
- Department of Biology, Faculty of Sciences, University Mohammed Premier, Oujda, Morocco
| | - Bart Van Rompaey
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Abdellatif Maamri
- Department of Biology, Faculty of Sciences, University Mohammed Premier, Oujda, Morocco
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Process, quality and challenges of diabetes care in primary care: a study of district health network in Thailand. Prim Health Care Res Dev 2020; 21:e46. [PMID: 33106200 PMCID: PMC7681172 DOI: 10.1017/s1463423620000468] [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: 11/06/2022] Open
Abstract
This study aimed to describe the process of care, assess the quality of care based on defined indicators, and identify challenges associated with providing diabetes care via sub-district health promotion hospital (SHPH) facilities in Thailand. Primary care policy has directed that diabetes care be delivered via SHPH in order to reduce hospital congestion and minimize travel costs for patients. Limited data is available regarding the structure for providing care. Likewise, barriers to delivery of optimal care have not been well defined, especially from the perspective of health care providers. This study employed mixed-methods research, which included semi-structured interviews to gain insights into the current diabetes care process, a descriptive study to evaluate quality of care, and use of a focus group to identify challenges associated with delivery of diabetic care via SHPH. Diabetes care processes in primary care included multiple steps and involved collaboration between various health care providers at both the hospital and SHPH. Four process indicators and one outcome had been achieved but performance of other indicators was apparently low. Three factors were found to pose challenges to providing this service: the resources of the health service, the delivery of services, and patient factors. SHPH require additional support, particularly in the areas of primary care workforce, finance, medical device procurement, and patient information systems. While delivery of diabetes care via primary care centers has been well established in Thailand, regional differences in the quality of care persist. Additional support is required to strengthen the primary care system nationwide.
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Sibounheuang P, Olson PS, Kittiboonyakun P. Patients' and healthcare providers’ perspectives on diabetes management: A systematic review of qualitative studies. Res Social Adm Pharm 2020; 16:854-874. [DOI: 10.1016/j.sapharm.2019.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 08/22/2019] [Accepted: 09/01/2019] [Indexed: 12/23/2022]
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Gucciardi E, Xu C, Vitale M, Lou W, Horodezny S, Dorado L, Sidani S, Shah BR. Evaluating the impact of onsite diabetes education teams in primary care on clinical outcomes. BMC FAMILY PRACTICE 2020; 21:48. [PMID: 32126965 PMCID: PMC7055112 DOI: 10.1186/s12875-020-01111-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 02/13/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND To evaluate the impact of integrating diabetes education teams in primary care on glycemic control, lipid, and blood-pressure management in type 2 diabetes patients. METHODS A historical cohort design was used to assess the integration of teams comprising nurse and dietitian educators in 11 Ontario primary-care sites, which delivered individualized self-management education. Of the 771 adult patients with A1C ≥ 7% recruited, 487 patients attended appointments with the diabetes teams, while the remaining 284 patients did not. The intervention's primary goal was to increase the proportion of patients with A1C ≤7%. Secondary goals were to reduce mean A1C, low-density lipoprotein, total cholesterol-high density lipoprotein, and diastolic and systolic blood pressure, as recommended by clinical-practice guidelines. RESULTS After 12 months, a higher proportion of intervention-group patients reached the target for A1C, compared with the control group. Mean A1C levels fell significantly among all patients, but the mean reduction was larger for the intervention group than the control group. Although more intervention-group patients reached targets for all clinical outcomes, the between-group differences were not statistically significant, except for A1C. CONCLUSIONS Nurse and dietitian diabetes-education teams can have a clinically meaningful impact on patients' ability to meet recommended A1C targets. Given the study's historical cohort design, results are generalizable and applicable to day-to-day primary-care practice. Longer follow-up studies are needed to investigate whether the positive outcomes of the intervention are sustainable.
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Affiliation(s)
- Enza Gucciardi
- grid.68312.3e0000 0004 1936 9422School of Nutrition, Ryerson University, Toronto, ON Canada
| | - Changchang Xu
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- grid.250674.20000 0004 0626 6184Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Modellicity Inc, Toronto, Canada
| | - Michele Vitale
- grid.68312.3e0000 0004 1936 9422Postdoctoral Research Fellow, School of Nutrition, Ryerson University, Toronto, Canada
| | - Wendy Lou
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Stacey Horodezny
- grid.417293.a0000 0004 0459 7334Adult Diabetes Programs, Trillium Health Partners, Mississauga, Canada
| | - Linda Dorado
- grid.68312.3e0000 0004 1936 9422Ryerson University, Toronto, Canada
| | - Souraya Sidani
- grid.68312.3e0000 0004 1936 9422Daphnee Cockwell School of Nursing, Ryerson University, Toronto, Canada
| | - Baiju R. Shah
- grid.17063.330000 0001 2157 2938Department of Medicine, University of Toronto, Toronto, Canada
- grid.413104.30000 0000 9743 1587Division of Endocrinology, Sunnybrook Health Sciences Centre, Toronto, Canada
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Abstract
Patients with stable chronic diseases such as diabetes and hypertension can be safely managed at the primary care level. Yet many such patients continue to follow-up with specialists at a higher expense with no added benefit. We introduce a new term to describe this phenomenon: scope inversion, defined as the provision of primary care by specialist physicians. We aimed to quantify the extent of scope inversion by conducting a systematic review. MEDLINE and five other databases were searched using the keywords 'specialist AND (routine OR primary) AND provi*' as well as other variations. The search was limited to human research without restrictions on language or date of publication. The inclusion criterion was studies on rates of the provision of routine primary care by specialist physicians. Thirteen observational studies met the inclusion criteria. A wide range of primary care involvement was observed among specialists, from 2.6% to 65% of clinic visits. Among children, 41.3% of visits with specialists were routine follow-ups for conditions such as allergic rhinitis and seborrhoeic dermatitis which could be managed in primary care. Data quality was moderate to low across the studies due to limitations of source data and varying definitions of primary care. Specialist physicians provide primary care to patients in a substantial proportion of clinic visits. Scope inversion is wasteful as it diverts patients to more expensive care without improving outcomes. A systems approach is needed to mitigate scope inversion and its harmful effects on healthcare service delivery.
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Affiliation(s)
- Muhammad Jawad Hashim
- Department of Family Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
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Lacasta Tintorer D, Manresa Domínguez JM, Jiménez-Zarco A, Rodríguez-Blanco T, Flayeh Beneyto S, Torán-Monserrat P, Mundet Tuduri X, Saigí-Rubió F. Efficiency as a determinant of loyalty among users of a Community of Clinical Practice: a comparative study between the implementation and consolidation phases. BMC FAMILY PRACTICE 2020; 21:15. [PMID: 31980016 PMCID: PMC6979059 DOI: 10.1186/s12875-020-1081-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/06/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND A community of clinical practice called the Online Communication Tool between Primary and Hospital Care (ECOPIH) was created to enable primary care and specialist care professionals to communicate with each other in order to resolve real clinical cases, thereby improving communication and coordination between care levels. The present work seeks to analyse whether ECOPIH makes it possible to reduce the number of referrals. To that end, the objectives are: (1) To find out the degree of loyalty among ECOPIH users, by comparing the medical professionals' profiles in the tool's implementation phase to those in its consolidation phase. (2) To evaluate the degree of fulfilment of users' expectations, by establishing the determining factors that had an influence on the physicians' intention to use ECOPIH in the implementation phase and observing whether its use had an effective, direct impact on the number of patient referrals that primary care physicians made to specialist care professionals. METHODS Two studies were conducted. Based on a survey of all the physicians in a Primary Care area, Study 1 was a descriptive study in ECOPIH's implementation phase. Study 2 was a randomised intervention study of ECOPIH users in the tool's consolidation phase. The results from both studies were compared. Various bivariate and multivariate statistical techniques (exploratory factor analysis, cluster analysis, logistic regression analysis and ANOVA) were used in both studies, which were conducted on a sample of 111 and 178 physicians, respectively. RESULTS We confirmed the existence of an ECOPIH user profile stable across both phases: under-50-year-old women. Regarding the second objective, there were two particular findings. First, the discriminant factors that had an influence on greater ECOPIH use were habitual Social media website and app use and Perceived usefulness for reducing costs. Second, PC professionals who were ECOPIH members made fewer referrals to SC professionals in Cardiology, Endocrinology and Gastroenterology than older PC professionals who were not ECOPIH members. CONCLUSIONS The use of a community of clinical practice by primary care and specialist care professionals helps to reduce the number of referrals among medical professionals.
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Affiliation(s)
- David Lacasta Tintorer
- Centre d’Atenció Primària Gran Sol, Gerència d’Àmbit d’Atenció Primària Metropolitana Nord, Institut Català de la Salut. Avinguda del Doctor Bassols, 112 - 130, 08914 Badalona, Spain
- Unitat de Suport a la Recerca Metropolitana Nord, IDIAP Jordi Gol, CAP El Maresme. Camí del Mig, 36 planta 4ª, 08303 Mataró, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès. Campus de la UAB, Plaça Cívica, s/n, 08193 Bellaterra, Barcelona, Spain
| | - Josep Maria Manresa Domínguez
- Unitat de Suport a la Recerca Metropolitana Nord, IDIAP Jordi Gol, CAP El Maresme. Camí del Mig, 36 planta 4ª, 08303 Mataró, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès. Campus de la UAB, Plaça Cívica, s/n, 08193 Bellaterra, Barcelona, Spain
| | - Ana Jiménez-Zarco
- Faculty of Economics and Business, Universitat Oberta de Catalunya, Barcelona, Spain
| | - Teresa Rodríguez-Blanco
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès. Campus de la UAB, Plaça Cívica, s/n, 08193 Bellaterra, Barcelona, Spain
- Institut Universitari d’Investigació en Atenció Primària (IDIAP Jordi Gol), Gran Via Corts Catalanes, 587, àtic, 08007 Barcelona, Spain
| | - Souhel Flayeh Beneyto
- Centre d’Atenció Primària Gran Sol, Gerència d’Àmbit d’Atenció Primària Metropolitana Nord, Institut Català de la Salut. Avinguda del Doctor Bassols, 112 - 130, 08914 Badalona, Spain
| | - Pere Torán-Monserrat
- Unitat de Suport a la Recerca Metropolitana Nord, IDIAP Jordi Gol, CAP El Maresme. Camí del Mig, 36 planta 4ª, 08303 Mataró, Spain
- Departament de Ciències Mèdiques, Universitat de Girona, C/ Emili Grahit, 77, 2n, 17003 Girona, Spain
| | - Xavier Mundet Tuduri
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès. Campus de la UAB, Plaça Cívica, s/n, 08193 Bellaterra, Barcelona, Spain
- Unitat de Suport a la Recerca Barcelona Ciutat, IDIAP Jordi Gol, Carrer Sardenya 375, 08025 Barcelona, Spain
| | - Francesc Saigí-Rubió
- Faculty of Health Sciences, Universitat Oberta de Catalunya, Barcelona. Av. Tibidabo, 39-43, 08035 Barcelona, Spain
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Smith TL, Kim B, Benzer JK, Yusuf Z, Fletcher TL, Walder AM. FLOW: Early results from a clinical demonstration project to improve the transition of patients with mental health disorders back to primary care. Psychol Serv 2019; 18:23-32. [PMID: 30869978 DOI: 10.1037/ser0000336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Access to mental health (MH) care is of paramount concern to U.S. health care delivery systems, including the Veterans Health Administration. To improve access, there is a need to better focus existing MH resources toward care for those most in need of specialty-level MH treatment. This article provides early results of Project FLOW's (not an acronym) approach to developing and evaluating electronic medical record (EMR)-based criteria to identify clinically stable patients and promote their effective transition from specialty MH back to primary care (PC). Implementation utilized a blended facilitation approach consistent with Integrated Promoting Action on Research Implementation in Health Services (iPARIHS). The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework guided measurement of implementation outcomes. During FLOW, 424 unique MH patients transitioned from MH to PC; of those, only 9 (2.1%) returned to MH after that transition. Most of those patients (n = 335; 79.0%) were first identified on the MH FLOW report, but 89 (21.0%) were other MH patients. The total number of patients discharged due to recovery or stabilization was 411. The 335 patients represent 21.3% of all unique patients (n = 1,566) who met the EMR criteria during the project. The 411 recovered/stabilized patients are 16.4% of all unique MH patients (n = 2,504) treated at the site. These early results suggest that this EMR-based system, combined with sound clinical practices, can be used to identify MH patients who are candidates for transition and foster their effective transition to care management in PC. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | - Bo Kim
- Veterans Affairs Health Services Research and Development Service Center for Healthcare Organization and Implementation Research
| | - Justin K Benzer
- Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans
| | - Zenab Yusuf
- South Central Mental Illness Research Education and Clinical Care, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Terri L Fletcher
- South Central Mental Illness Research Education and Clinical Care, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Annette M Walder
- South Central Mental Illness Research Education and Clinical Care, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
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Zhang Z, Monro J, Venn BJ. Carbohydrate Knowledge and Expectations of Nutritional Support among Five Ethnic Groups Living in New Zealand with Pre- and Type 2 Diabetes: A Qualitative Study. Nutrients 2018; 10:nu10091225. [PMID: 30181471 PMCID: PMC6163622 DOI: 10.3390/nu10091225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/03/2018] [Accepted: 09/03/2018] [Indexed: 01/29/2023] Open
Abstract
Despite availability of diabetes and nutrition information for people with pre- and type 2 diabetes, the uptake and understanding of these resources may differ among ethnic groups. Our objective was to explore dietary knowledge and diabetes experiences amongst Māori, European, Pacific Island, Indian and East Asian people living in New Zealand with a focus on carbohydrate-containing foods. A registered diabetes dietitian led ethnic-specific discussions in groups involving 29 people with pre- or type 2 diabetes. Discussions were audio-recorded, fully transcribed and coded independently by two investigators. Themes were developed using deductive and inductive techniques. Five themes emerged: knowledge, concerns, achievements, simplicity and self-determination. Nutritional knowledge was lacking and a greater awareness of trustworthy dietary resources was needed. There were concerns about diabetes complications and appropriate carbohydrate-containing foods and portions. Contrary to this, people felt proud when achieving dietary goals and grateful for support from health care providers and family. Participants were willing to engage in self-care if advice from health professionals was given in plain language, and in a culturally appropriate manner. Given the desire to take an active role in diabetes self-management and willingness to use electronic devices, an ethnic-specific nutrition education resource could be a valuable tool.
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Affiliation(s)
- Zhuoshi Zhang
- Department of Human Nutrition, University of Otago, PO Box 56, Dunedin 9054, New Zealand.
| | - John Monro
- New Zealand Institute for Plant & Food Research Ltd., Private Bag 11600, Palmerston North 4442, New Zealand.
| | - Bernard J Venn
- Department of Human Nutrition, University of Otago, PO Box 56, Dunedin 9054, New Zealand.
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Bouchonville MF, Hager BW, Kirk JB, Qualls CR, Arora S. ENDO ECHO IMPROVES PRIMARY CARE PROVIDER AND COMMUNITY HEALTH WORKER SELF-EFFICACY IN COMPLEX DIABETES MANAGEMENT IN MEDICALLY UNDERSERVED COMMUNITIES. Endocr Pract 2018; 24:40-46. [PMID: 29368967 DOI: 10.4158/ep-2017-0079] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine whether participation in a multidisciplinary telementorship model of healthcare delivery improves primary care provider (PCP) and community health worker (CHW) confidence in managing patients with complex diabetes in medically underserved regions. METHODS We applied a well-established healthcare delivery model, Project ECHO (Extension for Community Healthcare Outcomes), to the management of complex diabetes (Endo ECHO) in medically underserved communities. A multidisciplinary team at Project ECHO connected with PCPs and CHWs at 10 health centers across New Mexico for weekly videoconferencing virtual clinics. Participating PCPs and CHWs presented de-identified patients and received best practice guidance and mentor-ship from Project ECHO specialists and network peers. A robust curriculum was developed around clinical practice guidelines and presented by weekly didactics over the ECHO network. After 2 years of participation in Endo ECHO, PCPs and CHWs completed self-efficacy surveys comparing confidence in complex diabetes management to baseline. RESULTS PCPs and CHWs in rural New Mexico reported significant improvement in self-efficacy in all measures of complex diabetes management, including PCP ability to serve as a local resource for other healthcare providers seeking assistance in diabetes care. Overall self-efficacy improved by 130% in CHWs ( P<.0001) and by 60% in PCPs ( P<.0001), with an overall large Cohen's effect size. CONCLUSION Among PCPs and CHWS in rural, medically underserved communities, participation in Endo ECHO for 2 years significantly improved confidence in complex diabetes management. Application of the ECHO model to complex diabetes care may be useful in resource-poor communities with limited access to diabetes specialist services. ABBREVIATIONS CHW = community health worker; CME = Continuing Medical Education; ECHO = Extension for Community Healthcare Outcomes; FQHC = federally qualified health center; PCP = primary care provider.
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18
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Transitioning Patients From Specialty Care to Primary Care: What We Know and What We Can Do. J Ambul Care Manage 2018; 41:314-322. [PMID: 29923847 DOI: 10.1097/jac.0000000000000253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Growing demand for specialty care has resulted in longer wait times for appointments, particularly at US academic referral centers. A proportion of specialty visits are for routine follow-up care of stable problems, and there is evidence that primary care providers are willing and able to take responsibility for a significant proportion of these patients. However, little is known about how to transition care back to a referring primary care clinician in a manner that is acceptable to everyone involved. In this article, we describe social, legal, and financial barriers to effective care transition and propose communication strategies to overcome them.
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19
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Selvig D, Sewell JL, Tuot DS, Day LW. Gastroenterologist and primary care perspectives on a post-endoscopy discharge policy: impact on clinic wait times, provider satisfaction and provider workload. BMC Health Serv Res 2018; 18:16. [PMID: 29321069 PMCID: PMC5763538 DOI: 10.1186/s12913-017-2819-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/22/2017] [Indexed: 11/21/2022] Open
Abstract
Background To reduce unnecessary ambulatory gastroenterology (GI) visits and increase access to GI care, San Francisco Health Network gastroenterologists and primary care providers implemented guidelines in 2013 that discharged certain patients back to primary care after endoscopy with formal written recommendations. This study assesses the longer-term impact of this policy on GI clinic access, workflow, and provider satisfaction. Methods An email-based survey assessed gastroenterologist and primary care provider (PCP) opinions about the discharge process. Administrative data and chart review were used to assess clinic access, intervention fidelity, and re-referral rates. Results 102/299 (34%) of PCPs and 5/7 (71%) of gastroenterologists responded to the survey. 74% of PCPs and 100% of gastroenterologists were satisfied or very satisfied with the discharge process. 80% of gastroenterologists believed the discharge process decreased their workload, while 53.5% of primary care providers believed it increased their workload. 6.7% of patients discharged to primary care in 2013 had re-referrals to GI. Wait time for the third-next-available new outpatient GI clinic appointment had previously decreased from 158 days (2012, pre-intervention) to 74 days (2013, post-intervention). In 2015, wait time was 19 days (p < 0.001 for 2012 vs. 2015). Conclusions Primary care providers and gastroenterologists are satisfied with an intervention to discharge patients from gastroenterology to primary care after certain endoscopic procedures, although this conclusion is limited by a relatively low PCP survey response rate. Discharging appropriate patients using consensus criteria from the gastroenterology clinic was instrumental in sustainably reducing clinic wait times with low re-referral rates. Electronic supplementary material The online version of this article (10.1186/s12913-017-2819-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Selvig
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Justin L Sewell
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Delphine S Tuot
- Division of Nephrology, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.,UCSF Center for Innovation in Access and Quality at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. .,San Francisco General Hospital and Trauma Center, 1001 Potrero Avenue, 3D-5, San Francisco, CA, 94110, USA.
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Kostagiolas P, Kourouthanassis P, Martzoukou K, Korfiatis N, Niakas D. Information seeking behavioural paths of physicians for diabetes mellitus care: a qualitative comparative analysis of information needs, sources, and barriers. Health Syst (Basingstoke) 2018; 7:13-28. [PMID: 31214336 PMCID: PMC6452844 DOI: 10.1080/20476965.2017.1390050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 11/15/2016] [Accepted: 11/19/2016] [Indexed: 10/18/2022] Open
Abstract
This study addresses diabetes physicians' information seeking behavioural paths (digital, conventional, interpersonal) which lead to information needs satisfaction and the barriers encountered in this process. The study was based on empirical evidence from a survey of 159 physicians. Theoretical analysis was informed by Wilson's model of information seeking behaviour. The data were analysed using fuzzy set qualitative comparative analysis method. The method was successful in identifying five behavioural paths leading to physicians' information needs satisfaction (professional/health coaching) which demonstrate different relationships between information sources (conventional/interpersonal/digital) and information barriers (personal/digital illiteracy) and five behavioural paths that are not leading to satisfaction.
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Affiliation(s)
- P.A. Kostagiolas
- Department of Archive and Library Science, Ionian University, Corfu, Greece
| | | | - K. Martzoukou
- Department of Information Management, The Robert Gordon University, Aberdeen, Scotland
| | - N. Korfiatis
- Norwich Business School, University of East Anglia, Norwich, UK
| | - D. Niakas
- Faculty of Social Sciences, Health Care Management, Hellenic Open University, Patras, Greece
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Guthrie E, Afzal C, Blakeley C, Blakemore A, Byford R, Camacho E, Chan T, Chew-Graham C, Davies L, de Lusignan S, Dickens C, Drinkwater J, Dunn G, Hunter C, Joy M, Kapur N, Langer S, Lovell K, Macklin J, Mackway-Jones K, Ntais D, Salmon P, Tomenson B, Watson J. CHOICE: Choosing Health Options In Chronic Care Emergencies. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Elspeth Guthrie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Cara Afzal
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Greater Manchester Academic Health Science Network (GM AHSN), Manchester, UK
| | - Claire Blakeley
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Amy Blakemore
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Rachel Byford
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Elizabeth Camacho
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Tom Chan
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, UK
| | - Linda Davies
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Simon de Lusignan
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Chris Dickens
- Institute of Health Research, Medical School, University of Exeter, Exeter, UK
- Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), University of Exeter, Exeter, UK
| | | | - Graham Dunn
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Cheryl Hunter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mark Joy
- Faculty of Science, Engineering and Computing, Kingston University, London, UK
| | - Navneet Kapur
- Manchester Academic Health Science Centre, Manchester, UK
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Susanne Langer
- Department of Psychology, Manchester Metropolitan University, Manchester, UK
| | - Karina Lovell
- Manchester Academic Health Science Centre, Manchester, UK
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Kevin Mackway-Jones
- Manchester Academic Health Science Centre, Manchester, UK
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Dionysios Ntais
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Peter Salmon
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Barbara Tomenson
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Jennifer Watson
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
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Bouchonville MF, Paul MM, Billings J, Kirk JB, Arora S. Taking Telemedicine to the Next Level in Diabetes Population Management: a Review of the Endo ECHO Model. Curr Diab Rep 2016; 16:96. [PMID: 27549110 DOI: 10.1007/s11892-016-0784-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Worldwide increases in diabetes prevalence in the face of limited medical resources have prompted international interest in innovative healthcare delivery models. Project ECHO (Extension for Community Healthcare Outcomes) is a "telementoring" program which has been shown to increase capacity for complex disease management in medically underserved regions. In contrast to a traditional telemedicine model which might connect a specialist with one patient, the ECHO model allows for multiple patients to benefit simultaneously by building new expertise. We recently applied the ECHO model to improve health outcomes of patients with complex diabetes (Endo ECHO) living in rural New Mexico. We describe the design of the Endo ECHO intervention and a 4-year, prospective program evaluation assessing health outcomes, utilization patterns, and cost-effectiveness. The Endo ECHO evaluation will demonstrate whether and to what extent this intervention improves outcomes for patients with complex diabetes living in rural New Mexico, and will serve as proof-of-concept for academic medical centers wishing to replicate the model in underserved regions around the world.
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Affiliation(s)
- Matthew F Bouchonville
- Division of Endocrinology, Diabetes, and Metabolism, University of New Mexico School of Medicine, Albuquerque, NM, USA.
| | - Margaret M Paul
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - John Billings
- Wagner School of Public Service, New York University, New York, NY, USA
| | - Jessica B Kirk
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Sanjeev Arora
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Morgan HM, Entwistle VA, Cribb A, Christmas S, Owens J, Skea ZC, Watt IS. We need to talk about purpose: a critical interpretive synthesis of health and social care professionals' approaches to self-management support for people with long-term conditions. Health Expect 2016; 20:243-259. [PMID: 27075246 PMCID: PMC5354019 DOI: 10.1111/hex.12453] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2016] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Health policies internationally advocate 'support for self-management', but it is not clear how the promise of the concept can be fulfilled. OBJECTIVE To synthesize research into professional practitioners' perspectives, practices and experiences to help inform a reconceptualization of support for self-management. DESIGN Critical interpretive synthesis using systematic searches of literature published 2000-2014. FINDINGS We summarized key insights from 164 relevant papers in an annotated bibliography. The literature illustrates striking variations in approaches to support for self-management and interpretations of associated concepts. We focused particularly on the somewhat neglected question of the purpose of support. We suggest that this can illuminate and explain important differences between narrower and broader approaches. Narrower approaches support people to manage their condition(s) well in terms of disease control. This purpose can underpin more hierarchical practitioner-patient communication and more limited views of patient empowerment. It is often associated with experiences of failure and frustration. Broader approaches support people to manage well with their condition(s). They can keep work on disease control in perspective as attention focuses on what matters to people and how they can be supported to shape their own lives. Broader approaches are currently less evident in practice. DISCUSSION AND CONCLUSION Broader approaches seem necessary to fulfil the promise of support for self-management, especially for patient empowerment. A commitment to enable people to live well with long-term conditions could provide a coherent basis for the forms and outcomes of support that policies aspire to. The implications of such a commitment need further attention.
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Affiliation(s)
| | | | - Alan Cribb
- Centre for Public Policy Research, King's College London, London, UK
| | - Simon Christmas
- Centre for Public Policy Research, King's College London, London, UK
| | - John Owens
- Centre for Public Policy Research, King's College London, London, UK
| | - Zoë C Skea
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Ian S Watt
- Department of Health Sciences/Hull York Medical School, Faculty of Science, University of York, Heslington, York, UK
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Lutzko OK, Schifferle H, Ariola M, Rich A, Kon KM. Optimizing insulin initiation in primary care: the Diabetes CoStars patient support program. Pragmat Obs Res 2016; 7:3-10. [PMID: 27799841 PMCID: PMC5085308 DOI: 10.2147/por.s94456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the optimization of fasting blood glucose (FBG) levels in patients with type 2 diabetes mellitus newly initiated on insulin glargine who were enrolled in the Australian Diabetes CoStars Patient Support Program (PSP). PATIENTS AND METHODS A retrospective analysis of data from 514 patients with type 2 diabetes mellitus who completed the 12-week Diabetes CoStars PSP was performed. All patients were initiated on insulin glargine in primary care and enrolled by their general practitioner, who selected a predefined titration plan and support from a local Credentialled Diabetes Educator. The data collected included initial and final insulin dose, self-reported FBG, and glycated hemoglobin (A1c) levels. RESULTS The insulin dose increased in 81% of patients. Mean FBG was reduced from 208.8 mg/dL (11.6 mmol/L) to 136.8 mg/dL (7.6 mmol/L) after 12 weeks. Initial and final A1c values were available for 99 patients; mean A1c was reduced from 9.5% (80 mmol/mol) to 8.1% (65 mmol/mol). The reductions in mean FBG and A1c were similar irrespective of titration plan. Overall, 27.2% of patients achieved FBG levels within the titration plan target range of 72-108 mg/dL (4-6 mmol/L) and an additional 43.4% of patients achieved FBG within the range recommended by current Australian guidelines (110-144 mg/dL [6.1-8.0 mmol/L]). Overall, 23.3% of patients achieved the A1c target of ≤7%. CONCLUSION These data demonstrate that the majority of patients enrolled in the Diabetes CoStars PSP achieved acceptable FBG levels 12 weeks after starting insulin therapy irrespective of titration plan.
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Affiliation(s)
| | | | - Marita Ariola
- Innerwest Specialist Centre, Burwood, NSW, Australia
| | | | - Khen Meng Kon
- Sanofi Australia Pty Ltd, Macquarie Park, NSW, Australia
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Doyle MA, Malcolm JC, Liu D, Maranger J, Ooi TC, Keely E. Using a Structured Discharge Letter Template to Improve Communication During the Transition from a Specialized Outpatient Diabetes Clinic to a Primary Care Physician. Can J Diabetes 2015; 39:457-66. [DOI: 10.1016/j.jcjd.2015.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/19/2015] [Accepted: 06/23/2015] [Indexed: 10/22/2022]
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Gucciardi E, Espin S, Morganti A, Dorado L. Implementing Specialized Diabetes Teams in Primary Care in Southern Ontario. Can J Diabetes 2015; 39:467-77. [PMID: 26482885 DOI: 10.1016/j.jcjd.2015.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/14/2015] [Accepted: 07/22/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study explores the implementation processes of integrating specialized diabetes teams into primary care in southern Ontario, Canada. METHODS In-depth qualitative interviews were conducted with 23 patients, 20 diabetes educators and 16 primary care physicians. In addition, group debriefing sessions were conducted and field notes were collected from diabetes educators and diabetes education program managers to further explore the day-to-day issues of implementation. Data were analyzed using an inductive content analysis approach. RESULTS Analysis revealed 3 main themes: Right Place, Right Time, Right Service: the convenience and comfort of local care, timely, preventive management and delivering person-centred care; Creating Partnerships: generating intervention buy-in, formal discussion, service agreements, site orientation and team development; Operational Complexities and Strategies: access to electronic medical records and documentation, referral and scheduling procedures, and costs and resources. CONCLUSIONS Because situating diabetes teams in primary care currently involves using existing healthcare structures and human resources, pragmatic methods of fostering successful implementation of this model of practice are required. The utility of this model was perceived as being viable, and benefits were visible to all study participants. Strategies to facilitate implementation include outlining roles and expectations by educators and the primary care providers' team in the beginning, investment in the intervention by all stakeholders, and clear channels of communication that allow educators to perform their roles and leverage opportunities for team collaboration in patient care. Further evaluation of implementation processes can serve to expand this model of practice, which has proven so far to be favourable to the players involved.
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Affiliation(s)
- Enza Gucciardi
- School of Nutrition, Ryerson University, Toronto, Ontario, Canada.
| | - Sherry Espin
- Ryerson University, Daphne Cockwell School of Nursing, Toronto, Ontario, Canada
| | - Antonia Morganti
- School of Nutrition, Ryerson University, Toronto, Ontario, Canada
| | - Linda Dorado
- School of Nutrition, Ryerson University, Toronto, Ontario, Canada
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Sampson R, Cooper J, Barbour R, Polson R, Wilson P. Patients' perspectives on the medical primary-secondary care interface: systematic review and synthesis of qualitative research. BMJ Open 2015; 5:e008708. [PMID: 26474939 PMCID: PMC4611413 DOI: 10.1136/bmjopen-2015-008708] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To synthesise the published literature on the patient experience of the medical primary-secondary care interface and to determine priorities for future work in this field aimed at improving clinical outcomes. DESIGN Systematic review and metaethnographic synthesis of primary studies that used qualitative methods to explore patients' perspectives of the medical primary-secondary care interface. SETTING International primary-secondary care interface. DATA SOURCES EMBASE, MEDLINE, CINAHL Plus with Full text, PsycINFO, Psychology and Behavioural Sciences Collection, Health Business Elite, Biomedica Reference Collection: Comprehensive Library, Information Science & Technology Abstracts, eBook Collection, Web of Science Core Collection: Citation Indexes and Social Sciences Citation Index, and grey literature. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies were eligible for inclusion if they were full research papers employing qualitative methodology to explore patients' perspectives of the medical primary-secondary care interface. REVIEW METHODS The 7-step metaethnographic approach described by Noblit and Hare, which involves cross-interpretation between studies while preserving the context of the primary data. RESULTS The search identified 690 articles, of which 39 were selected for full-text review. 20 articles were included in the systematic review that encompassed a total of 689 patients from 10 countries. 4 important areas specific to the primary-secondary care interface from the patients' perspective emerged: barriers to care, communication, coordination, and 'relationships and personal value'. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Patients should be the focus of any transfer of care between primary and secondary systems. From their perspective, areas for improvement may be classified into four domains that should usefully guide future work aimed at improving quality at this important interface. TRIAL REGISTRATION NUMBER PROSPERO CRD42014009486.
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Affiliation(s)
| | | | | | - Rob Polson
- Highland Health Sciences Library, Centre for Health Science, Inverness, UK
| | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, The Centre for Health Science, Inverness, UK
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Niv Y, Dickman R, Levi Z, Neumann G, Ehrlich D, Bitterman H, Dreiher J, Cohen A, Comaneshter D, Halpern E. Establishing an integrated gastroenterology service between a medical center and the community. World J Gastroenterol 2015; 21:2152-8. [PMID: 25717251 PMCID: PMC4326153 DOI: 10.3748/wjg.v21.i7.2152] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 07/18/2014] [Accepted: 09/05/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established. METHODS Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators. RESULTS An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer. CONCLUSION Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.
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Moore JE, Mascarenhas A, Marquez C, Almaawiy U, Chan WH, D'Souza J, Liu B, Straus SE. Mapping barriers and intervention activities to behaviour change theory for Mobilization of Vulnerable Elders in Ontario (MOVE ON), a multi-site implementation intervention in acute care hospitals. Implement Sci 2014; 9:160. [PMID: 25928538 PMCID: PMC4225038 DOI: 10.1186/s13012-014-0160-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 10/16/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND As evidence-informed implementation interventions spread, they need to be tailored to address the unique needs of each setting, and this process should be well documented to facilitate replication. To facilitate the spread of the Mobilization of Vulnerable Elders in Ontario (MOVE ON) intervention, the aim of the current study is to develop a mapping guide that links identified barriers and intervention activities to behaviour change theory. METHODS Focus groups were conducted with front line health-care professionals to identify perceived barriers to implementation of an early mobilization intervention targeted to hospitalized older adults. Participating units then used or adapted intervention activities from an existing menu or developed new activities to facilitate early mobilization. A thematic analysis was performed on the focus group data, emphasizing concepts related to barriers to behaviour change. A behaviour change theory, the 'capability, opportunity, motivation-behaviour (COM-B) system', was used as a taxonomy to map the identified barriers to their root causes. We also mapped the behaviour constructs and intervention activities to overcome these. RESULTS A total of 46 focus groups were conducted across 26 hospital inpatient units in Ontario, Canada, with 261 participants. The barriers were conceptualized at three levels: health-care provider (HCP), patient, and unit. Commonly mentioned barriers were time constraints and workload (HCP), patient clinical acuity and their perceived 'sick role' (patient), and lack of proper equipment and human resources (unit level). Thirty intervention activities to facilitate early mobilization of older adults were implemented across hospitals; examples of unit-developed intervention activities include the 'mobility clock' communication tool and the use of staff champions. A mapping guide was created with barriers and intervention activities matched though the lens of the COM-B system. CONCLUSIONS We used a systematic approach to develop a guide, which maps barriers, intervention activities, and behaviour change constructs in order to tailor an implementation intervention to the local context. This approach allows implementers to identify potential strategies to overcome local-level barriers and to document adaptations.
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Affiliation(s)
- Julia E Moore
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Alekhya Mascarenhas
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Christine Marquez
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Ummukulthum Almaawiy
- Regional Geriatric Program of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3 M5, Canada.
| | - Wai-Hin Chan
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Jennifer D'Souza
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Barbara Liu
- Regional Geriatric Program of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3 M5, Canada. .,Department of Medicine, Faculty of Medicine, University of Toronto, 1 King's College Circle, Medical Sciences Building, Toronto, ON, M5S 1A8, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada. .,Department of Medicine, Faculty of Medicine, University of Toronto, 1 King's College Circle, Medical Sciences Building, Toronto, ON, M5S 1A8, Canada.
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Dutton H, Rowan MS, Liddy C, Maranger J, Ooi TC, Malcolm J, Keely E. Patient Perspectives on Discharge from Specialist Type 2 Diabetes Care Back to Primary Care: A Qualitative Study. Can J Diabetes 2014; 38:191-7. [DOI: 10.1016/j.jcjd.2013.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/22/2013] [Accepted: 10/25/2013] [Indexed: 11/17/2022]
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Guidoni CM, Borges APDS, Freitas OD, Pereira LRL. Analysis of treatment of comorbidities and the profile of medical consultations for diabetes mellitus. CIENCIA & SAUDE COLETIVA 2013; 18:3015-22. [PMID: 24061028 DOI: 10.1590/s1413-81232013001000026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 05/28/2012] [Indexed: 11/22/2022] Open
Abstract
The scope of this paper was to analyze the profile of medical consultations and drugs used for the treatment of comorbidities in patients with diabetes attended in the Brazilian Unified Health System. This was a pharmaco-epidemiological cross-sectional study conducted between March 2006 and February 2007 All patients with diabetes attended in the western sanitary district of Ribeirao Preto in the state of São Paulo were included in the study. The types of medical attendance (primary, secondary and emergency care) and the drugs prescribed for the treatment of comorbidities were analyzed. The drugs were classified according to the Anatomical Therapeutic Chemical Classification System and 3,198 patients were identified. The mean age was 60.4 years and more than 55% of the patients were 60 years or older. The cardiovascular drugs most used were captopril or enalapril (60%). About 40.6% of the patients used acetylsalicylic acid in platelet antiaggregant doses. The patients had an average of 5.1 medical consultations per year (primary care, secondary care and emergency care). The utilization of statins and acetylsalicylic acid was less than that reported in the literature and the data indicate a high prevalence of admission to emergency care.
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Winsor S, Smith A, Vanstone M, Giacomini M, Brundisini FK, DeJean D. Experiences of patient-centredness with specialized community-based care: a systematic review and qualitative meta-synthesis. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2013; 13:1-33. [PMID: 24228080 PMCID: PMC3817855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Specialized community-based care (SCBC) endeavours to help patients manage chronic diseases by formalizing the link between primary care providers and other community providers with specialized training. Many types of health care providers and community-based programs are employed in SCBC. Patient-centred care focuses on patients' psychosocial experience of health and illness to ensure that patients' care plans are modelled on their individual values, preferences, spirituality, and expressed needs. OBJECTIVES To synthesize qualitative research on patient and provider experiences of SCBC interventions and health care delivery models, using the core principles of patient-centredness. DATA SOURCES This report synthesizes 29 primary qualitative studies on the topic of SCBC interventions for patients with chronic conditions. Included studies were published between 2002 and 2012, and followed adult patients in North America, Europe, Australia, and New Zealand. REVIEW METHODS Qualitative meta-synthesis was used to integrate findings across primary research studies. RESULTS Three core themes emerged from the analysis: patients' health beliefs affect their participation in SCBC interventions;patients' experiences with community-based care differ from their experiences with hospital-based care;patients and providers value the role of nurses differently in community-based chronic disease care. LIMITATIONS Qualitative research findings are not intended to generalize directly to populations, although meta-synthesis across several qualitative studies builds an increasingly robust understanding that is more likely to be transferable. The diversity of interventions that fall under SCBC and the cross-interventional focus of many of the studies mean that findings might not be generalizable to all forms of SCBC or its specific components. CONCLUSIONS Patients with chronic diseases who participated in SCBC interventions reported greater satisfaction when SCBC helped them better understand their diagnosis, facilitated increased socialization, provided them with a role in managing their own care, and assisted them in overcoming psychological and social barriers. PLAIN LANGUAGE SUMMARY More and more, to reduce bed shortages in hospitals, health care systems are providing programs called specialized community-based care (SCBC) to patients with chronic diseases. These SCBC programs allow patients with chronic diseases to be managed in the community by linking their family physicians with other community-based health care providers who have specialized training. This report looks at the experiences of patients and health care providers who take part in SCBC programs, focusing on psychological and social factors. This kind of lens is called patient-centred. Three themes came up in our analysis: patients' health beliefs affect how they take part in SCBC interventions; patients' experiences with care in the community differ from their experiences with care in the hospital; patients and providers value the role of nurses differently. The results of this analysis could help those who provide SCBC programs to better meet patients' needs.
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Raaijmakers LGM, Hamers FJM, Martens MK, Bagchus C, de Vries NK, Kremers SPJ. Perceived facilitators and barriers in diabetes care: a qualitative study among health care professionals in the Netherlands. BMC FAMILY PRACTICE 2013; 14:114. [PMID: 23937325 PMCID: PMC3751909 DOI: 10.1186/1471-2296-14-114] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 08/06/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The need to understand barriers to the implementation of health care innovations in daily practice has been widely documented, but perceived facilitators and barriers in diabetes care by Dutch health care professionals remain unknown. The aim of this study was to investigate these factors among health care professionals (HCPs) using a qualitative research design. METHODS Data were collected from 18 semi-structured interviews with HCPs from all professions relevant to diabetes care. The interviews were recorded and transcribed verbatim and the data were analyzed using NVivo 8.0. RESULTS Major facilitators were the more prominent role of the practice nurses and diabetes nurses in diabetes care, benchmarking, the Care Standard (CS) of the Netherlands Diabetes federation and multidisciplinary collaboration, although collaboration with certain professional groups (i.e. dieticians, physical therapists and pharmacists), as well as the collaboration between primary and secondary care, could still be improved. The bundled payment system for the funding of diabetes care and the role of the health insurers were perceived as major barriers within the health care system. Other important barriers were reported to be the lack of motivation among patients and the lack of awareness of lifestyle programs and prevention initiatives for diabetes patients among professionals. CONCLUSIONS Organizational changes in diabetes care, as a result of the increased attention given to management continuity of care, have led to an increased need for multidisciplinary collaboration within and between health care sectors (e.g. public health, primary care and secondary care). To date, daily routines for shared care are still sub-optimal and improvements in facilities, such as registration systems, should be implemented to further optimize communication and exchange of information.
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Affiliation(s)
- Lieke GM Raaijmakers
- Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Femke JM Hamers
- Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | | | - Charlotte Bagchus
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | - Nanne K de Vries
- Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, P.O. Box 616, 6200 MD Maastricht, The Netherlands
- Caphri, School for Primary Care and Public Health, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Stef PJ Kremers
- Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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Mandrik O, Severens JL, Doroshenko O, Pan'kiv V, Kravchun N, Vlasenko M, Hulchiy M, Baljuk M, Komisarenko Y, Martsynik E, Sokolova L, Zalis'ka O, Mankovsky B. Impact of hypoglycemia on daily life of type 2 diabetes patients in Ukraine. J Multidiscip Healthc 2013; 6:249-57. [PMID: 23874102 PMCID: PMC3712743 DOI: 10.2147/jmdh.s39133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This study evaluates the impact of hypoglycemia on the lives of Ukrainian patients with type 2 diabetes mellitus. The secondary objective was to explore patient-physician relationships and the attitudes of patients towards various informational resources on diabetes management. Three focus groups with 26 patients were conducted. Qualitative information was evaluated using content analysis. The results show that patients with type 2 diabetes mellitus in Ukraine are adapting to potential attacks of hypoglycemia; however, they still experience periodic manifestations of hypoglycemia that significantly affect their psychological well-being. This result is similar to observations made in other countries. Ukrainian patients >40 years old mainly receive information on disease management from endocrinologists, and rarely use internet resources on diabetes management. Information provision was especially important at the early stage of the disease, when patients lack information on hypoglycemia manifestations and could therefore fail to identify and manage it properly.
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Affiliation(s)
- Olena Mandrik
- Erasmus University Rotterdam, Rotterdam, the Netherlands ; Danylo Halytsky Lviv National Medical University, Lviv ; MSD Ukraine
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Langer S, Chew-Graham C, Hunter C, Guthrie EA, Salmon P. Why do patients with long-term conditions use unscheduled care? A qualitative literature review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2013; 21:339-351. [PMID: 23009718 PMCID: PMC3796281 DOI: 10.1111/j.1365-2524.2012.01093.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Unscheduled care (UC) refers to non-routine face-to-face care, such as accident and emergency care, out-of-hours care, or walk-in centres. Current health service policy aims to reduce its use. Unscheduled care is common in people with long-term conditions such as diabetes, asthma, chronic obstructive pulmonary disease and coronary heart disease. By reviewing qualitative research literature, we aimed to understand the breadth of psychosocial and other influences on UC use in people with long-term conditions. Few qualitative papers specifically address UC in patients in these disease groups. Therefore, our literature search also included qualitative research that explored factors potentially relevant to UC use, including attitudes to healthcare use in general. By searching Medline, Embase, Psycinfo and Cinahl from inception to 2011, we identified 42 papers, published since 1984, describing relevant original research and took a meta-ethnographic approach in reviewing them. The review was conducted between Spring 2009 and April 2011, with a further search in December 2011. Most papers reported on asthma (n = 13) or on multiple or unspecified conditions (n = 12). The most common methods reported were interviews (n = 33) and focus groups (n = 13), and analyses were generally descriptive. Theoretical and ethical background was rarely explicit, but the implicit starting point was generally the 'problem' of UC, and health-care, use in general, decontextualised from the lives of the patients using it. Patients' use of UC emerged as understandable, rational responses to pressing clinical need in situations in which patients thought it the only option. This belief reflected the value that they had learned to attach to UC versus routine care through previous experiences. For socially or economically marginalised patients, UC offered access to clinical or social care that was otherwise unavailable to them.
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Affiliation(s)
- Susanne Langer
- Mental and Behavioural Health Sciences, Institute of Psychology, Health and Society, University of Liverpool, UK.
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Wu EQ, Zhou S, Yu A, Lu M, Sharma H, Gill J, Graf T. Outcomes associated with insulin therapy disruption after hospital discharge among patients with type 2 diabetes mellitus who had used insulin before and during hospitalization. Endocr Pract 2013; 18:651-9. [PMID: 22440990 DOI: 10.4158/ep11314.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate outcomes associated with insulin therapy disruption after hospital discharge in patients with type 2 diabetes mellitus who had used insulin before and during hospitalization. METHODS In this observational, retrospective analysis of medical records obtained from a coordinated health system in the United States, patients with type 2 diabetes mellitus who had used insulin 30 days before and during hospitalization were included. Clinical and cost outcomes were compared between patients who continued insulin therapy and those who had disrupted insulin therapy after hospital discharge. RESULTS In total, 2160 records were analyzed (851 patients with continued insulin therapy and 1309 patients with disrupted insulin therapy). Mean baseline glycated hemoglobin A1c levels were 8.56% and 7.73% in patients who continued insulin therapy and patients who disrupted insulin therapy, respectively (P<.001), suggesting that patients who discontinued insulin therapy had better glycemic control at baseline. Continued insulin therapy was associated with an expected greater reduction in glycated hemoglobin A1c (P<.001); similar hypoglycemia rates; lower risks of all-cause hospital readmission, diabetes-related readmission, and all-cause emergency department visits; and improved survival. Continued insulin therapy was associated with $3432 lower total medical service costs than disrupted therapy over the 6-month postdischarge period. CONCLUSION Ensuring adherence to insulin therapy in patients who require insulin therapy after hospitalization should be a priority for postdischarge patient care programs. However, the clinical implications of this study are limited by the fact that it could not be determined whether all patients required insulin therapy after hospital discharge.
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Affiliation(s)
- Eric Q Wu
- Analysis Group, Boston, Massachusetts, 02199, USA.
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Lauvergeon S, Burnand B, Peytremann-Bridevaux I. Chronic disease management: a qualitative study investigating the barriers, facilitators and incentives perceived by Swiss healthcare stakeholders. BMC Health Serv Res 2012; 12:176. [PMID: 22726820 PMCID: PMC3483191 DOI: 10.1186/1472-6963-12-176] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 06/22/2012] [Indexed: 11/22/2022] Open
Abstract
Background Chronic disease management has been implemented for some time in several countries to tackle the increasing burden of chronic diseases. While Switzerland faces the same challenge, such initiatives have only emerged recently in this country. The aim of this study is to assess their feasibility, in terms of barriers, facilitators and incentives to participation. Methods To meet our aim, we used qualitative methods involving the collection of opinions of various healthcare stakeholders, by means of 5 focus groups and 33 individual interviews. All the data were recorded and transcribed verbatim. Thematic analysis was then performed and five levels were determined to categorize the data: political, financial, organisational/ structural, professionals and patients. Results Our results show that, at each level, stakeholders share common opinions towards the feasibility of chronic disease management in Switzerland. They mainly mention barriers linked to the federalist political organization as well as to financing such programs. They also envision difficulties to motivate both patients and healthcare professionals to participate. Nevertheless, their favourable attitudes towards chronic disease management as well as the fact that they are convinced that Switzerland possesses all the resources (financial, structural and human) to develop such programs constitute important facilitators. The implementation of quality and financial incentives could also foster the participation of the actors. Conclusions Even if healthcare stakeholders do not have the same role and interest regarding chronic diseases, they express similar opinions on the development of chronic disease management in Switzerland. Their overall positive attitude shows that it could be further implemented if political, financial and organisational barriers are overcome and if incentives are found to face the scepticism and non-motivation of some stakeholders.
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Affiliation(s)
- Stéphanie Lauvergeon
- Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
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Kerlan V, Vergès B, Tawil C, Lahrichi N, Doucet J. Insulin initiation in elderly patients with type 2 diabetes in France: a subpopulation of the LIGHT study. Curr Med Res Opin 2012; 28:503-11. [PMID: 22313153 DOI: 10.1185/03007995.2012.664549] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the management of basal insulin analogue initiation in combination with oral antidiabetic drug (OAD) therapy in elderly patients with type 2 diabetes (aged ≥70 years) by physicians via comparison to the same treatment strategy in younger individuals (<70 years). METHODS This subanalysis of a longitudinal observational study took place in a clinical setting across 761 health centres in France. A total of 1802 patients with type 2 diabetes (519 aged ≥70 years and 1283 aged <70 years) participated. The primary endpoint of this study was to assess the management of basal insulin analogue initiation along with OADs in elderly patients (aged ≥70 years) by physicians. Secondary endpoints included HbA(1c), percentage of patients achieving HbA(1c) target (<7.0%), fasting plasma glucose, weight change (kg) and hypoglycaemia. RESULTS The initial mean (standard deviation [SD]) basal insulin analogue dose was similar in the elderly and younger patient subgroups (0.18 [0.09] IU/kg vs. 0.18 [0.11] IU/kg, respectively; not significant [NS]). The mean (SD) number of injections per day was also comparable between age groups (1 [0.2] per day vs. 1 [0.3] per day, respectively for elderly and younger patients; NS). Three months after initiation of long-acting insulin analogue therapy, 3.5% (n = 18) of elderly patients ceased insulin treatment. At study end, the mean (SD) HbA(1c) for elderly patients was 7.6% (0.9%), and for younger patients it was 7.5% (0.9%). Also, the rate of overall hypoglycaemia was comparable in the elderly and younger patients (0.38 [1.2] events/patient/month vs. 0.35 [1.0] events/patient/month, respectively; NS). Limitations of this study include the possibility of inaccurate patient recall of hypoglycaemic events and deficiencies in the adverse events reporting system. CONCLUSION Basal insulin analogues were successfully initiated in elderly patients in combination with OAD therapies and were shown to provide effective glycaemic control. Levels of hypoglycaemia were also similar to those seen in younger patients.
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Affiliation(s)
- Véronique Kerlan
- Centre Hospitalier Universitaire La Cavale Blanche, Brest, France.
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Vergès B, Brun JM, Tawil C, Alexandre B, Kerlan V. Strategies for insulin initiation: insights from the French LIGHT observational study. Diabetes Metab Res Rev 2012; 28:97-105. [PMID: 22218757 DOI: 10.1002/dmrr.1288] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The progressive nature of type 2 diabetes necessitates exogenous insulin use for most patients; basal insulin plus oral anti-diabetes drugs (OADs) is a well-validated way to facilitate insulin initiation. The primary aim of this study was to explore insulin initiation strategies and outcomes for patients using insulin detemir or glargine plus oral anti-diabetes drugs. METHODS LIGHT was a 3-month, longitudinal observational study conducted across 761 French centres in insulin-naïve type 2 diabetes patients managed under routine clinical care conditions, in either primary or secondary care. Endpoints included changes in HbA(1c) , fasting plasma glucose (FPG), rate of hypoglycaemia, weight, and adverse events. RESULTS Most physicians initiated a basal analogue to improve glycaemic control (97%), with many delaying beginning treatment for several months (9 ± 9.0 months for general practitioners, 10.2 ± 16.2 months for specialists). Most patients continued oral anti-diabetes drug therapy (95%) and lifestyle measures (92%), with 2-3 blood glucose readings per day and follow-up telephone calls for dose optimization. Mean change in HbA(1c) from baseline was - 1.3%, and - 3.1 mmol/L for fasting plasma glucose (both p < 0.0001). Hypoglycaemia increased from 1.4 to 5.6 events/patient/year (p < 0.0001), and weight decreased on average by 0.5 kg with detemir, with no change in glargine. Most patients (93%) reported being satisfied or very satisfied with their insulin. CONCLUSIONS Insulin initiation with detemir or glargine can be successfully managed in both primary and secondary care; the benefits of basal analogues (once-daily dosing, low rates of hypoglycaemia compared with neutral protamine Hagedorn) may have contributed to patient acceptance of the regimen.
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Ghaznavi K, Malik S. Provider and systems factors in diabetes quality of care. Curr Cardiol Rep 2011; 14:97-105. [PMID: 22173711 DOI: 10.1007/s11886-011-0234-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A gap exists in knowledge and the observed frequency with which patients with diabetes actually receive treatment for optimal cardiovascular risk reduction. Many interventions to improve quality of care have been targeted at the health systems level and provider organizations. Changes in several domains of care and investment in quality by organizational leaders are needed to make long-lasting improvements. In the studies reviewed, the most effective strategies often have multiple components, whereas the use of one single strategy, such as reminders only or an educational intervention, is less effective. More studies are needed to examine the effect of several care management strategies simultaneously, such as use of clinical information systems, provider financial incentives, and organizational model on processes of care and outcomes.
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Affiliation(s)
- Kimia Ghaznavi
- Division of Cardiology, Department of Medicine, University of California, Irvine, 101 City Drive South, Orange, CA 92868, USA
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Abstract
Type 2 diabetes is a disorder of glucose and lipid metabolism associated with increased risk of macrovascular and microvascular complications. The primary focus of treating type 2 diabetes is glycemic control; simultaneous management of cardiometabolic risk factors, including blood pressure, lipid profile and overweight/obesity, has been shown to improve outcomes. All patients with diabetes require individualized combination therapy including diet and exercise intervention to help prevent microvascular and macrovascular complications. Because primary care physicians in the United States provide the majority of care for patients with type 2 diabetes, this article discusses the management of cardiovascular risk with a specific focus on primary care. In addition, mechanisms by which existing and novel antidiabetes therapies may modulate the metabolic pathways and a review of the benefits of cardiovascular risk reduction using multifactorial, primary care-focused intervention strategies will be discussed. Finally, early- and late-stage disease management strategies are discussed.
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Gucciardi E, Chan VWS, Fortugno M, Khan S, Horodezny S, Swartzack SJ. Primary Care Physician Referral Patterns to Diabetes Education Programs in Southern Ontario, Canada. Can J Diabetes 2011. [DOI: 10.1016/s1499-2671(11)53009-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Cuddihy RM, Philis-Tsimikas A, Nazeri A. Type 2 Diabetes Care and Insulin Intensification. DIABETES EDUCATOR 2010; 37:111-23. [DOI: 10.1177/0145721710388426] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this study was to investigate the opinions of primary care physicians (PCPs) and diabetes specialists on their perceived role in tackling type 2 diabetes (T2D) and the challenges they face, particularly regarding insulin intensification. Methods Six hundred physicians from Germany, Japan, Spain, Turkey, the United Kingdom, and the United States were recruited to complete an online survey. Screening criteria included T2D patients seen per week (Europe/Japan: all ≥2; United States: PCPs ≥5; specialists ≥10) and years in practice (3—30 years). Results Most physicians had seen an increase in TD2 patients in the past 5 years, and almost all agreed that the burden of diabetes is increasing. Notable proportions of PCPs never initiate/modify insulin and never/rarely intensify insulin. Main barriers to insulin intensification cited were lack of experience and lack of time to educate patients. Better collaboration between primary and secondary care was considered one of the most important factors in improving insulin treatment of T2D. Conclusions PCPs are less involved in the initiation and intensification of insulin than specialists; however, all physicians appreciate the need for increased PCP involvement. A multidisciplinary approach that includes using the skills of diabetes educators will assist physicians in improving management of T2D.
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Affiliation(s)
| | | | - A. Nazeri
- Global Medical Affairs, Novo Nordisk A/S, Bagsvaerd,
Denmark
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Le Floch JP. Critical appraisal of the safety and efficacy of insulin detemir in glycemic control and cardiovascular risk management in diabetics. Diabetes Metab Syndr Obes 2010; 3:197-213. [PMID: 21437089 PMCID: PMC3047990 DOI: 10.2147/dmsott.s7315] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Insulin detemir is an analog of human insulin designed to provide a long duration of basal insulin action. This is achieved by protracted absorption from the injection depot, which results in part from increased self-association of insulin detemir molecules and in part from reversible albumin binding. Subsequent albumin binding in the circulation is thought to buffer changes in the effects at target tissues that could otherwise arise from variability in absorption rate. In consequence, insulin detemir has shown a less variable pharmacodynamic profile than alternative basal insulins; this manifests as more consistent temporal glucose reduction profiles in repeat-clamp studies. In clinical trials, insulin detemir has been characterized by consistent risk reductions in hypoglycemia, as well as reduced weight gain in comparison with other basal insulins. Given some recent associations that have been made in prospective and epidemiologic studies between glucose variability and/or hypoglycemia and increased cardiovascular risk, and the long-known association between excess weight and cardiovascular risk, it is possible that the clinical profile of insulin detemir may carry prognostic value with regard to cardiovascular safety, although this is yet to be substantiated. There have also been some concerns raised recently over the use of insulin analogs and cancer risk, but available clinical data and the receptor interaction profile of insulin detemir suggest no excess in risk in comparison with human insulin therapy. Optimal approaches for the clinical use of insulin detemir have been emerging through an increasing clinical study base, and the analog is becoming established as a potentially valuable therapy option.
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Affiliation(s)
- Jean-Pierre Le Floch
- Correspondence: Jean-Pierre Le Floch, Department of Diabetology, Medical Clinic, 8 Boulevard Richerand, 94440 Villecresnes, France, Tel +33 145 955 757, Fax +33 145 697 584, Email
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