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Whitehead L, Palamara P, Babatunde-Sowole OO, Boak J, Franklin N, Quinn R, George C, Allen J. Nurses' experience of managing adults living with multimorbidity: A qualitative study. J Adv Nurs 2023. [PMID: 36861787 DOI: 10.1111/jan.15600] [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: 08/17/2022] [Revised: 01/09/2023] [Accepted: 02/05/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The number of adults living with two or more chronic conditions is increasing worldwide. Adults living with multimorbidity have complex physical, psychosocial and self-management care needs. AIM This study aimed to describe Australian nurses' experience of care provision for adults living with multimorbidity, their perceived education needs and future opportunities for nurses in the management of multimorbidity. DESIGN Qualitative exploratory. METHODS Nurses providing care to adults living with multimorbidity in any setting were invited to take part in a semi-structured interview in August 2020. Twenty-four registered nurses took part in a semi-structured telephone interview. RESULTS Three main themes were developed: (1) The care of adults living with multimorbidity requires skilled collaborative and holistic care; (2) nurses' practice in multimorbidity care is evolving; and (3) nurses value education and training in multimorbidity care. CONCLUSION Nurses recognize the challenge and the need for change in the system to support them to respond to the increasing demands they face. IMPACT The complexity and prevalence of multimorbidity creates challenges for a healthcare system configured to treat individual disease. Nurses are key in providing care for this population, but little is known about nurses' experiences and perceptions of their role. Nurses believe a person-centred approach is important to address the complex needs of adults living with multimorbidity. Nurses described their role as evolving in response to the growing demand for quality care and believed inter-professional approaches achieve the best outcomes for adults living with multimorbidity. The research has relevance for all healthcare providers seeking to provide effective care for adults living with multimorbidity. Understanding how best to equip and support the workforce to meet the issues and demands of managing the care of adults living with multimorbidity has the potential to improve patient outcomes. PATIENT OR PUBLIC CONTRIBUTION There was no patient or public contribution. The study only concerned the providers of the service.
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Affiliation(s)
- Lisa Whitehead
- Centre for Nursing, Midwifery & Health Services Research, School of Nursing & Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia.,Australian College of Nursing, Parramatta, New South Wales, Australia
| | - Peter Palamara
- Centre for Nursing, Midwifery & Health Services Research, School of Nursing & Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Olutoyin Oluwakemi Babatunde-Sowole
- Australian College of Nursing, Parramatta, New South Wales, Australia.,Faculty of Health, School of Nursing and Midwifery, University of Technology, Sydney, New South Wales, Australia.,School of Nursing, Midwifery and Paramedicine, Australian Catholic University, North Sydney, New South Wales, Australia
| | - Jennifer Boak
- Australian College of Nursing, Parramatta, New South Wales, Australia.,Bendigo Health, Bendigo, Victoria, Australia
| | - Natasha Franklin
- Australian College of Nursing, Parramatta, New South Wales, Australia.,Australian Catholic University, Faculty of Health Sciences, School of Nursing, Midwifery and Paramedicine, Blacktown, New South Wales, Australia
| | - Robyn Quinn
- Australian College of Nursing, Parramatta, New South Wales, Australia
| | - Cobie George
- Australian College of Nursing, Parramatta, New South Wales, Australia
| | - Jacqueline Allen
- Australian College of Nursing, Parramatta, New South Wales, Australia.,School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
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Multimorbidity prevalence and patterns in chronic kidney disease: findings from an observational multicentre UK cohort study. Int Urol Nephrol 2023:10.1007/s11255-023-03516-1. [PMID: 36806100 DOI: 10.1007/s11255-023-03516-1] [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: 05/17/2022] [Accepted: 02/12/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE Multimorbidity [defined as two or more long-term conditions (LTCs)] contributes to increased treatment and medication burden, poor health-related quality of life, and worse outcomes. Management strategies need to be patient centred and tailored depending on existing comorbidities; however, little is known about the prevalence and patterns of comorbidities in people with chronic kidney disease (CKD). We investigated the prevalence of multimorbidity and comorbidity patterns across all CKD stages. METHODS Multimorbidity was assessed, using a composite of self-report and clinical data, across four CKD groups stratified by eGFR [stage 1-2, stage 3a&b, stage 4-5, and kidney transplant (KTx)]. Principal component analysis using varimax rotation was used to identify comorbidity clusters across each group. RESULTS Of the 978 participants (mean 66.3 ± 14 years, 60% male), 96.0% had multimorbidity. In addition to CKD, the mean number of comorbidities was 3.0 ± 1.7. Complex multimorbidity (i.e. ≥ 4 multiple LTCs) was identified in 560 (57.3%) participants. When stratified by CKD stage, the two most prevalent comorbidities across all stages were hypertension (> 55%) and musculoskeletal disorders (> 40%). The next most prevalent comorbidity for CKD stages 1-2 was lung conditions and for CKD stages 3 and 4-5 it was heart problems. CKD stages 1-2 showed different comorbidity patterns and clustering compared to other CKD stages. CONCLUSION Most people across the spectrum of CKD have multimorbidity. Different patterns of multimorbidity exist at different stages of CKD, and as such, clinicians should consider patient comorbidities to integrate care and provide effective treatment strategies.
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Okawa Y, Yamashita H, Masuyama S, Fukazawa Y, Wakayama I. Quality assessment of Japanese clinical practice guidelines including recommendations for acupuncture. Integr Med Res 2022; 11:100838. [PMID: 35340335 PMCID: PMC8943251 DOI: 10.1016/j.imr.2022.100838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/05/2022] [Accepted: 02/06/2022] [Indexed: 11/19/2022] Open
Abstract
Background The quality of clinical practice guidelines (CPGs) should be extensively evaluated. This study aimed to evaluate Japanese CPGs that include recommendations for acupuncture. Methods In a literature search, CPGs including recommendations for acupuncture published in Japan until October 2021 were sought. We assessed (1) whether the CPGs were developed in accordance with the Grading Recommendations Assessment, Development and Evaluation (GRADE) system, (2) the quality of the CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE) II, and (3) whether the strength of the recommendations for acupuncture was consistent with each CPG's predefined procedure. Results Seventeen CPGs including 23 recommendations in total were identified and assessed. (1) Three CPGs were in accordance with the GRADE system. (2) The mean score of overall assessment using AGREE II was 4.5 on a 7-point Likert scale. The mean domain scores were 77% for domain 1 (scope and purpose), 54% for domain 2 (stakeholder involvement), 48% for domain 3 (rigor of development), 78% for domain 4 (clarity of presentation), 20% for domain 5 (applicability), and 51% for domain 6 (editorial independence). (3) The strength of the recommendations for acupuncture in two CPGs was judged to be underestimated. Some of the CPGs contained elementary problems that were not considered in AGREE II. Conclusion The methodological quality of Japanese CPGs including recommendations for acupuncture was not necessarily high. Since technical issues exist in each field of therapy, the respective experts should be involved in developing and reviewing CPGs to disseminate accurate health information.
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Sarmiento LL. Patrones de multimorbilidad en la población chilena mayor de 15 años: análisis de datos epidemiológicos de la encuesta nacional de salud 2016-2017. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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5
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Oliveira M, Palacios-Fernandez S, Cervera R, Espinosa G. Clinical practice guidelines and recommendations for the management of patients with systemic lupus erythematosus: a critical comparison. Rheumatology (Oxford) 2021; 59:3690-3699. [PMID: 32375178 DOI: 10.1093/rheumatology/keaa142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/26/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE SLE has a great clinical heterogeneity and low prevalence, thus making the development of recommendations or clinical practice guidelines (CPG) based on high-quality evidence difficult. In the last few years, several CPG appeared addressing the management of the disease. The aim of this review is to critically compare the recommendations made in the most recent CPG and to analyse and compare their methodological quality. METHODS The Appraisal of Guidelines for Research and Evaluation (AGREE) II tool was used to compare the methodological quality of each of the CPG. RESULTS Most CPG agreed in the general management and first-line treatment recommendations where there is higher quality evidence and disagreed in refractory disease treatment where there is lack of quality evidence. Also, the CPG are agreed in whether a patient should be treated regarding the most severe clinical manifestation or taking into account the treatment that best serves all clinical manifestations. The majority of the appraised CPG scored high-quality ratings, especially for scope and purpose and clarity of presentation, while they were of less quality when assessing applicability of each CPG. CONCLUSION CPG should aid, but not replace, the health professional's clinical judgment in daily clinical patient management.
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Affiliation(s)
- Margarida Oliveira
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain.,Department of Internal Medicine, Hospital Pedro Hispano, Matosinhos Local Health Unit, Matosinhos, Portugal
| | - Sergio Palacios-Fernandez
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain.,Hospital Universitario San Juan de Alicante, Alicante, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
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Damarell RA, Morgan DD, Tieman JJ, Healey DF. Multimorbidity through the lens of life-limiting illness: how helpful are Australian clinical practice guidelines to its management in primary care? Aust J Prim Health 2021; 27:122-129. [PMID: 33461658 DOI: 10.1071/py20164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/28/2020] [Indexed: 11/23/2022]
Abstract
This study assessed Australian clinical practice guidelines for life-limiting index conditions for the extent to which they acknowledged comorbidities and framed management recommendations within the context of older age and reduced life expectancy. A comprehensive search identified current, evidence-based Australian guidelines for chronic life-limiting conditions directed at general practitioners. Guideline content was analysed qualitatively before comorbidity acknowledgements were quantified using a 17-item checklist. Full guidelines were quality appraised using AGREE-II. Ten documents covering chronic obstructive pulmonary disease, heart failure, cancer pain, dementia and palliative care in aged care were identified. Most guidelines addressed one 'comorbid' condition and prompted clinicians to consider patient quality of life and personal preferences. Fewer addressed burden of treatment and half suggested modifying treatments to account for limited life expectancy, age or time horizon to benefit. Half warned of potential adverse drug interactions. Guidelines were of moderate to very high quality. Guidelines naturally prioritised their index condition, directing attention to only the most common comorbidities. However, there may be scope to include more condition-agnostic guidance on multimorbidity management. This might be modelled on the 'guiding principles' approach now emerging internationally from organisations such as the American Geriatrics Society in response to increasing multimorbidity prevalence and evidence limitations.
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Affiliation(s)
- Raechel A Damarell
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Rehabilitation and Palliative Care Building, 4W330, Flinders Medical Centre, Bedford Park, SA 5042, Australia; and Corresponding author
| | - Deidre D Morgan
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Rehabilitation and Palliative Care Building, 4W330, Flinders Medical Centre, Bedford Park, SA 5042, Australia; and Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia
| | - Jennifer J Tieman
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Rehabilitation and Palliative Care Building, 4W330, Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - David F Healey
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia
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Koc EM, Aksoy H, Ayhan Baser D, Baydar Artantas A, Kahveci R, Cihan FG. Evaluation of clinical practice guideline quality: comparison of two appraisal tools. Int J Qual Health Care 2020; 32:663-670. [DOI: 10.1093/intqhc/mzaa129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/23/2020] [Accepted: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
The tools used for critically appraising the quality of clinical practice guidelines are complex and not suitable for the busy end users. So rapid, effective and simple instruments are more preferred. The aim of this study is to compare two critical appraisal tools: iCAHE as a rapid instrument and AGREE II as a complex instrument on guideline quality assessment.
Material and Methods
The diabetes mellitus guidelines of the Scottish Intercollegiate Guidelines Network (SIGN), the National Institute for Health and Clinical Excellence (NICE), the International Diabetes Federation (IDF) and the Society of Endocrinology and Metabolism of Turkey (SEMT) were assessed separately by four appraisers using the iCAHE and AGREE II instruments. The mean iCAHE criteria scores and the total and domain AGREE II scores given by the four appraisers are presented for each guideline.
Results
No statistically significant difference was detected between the iCAHE scale scores of the guidelines evaluated (P = 0.063). The rank of the guidelines according to their average total iCAHE and AGREE II instrument scores was similar. The iCAHE mean scores of the guidelines were as follows: NICE, 92.85%; SIGN, 92.85%; IDF, 66.07% and SEMT, 73.21%. The AGREE II mean scores of the guidelines were as follows: NICE, 87.13%; SIGN, 78.25%; IDF, 53.44% and SEMT, 53.22%.
Conclusions
In addition to being a quality scale, the iCAHE checklist is easy, practical and short to implement. It also helps the users to understand the quality of the guideline in a shorter time. To increase the use of guidelines, it is important that users with little experience and time use the iCAHE scale as a rapid appraisal tool, but more studies are needed to decide the best appraisal tool.
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Affiliation(s)
- Esra Meltem Koc
- Katip Celebi University Faculty of Medicine, Department of Family Medicine, Izmir, Turkey
| | - Hilal Aksoy
- Hacettepe University Faculty of Medicine, Department of Family Medicine, Ankara, 06230, Turkey
| | - Duygu Ayhan Baser
- Hacettepe University Faculty of Medicine, Department of Family Medicine, Ankara, 06230, Turkey
| | - Aylin Baydar Artantas
- University of Health Sciences Ankara Bilkent City Hospital, Department of Family Medicine, Ankara, Turkey
| | - Rabia Kahveci
- Health Technology Assessment Department, Ukraine Ministry of Health, Kiev Region, Ukraine
| | - Fatma Goksin Cihan
- Necmettin Erbakan University, Faculty of Medicine, Department of Family Medicine, Konya, Turkey
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8
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Fisher K, Markle-Reid M, Ploeg J, Bartholomew A, Griffith LE, Gafni A, Thabane L, Yous ML. Self-management program versus usual care for community-dwelling older adults with multimorbidity: A pragmatic randomized controlled trial in Ontario, Canada. JOURNAL OF COMORBIDITY 2020; 10:2235042X20963390. [PMID: 33117723 PMCID: PMC7573753 DOI: 10.1177/2235042x20963390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 08/13/2020] [Accepted: 08/31/2020] [Indexed: 12/30/2022]
Abstract
Background: Multimorbidity, the co-existence of 2+ (or 3+) chronic diseases in an individual, is an increasingly common global phenomenon leading to reduced quality of life and functional status, and higher healthcare service use and mortality. There is an urgent need to develop and test new models of care that incorporate the components of multimorbidity interventions recommended by international organizations, including care coordination, interdisciplinary teams, and care plans developed with patients that are tailored to their needs and preferences. Purpose: To determine the effectiveness of a 6-month, community-based, multimorbidity intervention compared to usual home care services for community-dwelling older adults (age 65+ years) with multimorbidity (3+ chronic conditions) that were newly referred to and receiving home care services. Methods: A pragmatic, parallel, two-arm randomized controlled trial evaluated the intervention, which included in-home visits by an interdisciplinary team, personal support worker visits, and monthly case conferences. The study took place in two sites in central Ontario, Canada. Eligible and consenting participants were randomly allocated to the intervention and control group using a 1:1 ratio. The participants, statistician/analyst, and research assistants collecting assessment data were blinded. The primary outcome was the Physical Component Summary (PCS) score of the 12-Item Short-Form health survey (SF-12). Secondary outcomes included the SF-12 Mental Component Summary (MCS) score, Center for Epidemiological Studies of Depression (CESD-10), Generalized Anxiety Disorder (GAD-7), Self-Efficacy for Managing Chronic Disease, and service use and costs. Analysis of covariance (ANCOVA) tested group differences using multiple imputation to address missing data, and non-parametric methods explored service use and cost differences. Results: 59 older adults were randomized into the intervention (n = 30) and control (n = 29) groups. At baseline, groups were similar for the primary outcome and number of chronic conditions (mean of 8.6), but the intervention group had lower mental health status. The intervention was cost neutral and no significant group differences were observed for the primary outcome of PCS from SF-12 (mean difference: −4.94; 95% CI: −12.53 to 2.66; p = 0.20) or secondary outcomes. Conclusion: We evaluated a 6-month, self-management intervention for older adults with multimorbidity. While the intervention was cost neutral in comparison to usual care, it was not found to improve the PCS from SF-12 or secondary health outcomes. Recruitment and retention challenges were significant obstacles limiting our ability to assess intervention effectiveness. Yet, the intervention was grounded in internationally-endorsed recommendations and implemented in a practice setting (home care) viewed as a key upstream resource fostering independence in older adults. These features collectively support the identification of ways to recruit/retain older adults and test alternative implementation strategies for interventions that are based on sound principles of multimorbidity management.
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Affiliation(s)
- Kathryn Fisher
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Maureen Markle-Reid
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jenny Ploeg
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Department of Health, Aging and Society, McMaster University, Hamilton, Ontario, Canada
| | - Amy Bartholomew
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amiram Gafni
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marie-Lee Yous
- Aging, Community and Health Research Unit (ACHRU), McMaster University, Hamilton, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada
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Liu X, Shahid R, Patel AB, McDonald T, Bertazzon S, Waters N, Seidel JE, Marshall DA. Geospatial patterns of comorbidity prevalence among people with osteoarthritis in Alberta Canada. BMC Public Health 2020; 20:1551. [PMID: 33059639 PMCID: PMC7559790 DOI: 10.1186/s12889-020-09599-0] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 09/23/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Knowledge of geospatial pattern in comorbidities prevalence is critical to an understanding of the local health needs among people with osteoarthritis (OA). It provides valuable information for targeting optimal OA treatment and management at the local level. However, there is, at present, limited evidence about the geospatial pattern of comorbidity prevalence in Alberta, Canada. METHODS Five administrative health datasets were linked to identify OA cases and comorbidities using validated case definitions. We explored the geospatial pattern in comorbidity prevalence at two standard geographic areas levels defined by the Alberta Health Services: descriptive analysis at rural-urban continuum level; spatial analysis (global Moran's I, hot spot analysis, cluster and outlier analysis) at the local geographic area (LGA) level. We compared area-level indicators in comorbidities hotspots to those in the rest of Alberta (non-hotspots). RESULTS Among 359,638 OA cases in 2013, approximately 60% of people resided in Metro and Urban areas, compared to 2% in Rural Remote areas. All comorbidity groups exhibited statistically significant spatial autocorrelation (hypertension: Moran's I index 0.24, z score 4.61). Comorbidity hotspots, except depression, were located primarily in Rural and Rural Remote areas. Depression was more prevalent in Metro (Edmonton-Abbottsfield: 194 cases per 1000 population, 95%CI 192-195) and Urban LGAs (Lethbridge-North: 169, 95%CI 168-171) compared to Rural areas (Fox Creek: 65, 95%CI 63-68). Comorbidities hotspots included a higher percentage of First Nations or Inuit people. People with OA living in hotspots had lower socioeconomic status and less access to care compared to non-hotspots. CONCLUSIONS The findings highlight notable rural-urban disparities in comorbidities prevalence among people with OA in Alberta, Canada. Our study provides valuable evidence for policy and decision makers to design programs that ensure patients with OA receive optimal health management tailored to their local needs and a reduction in current OA health disparities.
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Affiliation(s)
- Xiaoxiao Liu
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, HRIC Building, Room 3C58, Calgary, AB, T2N 4Z6, Canada
- McCaig Bone and Joint Health Institute, University of Calgary, Calgary, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Rizwan Shahid
- Department of Geography, University of Calgary, Calgary, Canada
- Applied Research and Evaluation Services, Alberta Health Services, Calgary, Canada
| | - Alka B Patel
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, HRIC Building, Room 3C58, Calgary, AB, T2N 4Z6, Canada
- Applied Research and Evaluation Services, Alberta Health Services, Calgary, Canada
| | - Terrence McDonald
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Nigel Waters
- Department of Geography, University of Calgary, Calgary, Canada
| | - Judy E Seidel
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, HRIC Building, Room 3C58, Calgary, AB, T2N 4Z6, Canada
- Applied Research and Evaluation Services, Alberta Health Services, Calgary, Canada
| | - Deborah A Marshall
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, HRIC Building, Room 3C58, Calgary, AB, T2N 4Z6, Canada.
- McCaig Bone and Joint Health Institute, University of Calgary, Calgary, Canada.
- O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.
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Lopez-Olivo MA, Colmegna I, Karpes Matusevich AR, Qi SR, Zamora NV, Sharma R, Pratt G, Suarez-Almazor ME. Systematic Review of Recommendations on the Use of Disease-Modifying Antirheumatic Drugs in Patients With Rheumatoid Arthritis and Cancer. Arthritis Care Res (Hoboken) 2020; 72:309-318. [PMID: 30821928 DOI: 10.1002/acr.23865] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 02/26/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate consensus recommendations regarding management of rheumatoid arthritis (RA) in patients with cancer. METHODS We searched electronic databases, guideline registries, and relevant web sites for cancer-specific recommendations on RA management. Reviewers independently selected and appraised the recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. We identified similarities and discrepancies among recommendations. RESULTS Of 4,077 unique citations, 39 recommendations were identified, of which half described their consensus process. Average scores for the AGREE II domains ranged from 33% to 87%. Cancer risk in RA was addressed in 79% of recommendations, with acknowledgement of increased overall cancer risk. Recommendations did not agree on the safety of using disease-modifying antirheumatic drugs (DMARDs) in RA patients with cancer, except for the contraindication of tumor necrosis factor inhibitors in patients at risk for lymphoma. Most recommendations agreed that RA treatment should be stopped and re-evaluated with a new diagnosis of cancer. Recommendations for patients with a history of cancer differed depending on the drug, cancer type, and time since cancer diagnosis. Few recommendations addressed all issues. CONCLUSION Recommendations for the treatment of RA in patients with cancer often fail to meet expected methodologic criteria. There was agreement on the need for caution when prescribing DMARDs to these patients. However, several areas continue to lack consensus, and given the paucity of evidence, there is an urgent need for research and expert opinion to guide and standardize the management of RA in patients with cancer.
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Affiliation(s)
| | | | | | | | | | - Robin Sharma
- University of Texas MD Anderson Cancer Center, Houston
| | - Gregory Pratt
- Research Medical Library, University of Texas MD Anderson Cancer Center, Houston
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General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research. BMC FAMILY PRACTICE 2020; 21:131. [PMID: 32611391 PMCID: PMC7331183 DOI: 10.1186/s12875-020-01197-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 06/17/2020] [Indexed: 12/21/2022]
Abstract
Background General practitioners (GPs) increasingly manage patients with multimorbidity but report challenges in doing so. Patients describe poor experiences with health care systems that treat each of their health conditions separately, resulting in fragmented, uncoordinated care. For GPs to provide the patient-centred, coordinated care patients need and want, research agendas and health system structures and policies will need to adapt to address this epidemiologic transition. This systematic review seeks to understand if and how multimorbidity impacts on the work of GPs, the strategies they employ to manage challenges, and what they believe still needs addressing to ensure quality patient care. Methods Systematic review and thematic synthesis of qualitative studies reporting GP experiences of managing patients with multimorbidity. The search included nine major databases, grey literature sources, Google and Google Scholar, a hand search of Journal of Comorbidity, and the reference lists of included studies. Results Thirty-three studies from fourteen countries were included. Three major challenges were identified: practising without supportive evidence; working within a fragmented health care system whose policies and structures remain organised around single condition care and specialisation; and the clinical uncertainty associated with multimorbidity complexity and general practitioner perceptions of decisional risk. GPs revealed three approaches to mitigating these challenges: prioritising patient-centredness and relational continuity; relying on knowledge of patient preferences and unique circumstances to individualise care; and structuring the consultation to create a sense of time and minimise patient risk. Conclusions GPs described an ongoing tension between applying single condition guidelines to patients with multimorbidity as security against uncertainty or penalty, and potentially causing patients harm. Above all, they chose to prioritise their long-term relationships for the numerous gains this brought such as mutual trust, deeper insight into a patient’s unique circumstances, and useable knowledge of each individual’s capacity for the work of illness and goals for life. GPs described a need for better multimorbidity management guidance. Perhaps more than this, they require policies and models of practice that provide remunerated time and space for nurturing trustful therapeutic partnerships.
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McMahon NE, Bangee M, Benedetto V, Bray EP, Georgiou RF, Gibson JME, Lane DA, Al-Khalidi AH, Chatterjee K, Chauhan U, Clegg AJ, Lightbody CE, Lip GYH, Sekhar A, Watkins CL. Etiologic Workup in Cases of Cryptogenic Stroke: A Systematic Review of International Clinical Practice Guidelines. Stroke 2020; 51:1419-1427. [PMID: 32279620 PMCID: PMC7185056 DOI: 10.1161/strokeaha.119.027123] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is available in the text. Identifying the etiology of acute ischemic stroke is essential for effective secondary prevention. However, in at least one third of ischemic strokes, existing investigative protocols fail to determine the underlying cause. Establishing etiology is complicated by variation in clinical practice, often reflecting preferences of treating clinicians and variable availability of investigative techniques. In this review, we systematically assess the extent to which there exists consensus, disagreement, and gaps in clinical practice recommendations on etiologic workup in acute ischemic stroke.
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Affiliation(s)
- Naoimh E McMahon
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Munirah Bangee
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Valerio Benedetto
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Emma P Bray
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Rachel F Georgiou
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Josephine M E Gibson
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, United Kingdom (D.A.L., G.Y.H.L.).,Department of Clinical Medicine, Aalborg University, Denmark (D.A.L., G.Y.H.L.)
| | | | | | - Umesh Chauhan
- Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, United Kingdom (U.C.)
| | - Andrew J Clegg
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - C Elizabeth Lightbody
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Gregory Y H Lip
- Department of Clinical Medicine, Aalborg University, Denmark (D.A.L., G.Y.H.L.).,Medtronic Limited, Watford, United Kingdom (A.H.A.-K.)
| | - Alakendu Sekhar
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom (A.S.)
| | - Caroline L Watkins
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
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Poitras ME, Hudon C, Godbout I, Bujold M, Pluye P, Vaillancourt VT, Débarges B, Poirier A, Prévost K, Spence C, Légaré F. Decisional needs assessment of patients with complex care needs in primary care. J Eval Clin Pract 2020; 26:489-502. [PMID: 31815348 DOI: 10.1111/jep.13325] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/22/2019] [Accepted: 11/12/2019] [Indexed: 12/01/2022]
Abstract
RATIONALE Patients with complex care needs who frequently use health services often face challenges in managing their health and with integrated care, leading to frequent decision making. These complex care needs require a good understanding of health issues and their impact on daily life. As the decisional needs of this particular clientele have yet to be described in scientific literature, they warrant further study. OBJECTIVES To assess the decision-making needs of patients with complex care needs (PCCN) who frequently use health care services. METHODS We performed a multicenter cross-sectional qualitative descriptive study in four institutions of the health and social services network of Quebec (Canada). We enrolled a convenience sample of PCCNs who frequently use health care services, health care providers, case managers, and decision-makers. We conducted interviews and focus groups and investigated decisional needs according to the Ottawa decision support framework: roles played and desired in the decision-making process, facilitators, and barriers. We conducted qualitative data collection and qualitative deductive/inductive thematic analysis within and across participating groups. RESULTS In total, 16 patients, 38 clinicians, six case managers, and 14 decision-makers participated in the study. The decisional needs of this clientele are numerous, varied and different from those of the general population. We identified 26 decisional needs grouped under five themes. The most frequent decisions related to visiting the emergency department, moving to a nursing home, and adhering to a plan or treatment. In addition, we identified new themes such as patients' fear and mistrust of health professionals, differences of opinion between health professionals and health professionals' preconceived opinions of patients. CONCLUSION We observed a wide range of types of decisions that patients face and differences in decision-making needs across participating groups. Our results should inform future research on the development of a patient decision aid tool.
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Affiliation(s)
- Marie-Eve Poitras
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Isabelle Godbout
- Quebec SPOR Unit (Health Systems and Social Services Research Component, Knowledge Translation and Implementation) and Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Saguenay-Lac-Saint-Jean, Chicoutimi, Quebec, Canada
| | - Mathieu Bujold
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Pierre Pluye
- Method Development, Quebec SPOR SUPPORT Unit (Patient Oriented Research), Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Vanessa T Vaillancourt
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Béatrice Débarges
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Quebec, Quebec, Canada
| | - Annie Poirier
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Quebec, Quebec, Canada
| | - Karina Prévost
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Quebec, Quebec, Canada
| | - Claude Spence
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Quebec, Quebec, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Quebec, Quebec, Canada
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Bray EP, McMahon NE, Bangee M, Al-Khalidi AH, Benedetto V, Chauhan U, Clegg AJ, Georgiou RF, Gibson J, Lane DA, Lip GYH, Lightbody E, Sekhar A, Chatterjee K, Watkins CL. Etiologic workup in cases of cryptogenic stroke: protocol for a systematic review and comparison of international clinical practice guidelines. Syst Rev 2019; 8:331. [PMID: 31847884 PMCID: PMC6918649 DOI: 10.1186/s13643-019-1247-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 11/26/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Stroke is a leading cause of death and disability worldwide. Identifying the aetiology of ischaemic stroke is essential in order to initiate appropriate and timely secondary prevention measures to reduce the risk of recurrence. For the majority of ischaemic strokes, the aetiology can be readily identified, but in at least 30% of cases, the exact aetiology cannot be determined using existing investigative protocols. Such strokes are classed as 'cryptogenic' or as a stroke of unknown origin. However, there exists substantial variation in clinical practice when investigating cases of seemingly cryptogenic stroke, often reflecting local service availability and the preferences of treating clinicians. This variation in practice is compounded by the lack of international consensus as to the optimum level and timing of investigations required following a stroke. To address this gap, we aim to systematically review and compare recommendations in evidence-based clinical practice guidelines (CPGs) that relate to the assessment and investigation of the aetiology of ischaemic stroke, and any subsequent diagnosis of cryptogenic stroke. METHOD We will search for CPGs using electronic databases (MEDLINE, Health Management Information Consortium (HMIC), EMBASE, and CINAHL), relevant websites and search engines (e.g. guideline specific websites, governmental, charitable, and professional practice organisations) and hand-searching of bibliographies and reference lists. Two reviewers will independently screen titles, abstracts and CPGs using a pre-defined relevance criteria form. From each included CPG, we will extract definitions and terms for cryptogenic stroke; recommendations related to assessment and investigation of the aetiology of stroke, including the grade of recommendations and underpinning evidence. The quality of the included CPGs will be assessed using the AGREE II (Appraisal of Guidelines for Research and Evaluation) tool. Recommendations across the CPGs will be summarised descriptively highlighting areas of convergence and divergence between CPGs. DISCUSSION To our knowledge, this will be the first review to systematically compare recommendations of international CPGs on investigating the aetiology of ischaemic stroke. The findings will allow for a better understanding of international perspectives on the optimum level of investigations required following a stroke and thus contribute to achieving greater international consensus on best practice in this important and complex area. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019127822.
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Affiliation(s)
- Emma P. Bray
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Naoimh E. McMahon
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Munirah Bangee
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - A. Hakam Al-Khalidi
- Medtronic Limited, Building 9, Croxley Park, Hatters Lane, Watford, WD18 8WW UK
| | - Valerio Benedetto
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Umesh Chauhan
- Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE UK
| | - Andrew J. Clegg
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Rachel F. Georgiou
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Josephine Gibson
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Elizabeth Lightbody
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Alakendu Sekhar
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ UK
| | | | - Caroline L. Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
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15
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Marshall DA, Liu X, Barnabe C, Yee K, Faris PD, Barber C, Mosher D, Noseworthy T, Werle J, Lix L. Existing comorbidities in people with osteoarthritis: a retrospective analysis of a population-based cohort in Alberta, Canada. BMJ Open 2019; 9:e033334. [PMID: 31753902 PMCID: PMC6887009 DOI: 10.1136/bmjopen-2019-033334] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES The purpose of this study is to estimate the prevalence of comorbidities among people with osteoarthritis (OA) using administrative health data. DESIGN Retrospective cohort analysis. SETTING All residents in the province of Alberta, Canada registered with the Alberta Health Care Insurance Plan population registry. PARTICIPANTS 497 362 people with OA as defined by 'having at least one OA-related hospitalization, or at least two OA-related physician visits or two ambulatory care visits within two years'. PRIMARY OUTCOME MEASURES We selected eight comorbidities based on literature review, clinical consultation and the availability of validated case definitions to estimate their frequencies at the time of diagnosis of OA. Sex-stratified age-standardised prevalence rates per 1000 population of eight clinically relevant comorbidities were calculated using direct standardisation with 95% CIs. We applied χ2 tests of independence with a Bonferroni correction to compare the percentage of comorbid conditions in each age group. RESULTS 54.6% (n=2 71 794) of people meeting the OA case definition had at least one of the eight selected comorbidities. Females had a significantly higher rate of comorbidities compared with males (standardised rates ratio=1.26, 95% CI 1.25 to 1.28). Depression, chronic obstructive pulmonary disease (COPD) and hypertension were the most prevalent in both females and males after age-standardisation, with 40% of all cases having any combination of these comorbidities. We observed a significant difference in the percentage of comorbidities among age groups, illustrated by the youngest age group (<45 years) having the highest percentage of cases with depression (24.6%), compared with a frequency of 16.1% in those >65 years. CONCLUSIONS Our findings highlight the high frequency of comorbidity in people with OA, with depression having the highest age-standardised prevalence rate. Comorbidities differentially affect females, and vary by age. These factors should inform healthcare programme and delivery.
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Affiliation(s)
- Deborah A Marshall
- Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
- McCaig Bone and Joint Health Institute, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Calgary, Alberta, Canada
| | - Xiaoxiao Liu
- Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
- McCaig Bone and Joint Health Institute, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Calgary, Alberta, Canada
| | - Cheryl Barnabe
- Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Karen Yee
- Research Facilitation, Alberta Health Services, Calgary, Alberta, Canada
| | - Peter D Faris
- Research Facilitation, Alberta Health Services, Calgary, Alberta, Canada
| | - Claire Barber
- Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Dianne Mosher
- Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Thomas Noseworthy
- Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jason Werle
- Department of Surgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Lisa Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Mallery L, MacLeod T, Allen M, McLean-Veysey P, Rodney-Cail N, Bezanson E, Steeves B, LeBlanc C, Moorhouse P. Systematic review and meta-analysis of second-generation antidepressants for the treatment of older adults with depression: questionable benefit and considerations for frailty. BMC Geriatr 2019; 19:306. [PMID: 31718566 PMCID: PMC6852920 DOI: 10.1186/s12877-019-1327-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 10/23/2019] [Indexed: 11/21/2022] Open
Abstract
Background Frail older adults are commonly prescribed antidepressants. Yet, there is little evidence to determine the efficacy and safety of antidepressants to treat depression with concomitant frailty. To better understand this issue, we examined the efficacy and safety of second-generation antidepressants for the treatment of older adults with depression and then considered implications for frailty. Methods Due to the absence of therapeutic studies of frail older adults with depression, we conducted a systematic review and meta-analysis of double-blind, randomized controlled trials that compared antidepressants versus placebo for adults with depression, age 65 years or older. We searched PubMed/MEDLINE, Cochrane Library, reference lists from meta-analyses/studies, hand searches of publication lists, and related articles on PubMed. Outcomes included rates of response, remission, and adverse events. After evaluating the data, we applied a frailty-informed framework to consider how the evidence could be applied to frailty. Results Nine trials were included in the meta-analysis (n = 2704). Subjects had moderate to severe depression. For older adults with depression, there was no statistically significant difference in response or remission to second-generation antidepressants compared to placebo. Response occurred in 45.3% of subjects receiving an antidepressant compared to 40.5% receiving placebo (RR 1.15, 95% CI: 0.96 – 1.37, p = 0.12, I2 = 71%). Remission occurred in 33.1% with antidepressant versus 31.3% with placebo (RR 1.10, 95% CI: 0.92 – 1.31, p = 0.30, I2 = 56%) (Figure 2 and 3). There were more withdrawals due to adverse events with antidepressants, 13% versus 5.8% (RR 2.30, 95% CI: 1.45–3.63; p < 0.001; I2 = 61%; NNH 14, 95% CI:10–28). Implications for frailty Subjects in the meta-analysis did not have obvious characteristics of frailty. Using framework questions to consider the implications of frailty, we hypothesize that, like older adults, frail individuals with depression may not respond to antidepressants. Further, observational studies suggest that those who are frail may be less responsive to antidepressants compared to the non-frail. Given the vulnerability of frailty, adverse events may be more burdensome. Conclusions Second-generation antidepressants have uncertain benefit for older adults with depression and cause more adverse events compared to placebo. Until further research clarifies benefit, careful consideration of antidepressant prescribing with frailty is warranted.
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Affiliation(s)
- Laurie Mallery
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Tanya MacLeod
- Continuing Professional Development, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Allen
- Continuing Professional Development, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Pamela McLean-Veysey
- Drug Evaluation Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Natasha Rodney-Cail
- Drug Evaluation Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Evan Bezanson
- Sobeys National Pharmacy Group, Halifax, Nova Scotia, Canada
| | - Brian Steeves
- RK MacDonald Nursing Home, Halifax, Nova Scotia, Canada
| | - Constance LeBlanc
- Continuing Professional Development, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paige Moorhouse
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Contant É, Loignon C, Bouhali T, Almirall J, Fortin M. A multidisciplinary self-management intervention among patients with multimorbidity and the impact of socioeconomic factors on results. BMC FAMILY PRACTICE 2019; 20:53. [PMID: 31010425 PMCID: PMC6477711 DOI: 10.1186/s12875-019-0943-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/04/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Limited studies exist on successful interventions for patients with multimorbidity. Even more limited is the knowledge on how socioeconomic factors have an impact on these interventions. The objective of this study was to analyze the effect of a multidisciplinary self-management intervention among patients with multimorbidity and the impact of socioeconomic factors on the results. METHODS Secondary data analysis limited to multimorbid patients from of a pragmatic randomized trial evaluating an intervention that included patients (18 to 75 yrs.) from eight primary care practices in Quebec, Canada. The intervention included self-management support and patient-centred motivational approaches. Self-management was evaluated using the Health Education Impact Questionnaire (heiQ) which measures eight different domains. Changes in heiQ were analyzed following the three-month intervention with univariate and multivariate logistic regressions. RESULTS Participants with three or more chronic conditions (n = 281), randomized to intervention or control groups, were included in this analysis. The effect of the intervention on the likelihood of an improvement in self-management was significant in six heiQ domains in the univariate analysis (Odd ratio; 95% CI): Health-directed behaviour (2.03; 1.16-3.55), Emotional well-being (1.97; 1.05-3.68), Self-monitoring and insight (2.35; 1.02-5.40), Constructive attitudes and approaches (2.91; 1.45-5.84), Skill and technique acquisition (1.96; 1.13-3.39), and Health services navigation (2.52; 1.21-5.21). After controlling for age and gender the results remained essentially the same. After additional adjustments for family income, education and self-perceived financial status, the likelihood of an improvement was no longer significant in the domains Emotional well-being and Self-monitoring and insight. CONCLUSIONS The intervention produced significant improvements in multimorbid patients for most domains of self-management. Socioeconomic factors had a minor impact on the results. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01319656.
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Affiliation(s)
- Éric Contant
- Postgraduate student, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Quebec, Canada
| | - Christine Loignon
- Family Medicine Department, Université de Sherbrooke, Quebec, Canada
| | - Tarek Bouhali
- Family Medicine Department, Université de Sherbrooke, Quebec, Canada
| | - José Almirall
- Family Medicine Department, Université de Sherbrooke, Quebec, Canada
| | - Martin Fortin
- Professor, Family Medicine Department, Université de Sherbrooke, Quebec, Canada. .,Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean, 305 St-Vallier, Chicoutimi (Québec), G7H 5H6, Canada.
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Heine M, Fell BL, Robinson A, Abbas M, Derman W, Hanekom S. Patient-centred rehabilitation for non-communicable disease in a low-resource setting: study protocol for a feasibility and proof-of-concept randomised clinical trial. BMJ Open 2019; 9:e025732. [PMID: 30975678 PMCID: PMC6500351 DOI: 10.1136/bmjopen-2018-025732] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Non-communicable diseases (NCDs) are the leading cause of death globally. Even though NCD disproportionally affects low-to-middle income countries, these countries including South Africa, often have limited capacity for the prevention and control of NCDs. The standard evidence-based care for the long-term management of NCDs includes rehabilitation. However, evidence for the effectiveness of rehabilitation for NCDs originates predominantly from high-income countries. Despite the disproportionate disease burden in low-resourced settings, and due to the complex context and constraints in these settings, the delivery and study of evidence-based rehabilitation treatment in a low-resource setting is poorly understood. This study aims to test the design, methodology and feasibility of a minimalistic, patient-centred, rehabilitation programme for patients with NCD specifically designed for and conducted in a low-resource setting. METHODS AND ANALYSIS Stable patients with cancer, cardiovascular disease, chronic respiratory disease and/or diabetes mellitus will be recruited over the course of 1 year from a provincial day hospital located in an urban, low-resourced setting (Bishop Lavis, Cape Town, South Africa). A postponed information model will be adopted to allocate patients to a 6-week, group-based, individualised, patient-centred rehabilitation programme consisting of multimodal exercise, exercise education and health education; or usual care (ie, no care). Outcomes include feasibility measures, treatment fidelity, functional capacity (eg, 6 min walking test), physical activity level, health-related quality of life and a patient-perspective economic evaluation. Outcomes are assessed by a blinded assessor at baseline, postintervention and 8-week follow-up. Mixed-method analyses will be conducted to inform future research. ETHICS AND DISSEMINATION This study has been approved by the Health Research and Ethics Council, Stellenbosch University (M17/09/031). Information gathered in this research will be published in peer-reviewed journals, presented at national and international conferences, as well as local stakeholders. TRIAL REGISTRATION NUMBER PACTR201807847711940; Pre-results.
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Affiliation(s)
- Martin Heine
- Institute of Sport and Exercise Medicine, Stellenbosch University, Cape Town, South Africa
- Department of Physiotherapy, Stellenbosch University, Cape Town, South Africa
| | - Brittany Leigh Fell
- Institute of Sport and Exercise Medicine, Stellenbosch University, Cape Town, South Africa
- Department of Physiotherapy, Stellenbosch University, Cape Town, South Africa
| | - Ashleigh Robinson
- Institute of Sport and Exercise Medicine, Stellenbosch University, Cape Town, South Africa
- Department of Physiotherapy, Stellenbosch University, Cape Town, South Africa
| | - Mumtaz Abbas
- Western Cape Department of Health, Bishop Lavis Community Health Centre, Cape Town, South Africa
| | - Wayne Derman
- Institute of Sport and Exercise Medicine, Stellenbosch University, Cape Town, South Africa
- International Olympic Committee (IOC) research centre, Cape Town, South Africa
| | - Susan Hanekom
- Department of Physiotherapy, Stellenbosch University, Cape Town, South Africa
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Gagnon MP, Ndiaye MA, Larouche A, Chabot G, Chabot C, Buyl R, Fortin JP, Giguère A, Leblanc A, Légaré F, Motulsky A, Sicotte C, Witteman HO, Kavanagh E, Lépinay F, Roberge J, Délétroz C, Abbasgholizadeh-Rahimi S. Optimising patient active role with a user-centred eHealth platform (CONCERTO+) in chronic diseases management: a study protocol for a pilot cluster randomised controlled trial. BMJ Open 2019; 9:e028554. [PMID: 30944143 PMCID: PMC6500232 DOI: 10.1136/bmjopen-2018-028554] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Multimorbidity increases care needs and primary care use among people with chronic diseases. The Concerto Health Program (CHP) has been developed to optimise chronic disease management in primary care services. However, in its current version, the CHP primarily targets clinicians and does not aim to answer directly patients' and their informal caregivers' needs for chronic disease management. Various studies have shown that interventions that increase patient activation level are associated with better health outcomes. Furthermore, educational tools must be adapted to patients and caregivers in terms of health literacy and usability. This project aims to develop, implement and evaluate a user-centred, multifunctional and personalised eHealth platform (CONCERTO+) to promote a more active patient role in chronic disease management and decision-making. METHODS AND ANALYSIS This project uses a collaborative research approach, aiming at the personalisation of CHP through three phases: (1) the development of one module of an eHealth platform based on scientific evidence and user-centred design; (2) a feasibility study of CONCERTO+ through a pilot cluster randomised controlled trial where patients with chronic diseases from a primary healthcare practice will receive CONCERTO+ during 6 months and be compared to patients from a control practice receiving usual care and (3) an analysis of CONCERTO+ potential for scaling up. To do so, we will conduct two focus groups with patients and informal caregivers and individual interviews with health professionals at the two study sites, as well as health care managers, information officers and representatives of the Ministry of Health. ETHICS AND DISSEMINATION This study received ethical approval from Ethics Committee of Université Laval. The findings will be used to inform the effectiveness of CONCERTO+ to improve management care in chronic diseases. We will disseminate findings through presentations in scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03628963; Pre-results.
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Affiliation(s)
- Marie-Pierre Gagnon
- Centre de Recherche sur les Soins et les Services de Première Ligne de l’Université Laval, Quebec City, QC, Canada
- Faculty of Nursing Sciences, Université Laval, Quebec City, QC, Canada
| | - Mame Awa Ndiaye
- Centre de Recherche sur les Soins et les Services de Première Ligne de l’Université Laval, Quebec City, QC, Canada
| | | | | | | | - Ronald Buyl
- Faculty of Medicine and Pharmacy, VrjeUniversiteit, Brussel, Belgium
| | - Jean-Paul Fortin
- Centre de Recherche sur les Soins et les Services de Première Ligne de l’Université Laval, Quebec City, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Quebec City, QC, Canada
| | - Anik Giguère
- Centre de Recherche sur les Soins et les Services de Première Ligne de l’Université Laval, Quebec City, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Quebec City, QC, Canada
| | - Annie Leblanc
- Centre de Recherche sur les Soins et les Services de Première Ligne de l’Université Laval, Quebec City, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Quebec City, QC, Canada
| | - France Légaré
- Centre de Recherche sur les Soins et les Services de Première Ligne de l’Université Laval, Quebec City, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Quebec City, QC, Canada
| | - Aude Motulsky
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montréal, QC, Canada
| | - Claude Sicotte
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montréal, QC, Canada
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Université Laval, Quebec City, QC, Canada
| | - Eric Kavanagh
- École de design, Université Laval, Quebec City, QC, Canada
| | | | | | - Carole Délétroz
- School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts Western Switzerland Lausanne, Lausanne, Switzerland
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Boyd C, Smith CD, Masoudi FA, Blaum CS, Dodson JA, Green AR, Kelley A, Matlock D, Ouellet J, Rich MW, Schoenborn NL, Tinetti ME. Decision Making for Older Adults With Multiple Chronic Conditions: Executive Summary for the American Geriatrics Society Guiding Principles on the Care of Older Adults With Multimorbidity. J Am Geriatr Soc 2019; 67:665-673. [DOI: 10.1111/jgs.15809] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Cynthia Boyd
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | | | - Frederick A. Masoudi
- Department of Medicine (Cardiology); University of Colorado Anschutz Medical Campus; Aurora Colorado
| | - Caroline S. Blaum
- Department of Medicine; New York University School of Medicine; New York New York
| | - John A. Dodson
- Department of Medicine; New York University School of Medicine; New York New York
| | - Ariel R. Green
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Amy Kelley
- Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - Daniel Matlock
- Department of Medicine (General Internal Medicine); University of Colorado School of Medicine; Denver Colorado
| | - Jennifer Ouellet
- Department of Internal Medicine; Yale School of Medicine, Yale School of Public Health; New Haven Connecticut
| | - Michael W. Rich
- Department of Internal Medicine; Washington University School of Medicine; St Louis Missouri
| | - Nancy L. Schoenborn
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Mary E. Tinetti
- Department of Internal Medicine; Yale School of Medicine, Yale School of Public Health; New Haven Connecticut
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Family practitioners' top medical priorities when managing patients with multimorbidity: a cross-sectional study. BJGP Open 2019; 3:bjgpopen18X101622. [PMID: 31049405 PMCID: PMC6480857 DOI: 10.3399/bjgpopen18x101622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/16/2018] [Indexed: 11/09/2022] Open
Abstract
Background Managing multiple chronic and acute conditions in patients with multimorbidity requires setting medical priorities. How family practitioners (FPs) rank medical priorities between highly, moderately, or rarely prevalent chronic conditions (CCs) has never been described. The authors hypothesised that there was no relationship between the prevalence of CCs and their medical priority ranking in individual patients with multimorbidity. Aim To describe FPs’ medical priority ranking of conditions relative to their prevalence in patients with multimorbidity. Design & setting This cross-sectional study of 100 FPs in Switzerland included patients with ≥3 CCs on a predefined list of 75 items from the International Classification of Primary Care 2 (ICPC-2); other conditions could be added. FPs ranked all conditions by their medical priority. Method Priority ranking and distribution were calculated for each condition separately and for the top three priorities together. Results The sample contained 888 patients aged 28–98 years (mean 73), of which 48.2% were male. Included patients had 3–19 conditions (median 7; interquantile range [IQR] 6–9). FPs used 74/75 CCs from the predefined list, of which 27 were highly prevalent (>5%). In total, 336 different conditions were recorded. Highly prevalent CCs were only the top medical priority in 66%, and the first three priorities in 33%, of cases. No correlation was found between prevalence and the ranking of medical priorities. Conclusion FPs faced a great diversity of different conditions in their patients with multimorbidity, with nearly every condition being found at nearly every rank of medical priority, depending on the patient. Medical priority ranking was independent of the prevalence of CCs.
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Petrosyan Y, Barnsley JM, Kuluski K, Liu B, Wodchis WP. Quality indicators for ambulatory care for older adults with diabetes and comorbid conditions: A Delphi study. PLoS One 2018; 13:e0208888. [PMID: 30543672 PMCID: PMC6292587 DOI: 10.1371/journal.pone.0208888] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/26/2018] [Indexed: 01/26/2023] Open
Abstract
Background An increasing number of people are living with multiple chronic conditions and it is unclear which quality indicators should be used to guide care for this population. Objective To critically appraise and select the most appropriate set of quality indicators for ambulatory care for older adults with five selected disease combinations. Methods A two-round web-based Delphi process was used to critically appraise and select quality of care indicators for older adults with diabetes and comorbidities. A fifteen-member Canadian expert panel with broad geographical and clinical representation participated in this study. The panel evaluated process indicators for meaningfulness, potential for improvements in clinical practice, and overall value of inclusion, while outcome indicators were evaluated for importance, modifiability and overall value of inclusion. A 70% agreement threshold was required for high consensus, and 60–69% for moderate consensus as measured on a 5-point Likert type scale. Results Twenty high-consensus and nineteen medium-consensus process and outcome indicators were selected for assessing care for older adults with selected disease combinations, including 1) concordant (conditions with a common management plan), 2) discordant (conditions with unrelated management plans), and 3) both types. Panelists reached rapid consensus on quality indicators for care for older adults with concordant comorbid conditions, but not for those with discordant conditions. All selected indicators assess clinical aspects of care. The feedback from the panelists emphasized the importance of developing indicators related to patient-centred aspects of care, including patient self-management, education, patient-physician relationships, and patient’s preferences. Conclusions The selected quality indicators are not intended to provide a comprehensive tool set for measuring quality of care for older adults with selected disease combinations. The recommended indicators address clinical aspects of care and can be used as a starting point for ambulatory care settings and development of additional quality indicators.
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Affiliation(s)
- Yelena Petrosyan
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jan M. Barnsley
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Kerry Kuluski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Barbara Liu
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Walter P. Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Toronto Rehabilitation Institute, Toronto, Canada
- * E-mail:
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Johnston A, Hsieh SC, Carrier M, Kelly SE, Bai Z, Skidmore B, Wells GA. A systematic review of clinical practice guidelines on the use of low molecular weight heparin and fondaparinux for the treatment and prevention of venous thromboembolism: Implications for research and policy decision-making. PLoS One 2018; 13:e0207410. [PMID: 30412622 PMCID: PMC6226206 DOI: 10.1371/journal.pone.0207410] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/30/2018] [Indexed: 11/18/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a major global cause of morbidity and mortality. Low molecular weight heparin (LMWH) and fondaparinux (FDP) are frequently used to treat and prevent VTE and have a variety of safety and practical advantages over other anticoagulants, including use in outpatient settings. These medications are commonly listed on drug formularies, which act as a gateway for health plan prescription coverage by outlining the circumstances under which patients will be covered for specific drugs and drug products. Because patient access to medications is impacted by the nature of their listing on formularies, they must be rigorously reviewed and modernized as new evidence emerges. Methods As part of a broader drug class review team, we completed a systematic review of clinical practice guidelines to determine whether the recommendations they reported aligned with the indications listed for the coverage of LMWH and FDP in an outpatient drug formulary. Guideline quality was assessed using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool. Recommendation matrices were used to systematically compare, categorize, and summarize included recommendations. Results Twenty-seven guidelines were included from which 168 eligible recommendations were identified. Generally, AGREE II domains were adequately addressed; however, domain five (applicability) was poorly addressed. Most recommendations were based on moderate- to low-quality/limited evidence and reported on the use of LMWHs generally; few reported on specific agents. Conclusions Our findings contributed to the recommendation that the formulary listing for LMWH and FDP be streamlined to include coverage for specific outpatient indications. The paucity of available evidence on the comparative efficacy of specific LMWH agents against each other and FDP limited agent-specific listing recommendations, highlighting the need for high-quality comparative studies on this topic.
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Affiliation(s)
- Amy Johnston
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Shu-Ching Hsieh
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, Division of Hematology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Shannon E. Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Zemin Bai
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | - George A. Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail:
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Okeowo D, Patterson A, Boyd C, Reeve E, Gnjidic D, Todd A. Clinical practice guidelines for older people with multimorbidity and life-limiting illness: what are the implications for deprescribing? Ther Adv Drug Saf 2018; 9:619-630. [PMID: 30479737 PMCID: PMC6243426 DOI: 10.1177/2042098618795770] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/07/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The aim of this study was (1) to apply the current United Kingdom (UK) National Institute for Health and Care Excellence (NICE) clinical practice guidelines to a hypothetical older patient with multimorbidity and life-limiting illness; (2) consider how treatment choices could be influenced by NICE guidance specifically related to multimorbidity; and, (3) ascertain if such clinical practice guidelines describe how and when medication should be reviewed, reduced and stopped. METHODS Based upon common long-term conditions in older people, a hypothetical older patient was constructed. Relevant NICE guidelines were applied to the hypothetical patient to determine what medication should be initiated in three treatment models: a new patient model, a treatment-resistant model, and a last-line model. Medication complexity for each model was assessed according to the medication regimen complexity index (MRCI). RESULTS The majority of the guidelines recommended the initiation of medication in the hypothetical patient; if the initial treatment approach was unsuccessful, each guideline advocated the use of more medication, with the regimen becoming increasingly complex. In the new patient model, 4 separate medications (9 dosage units) would be initiated per day; for the treatment-resistant model, 6 separate medications (15 dosage units); and, for the last-line model, 11 separate medications (20 dosage units). None of the guidelines used for the hypothetical patient discussed approaches to stopping medication. CONCLUSIONS In a UK context, disease-specific clinical practice guidelines routinely advocate the initiation of medication to manage long-term conditions, with medication regimens becoming increasingly complex through the different steps of care. There is often a lack of information regarding specific treatment recommendations for older people with life-limiting illness and multimorbidity. While guidelines frequently explain how and when a medication should be initiated, there is often no information concerning when and how the medications should be reduced or stopped.
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Affiliation(s)
- Daniel Okeowo
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Alastair Patterson
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily Reeve
- NHMRC-Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada College of Pharmacy, Faculty of Health, Dalhousie University, NS, Canada
| | - Danijela Gnjidic
- Faculty of Pharmacy and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Adam Todd
- Faculty of Medical Sciences, School of Pharmacy, Newcastle University, Rm G.66, King George VI Building, Queen Victoria Road, Newcastle upon Tyne, NE1 7RU, UK
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Pouplier S, Olsen MÅ, Willadsen TG, Sandholdt H, Siersma V, Andersen CL, Olivarius NDF. The development of multimorbidity during 16 years after diagnosis of type 2 diabetes. JOURNAL OF COMORBIDITY 2018; 8:2235042X18801658. [PMID: 30363325 PMCID: PMC6169975 DOI: 10.1177/2235042x18801658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 08/14/2018] [Indexed: 12/21/2022]
Abstract
Objective: The aims of this study were to (1) quantify the development and composition
of multimorbidity (MM) during 16 years following the diagnosis of type 2
diabetes and (2) evaluate whether the effectiveness of structured personal
diabetes care differed between patients with and without MM. Research design and methods: One thousand three hundred eighty-one patients with newly diagnosed type 2
diabetes were randomized to receive either structured personal diabetes care
or routine diabetes care. Patients were followed up for 19 years in Danish
nationwide registries for the occurrence of outcomes. We analyzed the
prevalence and degree of MM based on 10 well-defined disease groups. The
effect of structured personal care in diabetes patients with and without MM
was analyzed with Cox regression models. Results: The proportion of patients with MM increased from 31.6% at diabetes diagnosis
to 80.4% after 16 years. The proportion of cardiovascular and
gastrointestinal diseases in surviving patients decreased, while, for
example, musculoskeletal, eye, and neurological diseases increased. The
effect of the intervention was not different between type 2 diabetes
patients with or without coexisting chronic disease. Conclusions: In general, the proportion of patients with MM increased after diabetes
diagnosis, but the composition of chronic disease changed during the 16
years. We found cardiovascular and musculoskeletal disease to be the most
prevalent disease groups during all 16 years of follow-up. The post hoc
analysis of the intervention showed that its effectiveness was not different
among patients who developed MM compared to those who continued to have
diabetes alone.
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Affiliation(s)
- Sandra Pouplier
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Maria Åhlander Olsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Tora Grauers Willadsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Håkon Sandholdt
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Christen Lykkegaard Andersen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Niels de Fine Olivarius
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Haggerty J, Fortin M, Breton M. Snapshot of the primary care waiting room: Informing practice redesign to align with the Patient's Medical Home model. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2018; 64:e407-e413. [PMID: 30209115 PMCID: PMC6135124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To describe the demographic characteristics, health, and health care experiences of adult patients in primary care waiting rooms in Quebec, and to determine which pillars of the Patient's Medical Home (PMH) are a priority to align primary care practices with the PMH model. DESIGN Baseline survey of a prospective cohort study using self-administered on-site and mailed questionnaires. SETTING Twelve primary care clinics within the geographic boundaries of 4 local health care networks in metropolitan, urban, rural, and remote settings in Quebec. PARTICIPANTS A total of 1029 adult patients aged between 25 and 75 who were selected during a 1-week period in the 12 primary care clinics; 789 returned questionnaires. MAIN OUTCOME MEASURES Patients' health profiles, health behaviour patterns, reasons for the visit, and health care experiences. RESULTS In this 2010 snapshot, 66.8% of patients waited longer than 2 weeks for their appointment, 71.0% of visits were for routine or follow-up care, and longer wait times and patient multimorbidity correlated with more reasons for the visit. After the visit, most patients reported being able to express their most important needs and that the doctor listened well; however, only 28.1% reported that the doctor had explored whether the recommendations would be realistic for them, and only 18.0% indicated that the doctor had explored the personal or family dimensions that affected their health. Among all patients, 56.9% reported having at least 3 chronic conditions (multimorbidity), and 30.3% reported having high or moderate levels of psychological distress. When describing their financial status, 30.7% of patients indicated it was "poor to squeezed or tight." Slightly more than half of patients did not have complementary private health insurance to cover costs of psychological services. CONCLUSION In this study, the 4 priority pillars for practices to align with the PMH were timely access, team-based care, comprehensive care, and a patient-centred approach. Widespread implementation of advanced access is an urgent priority in light of persisting difficulties in timely access. Team-based and comprehensive care are needed to address the high prevalence of multimorbidity and psychological distress and to support health behaviour change. Finally, the patient-centred approach needs to underpin every care encounter.
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Affiliation(s)
- Jeannie Haggerty
- Health services epidemiologist in Montreal, Que, Full Professor in the Department of Family Medicine at McGill University in Montreal, and McGill Chair in Family and Community Medicine at St Mary's Hospital in Montreal.
| | - Martin Fortin
- Family physician in the Family Medicine Unit at the Chicoutimi Health and Social Services Center and at the Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean in Quebec, Full Professor in the Department of Family Medicine and Emergency Medicine at the Université de Sherbrooke in Quebec, and Research Chair on Chronic Diseases in Primary Care
| | - Mylaine Breton
- Associate Professor in the Department of Community Health Sciences in the Université de Sherbrooke in Quebec, and Canada Research Chair in Clinical Governance on Primary Health Care
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Kastner M, Cardoso R, Lai Y, Treister V, Hamid JS, Hayden L, Wong G, Ivers NM, Liu B, Marr S, Holroyd-Leduc J, Straus SE. Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults: a systematic review and meta-analysis. CMAJ 2018; 190:E1004-E1012. [PMID: 30150242 PMCID: PMC6110649 DOI: 10.1503/cmaj.171391] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2018] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION More than half of older adults (age ≥ 65 yr) have 2 or more high-burden multimorbidity conditions (i.e., highly prevalent chronic diseases, which are associated with increased health care utilization; these include diabetes [DM], dementia, depression, chronic obstructive pulmonary disease [COPD], cardiovascular disease [CVD], arthritis, and heart failure [HF]), yet most existing interventions for managing chronic disease focus on a single disease or do not respond to the specialized needs of older adults. We conducted a systematic review and meta-analysis to identify effective multimorbidity interventions compared with a control or usual care strategy for older adults. METHODS We searched bibliometric databases for randomized controlled trials (RCTs) evaluating interventions for managing multiple chronic diseases in any language from 1990 to December 2017. The primary outcome was any outcome specific to managing multiple chronic diseases as reported by studies. Reviewer pairs independently screened citations and full-text articles, extracted data and assessed risk of bias. We assessed statistical and methodological heterogeneity and performed a meta-analysis of RCTs with similar interventions and components. RESULTS We included 25 studies (including 15 RCTs and 6 cluster RCTs) (12 579 older adults; mean age 67.3 yr). In patients with [depression + COPD] or [CVD + DM], care-coordination strategies significantly improved depressive symptoms (standardized mean difference -0.41; 95% confidence interval [CI] -0.59 to -0.22; I2 = 0%) and reduced glycosylated hemoglobin (HbA1c) levels (mean difference -0.51; 95% CI -0.90 to -0.11; I2 = 0%), but not mortality (relative risk [RR] 0.79; 95% CI 0.53 to 1.17; I2 = 0%). Among secondary outcomes, care-coordination strategies reduced functional impairment in patients with [arthritis + depression] (between-group difference -0.82; 95% CI -1.17 to -0.47) or [DM + depression] (between-group difference 3.21; 95% CI 1.78 to 4.63); improved cognitive functioning in patients with [DM + depression] (between-group difference 2.44; 95% CI 0.79 to 4.09) or [HF + COPD] (p = 0.006); and increased use of mental health services in those with [DM + (CVD or depression)] (RR 2.57; 95% CI 1.90 to 3.49; I2 = 0%). INTERPRETATION Subgroup analyses showed that older adults with diabetes and either depression or cardiovascular disease, or with coexistence of chronic obstructive pulmonary disease and heart failure, can benefit from care-coordination strategies with or without education to lower HbA1c, reduce depressive symptoms, improve health-related functional status, and increase the use of mental health services. PROTOCOL REGISTRATION PROSPERO-CRD42014014489.
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Affiliation(s)
- Monika Kastner
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont.
| | - Roberta Cardoso
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Yonda Lai
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Victoria Treister
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Jemila S Hamid
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Leigh Hayden
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Geoff Wong
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Noah M Ivers
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Barbara Liu
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Sharon Marr
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Jayna Holroyd-Leduc
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
| | - Sharon E Straus
- Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont
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Poitras ME, Chouinard MC, Fortin M, Girard A, Crossman S, Gallagher F. Nursing activities for patients with chronic disease in family medicine groups: A multiple-case study. Nurs Inq 2018; 25:e12250. [DOI: 10.1111/nin.12250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 04/27/2018] [Accepted: 05/13/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Marie-Eve Poitras
- Département des Sciences de la Santé; Université du Québec à Chicoutimi; Chicoutimi Québec Canada
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean; Saguenay Québec Canada
| | - Maud-Christine Chouinard
- Département des Sciences de la Santé; Université du Québec à Chicoutimi; Chicoutimi Québec Canada
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean; Saguenay Québec Canada
| | - Martin Fortin
- Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean; Saguenay Québec Canada
- Faculté de Médecine et des Sciences de la Santé; Université de Sherbrooke; Sherbrooke Québec Canada
| | - Ariane Girard
- Faculté de Médecine et des Sciences de la Santé; Université de Sherbrooke; Sherbrooke Québec Canada
| | | | - Frances Gallagher
- Faculté de Médecine et des Sciences de la Santé; Université de Sherbrooke; Sherbrooke Québec Canada
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Poitras ME, Maltais ME, Bestard-Denommé L, Stewart M, Fortin M. What are the effective elements in patient-centered and multimorbidity care? A scoping review. BMC Health Serv Res 2018; 18:446. [PMID: 29898713 PMCID: PMC6001147 DOI: 10.1186/s12913-018-3213-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 05/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interventions to improve patient-centered care for persons with multimorbidity are in constant growth. To date, the emphasis has been on two separate kinds of interventions, those based on a patient-centered care approach with persons with chronic disease and the other ones created specifically for persons with multimorbidity. Their effectiveness in primary healthcare is well documented. Currently, none of these interventions have synthesized a patient-centered care approach for care for multimorbidity. The objective of this project is to determine the particular elements of patient-centered interventions and interventions for persons with multimorbidity that are associated with positive health-related outcomes for patients. METHOD A scoping review was conducted as the method supports the rapid mapping of the key concepts underpinning a research area and the main sources and types of evidence available. A five-stage approach was adopted: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing and reporting results. We searched for interventions for persons with multimorbidity or patient-centered care in primary care. Relevant studies were identified in four systematic reviews (Smith et al. (2012;2016), De Bruin et al. (2012), and Dwamena et al. (2012)). Inductive analysis was performed. RESULTS Four systematic reviews and 98 original studies were reviewed and analysed. Elements of interventions can be grouped into three main types and clustered into seven categories of interventions: 1) Supporting decision process and evidence-based practice; 2) Providing patient-centered approaches; 3) Supporting patient self-management; 4) Providing case/care management; 5) Enhancing interdisciplinary team approach; 6) Developing training for healthcare providers; and 7) Integrating information technology. Providing patient-oriented approaches, self-management support interventions and developing training for healthcare providers were the most frequent categories of interventions with the potential to result in positive impact for patients with chronic diseases. CONCLUSION This scoping review provides evidence for the adaption of patient-centered interventions for patients with multimorbidity. Findings from this scoping review will inform the development of a toolkit to assist chronic disease prevention and management programs in reorienting patient care.
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Affiliation(s)
- Marie-Eve Poitras
- Département des sciences de la santé, Université du Québec à Chicoutimi, 555 Boulevard Université, Chicoutimi, Québec, G7H 2B1, Canada.
| | - Marie-Eve Maltais
- Département de médecine de famille, Université de Sherbrooke, Sherbrooke, Canada
| | - Louisa Bestard-Denommé
- Centre for Studies in Family Medicine, The Western Centre for Public Health and Family Medicine, 2nd Floor, London, Canada
| | - Moira Stewart
- Centre for Studies in Family Medicine, The Western Centre for Public Health and Family Medicine, 2nd Floor, London, Canada
| | - Martin Fortin
- Département de médecine de famille, Université de Sherbrooke, Sherbrooke, Canada
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Garnett A, Ploeg J, Markle-Reid M, Strachan PH. Self-Management of Multiple Chronic Conditions by Community-Dwelling Older Adults: A Concept Analysis. SAGE Open Nurs 2018; 4:2377960817752471. [PMID: 33415188 PMCID: PMC7774451 DOI: 10.1177/2377960817752471] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/29/2017] [Accepted: 12/10/2017] [Indexed: 11/16/2022] Open
Abstract
The proportion of the aging population living with multiple chronic conditions (MCC) is increasing. Self-management is valuable in helping individuals manage MCC. The purpose of this study was to conduct a concept analysis of self-management in community-dwelling older adults with MCC using Walker and Avant's method. The review included 30 articles published between 2000 and 2017. The following attributes were identified: (a) using financial resources for chronic disease management, (b) acquiring health- and disease-related education, (c) making use of ongoing social supports, (d) responding positively to health changes, (e) ongoing engagement with the health system, and (f) actively participating in sustained disease management. Self-management is a complex process; the presence of these attributes increases the likelihood that an older adult will be successful in managing the symptoms of MCC.
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Affiliation(s)
- Anna Garnett
- Aging, Community and Health Research Unit, School of Nursing, McMaster University, Hamilton, ON, Canada.,School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Jenny Ploeg
- Aging, Community and Health Research Unit, School of Nursing, McMaster University, Hamilton, ON, Canada.,School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Maureen Markle-Reid
- Aging, Community and Health Research Unit, School of Nursing, McMaster University, Hamilton, ON, Canada.,School of Nursing, McMaster University, Hamilton, ON, Canada
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Déruaz-Luyet A, N'Goran AA, Senn N, Bodenmann P, Pasquier J, Widmer D, Tandjung R, Rosemann T, Frey P, Streit S, Zeller A, Haller DM, Excoffier S, Burnand B, Herzig L. Multimorbidity and patterns of chronic conditions in a primary care population in Switzerland: a cross-sectional study. BMJ Open 2017; 7:e013664. [PMID: 28674127 PMCID: PMC5734197 DOI: 10.1136/bmjopen-2016-013664] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To characterise in details a random sample of multimorbid patients in Switzerland and to evaluate the clustering of chronic conditions in that sample. METHODS 100 general practitioners (GPs) each enrolled 10 randomly selected multimorbid patients aged ≥18 years old and suffering from at least three chronic conditions. The prevalence of 75 separate chronic conditions from the International Classification of Primary Care-2 (ICPC-2) was evaluated in these patients. Clusters of chronic conditions were studied in parallel. RESULTS The final database included 888 patients. Mean (SD) patient age was 73.0 (12.0) years old. They suffered from 5.5 (2.2) chronic conditions and were prescribed 7.7 (3.5) drugs; 25.7% suffered from depression. Psychological conditions were more prevalent among younger individuals (≤66 years old). Cluster analysis of chronic conditions with a prevalence ≥5% in the sample revealed four main groups of conditions: (1) cardiovascular risk factors and conditions, (2) general age-related and metabolic conditions, (3) tobacco and alcohol dependencies, and (4) pain, musculoskeletal and psychological conditions. CONCLUSION Given the emerging epidemic of multimorbidity in industrialised countries, accurately depicting the multiple expressions of multimorbidity in family practices' patients is a high priority. Indeed, even in a setting where patients have direct access to medical specialists, GPs nevertheless retain a key role as coordinators and often as the sole medical reference for multimorbid patients.
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Affiliation(s)
- Anouk Déruaz-Luyet
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
| | | | - Nicolas Senn
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
| | - Patrick Bodenmann
- Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Jérôme Pasquier
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Daniel Widmer
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
| | - Ryan Tandjung
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Peter Frey
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Dagmar M Haller
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sophie Excoffier
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Lilli Herzig
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
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Guthrie B, Thompson A, Dumbreck S, Flynn A, Alderson P, Nairn M, Treweek S, Payne K. Better guidelines for better care: accounting for multimorbidity in clinical guidelines – structured examination of exemplar guidelines and health economic modelling. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05160] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BackgroundMultimorbidity is common but most clinical guidelines focus on single diseases.AimTo test the feasibility of new approaches to developing single-disease guidelines to better account for multimorbidity.DesignLiterature-based and economic modelling project focused on areas where multimorbidity makes guideline application problematic.Methods(1) Examination of accounting for multimorbidity in three exemplar National Institute for Health and Care Excellence guidelines (type 2 diabetes, depression, heart failure); (2) examination of the applicability of evidence in multimorbidity for the exemplar conditions; (3) exploration of methods for comparing absolute benefit of treatment; (4) incorporation of treatment pay-off time and competing risk of death in an exemplar economic model for long-term preventative treatments with slowly accruing benefit; and (5) development of a discrete event simulation model-based cost-effectiveness analysis for people with both depression and coronary heart disease.Results(1) Comorbidity was rarely accounted for in the clinical research questions that framed the development of the exemplar guidelines, and was rarely accounted for in treatment recommendations. Drug–disease interactions were common only for comorbid chronic kidney disease, but potentially serious drug–drug interactions between recommended drugs were common and rarely accounted for in guidelines. (2) For all three conditions, the trials underpinning treatment recommendations largely excluded older, more comorbid and more coprescribed patients. The implications of low applicability varied by condition, with type 2 diabetes having large differences in comorbidity, whereas potentially serious drug–drug interactions were more important for depression. (3) Comparing absolute benefit of treatments for different conditions was shown to be technically feasible, but only if guideline developers are willing to make a number of significant assumptions. (4) The lifetime absolute benefit of statins for primary prevention is highly sensitive to the presence of both the direct treatment disutility of taking a daily tablet and competing risk of death. (5) It was feasible to use a discrete event simulation-based model to represent the relevant care pathways to estimate the relative cost-effectiveness of pharmacological treatments of major depressive disorder in primary care for patients who are also likely to go on and receive treatment for coronary heart disease but the analysis was reliant on eliciting some parameter values from experts, which increases the inherent uncertainty in the results. The key limitation was that real-life use in guideline development was not examined.ConclusionsGuideline developers could feasibly (1) use epidemiological data characterising the guideline population to inform consideration of applicability and interactions; (2) systematically compare the absolute benefit of long-term preventative treatments to inform decision-making in people with multimorbidity and high treatment burden; and (3) modify the output from economic models used in guideline development to examine time to benefit in terms of the pay-off time and varying competing risk of death from other conditions.Future workFurther research is needed to optimise presentation of comparative absolute benefit information to clinicians and patients, to evaluate the use of epidemiological and time-to-benefit data in guideline development, to better quantify direct treatment disutility and to better quantify benefit and harm in people with multimorbidity.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Bruce Guthrie
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Alexander Thompson
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Siobhan Dumbreck
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Angela Flynn
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Phil Alderson
- Centre for Clinical Practice, National Institute for Health and Care Excellence, Manchester, UK
| | - Moray Nairn
- Scottish Intercollegiate Guidelines Network, Edinburgh, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
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Çekiç İ, Kahveci R, Ayhan Başer D, Koç EM, Baydar Artantaş A. Türkiye’deki Sivil Toplum Kuruluşlarının Klinik Uygulama Rehberleri Alanındaki Faaliyetleri. ANKARA MEDICAL JOURNAL 2017. [DOI: 10.17098/amj.304662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Nelson MLA, McKellar KA, Yi J, Kelloway L, Munce S, Cott C, Hall R, Fortin M, Teasell R, Lyons R. Stroke rehabilitation evidence and comorbidity: a systematic scoping review of randomized controlled trials. Top Stroke Rehabil 2017; 24:374-380. [DOI: 10.1080/10749357.2017.1282412] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Michelle L. A. Nelson
- Bridgepoint Collaboratory, Lunenfeld-Tanenbaum Research Institute, Sinai Health Systems, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, Canada
| | - Kaileah A. McKellar
- Bridgepoint Collaboratory, Lunenfeld-Tanenbaum Research Institute, Sinai Health Systems, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Juliana Yi
- Bridgepoint Collaboratory, Lunenfeld-Tanenbaum Research Institute, Sinai Health Systems, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Sarah Munce
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Cheryl Cott
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Ruth Hall
- Institute of Clinical Evaluative Sciences, Toronto, Canada
| | - Martin Fortin
- Département de médecine de famille, Universite de Sherbrooke, Sherbrooke, Canada
| | - Robert Teasell
- St. Joseph’s Stroke Rehabilitation Program, Lawson Health Research Institute, Western University, London, Canada
| | - Renee Lyons
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Gassmann D, Cheetham M, Siebenhuener K, Holzer BM, Meindl-Fridez C, Hildenbrand FF, Virgini V, Martin M, Battegay E. The multimorbidity interaction severity index (MISI): A proof of concept study. Medicine (Baltimore) 2017; 96:e6144. [PMID: 28225495 PMCID: PMC5569438 DOI: 10.1097/md.0000000000006144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Therapeutic decision-making for patients with multimorbidity (MM) is challenging. Clinical practice guidelines inadequately address harmful interactions and resulting therapeutic conflicts within and among diseases. A patient-specific measure of MM severity that takes account of this conflict is needed.As a proof of concept, we evaluated whether the new Multimorbidity Interaction Severity Index (MISI) could be used to reliably differentiate patients in terms of lower versus higher potential for harmful interactions.Two hypothetical patient cases were generated, each with 6 concurrent morbidities. One case had a low (i.e., low conflict case) and the other a high (i.e., high conflict case) potential for harmful interactions. All possible interactions between conditions and treatments were extracted from each case's record into a multimorbidity interaction matrix. Experienced general internists (N = 18) judged each interaction in the matrix in terms of likely resource utilization needed to manage the interaction. Based on these judgements, a composite index of MM interaction severity, that is, the MISI, was generated for each physician and case.The difference between each physician's MISI score for the 2 cases (MISIdiff) was computed. Based on MISIdiff, the high conflict case was judged to be of significantly greater MM severity than was the low conflict case. The positive values of the inter-quartile range, a measure of variation (or disagreement) between the 2 cases, indicated general consistency of individual physicians in judging MM severity.The data indicate that the MISI can be used to reliably differentiate hypothetical multimorbid patients in terms of lesser versus greater severity of potentially harmful interactive effects. On this basis, the MISI will be further developed for use in patient-specific assessment and management of MM. The clinical relevance of the MISI as an alternative approach to defining MM severity is discussed.
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Affiliation(s)
- Dimitri Gassmann
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | - Marcus Cheetham
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
- University Research Priority Program “Dynamics of Healthy Aging,” University of Zurich
| | - Klarissa Siebenhuener
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | - Barbara M. Holzer
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | - Claudine Meindl-Fridez
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | - Florian F. Hildenbrand
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
| | | | - Mike Martin
- Center of Competence Multimorbidity
- University Research Priority Program “Dynamics of Healthy Aging,” University of Zurich
- Division of Gerontopsychology and Gerontology, Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Edouard Battegay
- Department of Internal Medicine, University Hospital Zurich
- Center of Competence Multimorbidity
- University Research Priority Program “Dynamics of Healthy Aging,” University of Zurich
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Prados-Torres D, Del Cura-González I, Prados-Torres A. [Towards a multimorbidity care model in Primary Care]. Aten Primaria 2017; 49:261-262. [PMID: 28089227 PMCID: PMC6875925 DOI: 10.1016/j.aprim.2016.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Daniel Prados-Torres
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria, Servicio Andaluz de Salud (SAS), Distrito Málaga/Guadalhorce, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España.
| | - Isabel Del Cura-González
- Unidad de Apoyo a la Investigación, Gerencia Asistencial de Atención Primaria, Madrid, España; REDISSEC ISCIII, Madrid, España
| | - Alexandra Prados-Torres
- REDISSEC ISCIII, Madrid, España; Instituto Aragonés de Ciencias de la Salud (IACS), Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España
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Fisher K, Griffith L, Gruneir A, Panjwani D, Gandhi S, Sheng LL, Gafni A, Chris P, Markle-Reid M, Ploeg J. Comorbidity and its relationship with health service use and cost in community-living older adults with diabetes: A population-based study in Ontario, Canada. Diabetes Res Clin Pract 2016; 122:113-123. [PMID: 27833049 DOI: 10.1016/j.diabres.2016.10.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 07/29/2016] [Accepted: 10/11/2016] [Indexed: 11/25/2022]
Abstract
AIMS This study describes the comorbid conditions in Canadian, community-dwelling older adults with diabetes and the association between the number of comorbidities and health service use and costs. METHODS This retrospective cohort study used multiple linked administrative data to determine 5-year health service utilization in a population-based cohort of community-living individuals aged 66 and over with a diabetes diagnosis as of April 1, 2008 (baseline). Utilization included physician visits, emergency department visits, hospitalizations, and home care services. RESULTS There were 376,421 cohort members at baseline, almost all (95%) of which had at least one comorbidity and half (46%) had 3 or more. The most common comorbidities were hypertension (83%) and arthritis (61%). Service use and associated costs consistently increased as the number of comorbidities increased across all services and follow-up years. Conditions generally regarded as nondiabetes-related were the main driver of service use. Over time, use of most services declined for people with the highest level of comorbidity (3+). Hospitalizations and emergency department visits represented the largest share of costs for those with the highest level of comorbidity (3+), whereas physician visits were the main costs for those with fewer comorbidities. CONCLUSIONS Comorbidities in community-living older adults with diabetes are common and associated with a high level of health service use and costs. Accordingly, it is important to use a multiple chronic conditions (not single-disease) framework to develop coordinated, comprehensive and patient-centred programs for older adults with diabetes so that all their needs are incorporated into care planning.
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Affiliation(s)
- Kathryn Fisher
- School of Nursing, McMaster University, 1280 Main Street West, Health Sciences Centre Room, Hamilton, Ontario L8S 4K1, Canada.
| | - Lauren Griffith
- Department of Clinical Epidemiology and Biostatistics, McMaster University, McMaster Innovation Park, 175 Longwood Road South, Hamilton, ON L8P 0A1, Canada.
| | - Andrea Gruneir
- Department of Family Medicine, 6-40 University of Alberta, 6-10 University Terrace, Edmonton, AB T6G 2T4, Canada.
| | - Dilzayn Panjwani
- Women's College Research Institute, Women's College Hospital, 790 Bay Street, 7th Floor, Toronto, ON M5G 1N8, Canada.
| | - Sima Gandhi
- Institute for Clinical Evaluative Sciences (ICES), 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.
| | - Li Lisa Sheng
- Institute for Clinical Evaluative Sciences (ICES), 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.
| | - Amiram Gafni
- Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Room CRL-208, Hamilton, Ontario L8S 4K1, Canada,.
| | - Patterson Chris
- Department of Medicine, McMaster University, 1280 Main Street West, Health Sciences Centre, Room 3N25B, Hamilton, Ontario L8S 4K, Canada.
| | - Maureen Markle-Reid
- School of Nursing, McMaster University, 1280 Main Street West, Health Sciences Centre Room, Hamilton, Ontario L8S 4K1, Canada.
| | - Jenny Ploeg
- School of Nursing, McMaster University, 1280 Main Street West, Health Sciences Centre Room, Hamilton, Ontario L8S 4K1, Canada.
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Wilson MG, Lavis JN, Gauvin FP. Designing Integrated Approaches to Support People with Multimorbidity: Key Messages from Systematic Reviews, Health System Leaders and Citizens. Healthc Policy 2016; 12:91-104. [PMID: 28032827 PMCID: PMC5221714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Living with multiple chronic conditions (multimorbidity) - and facing complex, uncoordinated and fragmented care - is part of the daily life of a growing number of Canadians. METHODS We undertook: a knowledge synthesis; a "gap analysis" of existing systematic reviews; an issue brief that synthesized the available evidence about the problem, three options for addressing it and implementation considerations; a stakeholder dialogue involving key health-system leaders; and a citizen panel. RESULTS We identified several recommendations for actions that can be taken, including: developing evidence-based guidance that providers can use to help achieve goals set by patients; embracing approaches to supporting self-management; supporting greater communication and collaboration across healthcare providers as well as between healthcare providers and patients; and investing more efforts in health promotion and disease prevention. CONCLUSIONS Our results point to the need for health system decision-makers to support bottom-up, person-centred approaches to developing models of care that are tailored for people with multimorbidity and support a research agenda to address the identified priorities.
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Affiliation(s)
- Michael G. Wilson
- McMaster Health Forum, McMaster University, Centre for Health Economics and Policy Analysis, McMaster University, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON
| | - John N. Lavis
- McMaster Health Forum, McMaster University, Centre for Health Economics and Policy Analysis, McMaster University, Department of Clinical Epidemiology and Biostatistics, McMaster University, Department of Political Science, McMaster University, Hamilton, ON, Department of Global Health and Population, Harvard School of Public Health, Cambridge, MA
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40
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Yaşar I, Kahveci R, Baydar Artantaş A, Ayhan Başer D, Gökşin Cihan F, Şencan I, Koç EM, Özkara A. Quality Assessment of Clinical Practice Guidelines Developed by Professional Societies in Turkey. PLoS One 2016; 11:e0156483. [PMID: 27295303 PMCID: PMC4905636 DOI: 10.1371/journal.pone.0156483] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 05/16/2016] [Indexed: 11/17/2022] Open
Abstract
Background Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. There is a limited number of studies on guidelines in Turkey. The quality of Ministry of Health guidelines have formerly been assessed whereas there is no information on the other guidelines developed in the country. Aim This study aims to assess the quality of CPGs that are developed by professional societies that work for the health sector in Turkey, and compare the findings with international guidelines. Methodology Professional societies that work for the health sector were determined by using the data obtained from the Ministry of Internal Affairs. Inclusion and exclusion criteria were defined for selecting the CPGs. Guidelines containing recommendations about disease management to the doctors, accessible online, developed within the past 5 years, citing references for recommendations, about the diseases over 1% prevalence according to the “Statistical Yearbook of Turkey 2012” were included in the study. The quality of CPGs were assessed with the AGREE II instrument, which is an internationally recognized tool for this purpose. Four independent reviewers, who did not participate in the development of the selected guidelines and were trained in CPG appraisal, used the AGREE instrument for assessment of the selected guidelines. Findings 47 professional societies were defined which provided access to CPGs in their websites; 3 of them were only open to members so these could not be reached. 8 CPGs from 7 societies were selected from a total of 401 CPGs from 44 societies. The mean scores of the domains of the guidelines which were assessed by the AGREE II tool were; Scope and purpose: 64%, stakeholder involvement: 37.9%, rigour of development: 35.3%, clarity and presentation: 77.9%, applicability: 49.0% and editorial independence: 46.0%. Conclusion This is the first study in Turkey regarding quality appraisal of guidelines developed by the local professional societies. It adds to the limited amount of information in the literature that comes from Turkey as well as other developing countries.
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Affiliation(s)
- Ilknur Yaşar
- Department of Family Medicine, Ankara Yenimahalle Public Health Center, Ankara, Turkey
| | - Rabia Kahveci
- Department of Family Medicine, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Aylin Baydar Artantaş
- Department of Family Medicine, Ankara Training and Research Hospital, Ankara, Turkey
| | - Duygu Ayhan Başer
- Department of Kocaeli Peliublic Health Directorate, Health of Child, Adollesence,Woman Reproduction, Koc, Turkey
| | - Fatma Gökşin Cihan
- Department of Family Medicine, Konya Necmettin Erbakan University, Konya, Turkey
| | - Irfan Şencan
- Department of Family Medicine, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Esra Meltem Koç
- Department of Family Medicine, Ankara Mamak Public Health Center, Ankara, Turkey
| | - Adem Özkara
- Department of Family Medicine, Ankara Numune Training and Research Hospital, Ankara, Turkey
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Willadsen TG, Bebe A, Køster-Rasmussen R, Jarbøl DE, Guassora AD, Waldorff FB, Reventlow S, Olivarius NDF. The role of diseases, risk factors and symptoms in the definition of multimorbidity - a systematic review. Scand J Prim Health Care 2016; 34:112-21. [PMID: 26954365 PMCID: PMC4977932 DOI: 10.3109/02813432.2016.1153242] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 01/30/2016] [Indexed: 01/23/2023] Open
Abstract
UNLABELLED Objective is to explore how multimorbidity is defined in the scientific literature, with a focus on the roles of diseases, risk factors, and symptoms in the definitions. DESIGN Systematic review. METHODS MEDLINE (PubMed), Embase, and The Cochrane Library were searched for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diagnoses, risk factors, and symptoms. We reviewed 163 articles. In 61 articles (37%), the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions, with diabetes as the most frequent. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways. The definition of multimorbidity is heterogeneous and risk factors are more often included than symptoms. The severity of conditions is seldom included. Since the number of people living with multimorbidity is increasing there is a need to develop a concept of multimorbidity that is more useful in daily clinical work. Key points The increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice. Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4-147 different conditions. Diseases are included in all definitions of multimorbidity. Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included.
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Affiliation(s)
- Tora Grauers Willadsen
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Lolland Falster Population Study (LOFUS), Nykøbing F, Denmark;
| | - Anna Bebe
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Lolland Falster Population Study (LOFUS), Nykøbing F, Denmark;
| | - Rasmus Køster-Rasmussen
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
| | - Dorte Ejg Jarbøl
- The Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ann Dorrit Guassora
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
| | - Frans Boch Waldorff
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Susanne Reventlow
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Lolland Falster Population Study (LOFUS), Nykøbing F, Denmark;
| | - Niels de Fine Olivarius
- The Research Unit for General Practice and Department of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- The Lolland Falster Population Study (LOFUS), Nykøbing F, Denmark;
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Grudniewicz A, Nelson M, Kuluski K, Lui V, Cunningham HV, X Nie J, Colquhoun H, Wodchis WP, Taylor S, Loganathan M, Upshur RE. Treatment goal setting for complex patients: protocol for a scoping review. BMJ Open 2016; 6:e011869. [PMID: 27225653 PMCID: PMC4885433 DOI: 10.1136/bmjopen-2016-011869] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION An increasing number of people are living longer with multiple health and social care needs, and may rely heavily on health system resources. When dealing with multiple conditions, patients, caregivers and healthcare providers (HCPs) often experience high treatment burden due to unclear care trajectories, a myriad of treatment decisions and few guidelines on how to manage care needs. By understanding patient and caregiver priorities, and setting treatment goals, HCPs may help improve patient outcomes and experiences. This study aims to examine the extent and nature of the literature on treatment goal setting in complex patients, identify gaps in evidence and areas for further inquiry and guide a research programme to develop definitions, measures and recommendations for treatment goal setting. METHODS AND ANALYSIS This study protocol outlines a scoping review of the peer reviewed and the grey literature, using established scoping review methodology. Literature will be identified using a multidatabase and grey literature search strategy developed by two librarians. Papers and reports on the topic of goal setting that address complexity or complex patients will be included. Results of the search will be screened independently by two reviewers and included studies will be abstracted and charted in duplicate. ETHICS AND DISSEMINATION Ethics approval is not required for this scoping review. Working with the knowledge users on the team, we will prepare educational materials and presentations to disseminate study findings to HCPs, caregivers and patients, and at relevant national and international conferences. Results will also be published in a peer-reviewed journal.
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Affiliation(s)
- Agnes Grudniewicz
- Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Nelson
- Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Kerry Kuluski
- Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Vincci Lui
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Heather V Cunningham
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jason X Nie
- Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Heather Colquhoun
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Susan Taylor
- Health Quality Ontario, Toronto, Ontario, Canada
| | | | - Ross E Upshur
- Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Blom JW, El Azzi M, Wopereis DM, Glynn L, Muth C, van Driel ML. Reporting of patient-centred outcomes in heart failure trials: are patient preferences being ignored? Heart Fail Rev 2016; 20:385-92. [PMID: 25690985 PMCID: PMC4464642 DOI: 10.1007/s10741-015-9476-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Older people often suffer from multiple diseases. Therefore, universal cross-disease outcomes (e.g. functional status, quality of life, overall survival) are more relevant than disease-specific outcomes, and a range of potential outcomes are needed for medical decision-making. To assess how patient-relevant outcomes have penetrated randomized controlled trials (RCTs), reporting of these outcomes was reviewed in heart failure trials that included patients with multimorbidity. We systematically reviewed RCTs (Jan 2011–June 2012) and evaluated reported outcomes. Heart failure was chosen as condition of interest as this is common among older patients with multimorbidity. The main outcome was the proportion of RCTs reporting all-cause mortality, all-cause hospital admission, and outcomes in four domains of health, i.e. functional, signs and symptoms, psychological, and social domains. Of the 106 included RCTs, 50 (47 %) reported all-cause mortality and cardiovascular mortality and 29 (27 %) reported all-cause hospitalization and cardiovascular hospitalization. Of all trials, 68 (64 %) measured outcomes in the functional domain, 80 (75 %) in the domain of signs and symptoms, 65 (61 %) in the psychological domain, and 59 (56 %) in the social domain. Disease-specific instruments were more often used than non-disease-specific instruments. This review shows increasing attention for more patient-relevant outcomes; this is promising and indicates more awareness of the importance of a variety of outcomes desirable for patients. However, patients’ individual goal attainments were universally absent. For continued progress in patient-centred care, efforts are needed to develop these outcomes, study their merits and pitfalls, and intensify their use in research.
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Affiliation(s)
- Jeanet W Blom
- Department of Public Health and Primary Care (V0-P), Leiden University Medical Center, Postbox 9600, 2300 RC, Leiden, The Netherlands,
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Poitras MÈ, Chouinard MC, Fortin M, Girard A, Gallagher F. Les activités des infirmières œuvrant en soins de première ligne auprès des personnes atteintes de maladies chroniques : une revue systématique de la littérature. Rech Soins Infirm 2016. [DOI: 10.3917/rsi.126.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Young CE, Boyle FM, Brooker KS, Mutch AJ. Incorporating patient preferences in the management of multiple long-term conditions: is this a role for clinical practice guidelines? JOURNAL OF COMORBIDITY 2015; 5:122-131. [PMID: 29090160 PMCID: PMC5636037 DOI: 10.15256/joc.2015.5.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/15/2015] [Indexed: 12/05/2022]
Abstract
BACKGROUND Clinical practice guidelines provide an evidence-based approach to managing single chronic conditions, but their applicability to multiple conditions has been actively debated. Incorporating patient-preference recommendations and involving consumers in guideline development may enhance their applicability, but further understanding is needed. OBJECTIVES To assess guidelines that include recommendations for comorbid conditions to determine the extent to which they incorporate patient-preference recommendations; use consumer-engagement processes during development, and, if so, whether these processes produce more patient-preference recommendations; and meet standard quality criteria, particularly in relation to stakeholder involvement. DESIGN A review of Australian guidelines published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. Document analysis of guidelines examined the presence of patient-preference recommendations and the consumer-engagement processes used. The Appraisal of Guidelines for Research and Evaluation instrument was used to assess guideline quality. RESULTS Thirteen guidelines were reviewed. Twelve included at least one core patient-preference recommendation. Ten used consumer-engagement processes, including participation in development groups (seven guidelines) and reviewing drafts (ten guidelines). More extensive consumer engagement was generally linked to greater incorporation of patient-preference recommendations. Overall quality of guidelines was mixed, particularly in relation to stakeholder involvement. CONCLUSIONS Guidelines do incorporate some patient-preference recommendations, but more explicit acknowledgement is required. Consumer-engagement processes used during guideline development have the potential to assist in identifying patient preferences, but further research is needed. Clarification of the consumer role and investment in consumer training may strengthen these processes.
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Affiliation(s)
- Charlotte E Young
- School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Frances M Boyle
- School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Katie S Brooker
- Queensland Centre for Intellectual and Developmental Disability (QCIDD), School of Medicine, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Allyson J Mutch
- School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
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AlRuthia YSH, Hong SH, Graff C, Kocak M, Solomon D, Nolly R. Exploring the factors that influence medication rating Web sites value to older adults: A cross-sectional study. Geriatr Nurs 2015; 37:36-43. [PMID: 26563919 DOI: 10.1016/j.gerinurse.2015.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 10/03/2015] [Accepted: 10/12/2015] [Indexed: 11/28/2022]
Abstract
In this cross-sectional study, we evaluated factors that affected the perceived value of medication rating Web sites to 284 people aged ≥ 60 years who were taking prescription medications. The Patient Reviews of Medication Experience (PROMEX) questionnaire score, which assessed participant opinions about the value of online reviews of medications, was positively associated with preference to share health care decision making with the health care provider and negatively associated with the Physical Component Summary (PCS-12) and Mental Component Summary scores of the Short Form 12 health survey. The Primary Care Assessment Survey Communication score, which measured participant satisfaction with the communication from the health care provider, was positively associated with PCS-12 and health literacy. In summary, older adults who had poor physical and mental health-related quality of life were more likely to believe that medication rating Web sites were useful and helpful in facilitating communication with health care providers.
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Affiliation(s)
- Yazed Sulaiman H AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Song Hee Hong
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Carolyn Graff
- Department of Advanced Practice and Doctoral Studies, College of Nursing, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mehmet Kocak
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Solomon
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert Nolly
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
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47
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Tonelli M, Wiebe N, Guthrie B, James MT, Quan H, Fortin M, Klarenbach SW, Sargious P, Straus S, Lewanczuk R, Ronksley PE, Manns BJ, Hemmelgarn BR. Comorbidity as a driver of adverse outcomes in people with chronic kidney disease. Kidney Int 2015. [DOI: 10.1038/ki.2015.228] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Osmun WE, Kim GP, Harrison ER. Patients with multiple comorbidities: simple teaching strategy. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2015; 61:378-381. [PMID: 25873707 PMCID: PMC4396766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- W E Osmun
- Associate Professor of Family Medicine at Western University in London, Ont, and a family physician practising in Mount Brydges, Ont
| | - George P Kim
- Assistant Professor of Family Medicine at Western University and a family physician practising at Byron Family Medical Centre in London
| | - Emily Rae Harrison
- Senior medical student at the Schulich School of Medicine and Dentistry at Western University
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Gagliardi AR, Brouwers MC. Do guidelines offer implementation advice to target users? A systematic review of guideline applicability. BMJ Open 2015; 5:e007047. [PMID: 25694459 PMCID: PMC4336454 DOI: 10.1136/bmjopen-2014-007047] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Providers and patients are most likely to use and benefit from guidelines accompanied by implementation support. Guidelines published in 2007 and earlier assessed with the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument scored poorly for applicability, which reflects the inclusion of implementation instructions or tools. The purpose of this study was to examine the applicability of guidelines published in 2008 or later and identify factors associated with applicability. DESIGN Systematic review of studies that used AGREE to assess guidelines published in 2008 or later. DATA SOURCES MEDLINE and EMBASE were searched from 2008 to July 2014, and the reference lists of eligible items. Two individuals independently screened results for English language studies that reviewed guidelines using AGREE and reported all domain scores, and extracted data. Descriptive statistics were calculated across all domains. Multilevel regression analysis with a mixed effects model identified factors associated with applicability. RESULTS Of 245 search results, 53 were retrieved as potentially relevant and 20 studies were eligible for review. The mean and median domain scores for applicability across 137 guidelines published in 2008 or later were 43.6% and 42.0% (IQR 21.8-63.0%), respectively. Applicability scored lower than all other domains, and did not markedly improve compared with guidelines published in 2007 or earlier. Country (UK) and type of developer (disease-specific foundation, non-profit healthcare system) appeared to be associated with applicability when assessed with AGREE II (not original AGREE). CONCLUSIONS Despite increasing recognition of the need for implementation tools, guidelines continue to lack such resources. To improve healthcare delivery and associated outcomes, further research is needed to establish the type of implementation tools needed and desired by healthcare providers and consumers, and methods for developing high-quality tools.
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Stroke rehabilitation and patients with multimorbidity: a scoping review protocol. JOURNAL OF COMORBIDITY 2015; 5:1-10. [PMID: 29090155 PMCID: PMC5636031 DOI: 10.15256/joc.2015.5.47] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/13/2015] [Indexed: 11/28/2022]
Abstract
Stroke care presents unique challenges for clinicians, as most strokes occur in the context of other medical diagnoses. An assessment of capacity for implementing “best practice” stroke care found clinicians reporting a strong need for training specific to patient/system complexity and multimorbidity. With mounting patient complexity, there is pressure to implement new models of healthcare delivery for both quality and financial sustainability. Policy makers and administrators are turning to clinical practice guidelines to support decision-making and resource allocation. Stroke rehabilitation programs across Canada are being transformed to better align with the Canadian Stroke Strategy’s Stroke Best Practice Recommendations. The recommendations provide a framework to facilitate the adoption of evidence-based best practices in stroke across the continuum of care. However, given the increasing and emerging complexity of patients with stroke in terms of multimorbidity, the evidence supporting clinical practice guidelines may not align with the current patient population. To evaluate this, electronic databases and gray literature will be searched, including published or unpublished studies of quantitative, qualitative or mixed-methods research designs. Team members will screen the literature and abstract the data. Results will present a numerical account of the amount, type, and distribution of the studies included and a thematic analysis and concept map of the results. This review represents the first attempt to map the available literature on stroke rehabilitation and multimorbidity, and identify gaps in the existing research. The results will be relevant for knowledge users concerned with stroke rehabilitation by expanding the understanding of the current evidence.
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