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Redley B, Campbell D, Stockman K, Barnes S. Mixed methods quality evaluation of structured interprofessional medical ward rounds. Intern Med J 2021; 50:222-231. [PMID: 31069904 DOI: 10.1111/imj.14330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/31/2019] [Accepted: 04/08/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Standardised structure and content of interdisciplinary medical ward rounds can promote patient safety and patient-centred teamwork. AIMS To evaluate interdisciplinary ward rounds using a Structured Interdisciplinary Bedside Rounding (SIBR) intervention. METHODS The study involved multi-method, repeat measures with a non-equivalent control group. Non-participant observations were collected at: 1 and 6 months, on an intervention ward that introduced SIBR; and a control ward that continued traditional rounds. Focus group and survey data were also collected on the intervention ward. Participants were clinicians (medicine, nursing and allied health) working in two general medicine wards at a tertiary hospital in Melbourne, Australia. RESULTS Seventy-eight patient rounds were observed at Time 1, and 239 at Time 2. The SIBR ward rounds had all clinician disciplines represented, whereas allied health and nurses were present for less than 20% of non-SIBR rounds. Interdisciplinary participation and frequency of desired clinician behaviours increased, and variability in duration of time per patient decreased, on the SIBR rounds. Longitudinal data reflected decreased performance of some SIBR behaviours in the intervention ward, while some desired behaviours increased in the control ward. Qualitative survey and focus group data indicated many positive views, but fit with broader ward routines impacted SIBR implementation. CONCLUSIONS The overall recommendation by staff was that SIBR should continue. The results provide insights into the adoption of SIBR behaviours and illustrated diffusion of behaviours across wards. Highlighting successes and identifying barriers can help meet challenges for ongoing improvement.
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Affiliation(s)
- Bernice Redley
- Centre for Quality and Patient Safety Research - Monash Health Partnership School of Nursing and Midwifery, Deakin University, Melbourne, Victoria, Australia
| | - Don Campbell
- Department of General Medicine, Monash Health Department of Medicine, Monash University, Monash Health, Melbourne, Victoria, Australia
| | - Keith Stockman
- Health Operations Research Unit, Monash Health Community, Melbourne, Victoria, Australia
| | - Sara Barnes
- Department of General Medicine, Monash Health Department of Medicine, Monash University, Melbourne, Victoria, Australia
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Candidate SNP Markers of Atherogenesis Significantly Shifting the Affinity of TATA-Binding Protein for Human Gene Promoters show stabilizing Natural Selection as a Sum of Neutral Drift Accelerating Atherogenesis and Directional Natural Selection Slowing It. Int J Mol Sci 2020; 21:ijms21031045. [PMID: 32033288 PMCID: PMC7037642 DOI: 10.3390/ijms21031045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 12/15/2022] Open
Abstract
(1) Background: The World Health Organization (WHO) regards atherosclerosis-related myocardial infarction and stroke as the main causes of death in humans. Susceptibility to atherogenesis-associated diseases is caused by single-nucleotide polymorphisms (SNPs). (2) Methods: Using our previously developed public web-service SNP_TATA_Comparator, we estimated statistical significance of the SNP-caused alterations in TATA-binding protein (TBP) binding affinity for 70 bp proximal promoter regions of the human genes clinically associated with diseases syntonic or dystonic with atherogenesis. Additionally, we did the same for several genes related to the maintenance of mitochondrial genome integrity, according to present-day active research aimed at retarding atherogenesis. (3) Results: In dbSNP, we found 1186 SNPs altering such affinity to the same extent as clinical SNP markers do (as estimated). Particularly, clinical SNP marker rs2276109 can prevent autoimmune diseases via reduced TBP affinity for the human MMP12 gene promoter and therefore macrophage elastase deficiency, which is a well-known physiological marker of accelerated atherogenesis that could be retarded nutritionally using dairy fermented by lactobacilli. (4) Conclusions: Our results uncovered SNPs near clinical SNP markers as the basis of neutral drift accelerating atherogenesis and SNPs of genes encoding proteins related to mitochondrial genome integrity and microRNA genes associated with instability of the atherosclerotic plaque as a basis of directional natural selection slowing atherogenesis. Their sum may be stabilizing the natural selection that sets the normal level of atherogenesis.
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Hiltunen AM, Hörhammer I, Silander K, Kaikuluoma J, Linna M. Integrating health service delivery for geriatric patients after hospital admission-A register study on the outcomes and costs. Health Serv Manage Res 2019; 33:24-32. [PMID: 31771358 DOI: 10.1177/0951484819887668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
After a care episode in a hospital, elderly patients often face delays in transitions to permanent residence. Poor care coordination burdens both the patients and the healthcare system. Whereas different models for coordinating geriatric patients’ care and discharge planning have been developed, evidence on their cost-effectiveness remains scant. In this study, we evaluated the associations of an integrated care model on health and social care costs and service utilization among geriatric patients admitted to a hospital in a Finnish city with c. 68,000 citizens. Elderly patient cohorts admitted before (N = 709) and after (N = 364) the implementation of the integrated care model were compared restrospectively. The new model consisted of changes in regional care criteria, discharge planning, coordination between inpatient facilities, and the daily work of nursing staff. Patients treated in the new model spent, on average, 7.4 days less in institutionalized care during one year, and the total annual cost of care decreased by 967€ per patient. A regionally coordinated care pathway from hospital admission to permanent residence may improve the cost-effectiveness of elderly care. Coordination and monitoring of outcomes at regional level is essential to avoid fragmentation of care and suboptimization among different care providers serving the elderly.
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Affiliation(s)
- Anna-Maria Hiltunen
- HEMA Institute, Department of Industrial Engineering and Management, Aalto University, Espoo, Finland.,Nordic Healthcare Group, Helsinki, Finland
| | - Iiris Hörhammer
- HEMA Institute, Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | | | - Jaakko Kaikuluoma
- HEMA Institute, Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Miika Linna
- HEMA Institute, Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
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Jørgensen L, Kastrup Jensen S, Brogaard B. Situational awareness in the outpatient encounter between patients with breast cancer or malignant melanoma and healthcare professionals: Patients' perceptions. J Clin Nurs 2019; 29:1981-1990. [PMID: 31769553 DOI: 10.1111/jocn.15122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 10/31/2019] [Accepted: 11/19/2019] [Indexed: 02/03/2023]
Abstract
AIMS AND OBJECTIVES To explore patients' experiences of situational awareness in the outpatient encounter when they are informed about the diagnosis of breast cancer or malignant melanoma. BACKGROUND Patients enter a stressful situation when receiving a diagnosis of breast cancer or malignant melanoma, and research indicates that needs are most prominent at this time. However, healthcare professionals often fail to address these needs adequately. It is unclear how patients experience situational awareness practised to meet their fundamental needs in the encounter when they are informed about the diagnosis of cancer. DESIGN This study used a phenomenological hermeneutical approach. METHODS Nine semi-structured interviews with patients being diagnosed with breast cancer or malignant melanoma were performed. The interpretation theory of Paul Ricoeur guided the analysis. The study is presented in line with the COREQ checklist. RESULTS The analysis resulted in three themes: 1) "Being accompanied" refers to how patients need information to be targeted to them as individuals. 2) "Being seen" points to HCPs' exploration of the patients' perspectives to get an understanding of their preferences. 3) "Being taken care of" indicates that patients feel supported if situational awareness is practised by the healthcare professionals. CONCLUSION Practicing situational awareness in the outpatient encounter is essential to patients' experience of feeling accommodated or rejected. Patients feel rejected when their fundamental needs are not met while experiencing situational awareness seems to accommodate fundamental needs and pre-empt an inappropriate patient outcome. RELEVANCE TO CLINICAL PRACTICE HCPs need to acknowledge the importance of using a structured approach to meeting patients' fundamental needs in a stressful situation. Each patient is different and may experience different needs in encounters where they are receiving the diagnosis of breast cancer or malignant melanoma. Therefore, treatment and care must be tailored to the individual patient based on a caring relationship.
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Affiliation(s)
- Lone Jørgensen
- Clinic for Surgery and Cancer Treatment, Aalborg University Hospital, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Susanne Kastrup Jensen
- Department of Plastic Surgery, Clinic for Surgery and Cancer Treatment, Aalborg University Hospital, Aalborg, Denmark
| | - Bettina Brogaard
- Department of Breast Surgery, Clinic for Surgery and Cancer Treatment, Aalborg University Hospital, Aalborg, Denmark
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Li R, Qiao M, Zhao X, Yan J, Wang X, Sun Q. MiR-20a-3p regulates TGF-β1/Survivin pathway to affect keratinocytes proliferation and apoptosis by targeting SFMBT1 in vitro. Cell Signal 2018; 49:95-104. [PMID: 29886071 DOI: 10.1016/j.cellsig.2018.06.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/21/2018] [Accepted: 06/05/2018] [Indexed: 12/18/2022]
Abstract
Psoriasis is a common immune-mediated chronic inflammatory skin disease characterized by abnormal keratinocyte proliferation, differentiation and apoptosis. However, the exact etiology and pathogenesis are still unclear. Evidence is rapidly accumulating for the role of microRNAs in psoriasis. It has been demonstrated that Interleukin-22 (IL-22) plays vital role in T cell-mediated immune response by interacting with keratinocytes in the pathogenesis of psoriasis. The aim of our study was to explore the possible functional role of miR-20a-3p in psoriasis and in IL-22 induced keratinocyte proliferation. Here, we found that miR-20a-3p was down-regulated in psoriatic lesions and in HaCaT cells (human keratinocyte cell line) treated by IL-22 stimulation. Functional experiments showed that overexpression of miR-20a-3p in HaCaT cells suppressed proliferation and induced apoptosis while its knockdown promoted cell proliferation and reduces cell apoptosis. Mechanistically, SFMBT1 was identified as the direct target of miR-20a-3p by dual luciferase reporter assay. SFMBT1 knockdown was demonstrated to inhibit cell growth and induced apoptosis, which was consistent with the function of miR-20a-3p upregulation in HaCaT cells. In addition, results of western blot analysis showed that miR-20a-3p upregulation or SFMBT1 knockdown changed the protein expression levels of TGF-β1 and survivin. Our findings suggest that miR-20a-3p play roles through targeting SFMBT1 and TGF-β1/Survivin pathway in HaCaT cells, and loss of miR-20a-3p in psoriasis may contribute to hyperproliferation and aberrant apoptosis of keratinocytes.
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Affiliation(s)
- Ronghua Li
- Department of Dermatology, Qilu Hospital, Shandong University, 107 West Wenhua Road, Jinan, Shandong, China
| | - Meng Qiao
- Department of Dermatology, Qilu Hospital, Shandong University, 107 West Wenhua Road, Jinan, Shandong, China
| | - Xintong Zhao
- Department of Dermatology, Qilu Hospital, Shandong University, 107 West Wenhua Road, Jinan, Shandong, China
| | - Jianjun Yan
- Department of Dermatology, Qilu Hospital, Shandong University, 107 West Wenhua Road, Jinan, Shandong, China
| | - Xiaoyan Wang
- Department of Dermatology, Qingdao Municipal Hospital (Group), No. 1, Jiaozhou Road, Qingdao, Shandong, China
| | - Qing Sun
- Department of Dermatology, Qilu Hospital, Shandong University, 107 West Wenhua Road, Jinan, Shandong, China.
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Vestjens L, Cramm JM, Birnie E, Nieboer AP. Evaluating an integrated primary care approach to improve well-being among frail community-living older people: A theory-guided study protocol. BMC Geriatr 2018; 18:173. [PMID: 30071842 PMCID: PMC6091022 DOI: 10.1186/s12877-018-0832-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 06/06/2018] [Indexed: 01/21/2023] Open
Abstract
Background A major challenge in primary healthcare is the substantial increase in the proportion of frail community-dwelling older persons with long-term conditions and multiple complex needs. Consequently, a fundamental transformation of current models of primary care by means of implementing proactive integrated care is necessary. Therefore, an understanding of the effects of integrated primary care approaches and underlying mechanisms is essential. This article presents the design of a theory-based evaluation of an integrated primary care approach to improve well-being among frail community-living older adults, which is called “Finding and Follow-up of Frail older persons” (FFF). First, we present a theoretical model to facilitate a sound theory-guided evaluation of integrated primary care approaches for frail community-dwelling older people. The model incorporates interrelated elements of integrated primary care approaches (e.g. proactive case finding and self-management support). Efforts to improve primary care should integrate these promising components to assure productive patient-professional interactions and to improve well-being. Moreover, cognitive and behavioral components of healthcare professionals and patients are assumed to be important. Second, we present the design of the study to evaluate the FFF approach which consists of the following key components: (1) proactive case finding, (2) case management, (3) medication review, (4) self-management support, and (5) working in multidisciplinary care teams. Methods The longitudinal evaluation study has a matched quasi-experimental design with one pretest and one posttest (12 month follow-up) and is conducted in the Netherlands between 2014 and 2017. Both quantitative and qualitative methods are used to evaluate effectiveness, processes, and cost-effectiveness. In total, 250 frail older persons (75 years and older) of 11 GP (general practitioner) practices that implemented the FFF approach are compared with 250 frail older patients of 4 GP practices providing care as usual. In addition, data are collected from healthcare professionals. Outcome measures are based on our theoretical model. Discussion The proposed evaluation study will reveal insight into the (cost)effectiveness and underlying mechanisms of the proactive integrated primary care approach FFF. A major strength of the study is the comprehensive evaluation based on a theoretical framework. The quasi-experimental design presents some challenges.
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Affiliation(s)
- Lotte Vestjens
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands.
| | - Jane M Cramm
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands
| | - Erwin Birnie
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands
| | - Anna P Nieboer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands
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de Vos A, Cramm J, van Wijngaarden JDH, Bakker TJEM, Mackenbach JP, Nieboer AP. Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred. Int J Health Plann Manage 2017; 32:608-636. [PMID: 27682420 PMCID: PMC5716249 DOI: 10.1002/hpm.2383] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 08/10/2016] [Accepted: 08/22/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The Prevention and Reactivation Care Program (PReCaP) provides a novel approach targeting hospital-related functional decline among elderly patients. Despite the high expectations, the PReCaP was not effective in preventing functional decline (ADL and iADL) among older patients. Although elderly PReCaP patients demonstrated slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2-0.6]), lower depression (Geriatric Depression Scale 15; -0.9 [95% -1.1 to -0.6]), and higher perceived health (Short-form 20; 5.6 [95% CI 2.8-8.4]) 1 year after admission than control patients, the clinical relevance was limited. Therefore, this study aims to identify factors impacting on the effectiveness of the implementation of the PReCaPand geriatric care 'as usual'. METHODS We conducted semi-structured interviews with 34 professionals working with elderly patients in three hospitals, selected for their comparable patient case mix and different levels of geriatric care. Five non-participatory observations were undertaken during multidisciplinary meetings. Patient files (n = 42), hospital protocols, and care plans were screened for elements of geriatric care. Clinical process data were analysed for PReCaP components. RESULTS The establishment of a geriatric unit and employment of geriatricians demonstrates commitment to geriatric care in hospital A. Although admission processes are comparable, early identification of frail elderly patients only takes place in hosptial A. Furthermore, nursing care in the hospital A geriatric unit excels with regard to maximizing patient independency, an important predictor for hospital-related functional decline. Transfer nurses play a key role in arranging post-discharge geriatric follow-up care. Geriatric consultations are performed by geriatricians, geriatric nurses, and PReCaP case managers in hospital A. Yet hospital B consultative psychiatric nurses provide similar consultation services. The combination of standardized procedures, formalized communication channels, and advanced computerization contributes significantly to geriatric care in hospital B. Nevertheless, a small size hospital (hospital C) provides informal opportunities for information sharing and decision making, which are essential in geriatric care, given its multidisciplinary nature. CONCLUSIONS Geriatric care for patients with multimorbidity requires a multidisciplinary approach in a geriatric unit. Geriatric care, which integrates medical and reactivation treatment, by means of early screening of risk factors for functional decline, promotion of physical activity, and adequate discharge planning, potentially reduces the incidence of functional decline in elderly patients. Yet low treatment fidelity played a major role in the ineffective implementation of the PReCaP. Treatment fidelity issues are caused by various factors, including the complexity of projects, limited attention for implementation, and inadequate interdisciplinary communication. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.
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Olomu A, Hart-Davidson W, Luo Z, Kelly-Blake K, Holmes-Rovner M. Implementing shared decision making in federally qualified health centers, a quasi-experimental design study: the Office-Guidelines Applied to Practice (Office-GAP) program. BMC Health Serv Res 2016; 16:334. [PMID: 27484348 PMCID: PMC4970246 DOI: 10.1186/s12913-016-1603-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 07/29/2016] [Indexed: 11/17/2022] Open
Abstract
Background Use of Shared Decision-Making (SDM) and Decision Aids (DAs) has been encouraged but is not regularly implemented in primary care. The Office-Guidelines Applied to Practice (Office-GAP) intervention is an application of a previous model revised to address guidelines based care for low-income populations with diabetes and coronary heart disease (CHD). Objective: To evaluate Office-GAP Program feasibility and preliminary efficacy on medication use, patient satisfaction with physician communication and confidence in decision in low-income population with diabetes and coronary heart disease (CHD) in a Federally Qualified Healthcare Center (FQHC). Method Ninety-five patients participated in an Office-GAP program. A quasi-experimental design study, over 6 months with 12-month follow-up. Office-GAP program integrates health literacy, communication skills education for patients and physicians, patient/physician decision support tools and SDM into routine care. Main Measures: 1) Implementation rates of planned program elements 2) Patient satisfaction with communication and confidence in decision, and 3) Medication prescription rates. We used the GEE method for hierarchical logistic models, controlling for confounding. Results Feasibility of the Office-GAP program in the FQHC setting was established. We found significant increase in use of Aspirin/Plavix, statin and beta-blocker during follow-up compared to baseline: Aspirin OR 1.5 (95 % CI: 1.1, 2.2) at 3-months, 1.9 (1.3, 2.9) at 6-months, and 1.8 (1.2, 2.8) at 12-months. Statin OR 1.1 (1.0, 1.3) at 3-months and 1.5 (1.1, 2.2) at 12-months; beta-blocker 1.8 (1.1, 2.9) at 6-months and 12-months. Program elements were consistently used (≥ 98 % clinic attendance at training and tool used). Patient satisfaction with communication and confidence in decision increased. Conclusions The use of Office-GAP program to teach SDM and use of DAs in real time was demonstrated to be feasible in FQHCs. It has the potential to improve satisfaction with physician communication and confidence in decisions and to improve medication use. The Office-GAP program is a brief, efficient platform for delivering patient and provider education in SDM and could serve as a model for implementing guideline based care for all chronic diseases in outpatient clinical settings. Further evaluation is needed to establish feasibility outside clinical study, reach, effectiveness and cost-effectiveness of this approach.
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Affiliation(s)
- Adesuwa Olomu
- Department of Medicine, Michigan State University, East Lansing, USA.
| | | | - Zhehui Luo
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, USA
| | - Karen Kelly-Blake
- Center for Ethics and Humanities in the Life Sciences and Department of Medicine, Michigan State University, East Lansing, USA
| | - Margaret Holmes-Rovner
- Center for Ethics and Humanities in the Life Sciences and Department of Medicine, Michigan State University, East Lansing, USA
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Sakai M, Naruse T, Nagata S. Relational coordination among home healthcare professions and goal attainment in nursing care. Jpn J Nurs Sci 2016; 13:402-10. [PMID: 26820241 DOI: 10.1111/jjns.12117] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 11/17/2015] [Indexed: 11/26/2022]
Abstract
AIM To examine whether interprofessional coordination is related to goal attainment in home visit nursing care. METHODS Self-administered questionnaire surveys were administered to home visit nursing agencies in Chiba Prefecture, Japan, from July to December 2014. Nurses evaluated their interprofessional coordination with professional groups (nursing colleague and managers, home doctors, care managers, home care workers, visiting therapists, day service and day care professionals, visiting bath professionals, and short stay professionals) using the Japanese version of the Relational Coordination Scale (RCS-J). Goal attainment across all clients during the most recent 3 months was measured with a rating scale ranging from incompletely attained (0) to completely attained (10). Data were analyzed with multivariate logistic regression analysis. RESULTS A total of 83 nurses in 14 agencies responded, and data from 74 nurses were analyzed. The mean RCS-J and goal attainment scores were 3.59 (standard deviation = 0.47) and 6.51 (1.40), respectively. The RCS-J scores of the low and high goal attainment groups were 3.41 (0.46) and 3.73 (0.42), respectively. Multivariate logistic regression analysis revealed that RCS-J scores were positively associated with goal attainment (odds ratio, 5.71; 95% confidence interval, 1.65-19.79). CONCLUSION The finding of this study suggest that well-coordinated professionals may fulfill client needs better than poorly coordinated professionals do. Future research is needed to determine whether similar results are obtained in individual clients using a well-validated goal attainment scale.
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Affiliation(s)
- Mahiro Sakai
- Department of Community Health Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Naruse
- Department of Community Health Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoko Nagata
- Department of Community Health Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Cramm JM, Nieboer AP. The changing nature of chronic care and coproduction of care between primary care professionals and patients with COPD and their informal caregivers. Int J Chron Obstruct Pulmon Dis 2016; 11:175-82. [PMID: 26869783 PMCID: PMC4734725 DOI: 10.2147/copd.s94409] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to investigate whether care delivery in accordance with a care model is associated with co-productive relationships between professionals and COPD patients and their informal caregivers. A co-productive relationship refers to productive patient–professional interaction or shared decision making. This cross-sectional study was conducted in 2014 among 411 patients (out of 981) enrolled in the Dutch COPD care program Kennemer Lucht and 62 professionals treating them (out of 97). Kennemer Lucht COPD involved multicomponent interventions within all six dimensions of the chronic care model (organizational support, community, self-management, decision support, delivery system design, and information and communications technology) to improve the quality of care for patients with COPD. This approach was expected to improve relational coproduction of care between professionals and patients with COPD and their informal caregivers. Results show clearly that the perceived quality of chronic care delivery is related significantly to productive interaction/relational coproduction of care. The strength of the relationship between perceptions of quality of chronic care and relational coproduction among patients is strong (r=0.5; P≤0.001) and among professionals moderate (r=0.4; P≤0.001 relational coproduction with patients and informal caregivers). Furthermore, patients’ perceptions of the quality of chronic care were associated with the existence of productive interaction with health care professionals (β=0.7; P≤0.001). The changing nature of chronic care is associated with coproduction of care, leading to the development of more productive relationships between primary care professionals and COPD patients and their informal caregivers. Further research is necessary to determine how best to sustain these developments.
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Affiliation(s)
- Jane Murray Cramm
- Department of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Anna Petra Nieboer
- Department of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, the Netherlands
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Benzer JK, Cramer IE, Burgess JF, Mohr DC, Sullivan JL, Charns MP. How personal and standardized coordination impact implementation of integrated care. BMC Health Serv Res 2015; 15:448. [PMID: 26432790 PMCID: PMC4592548 DOI: 10.1186/s12913-015-1079-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 09/18/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Integrating health care across specialized work units has the potential to lower costs and increase quality and access to mental health care. However, a key challenge for healthcare managers is how to develop policies, procedures, and practices that coordinate care across specialized units. The purpose of this study was to identify how organizational factors impacted coordination, and how to facilitate implementation of integrated care. METHODS Semi-structured interviews were conducted in August 2009 with 30 clinic leaders and 35 frontline staff who were recruited from a convenience sample of 16 primary care and mental health clinics across eight medical centers. Data were drawn from a management evaluation of primary care-mental health integration in the US Department of Veterans Affairs. To protect informant confidentiality, the institutional review board did not allow quotations. RESULTS Interviews identified antecedents of organizational coordination processes, and highlighted how these antecedents can impact the implementation of integrated care. Overall, implementing new workflow practices were reported to create conflicts with pre-existing standardized coordination processes. Personal coordination (i.e., interpersonal communication processes) between primary care leaders and staff was reported to be effective in overcoming these barriers both by working around standardized coordination barriers and modifying standardized procedures. DISCUSSION This study identifies challenges to integrated care that might be solved with attention to personal and standardized coordination. A key finding was that personal coordination both between primary care and mental health leaders and between frontline staff is important for resolving barriers related to integrated care implementation. CONCLUSION Integrated care interventions can involve both new standardized procedures and adjustments to existing procedures. Aligning and integrating procedures between primary care and specialty care requires personal coordination amongst leaders. Interpersonal relationships should be strengthened between staff when personal connections are important for coordinating patient care across clinical settings.
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Affiliation(s)
- Justin K Benzer
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152-M), Boston, MA, 02130, USA.
- Department of Health Policy and Management, Boston University School of Public Health, 715 Albany Street Talbot Building, T2W, Boston, MA, 02118, USA.
- VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA.
| | - Irene E Cramer
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152-M), Boston, MA, 02130, USA.
- Department of Health Policy and Management, Boston University School of Public Health, 715 Albany Street Talbot Building, T2W, Boston, MA, 02118, USA.
| | - James F Burgess
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152-M), Boston, MA, 02130, USA.
- Department of Health Policy and Management, Boston University School of Public Health, 715 Albany Street Talbot Building, T2W, Boston, MA, 02118, USA.
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152-M), Boston, MA, 02130, USA.
- Department of Health Policy and Management, Boston University School of Public Health, 715 Albany Street Talbot Building, T2W, Boston, MA, 02118, USA.
| | - Jennifer L Sullivan
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152-M), Boston, MA, 02130, USA.
- Department of Health Policy and Management, Boston University School of Public Health, 715 Albany Street Talbot Building, T2W, Boston, MA, 02118, USA.
| | - Martin P Charns
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152-M), Boston, MA, 02130, USA.
- Department of Health Policy and Management, Boston University School of Public Health, 715 Albany Street Talbot Building, T2W, Boston, MA, 02118, USA.
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Cramm JM, Nieboer AP. Chronically ill patients' self-management abilities to maintain overall well-being: what is needed to take the next step in the primary care setting? BMC FAMILY PRACTICE 2015; 16:123. [PMID: 26374206 PMCID: PMC4571068 DOI: 10.1186/s12875-015-0340-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 09/10/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although widespread problems in patient-professional interaction and insufficient support of patients' self-management abilities have been recognized, research investigating the relationships among care quality, productive interaction, and self-management abilities to maintain overall well-being is lacking. Furthermore, studies have revealed differences in these characteristics among certain groups (e.g., less-educated and older patients). This longitudinal study thus aimed to identify relationships among background characteristics, quality of care, productivity of patient-professional interaction, and self-management abilities to maintain overall well-being in chronically ill patients participating in 18 Dutch disease management programs. METHODS This longitudinal study included patients participating in 18 Dutch disease management programs. Surveys were administered in 2011 (T1; n = 2191 (out of 4693), 47 % response rate) and 2012 (T2: n = 1722 (out of 4350), 40 % response rate). A total of 1279 patients completed questionnaires at both timepoints (T1 and T2) (27 % response rate). Self-management abilities to maintain well-being were measured using the short (18-item) version of the Self-Management Ability Scale (SMAS-S), patients' perceptions of the productivity of interactions with health care professionals were assessed with the relational coordination instrument and the short (11-item) version of the Patient Assessment of Chronic Illness Care (PACIC-S) was used to assess patients' perceptions of the quality of chronic care delivery. RESULTS Perceived and objective quality of care and the productivity of patient-professional interaction were found to be related to patients' self-management abilities to maintain overall well-being. These abilities were related negatively to and significantly predicted by low educational level, single status, and older age, despite the mediating role of productive interaction in their relationship with patients' perceptions of care quality. CONCLUSIONS These findings suggest that patient-professional interaction is not yet sufficiently productive to successfully protect against the deterioration of self-management abilities in some groups of chronically ill patients, although such interaction and high-quality care are important factors in such protection. Improvement of the quality of chronic care delivery should thus always be accompanied by investment in high-quality communication and patient-professional relationships.
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Affiliation(s)
- Jane Murray Cramm
- Institute of Health Policy & Management (iBMG), Erasmus University, Rotterdam, The Netherlands.
| | - Anna Petra Nieboer
- Institute of Health Policy & Management (iBMG), Erasmus University, Rotterdam, The Netherlands.
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The importance of productive patient-professional interaction for the well-being of chronically ill patients. Qual Life Res 2014; 24:897-903. [PMID: 25267102 PMCID: PMC4366564 DOI: 10.1007/s11136-014-0813-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2014] [Indexed: 11/05/2022]
Abstract
Objective To investigate patient–professional interactions and identify the association between quality of care, productivity of patient–professional interaction, and chronically ill patients’ well-being. Methods Questionnaires were distributed to chronically ill patients [T1 (2011), 2,191/4,693 (47 %) respondents; T2 (2012), 1,722/4,350 (40 %) respondents]. Results Patients perceived a higher degree of productive interaction with general practitioners compared to other professionals. Bivariate analyses showed that patients’ well-being at T2 was positively related to well-being at T1 (r = 0.70), quality of care (r = 0.12), and productive patient–professional interaction (r = 0.31; all p ≤ 0.001). Single status (r = –0.14), low education (r = –0.11), and female gender (r = –0.11; all p ≤ 0.001) were negatively associated with well-being. Multivariate analyses showed that after controlling for background characteristics and well-being at baseline quality of care is associated with patients’ well-being at T2 (p ≤ 0.01). When productive patient–professional interactions were entered into the equation, they not only were related to patients’ well-being (p ≤ 0.001) but also mediated the relationship between the quality of care and well-being. More productive patient–professional interactions were related to better well-being at T2 (B = 0.11), assuming that all other factors in the model remained constant. Conclusions Productive patient–professional interactions are associated with chronically ill patients’ well-being over time and mediate the relationship between well-being and quality of care. Improvement of the quality of chronic care delivery should always be accompanied by investment in the quality of relationships and communication between patients and professionals.
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Cramm JM, Nieboer AP. A longitudinal study to identify the influence of quality of chronic care delivery on productive interactions between patients and (teams of) healthcare professionals within disease management programmes. BMJ Open 2014; 4:e005914. [PMID: 25239294 PMCID: PMC4170203 DOI: 10.1136/bmjopen-2014-005914] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The chronic care model is an increasingly used approach to improve the quality of care through system changes in care delivery. While theoretically these system changes are expected to increase productive patient-professional interaction empirical evidence is lacking. This study aims to identify the influence of quality of care on productive patient-professional interaction. SETTING Longitudinal study in 18 Dutch regions. PARTICIPANTS Questionnaires were sent to all 5076 patients participating in 18 Disease Management Programmes (DMPs) in 2010 (2676 (53%) respondents). One year later (T1), 4693 patients still participating in the DMPs received a questionnaire (2191 (47%) respondents) and 2 years later (in 2012; T2) 1722 patients responded (out of 4350; 40% response). INTERVENTIONS DMPs PRIMARY OUTCOME MEASURE Patients' perceptions of the productivity of interactions (measured as relational coordination/coproduction of care) with professionals. Patients were asked about communication dimensions (frequent, accurate, and problem-solving communication) and relationship dimensions (shared goals and mutual respect). FINDINGS After controlling for background characteristics these results clearly show that quality of chronic care (T0), first-year changes in quality of chronic care (T1-T0) and second-year changes in quality of chronic care (T2-T1) predicted productive interactions between patients and professionals at T2 (all at p≤0.001). Furthermore, we found a negative relationship between lower educational level and productive interactions between patients and professionals 2 years later. CONCLUSIONS We can conclude that successfully dealing with the consequences of chronic illnesses requires proactive patients who are able to make productive decisions together with their healthcare providers. Since patients and professionals share responsibility for management of the chronic illness, they must also share control of interactions and decisions. The importance of patient-centeredness is growing and this study reports a first example of how quality of chronic care stimulates productive interactions between patients and professionals.
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Affiliation(s)
- Jane Murray Cramm
- Department of Health Policy & Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Anna Petra Nieboer
- Department of Health Policy & Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
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