Evaluation of the implementation of an integrated primary care network for prevention and management of cardiometabolic risk in Montréal

Effects on patients of variations in the implementation of a cardiometabolic risk intervention program in Montréal

INTRODUCTION

In 2011, the Agence de la santé et des services sociaux de Montréal (ASSSM), in partnership with the region's Centres de santé et de services sociaux (CSSS), coordinated the implementation of a program on cardiometabolic risk based on the Chronic Care Model. The program, intended for patients suffering from diabetes or hypertension, involved a series of individual follow-up appointments, group classes and exercise sessions. Our study assesses the impact on patient health outcomes of variations in the implementation of some aspects of the program among the six CSSSs taking part in the study.

METHODS

The evaluation was carried out using a quasi-experimental "before and after" design. Implementation variables were constructed based on data collected during the implementation analysis regarding resources, compliance with the clinical process set out in the regional program, the program experience and internal coordination within the care team. Differences in differences using propensity scores were calculated for HbA1c results, achieving the blood pressure (BP) target, and two lifestyle targets (exercise level and carbohydrate distribution) at the 6- and 12-month follow-ups, based on greater or lesser patient exposure to the implementation of various aspects of the program under study.

RESULTS

The results focus on 1185 patients for whom we had data at the 6-month follow- up and the 992 patients from the 12-month follow-up. The difference in differences analysis shows no clear association between the extent of implementation of the various aspects of the program under study and patient health outcomes.

CONCLUSION

The program produces effects on selected health indicators independent of variations in program implementation among the CSSSs taking part in the study. The results suggest that the effects of this type of program are more highly dependent on the delivery of interventions to patients than on the organizational aspects of its implementation.

Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes?

INTRODUCTION

Chronic disease management requires substantial services integration. A cardiometabolic risk management program inspired by the Chronic Care Model was implemented in Montréal for patients with diabetes or hypertension. One of this study's objectives was to assess the impact of care coordination between the interdisciplinary teams and physicians on patient participation in the program, lifestyle improvements and disease control.

METHODS

We obtained data on health outcomes from a register of clinical data, questionnaires completed by patients upon entry into the program and at the 12-month mark, and we drew information on the program's characteristics from the implementation analysis. We conducted multiple regression analyses, controlling for patient sociodemographic and health characteristics, to measure the association between interdisciplinary team coordination with primary care physicians and various health outcomes.

RESULTS

A total of 1689 patients took part in the study (60.1% participation rate). Approximately 40% of patients withdrew from the program during the first year. At the 12-month follow-up (n = 992), we observed a significant increase in the proportion of patients achieving the various clinical targets. The perception by the interdisciplinary team of greater care coordination with primary care physicians was associated with increased participation in the program and the achievement of better clinical results.

CONCLUSION

Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.

The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting

Background

Seven chronic disease prevention and management programs were implemented across Quebec with funding support from a provincial-private industry funding initiative. Given the complexity of implementing integrated primary care chronic disease management programs, a knowledge transfer meeting was held to share experiences across programs and synthesize common challenges and success factors for implementation.

Methods

The knowledge translation meeting was held in February 2014 in Montreal, Canada. Seventy-five participants consisting of 15 clinicians, 14 researchers, 31 knowledge users, and 15 representatives from the funding agencies were broken up into groups of 10 or 11 and conducted a strengths, weaknesses, opportunities, and threats analysis on either the implementation or the evaluation of these chronic disease management programs. Results were reported back to the larger group during a plenary and recorded. Audiotapes were transcribed and summarized using pragmatic thematic analysis.

Results and discussion

Strengths to leverage for the implementation of the seven programs include: (1) synergy between clinical and research teams; (2) stakeholders working together; (3) motivation of clinicians; and (4) the fact that the programs are evidence-based. Weaknesses to address include: (1) insufficient resources; (2) organizational change within the clinical sites; (3) lack of referrals from primary care physicians; and (4) lack of access to programs. Strengths to leverage for the evaluation of these programs include: (1) engagement of stakeholders and (2) sharing of knowledge between clinical sites. Weaknesses to address include: (1) lack of referrals; (2) difficulties with data collection; and (3) difficulties in identifying indicators and control groups. Opportunities for both themes include: (1) fostering new and existing partnerships and stakeholder relations; (2) seizing funding opportunities; (3) knowledge transfer; (4) supporting the transformation of professional roles; (5) expand the use of health information technology; and (6) conduct cost evaluations. Fifteen recommendations related to mobilisation of primary care physicians, support for the transformation of professional roles, and strategies aimed at facilitating the implementation and evaluation of chronic disease management programs were formulated based on the discussions at this knowledge translation event.

Conclusion

The results from this knowledge translation day will help inform the sustainability of these seven chronic disease management programs in Quebec and the implementation and evaluation of similar programs elsewhere.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1514-0) contains supplementary material, which is available to authorized users.

Identification, summary and comparison of tools used to measure organizational attributes associated with chronic disease management within primary care settings

RATIONALE, AIMS AND OBJECTIVES

Given the increasing emphasis being placed on managing patients with chronic diseases within primary care, there is a need to better understand which primary care organizational attributes affect the quality of care that patients with chronic diseases receive. This study aimed to identify, summarize and compare data collection tools that describe and measure organizational attributes used within the primary care setting worldwide.

METHODS

Systematic search and review methodology consisting of a comprehensive and exhaustive search that is based on a broad question to identify the best available evidence was employed.

RESULTS

A total of 30 organizational attribute data collection tools that have been used within the primary care setting were identified. The tools varied with respect to overall focus and level of organizational detail captured, theoretical foundations, administration and completion methods, types of questions asked, and the extent to which psychometric property testing had been performed. The tools utilized within the Quality and Costs of Primary Care in Europe study and the Canadian Primary Health Care Practice-Based Surveys were the most recently developed tools. Furthermore, of the 30 tools reviewed, the Canadian Primary Health Care Practice-Based Surveys collected the most information on organizational attributes.

CONCLUSIONS

There is a need to collect primary care organizational attribute information at a national level to better understand factors affecting the quality of chronic disease prevention and management across a given country. The data collection tools identified in this review can be used to establish data collection strategies to collect this important information.

Improving the prevention of cardiovascular disease in primary health care: the model for prevention study protocol

Background

Cardiovascular disease (CVD) is the leading cause of death globally, and accounted for nearly 31% of all deaths in Australia in 2011. The primary health care sector is at the frontline for addressing CVD, however, an evidence-to-practice gap exists in CVD risk assessment and management. General practice plays a key role in CVD risk assessment and management, but this sector cannot provide ongoing lifestyle change support in isolation. Community-based lifestyle modification services and programs provided outside the general practice setting have a key role in supporting and sustaining health behavior change. Fostering linkages between the health sector and community-based lifestyle services, and creating sustainable systems that support these sectors is important.

Objective

The objective of the study Model for Prevention (MoFoP) is to take a case study approach to examine a CVD risk reduction intervention in primary health care, with the aim of identifying the key elements required for an effective and sustainable approach to coordinate CVD risk reduction across the health and community sectors. These elements will be used to consider a new systems-based model for the prevention of CVD that informs future practice.

Methods

The MoFoP study will use a mixed methods approach, comprising two complementary research elements: (1) a case study, and (2) a pre/post quasi-experimental design. The case study will consider the organizations and systems involved in a CVD risk reduction intervention as a single case. The pre/post experimental design will be used for HeartLink, the intervention being tested, where a single cohort of patients between 45 and 74 years of age (or between 35 and 74 years of age if Aboriginal or Torres Strait Islander) considered to be at high risk for a CVD event will be recruited through general practice, provided with enhanced usual care and additional health behavior change support. A range of quantitative and qualitative data will be collected. This will include individual health and well being data collected at baseline and again at 12 months for HeartLink participants, and systems related data collected over the period of the intervention to inform the case study.

Results

The intervention is currently underway, with results expected in late 2015.

Conclusions

Gaining a better understanding of CVD prevention in primary health care requires a research approach that can capture and express its complexity. The MoFoP study aims to identify the key elements for effective CVD prevention across the health and community sectors, and to develop a model to better inform policy and practice in this key health priority area for Australia.

How healthcare organisations can act as institutional entrepreneurs in a context of change

Purpose

– The aim of this paper is to illustrate and discuss how healthcare organisations can act as institutional entrepreneurs in a context of change.

Design/methodology/approach

– The authors conducted an in-depth longitudinal case study (2005-2008) of a healthcare organisation in the province of Quebec, Canada. Data collection consisted of real-time observations of senior managers (n=87), interviews (n=24) with decision-makers and secondary data analysis of documents.

Findings

– The paper reports on the extent to which entrepreneurial healthcare organisations can be a driving force in the creation of a new practice. The authors analyse the development of a diabetes reference centre by a healthcare organisation acting as an institutional entrepreneur that illustrates the conceptualisation of an innovation and the mobilisation of resources to implement it and to influence other actors in the field. The authors discuss the case in reference to three stages of change: emergence, implementation and diffusion. The results illustrate the different strategies used by managers to advance their proposed projects.

Research limitations/implications

– This study helps to better understand the dynamics of mandated change in a mature field such as healthcare and the roles played by organisations in this process. By adopting a proactive strategy, a healthcare organisation can play an active role and strongly influence the evolution of its field.

Originality/value

– This paper is one of only a few to analyse strategies used by healthcare organisations in the context of mandated change.