Controlled trial of a collaborative primary care team model for patients with diabetes and depression: rationale and design for a comprehensive evaluation

The TELE-DD Randomised Controlled Trial on Treatment Adherence in Patients with Type 2 Diabetes and Comorbid Depression: Clinical Outcomes after 18-Month Follow-Up

Clinical depression is associated with poorer adherence to hypoglycaemic medication in patients with diabetes mellitus, leading to poorer glycaemic control, diabetes management, and increased complications. The main aim of the TELE-DD trial was to demonstrate the efficacy of a proactive and psychoeducational telephonic intervention based on motivational interviewing and collaborative care to reduce nonadherence and improve prognosis in individuals with diabetes mellitus and concurrent depression.

DESIGN

The TELE-DD project is a three-phased prospective study including a nested randomised controlled trial.

METHODS

The baseline cohort included the entire population of adult patients diagnosed with type 2 diabetes and concurrent depression. A randomised controlled trial was conducted in a selection of patients from the baseline cohort, distributed into a control group (n = 192) and an intervention group (n = 192). Monthly telephonic interventions delivered by specifically trained research nurses were centred on a psychoeducational individualised monitoring protocol including motivational interviewing and collaborative care strategies. Clinical and patient-centred data were systematically collected during an 18-month follow-up including HbA1c, Patient Health Questionnaire, and the Diabetes Distress Scale.

RESULTS

During the trial, 18-month follow-up HbA1C levels significantly (p < 0.001) decreased in the intervention group at every follow-up from an average of 8.72 (SD:1.49) to 7.03 (SD:1.09), but slightly increased in the control group from 8.65 (SD:1.40) to 8.84 (SD:1.38). Similar positive results were obtained in depression severity and diabetes distress, LDL-cholesterol, and systolic and diastolic blood pressure, but only at the 18-month follow-up in body mass index reduction.

CONCLUSIONS

This is the first trial to concurrently decrease biological and psychological outcomes with a monthly brief telephonic intervention, pointing out that a combined biopsychosocial intervention and collaborative care strategy is essential for current world health challenges.

CLINICALTRIALS

gov Identifier: NCT04097483. Patient or Public Contribution: Diabetic patients not belonging to the TELE-DD population or trial sample were consulted during the study design to review and guarantee the clarity and understanding of the trial psychoeducational materials.

Integrated self-management support provided by primary care nurses to persons with chronic diseases and common mental disorders: a scoping review

AIM

To map integrated and non-integrated self-management support interventions provided by primary care nurses to persons with chronic diseases and common mental disorders and describe their characteristics.

DESIGN

A scoping review.

DATA SOURCES

In April 2020, we conducted searches in several databases (Academic Research Complete, AMED, CINAHL, ERIC, MEDLINE, PsycINFO, Scopus, Emcare, HealthSTAR, Proquest Central) using self-management support, nurse, primary care and their related terms. Of the resulting 4241 articles, 30 were included into the analysis.

REVIEW METHODS

We used the Rainbow Model of Integrated Care to identify integrated self-management interventions and to analyze the data and the PRISMS taxonomy for the description of interventions. Study selection and data synthesis were performed by the team. Self-management support interventions were considered integrated if they were consistent with the Rainbow model's definition of clinical integration and person-focused care.

RESULTS

The 30 selected articles related to 10 self-management support interventions. Among these, five interventions were considered integrated. The delivery of the interventions showed variability. Strategies used were education, problem-solving therapies, action planning, and goal setting. Integrated self-management support intervention characteristics were nurse-person relationship, engagement, and biopsychosocial approach. A framework for integrated self-management was proposed. The main characteristics of the non-integrated self-management support were disease-specific approach, protocol-driven, and lack of adaptability.

CONCLUSION

Our review synthesizes integrated and non-integrated self-management support interventions and their characteristics. We propose recommendations to improve its clinical integration. However, further theoretical clarification and qualitative research are needed.

IMPLICATION FOR NURSING

Self-management support is an important activity for primary care nurses and persons with chronic diseases and common mental disorders, who are increasingly present in primary care, and require an integrated approach.

IMPACT

This review addresses the paucity of details surrounding integrated self-management support for persons with chronic diseases and common mental disorders and provides a framework to better describe its characteristics. The findings could be used to design future research and improve the clinical integration of this activity by nurses.

Soluble Epoxide Hydrolase and Diabetes Complications

Type 2 diabetes mellitus (T2DM) can result in microvascular complications such as neuropathy, retinopathy, nephropathy, and cerebral small vessel disease, and contribute to macrovascular complications, such as heart failure, peripheral arterial disease, and large vessel stroke. T2DM also increases the risks of depression and dementia for reasons that remain largely unclear. Perturbations in the cytochrome P450-soluble epoxide hydrolase (CYP-sEH) pathway have been implicated in each of these diabetes complications. Here we review evidence from the clinical and animal literature suggesting the involvement of the CYP-sEH pathway in T2DM complications across organ systems, and highlight possible mechanisms (e.g., inflammation, fibrosis, mitochondrial function, endoplasmic reticulum stress, the unfolded protein response and autophagy) that may be relevant to the therapeutic potential of the pathway. These mechanisms may be broadly relevant to understanding, preventing and treating microvascular complications affecting the brain and other organ systems in T2DM.

Modifying the quality-adjusted life year calculation to account for meaningful change in health-related quality of life: insights from a pragmatic clinical trial

BACKGROUND

We propose a modified quality-adjusted life year (QALY) calculation that aims to be consistent with guidance for interpreting change in patient-reported outcomes. This calculation incorporates the minimally important difference (MID) in generic preference-based health-related quality of life (HRQL) change scores to reflect what might be considered meaningful HRQL improvement/deterioration. In doing so, we review common issues in QALY calculations such as adjustment for baseline scores and standardizing for between-group differences.

METHODS

Using EQ-5D-5L outcome data from the Alberta TEAMCare-Primary Care Network trial in the management of depression for patients with type 2 diabetes (n = 98), this study compared results from different QALY calculation methods to investigate the impact of (i) adjusting for baseline HRQL score, (ii) standardizing between-group differences at baseline, and (iii) adjusting for 'meaningful' HRQL changes. The following QALY calculation methods are examined: area under curve (QALY-AUC), change from baseline (QALY-CFB), regression modelling (QALY-R), and incorporating an MID for HRQL changes from baseline (QALY-MID).

RESULTS

The incremental QALY-AUC estimate favoured the Collaborative Care group (0.031) while the incremental QALY-CFB (-0.028) estimate favoured Enhanced Care. Adjusting for meaningful HRQL changes resulted in a crude incremental QALY-MID of -0.023; however, after adjusting for between-group differences at baseline, QALY-R and adjusted incremental QALY-MID estimates were -0.007 and -0.001, respectively. In addition, recursive regression analyses showed that very low baseline HRQL scores impact incremental QALY estimates.

CONCLUSIONS

Uncertainty in incremental QALY estimates reflects uncertainty in the value of small within-individual change as well as the impact of small differences between groups at baseline. Applying a responder-definition approach yielded crude and adjusted QALY-MID estimates that were more in favour of Collaborative Care than QALY-CFB and QALY-R estimates, respectively, suggesting that ambiguous small changes in HRQL scores have the potential to influence QALY outcomes used in economic or non-economic applications.

Exploring the impact of pharmacist comprehensive annual care plans on perceived quality of chronic illness care by patients in Alberta, Canada

Background:

In 2012, the Government of Alberta introduced a funding program to remunerate pharmacists to develop a comprehensive annual care plan (CACP) for patients with complex needs. The objective of this study is to explore patients’ perceptions of the care they received through the pharmacist CACP program in Alberta.

Methods:

We invited 3442 patients who received a pharmacist-billed CACP within the previous 3 months and 6888 matched controls across Alberta to complete an online questionnaire. The questionnaire consisted of the short version Patient Assessment of Chronic Illness Care (PACIC-11), with 3 additional pharmacy-specific assessment questions added. Additional questions related to health status and demographics were also included.

Results:

Overall, most patients indicated a low level of chronic illness care by pharmacists, with few differences noted between CACP patients and non-CACP controls. Of note, controls reported higher quality of care for 5 domains within the adapted PACIC-like tool compared with CACP patients (p < 0.05 for all). Interestingly, only 79 (44%) of CACP patients reported that they had received a CACP, whereas only 192 (66%) of control patients reported that they did not receive a care plan. In a sensitivity analysis including only these respondents, individuals who received a CACP perceived a significantly higher quality of chronic illness care across all PACIC domains.

Conclusion:

Overall, chronic illness care incentivized by the pharmacist CACP program in Alberta is perceived to be moderate to low. When limited to respondents who explicitly recognized receiving the service or not, the perceptions of quality of care were more positive. This suggests that better implementation of CACP by pharmacists may be associated with improved quality of care and that some redesign is needed to engage patients more. Can Pharm J (Ott) 2021;154:xx-xx.

The TELE-DD project on treatment nonadherence in the population with type 2 diabetes and comorbid depression

Diabetic patients have increased depression rates, diminished quality of life, and higher death rates due to depression comorbidity or diabetes complications. Treatment adherence (TA) and the maintenance of an adequate and competent self-care are crucial factors to reach optimal glycaemic control and stable quality of life in these patients. In this report, we present the baseline population analyses in phase I of the TELE-DD project, a three-phased population-based study in 23 Health Centres from the Aragonian Health Service Sector II in Zaragoza, Spain. The objectives of the present report are: (1) to determine the point prevalence of T2D and clinical depression comorbidity and treatment nonadherence; (2) to test if HbA1c and LDL-C, as primary DM outcomes, are related to TA in this population; and (3) to test if these DM primary outcomes are associated with TA independently of shared risk factors for DM and depression, and patients' health behaviours. A population of 7,271 patients with type-2 diabetes and comorbid clinical depression was investigated for inclusion. Individuals with confirmed diagnoses and drug treatment for both illnesses (n = 3340) were included in the current phase I. A point prevalence of 1.9% was found for the T2D-depression comorbidity. The prevalence of patients nonadherent to treatment for these diseases was 35.4%. Multivariate analyses confirmed that lower diabetes duration, increased yearly PCS visits, HbA1c and LDL-C levels were independently related to treatment nonadherence. These findings informed the development of a telephonic monitoring platform for treatment of nonadherence for people with diabetes and comorbid depression and further trial, cost-effectiveness, and prognostic studies (phases II and III).

Interventions for improving outcomes in patients with multimorbidity in primary care and community settings

BACKGROUND

Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity.

OBJECTIVES

To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual.

SEARCH METHODS

We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies.

SELECTION CRITERIA

Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types.

MAIN RESULTS

We identified 17 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 11 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -0.41, 95% confidence interval (CI) -0.63 to -0.2). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited.

AUTHORS' CONCLUSIONS

This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression in people with co-morbidity.

Effect of Telephone-Delivered Collaborative Goal Setting and Behavioral Activation vs Enhanced Usual Care for Depression Among Adults With Uncontrolled Diabetes: A Randomized Clinical Trial

IMPORTANCE

Depression symptoms are present in one-third of patients with diabetes, contributing to significant adverse consequences. Population screening of high-risk patients coupled with telephone delivery of evidence-based therapies for comorbid diabetes may address barriers to care.

OBJECTIVE

To evaluate the effectiveness of proactive population screening plus telephone delivery of a collaborative goal-setting intervention among high-risk patients with uncontrolled diabetes and depression.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, 225 participants (intervention [n = 136] and control [n = 89]) were enrolled from a regional Veterans Healthcare System serving Southeast Texas from November 1, 2012, through June 24, 2016. Data were gathered at baseline and 6 and 12 months after intervention. Patients selected had uncontrolled diabetes (hemoglobin A1c [HbA1c] >7.5%]) and clinically significant depression (Patient Health Questionnaire-9 scores [PHQ-9] ≥10) and were living more than 20 miles from the Veterans Affairs medical center. Data collection was completed on December 6, 2016, and final analyses were completed by January 25, 2018. All analyses were intent to treat.

INTERVENTIONS

Healthy Outcomes Through Patient Empowerment (HOPE) included 9 telephone sessions with 24 trained health care professionals using collaborative goal-setting and behavioral activation methods. The control group received enhanced usual care (EUC) and notification of high-risk status.

MAIN OUTCOMES AND MEASURES

Change in depression symptoms using PHQ-9 and glycemic control using HbA1c from baseline to 6 months and to 12 months. Secondary analyses evaluated clinically significant responses for these measures.

RESULTS

Among 225 participants, 202 (89.8%) were men, the mean (SD) age was 61.9 (8.3) years, 145 (64.4%) were married, and 156 (69.3%) had some education beyond high school. For the overall study, 38 participants (16.9%) were lost to follow-up or withdrew at 6 months and another 21 (9.3%) were lost to follow-up or withdrew at 12 months. Repeated-measures analysis with multiple imputation for missing data assessing the interaction of treatment group (HOPE vs EUC) and time (baseline, 6 months, and 12 months) found no significant improvement in PHQ-9 (β, 1.56; 95% CI, -0.68 to 3.81; P = .17) or HbA1c (β, -0.005; 95% CI, -0.73 to 0.72; P = .82). Analyses using t test for change from baseline to 12 months showed a HOPE vs EUC between-group mean difference for PHQ-9 of 2.14 (95% CI, 0.18 to 4.10; P = .03) and for HbA1c of -0.06% (95% CI, -0.61% to 0.50%; P = .83). A secondary analysis of patients experiencing a clinical response found that 52.1% of HOPE participants had clinically significant responses in PHQ-9 at 12 months vs 32.9% in EUC (difference, 0.19; 95% CI, 0.04-0.33; P = .01).

CONCLUSIONS AND RELEVANCE

Telephone-delivered, collaborative goal setting produced clinically significant reductions in depression symptoms but not glycemic control among patients who remained engaged at 12 months compared with EUC among a population screened sample of high-risk patients with diabetes and depression. Although the intervention created some lasting effect for depression, additional strategies are needed to maintain engagement of this high-risk population within an interprofessional team approach to primary care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01572389.

Challenges of adopting the role of care manager when implementing the collaborative care model for people with common mental illnesses: A scoping review

This review aimed to identify the main factors influencing the adoption of the role of care manager (CM) by nurses when implementing the collaborative care model (CCM) for common mental illnesses in primary care settings. A total of 19 studies met the inclusion criteria, reporting on 14 distinct interventions implemented between 2000 and 2017 in five countries. Two categories of factors were identified and described as follows: (i) strategies for the CCM implementation (e.g. initial care management training and supervision by a mental health specialist) and (ii) context-specific factors (e.g. organizational factors, collaboration with team members, nurses' care management competency). Identified implementation strategies were mainly aimed towards improving the nurse's care management competency, but their efficacy in developing the set of competencies needed to fulfil a CM role was not well demonstrated. There is a need to better understand the relationship between the nurses' competencies, the care management activities, the strategies used to implement the CCM and the context-specific factors. Strategies to optimize the adoption of the CM role should not be solely oriented towards the individual's competency in care management, but also consider other context-specific factors. The CM also needs a favourable context in order to perform his or her activities with competency.

The measurement of collaboration within healthcare settings: a systematic review of measurement properties of instruments

BACKGROUND

There is a growing call by consumers and governments for healthcare to adopt systems and approaches to care to improve patient safety. Collaboration within healthcare settings is an important factor for improving systems of care. By using validated measurement instruments a standardized approach to assessing collaboration is possible, otherwise it is only an assumption that collaboration is occurring in any healthcare setting.

OBJECTIVES

The objective of this review was to evaluate and compare measurement properties of instruments that measure collaboration within healthcare settings, specifically those which have been psychometrically tested and validated.

INCLUSION CRITERIA, TYPES OF PARTICIPANTS

Participants could be healthcare professionals, the patient or any non-professional who contributes to a patient's care, for example, family members, chaplains or orderlies. The term participant type means the designation of any one participant; for example 'nurse', 'social worker' or 'administrator'. More than two participant types was mandatory.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

The focus of this review was the validity of tools used to measure collaboration within healthcare settings.

TYPES OF STUDIES

The types of studies considered for inclusion were validation studies, but quantitative study designs such as randomized controlled trials, controlled trials and case studies were also eligible for inclusion. Studies that focused on Interprofessional Education, were published as an abstract only, contained patient self-reporting only or were not about care delivery were excluded.

OUTCOMES

The outcome of interest was validation and interpretability of the instrument being assessed and included content validity, construct validity and reliability. Interpretability is characterized by statistics such as mean and standard deviation which can be translated to a qualitative meaning.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. The databases searched included PubMed, CINAHL, Embase, Cochrane Central Register of Controlled Trials, Emerald Fulltext, MD Consult Australia, PsycARTICLES, Psychology and Behavioural Sciences Collection, PsycINFO, Informit Health Databases, Scopus, UpToDate and Web of Science. The search for unpublished studies included EThOS (Electronic Thesis Online Service), Index to Theses and ProQuest- Dissertations and Theses.

METHODOLOGICAL QUALITY

The assessment of methodological quality of the included studies was undertaken using the COSMIN checklist which is a validated tool that assesses the process of design and validation of healthcare measurement instruments.

DATA COLLECTION

An Excel spreadsheet version of COSMIN was developed for data collection which included a worksheet for extracting participant characteristics and interpretability data.

DATA SYNTHESIS

Statistical pooling of data was not possible for this review. Therefore, the findings are presented in a narrative form including tables and figures to aid in data presentation. To make a synthesis of the assessments of methodological quality of the different studies, each instrument was rated by accounting for the number of studies performed with an instrument, the appraisal of methodological quality and the consistency of results between studies.

RESULTS

Twenty-one studies of 12 instruments were included in the review. The studies were diverse in their theoretical underpinnings, target population/setting and measurement objectives. Measurement objectives included: investigating beliefs, behaviors, attitudes, perceptions and relationships associated with collaboration; measuring collaboration between different levels of care or within a multi-rater/target group; assessing collaboration across teams; or assessing internal participation of both teams and patients.Studies produced validity or interpretability data but none of the studies assessed all validity and reliability properties. However, most of the included studies produced a factor structure or referred to prior factor analysis. A narrative synthesis of the individual study factor structures was generated consisting of nine headings: organizational settings, support structures, purpose and goals; communication; reflection on process; cooperation; coordination; role interdependence and partnership; relationships; newly created professional activities; and professional flexibility.

CONCLUSIONS

Among the many instruments that measure collaboration within healthcare settings, the quality of each instrument varies; instruments are designed for specific populations and purposes, and are validated in various settings. Selecting an instrument requires careful consideration of the qualities of each. Therefore, referring to systematic reviews of measurement properties of instruments may be helpful to clinicians or researchers in instrument selection.

IMPLICATIONS FOR PRACTICE

Systematic reviews of measurement properties of instruments are valuable in aiding in instrument selection. This systematic review may be useful in instrument selection for the measurement of collaboration within healthcare settings with a complex mix of participant types. Evaluating collaboration provides important information on the strengths and limitations of different healthcare settings and the opportunities for continuous improvement via any remedial actions initiated.

IMPLICATIONS FOR RESEARCH

Development of a tool that can be used to measure collaboration within teams of healthcare professionals and non-professionals is important for practice. The use of different statistical modelling techniques, such as Item Response Theory modelling and the translation of models into Computer Adaptive Tests, may prove useful. Measurement equivalence is an important consideration for future instrument development and validation. Further development of the COSMIN tool should include appraisal for measurement equivalence. Researchers developing and validating measurement tools should consider multi-method research designs.

Depression in people with type 2 diabetes: current perspectives

Type 2 diabetes mellitus (T2DM) is associated with depressive symptoms, and comorbid depression in those with T2DM has been associated with adverse clinical profiles. Recognizing and addressing psychological symptoms remain significant clinical challenges in T2DM. Possible mediators of the reciprocal relationship between T2DM and depression may include physical activity levels, effectiveness of self-management, distress associated with a new T2DM diagnosis, and frailty associated with advanced diabetes duration. The latter considerations contribute to a "J-shaped" trajectory from the time of diagnosis. There remain significant challenges to screening for clinical risks associated with psychological symptoms in T2DM; poorer outcomes may be associated with major depressive episodes, isolated (eg, anhedonic), or subsyndromal depressive symptoms, depressive-like symptoms more specific to T2DM (eg, diabetes-related distress), apathy or fatigue. In this review, we discuss current perspectives on depression in the context of T2DM with implications for screening and management of these highly comorbid conditions.

Ethics and practice of Trials within Cohorts: An emerging pragmatic trial design

BACKGROUND

With increasing emphasis on pragmatic trials, new randomized clinical trial designs are being proposed to enhance the "real world" nature of the data generated. We describe one such design, appropriate for unmasked pragmatic clinical trials in which the control arm receives usual care, called "Trials within Cohorts" that is increasingly used in various countries because of its efficiency in recruitment, advantages in reducing subject burden, and ability to better mimic real-world consent processes.

METHODS

Descriptive, ethical, and US regulatory analysis of the Trials within Cohorts design.

RESULTS

Trials within Cohorts design involves, after recruitment into a cohort, randomization of eligible subjects, followed by an asymmetric treatment of the two arms: those selected for the experimental arm provide informed consent for the intervention trial, while the data from the control arm are used based on prior broad permission. Thus, unlike the traditional Zelen post-randomization consent design, the cohort participants are informed about future research within the cohort; however, the extent of this disclosure currently varies among studies. Thus, ethical analysis is provided for two types of situations: when the pre-randomization disclosure and consent regarding the embedded trials are fairly explicit and detailed versus when they consist of only general statements about future data use. These differing ethical situations could have implications for how ethics review committees apply US research rules regarding waivers and alterations of informed consent.

CONCLUSION

Trials within Cohorts is a promising new pragmatic randomized controlled trial design that is being increasingly used in various countries. Although the asymmetric consent procedures for the experimental versus control arm subjects can initially raise ethical concerns, it is ethically superior to previous post-randomization consent designs and can have important advantages over traditional trial designs.

Integrating Maternal Mental Health Care in the Pediatric Medical Home: Treatment Engagement and Child Outcomes

Maternal depression is associated with an array of poor child health outcomes, and low-income women face many barriers to accessing treatment. In this pilot study, we assessed treatment engagement in a maternal mental health clinic staffed by a case manager and psychiatrist in an urban pediatric practice. We also examined factors associated with engagement as well as child health outcomes and health care use. Nearly half of the women enrolled attended at least 4 sessions with a psychiatrist in 6 months. Text messaging with the case manager was associated with a greater compliance with psychiatrist sessions. Comparing index children with their siblings prior to enrollment, a higher percentage had immunizations up to date at 1 year of age (82% vs 43%, P = .01), and well-child visit compliance trended toward significance (65% vs 35%, P = .06). The pediatric setting holds promise as an innovative venue to deliver maternal mental health care.

Developing interprofessional care plans in chronic care: a scoping review

Background

The number of people suffering from one or more chronic conditions is rising, resulting in an increase in patients with complex health care demands. Interprofessional collaboration and the use of shared care plans support the management of complex health care demands of patients with chronic illnesses. This study aims to get an overview of the scientific literature on developing interprofessional shared care plans.

Methods

We conducted a scoping review of the scientific literature regarding the development of interprofessional shared care plans. A systematic database search resulted in 45 articles being included, 5 of which were empirical studies concentrating purely on the care plan. Findings were synthesised using directed content analysis.

Results

This review revealed three themes. The first theme was the format of the shared care plan, with the following elements: patient’s current state; goals and concerns; actions and interventions; and evaluation. The second theme concerned the development of shared care plans, and can be categorised as interpersonal, organisational and patient-related factors. The third theme covered tools, whose main function is to support professionals in sharing patient information without personal contact. Such tools relate to documentation of and communication about patient information.

Conclusion

Care plan development is not a free-standing concept, but should be seen as the result of an underlying process of interprofessional collaboration between team members, including the patient. To integrate the patients’ perspectives into the care plans, their needs and values need careful consideration. This review indicates a need for new empirical studies examining the development and use of shared care plans and evaluating their effects.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0535-7) contains supplementary material, which is available to authorized users.

A qualitative study examining healthcare managers and providers' perspectives on participating in primary care implementation research

BACKGROUND

Primary care reforms should be supported by high-quality evidence across the entire life cycle of research. Front-line healthcare providers play an increasing role in implementation research. We recently evaluated two interventions for people with type 2 diabetes (T2D) in partnership with four Primary Care Networks (PCNs) in Alberta, Canada. Here, we report healthcare professionals perspectives on participating in primary care implementation research.

METHODS

Guided by the RE-AIM framework, we collected qualitative data before, during, and after both interventions. We conducted 34 in-person or telephone interviews with 17 individual PCN professionals. We used content analysis to identify emerging codes and concepts.

RESULTS

Two major themes emerged from the data. First, healthcare managers were eager to conduct implementation research in a primary care setting. Second, regardless of willingness to conduct research, there were challenges to implementing experimental study designs for both interventions. PCN professionals presumed the interventions were better than usual care, expressed role conflict, and reported administrative burdens related to research participation. Perceptions of patient vulnerability and an obligation to intervene exacerbated these issues.

CONCLUSIONS

Healthcare professionals with limited practical research experience might not foresee the challenges in implementing experimental study designs in primary care settings to generate high-quality evidence. These issues are intensified when healthcare professionals perceive target patient populations as vulnerable and in need of intervention based on the presenting illness. Possible solutions include further research training, involving healthcare professionals in study design development, and using non-clinical staff to conduct research activities, particularly among acutely unwell patient populations.

Interventions for improving outcomes in patients with multimorbidity in primary care and community settings

BACKGROUND

Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity.

OBJECTIVES

To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual.

SEARCH METHODS

We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies.

SELECTION CRITERIA

Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types.

MAIN RESULTS

We identified 18 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 12 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -2.23, 95% confidence interval (CI) -2.52 to -1.95). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence) although two studies that specifically targeted functional difficulties in participants had positive effects on functional outcomes with one of these studies also reporting a reduction in mortality at four year follow-up (Int 6%, Con 13%, absolute difference 7%). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited.

AUTHORS' CONCLUSIONS

This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression, or specific functional difficulties in people with multimorbidity.

Alternation as a form of allocation for quality improvement studies in primary healthcare settings: the on-off study design

Background

Randomized controlled trials are considered the “gold standard” for scientific rigor in the assessment of benefits and harms of interventions in healthcare. They may not always be feasible, however, when evaluating quality improvement interventions in real-world healthcare settings. Non-randomized controlled trials (NCTs) are designed to answer questions of effectiveness of interventions in routine clinical practice to inform a decision or process. The on-off NCT design is a relatively new design where participant allocation is by alternation. In alternation, eligible patients are allocated to the intervention “on” or control “off ” groups in time series dependent sequential clusters.

Methods

We used two quality improvement studies undertaken in a Canadian primary care setting to illustrate the features of the on-off design. We also explored the perceptions and experiences of healthcare providers tasked with implementing the on-off study design.

Results and discussion

The on-off design successfully allocated patients to intervention and control groups. Imbalances between baseline variables were attributed to chance, with no detectable biases. However, healthcare providers’ perspectives and experiences with the design in practice reveal some conflict. Specifically, providers described the process of allocating patients to the off group as unethical and immoral, feeling it was in direct conflict with their professional principle of providing care for all. The degree of dissatisfaction seemed exacerbated by: 1) the patient population involved (e.g., patient population viewed as high-risk (e.g., depressed or suicidal)), 2) conducting assessments without taking action (e.g., administering the PHQ-9 and not acting on the results), and 3) the (non-blinded) allocation process.

Conclusions

Alternation, as in the on-off design, is a credible form of allocation. The conflict reported by healthcare providers in implementing the design, while not unique to the on-off design, may be alleviated by greater emphasis on the purpose of the research and having research assistants allocate patients and collect data instead of the healthcare providers implementing the trial. In addition, consultation with front-line staff implementing the trials with an on-off design on appropriateness to the setting (e.g., alignment with professional values and the patient population served) may be beneficial.

Trial registration

Health Eating and Active Living with Diabetes: ClinicalTrials.gov identifier: NCT00991380 Date registered: 7 October 2009.

Controlled trial of a collaborative primary care team model for patients with diabetes and depression: Clintrials.gov Identifier: NCT01328639 Date registered: 30 March 2011.

Contextualizing the Effectiveness of a Collaborative Care Model for Primary Care Patients with Diabetes and Depression (Teamcare): A Qualitative Assessment Using RE-AIM

OBJECTIVE

We evaluated the implementation of an efficacious collaborative care model for patients with diabetes and depression in a controlled trial in 4 community-based primary care networks (PCNs) in Alberta, Canada. Similar to previous randomized trials, the nurse care manager-led TeamCare intervention demonstrated statistically significant improvements in depressive symptoms compared with usual care. We contextualized TeamCare's effectiveness by describing implementation fidelity at the organizational and patient levels.

METHODS

We used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate TeamCare. Qualitative methods used to collect data regarding the RE-AIM dimensions of Implementation and Effectiveness included interviews with PCN staff and specialists (n=36), research team reflections (n=4) and systematic documentation. We used content analysis, and Nvivo 10 for data management.

RESULTS

TeamCare was implemented as intended but with suboptimal fidelity. Deviations from the model included limited degrees of collaborative care practised within the PCNs, including varying physician participation, limited comfort in practising collaborative care and discontinuity of care managers. Despite suboptimal fidelity, respondents identified several implementation facilitators at the organizational level: training, ongoing implementation support, professional and personal qualities of the care manager and pre-existing relationships. Without knowledge of the effectiveness of the intervention in our controlled trial, respondents anticipated improved patient outcomes due to the main intervention components, including active patient follow up, specialist consultation and treat-to-target principles.

CONCLUSIONS

Despite suboptimal implementation in Alberta's primary care context, TeamCare resulted in improved outcomes similar to those demonstrated in previous randomized trials. A stronger culture of collaborative care would likely have yielded greater implementation fidelity and possibly better outcomes.

Behavioral health integration in primary care at Brigham and Women׳s Advanced Primary Care Associates, South Huntington

Of the many problems facing the US healthcare system, the shortage of behavioral health providers in outpatient settings is particularly profound. To address this issue, Boston׳s Brigham and Women׳s Hospital identified ways to incorporate behavioral health into primary care when it opened the South Huntington Primary Care clinic in August 2011. When the needs of its patients were more complex than anticipated, the clinic created assessment tools and refined care processes to identify, triage, and monitor patients with mental illness. Key insights from the South Huntington experience include. • Hiring for roles instead of training can decrease costs of implementation. • A process for reflection, assessment, and adaptation is a critical component of innovation. • Innovations must adapt to the specific needs of the local community. • Innovations are most effective when they reflect the capabilities of local providers.

Multimorbidity in a Mexican Community: Secondary Analysis of Chronic Illness and Depression Outcomes

The aims of this article are: 1) to examine the associations between health provider-diagnosed depression and multimorbidity, the condition of suffering from more than two chronic illnesses; 2) to assess the unique contribution of chronic illness in the prediction of depression; and 3) to suggest practice changes that would address risk of depression among individuals with chronic illnesses. Data collected in a cross-sectional community health study among adult Mexicans (n= 274) living in a low income neighborhood (colonia) in Ciudad Juárez, Chihuahua, Mexico, were examined. We tested the hypotheses that individuals who reported suffering chronic illnesses would also report higher rates of depression than healthy individuals; and having that two or more chronic illnesses further increased the risk of depression.

Collaborative care versus screening and follow-up for patients with diabetes and depressive symptoms: results of a primary care-based comparative effectiveness trial

OBJECTIVE

Depressive symptoms are common and, when coexisting with diabetes, worsen outcomes and increase health care costs. We evaluated a nurse case-manager-based collaborative primary care team model to improve depressive symptoms in diabetic patients.

RESEARCH DESIGN AND METHODS

We conducted a controlled implementation trial in four nonmetropolitan primary care networks. Eligible patients had type 2 diabetes and screened positive for depressive symptoms, based on a Patient Health Questionnaire (PHQ) score of ≥10. Patients were allocated using an "on-off" monthly time series. Intervention consisted of case-managers working 1:1 with patients to deliver individualized care. The main outcome was improvement in PHQ scores at 12 months. A concurrent cohort of 71 comparable patients was used as nonscreened usual care control subjects.

RESULTS

Of 1,924 patients screened, 476 (25%) had a PHQ score >10. Of these, 95 were allocated to intervention and 62 to active control. There were no baseline differences between groups: mean age was 57.8 years, 55% were women, and the mean PHQ score was 14.5 (SD 3.7). Intervention patients had greater 12-month improvements in PHQ (7.3 [SD 5.6]) compared with active-control subjects (5.2 [SD 5.7], P = 0.015). Recovery of depressive symptoms (i.e., PHQ reduced by 50%) was greater among intervention patients (61% vs. 44%, P = 0.03). Compared with trial patients, nonscreened control subjects had significantly less improvement at 12 months in the PHQ score (3.2 [SD 4.9]) and lower rates of recovery (24%, P < 0.05 for both).

CONCLUSIONS

In patients with type 2 diabetes who screened positive for depressive symptoms, collaborative care improved depressive symptoms, but physician notification and follow-up was also a clinically effective initial strategy compared with usual care.

Collaborative care for comorbid depression and diabetes: a systematic review and meta-analysis

OBJECTIVE

The collaborative care model is recommended for depression in adults with a chronic physical health problem like diabetes. We sought to systematically assess the effect of collaborative care on depression and glycaemia in adults with comorbid depression and diabetes to inform guidelines and practice.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, Scopus, Cochrane Library, CINAHL, Health Source Nursing, MEDLINE, PsychINFO and reference lists of retrieved articles published before August 2013.

INCLUSION CRITERIA

Randomised controlled trials (RCTs) on collaborative care (ie, coordinated multidisciplinary model of care) for depression that reported the effects on depression and glycaemic outcomes in adults with comorbid clinically relevant depression and diabetes were eligible.

DATA EXTRACTION AND ANALYSIS

Data on the mean difference in depression and glycaemic outcomes were extracted and pooled using random effects meta-analysis.

RESULTS

Seven RCTs included for review reported effects on depression outcomes in 1895 participants, and glycated haemoglobin (HbA1c) level in 1556 participants. Collaborative care significantly improved the depression score (standardised mean difference was -0.32 (95% CI -0.53 to -0.11); I(2)=79%) and HbA1c level (weighted mean difference was -0.33% (95% CI -0.66% to -0.00%); I(2)=72.9%) compared with control conditions. Depression remission did not predict better glycaemic control across studies.

CONCLUSIONS

Limited evidence from short-to-medium term RCTs predominantly conducted in the USA suggests that collaborative care for depression significantly improves both depression and glycaemia outcomes, independently, in people with comorbid depression and diabetes.

Prevalence of depression and associated risk factors among persons with type-2 diabetes mellitus without a prior psychiatric history: a cross-sectional study in clinical settings in urban Nepal

BACKGROUND

Diabetes is a growing health problem in South Asia. Despite an increasing number of studies exploring causal pathways between diabetes and depression in high-income countries (HIC), the pathway between the two disorders has received limited attention in low and middle-income countries (LMIC). The aim of this study is to investigate the potential pathway of diabetes contributing to depression, to assess the prevalence of depression, and to evaluate the association of depression severity with diabetes severity. This study uses a clinical sample of persons living with diabetes sequelae without a prior psychiatric history in urban Nepal.

METHODS

A cross-sectional study was conducted among 385 persons living with type-2 diabetes attending tertiary centers in Kathmandu, Nepal. Patients with at least three months of diagnosed diabetes and no prior depression diagnosis or family history of depression were recruited randomly using serial selection from outpatient medicine and endocrine departments. Blood pressure, anthropometrics (height, weight, waist and hip circumference) and glycated hemoglobin (HbA1c) were measured at the time of interview. Depression was measured using the validated Nepali version of the Beck Depression Inventory (BDI-Ia).

RESULTS

The proportion of respondents with depression was 40.3%. Using multivariable analyses, a 1-unit (%) increase in HbA1c was associated with a 2-point increase in BDI score. Erectile dysfunction was associated with a 5-point increase in BDI-Ia. A 10 mmHg increase in blood pressure (both systolic and diastolic) was associated with a 1.4-point increase in BDI-Ia. Other associated variables included waist-hip-ratio (9-point BDI-Ia increase), at least one diabetic complication (1-point BDI-Ia increase), treatment non-adherence (1-point BDI-Ia increase), insulin use (2-point BDI-Ia increase), living in a nuclear family (2-point BDI-Ia increase), and lack of family history of diabetes (1-point BDI-Ia increase). Higher monthly income was associated with increased depression severity (3-point BDI-Ia increase per 100,000 rupees, equivalent US$1000).

CONCLUSIONS

Depression is associated with indicators of more severe diabetes disease status in Nepal. The association of depression with diabetes severity and sequelae provide initial support for a causal pathway from diabetes to depression. Integration of mental health services in primary care will be important to combat development of depression among persons living with diabetes.

Applying the RE-AIM framework to the Alberta's Caring for Diabetes Project: a protocol for a comprehensive evaluation of primary care quality improvement interventions

INTRODUCTION

Diabetes represents a major public health and health system burden. As part of the Alberta's Caring for Diabetes (ABCD) Project, two quality-improvement interventions are being piloted in four Primary Care Networks in Alberta. Gaps between health research, policy and practice have been documented and the need to evaluate the impact of public health interventions in real-world settings to inform decision-making and clinical practice is paramount. In this article, we describe the application of the RE-AIM framework to evaluate the interventions beyond effectiveness.

METHODS AND ANALYSIS

Two quality-improvement interventions were implemented, based on previously proven effective models of care and are directed at improving the physical and mental health of patients with type-2 diabetes. Our goal is to adapt and apply the RE-AIM framework, using a mixed-methods approach, to understand the impact of the interventions to inform policy and clinical decision-making. We present the proposed measures, data sources and data management and analysis strategies used to evaluate the interventions by RE-AIM dimension.

ETHICS AND DISSEMINATION

Ethics approval for the ABCD Project has been granted from the Health Research Ethics Board (HREB #PRO00012663) at the University of Alberta. The RE-AIM framework will be used to structure our dissemination activities by dimension.

RESULTS

It will be presented at relevant conferences and prepared for publication in peer-reviewed journals. Various products, such as presentations, briefing reports and webinars, will be developed to inform key stakeholders of the findings. Presentation of findings by RE-AIM dimension will facilitate discussion regarding the public health impact of the two interventions within the primary care context of Alberta and lessons learned to be used in programme planning and care delivery for patients with type-2 diabetes. It will also promote the application of evaluation models to better assess the impact of community-based primary healthcare interventions through our dissemination activities.