Subjective assessments of comorbidity correlate with quality of life health outcomes: initial validation of a comorbidity assessment instrument

Health-related quality of life in older hematological cancer survivors (70+) compared to older general population-A German cancer-register-based cross-sectional comparative study

OBJECTIVES

The extent of health-related quality of life (HRQOL) impairments in older hematological cancer survivors (HCS) has not been sufficiently studied. We therefore examined HRQOL in older HCS compared to a community sample (CS) and investigated sociodemographic, disease- and treatment-specific, geriatric, and psychosocial factors associated with reduced HRQOL.

MATERIALS AND METHODS

In this cancer-register-based cross-sectional comparative study 200 HCS, aged ≥70 years, and 252 persons of an age- and gender-matched CS completed validated questionnaires including the EORTC QLQ-C30 and EORTC QLQ-ELD14.

RESULTS

Older HCS reported a reduced HRQOL in the dimensions of global QOL, physical, role, and social functioning (small clinical significance) and higher symptom burden of fatigue, nausea and vomiting, appetite loss, and poorer mobility compared to the CS (fatigue and mobility with medium, the others with small clinical significance). Perceived disease burden of comorbidities, functional disabilities, psychological distress, and depression showed statistical significance for reduced HRQOL in older HCS in multiple linear regression analysis (R2 = .602, p < .001).

DISCUSSION

The screening and treatment of functional limitations and individual symptoms and the integration of a geriatric assessment into oncological practice can help to identify supportive care needs, to implement individualized, patient-centered cancer survivorship care programs and to improve older HCS's HRQOL.

Feasibility of a digital palliative care intervention (Convoy-Pal) for older adults with heart failure and multiple chronic conditions and their caregivers: a waitlist randomized control trial

BACKGROUND

Although older adults with heart failure (HF) and multiple chronic conditions (MCC) frequently rely on caregivers for health management, digital health systems, such as patient portals and mobile apps, are designed for individual patients and often exclude caregivers. There is a need to develop approaches that integrate caregivers into care. This study tested the feasibility of the Social Convoy Palliative Care intervention (Convoy-Pal), a 12-week digital self-management program that includes assessment tools and resources for clinical palliative care, designed for both patients and their caregivers.

METHODS

A randomized waitlist control feasibility trial involving patients over 65 years old with MCC who had been hospitalized two or more times for HF in the past 12 months and their caregivers. Descriptive statistics were used to evaluate recruitment, retention, missing data, self-reported social functioning, positive aspects of caregiving, and the acceptability of the intervention.

RESULTS

Of 126 potentially eligible patients, 11 were ineligible and 69 were deceased. Of the 46 eligible patients, 31 enrolled in the trial. Although 48 caregivers were identified, only 15 enrolled. The average age was 76.3 years for patients and 71.6 years for caregivers, with most participants being non-Hispanic White. Notably, 4% did not have access to a personal mobile device or computer. Retention rates were 79% for intervention patients, 57% for intervention caregivers, and 60% for control participants. Only 4.6% of survey subscales were missing, aided by robust technical support. Intervention patients reported improved social functioning (SF-36: 64.6 ± 25.8 to 73.2 ± 31.3) compared to controls (64.6 ± 27.1 to 67.5 ± 24.4). Intervention caregivers also reported increased positive perceptions of caregiving (29.5 ± 5.28 to 35.0 ± 5.35) versus control caregivers (29.4 ± 8.7 to 28.0 ± 4.4). Waitlist control participants who later joined the Convoy-Pal program showed similar improvements. The intervention was well-rated for acceptability, especially regarding the information provided (3.96 ± .57 out of 5).

CONCLUSIONS

Recruiting informal caregivers proved challenging. Nonetheless, Convoy-Pal retained patients and collected meaningful self-reported outcomes, showing potential benefits for both patients and caregivers. Given the importance of a patient and caregiver approach in palliative care, further research is needed to design digital tools that cater to multiple simultaneous users.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04779931. Date of registration: March 3, 2021.

Concurrent Medication Adherence in Hypertensive Patients With High-Risk Comorbidities

BACKGROUND

Hypertensive patients with high-risk comorbidities require medications for each condition, leading to greater burden. The number of chronic conditions can affect patients' concurrent medication adherence.

OBJECTIVE

We aimed to compare the characteristics of groups based on their concurrent medication adherence and investigate the association between the number of high-risk comorbidities and concurrent medication adherence for patients with hypertension and high-risk comorbidities.

METHODS

A secondary data analysis was performed with the 2018 Korea Health Panel Survey, including 2230 patients with hypertension and at least 1 high-risk comorbidity who were prescribed medications for at least 2 conditions. Using medication adherence for each condition, we identified 3 concurrent medication adherence groups: adherent, suboptimal, and nonadherent groups. Multinominal logistic regression was used to determine the association between the number of high-risk comorbidities and the concurrent medication adherence groups.

RESULTS

Adherent, suboptimal, and nonadherent groups included 85%, 11%, and 4% of the patients, respectively. Whereas having more high-risk comorbidities was associated with belonging to the suboptimal group compared with the adherent group (adjusted odds ratio, 1.46), having fewer high-risk comorbidities was associated with belonging to the nonadherent group compared with the adherent group (adjusted odds ratio, 0.52).

CONCLUSIONS

We identified 3 groups based on their concurrent medication adherence. Our results indicated that the relationship of the number of high-risk comorbidities with the concurrent medication adherence group was inconsistent.

Case management in primary healthcare for people with complex needs to improve integrated care: a large-scale implementation study protocol

INTRODUCTION

Case management (CM) is among the most studied effective models of integrated care for people with complex needs. The goal of this study is to scale up and assess CM in primary healthcare for people with complex needs.

METHODS AND ANALYSIS

The research questions are: (1) which mechanisms contribute to the successful scale-up of CM for people with complex needs in primary healthcare?; (2) how do contextual factors within primary healthcare organisations contribute to these mechanisms? and (3) what are the relationships between the actors, contextual factors, mechanisms and outcomes when scaling-up CM for people with complex needs in primary healthcare? We will conduct a mixed methods Canadian interprovincial project in Quebec, New-Brunswick and Nova Scotia. It will include a scale-up phase and an evaluation phase. At inception, a scale-up committee will be formed in each province to oversee the scale-up phase. We will assess scale-up using a realist evaluation guided by the RAMESES checklist to develop an initial programme theory on CM scale-up. Then we will test and refine the programme theory using a mixed-methods multiple case study with 10 cases, each case being the scalable unit of the intervention in a region. Each primary care clinic within the case will recruit 30 adult patients with complex needs who frequently use healthcare services. Qualitative data will be used to identify contexts, mechanisms and certain outcomes for developing context-mechanism-outcome configurations. Quantitative data will be used to describe patient characteristics and measure scale-up outcomes.

ETHICS AND DISSEMINATION

Ethics approval was obtained. Engaging researchers, decision-makers, clinicians and patient partners on the study Steering Committee will foster knowledge mobilisation and impact. The dissemination plan will be developed with the Steering Committee with messages and dissemination methods targeted for each audience.

Estimating the prevalence of mental disorders in patients with newly diagnosed cancer in relation to socioeconomic status: a multicenter prospective observational study

BACKGROUND

The purpose of this study was to provide the 4-week prevalence estimates of mental disorders in newly diagnosed cancer patients in relation to socioeconomic status (SES).

PATIENTS AND METHODS

We enrolled newly diagnosed patients with a confirmed solid tumor within 2 months of diagnosis. We calculated patients' SES on the basis of their educational level, professional qualification, income and occupational status. We used the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-Clinical Version (SCID-5-CV) to assess the 4-week prevalence of mental disorders in addition to a comorbidity questionnaire to assess the level of physical impairment.

RESULTS

We identified a total of 1702 patients with mixed cancers after reviewing their medical records and contacting them in person or by post due to coronavirus pandemic patient safety restrictions. 1030 patients (53.2% men, mean age 60.2 years) had completed SCID-5-CV. When weighted according to the SES distribution to account for over- and under-sampling of SES groups, 20.9% [95% confidence interval (CI) 18.1% to 23.6%] of patients were diagnosed with any mental disorder. The most prevalent were depressive disorders (9.9%, 95% CI 7.9% to 11.9%), trauma and stress-related disorders (6.3%, 95% CI 4.7% to 7.9%) and anxiety disorders (4.2%, 95% CI 2.9% to 5.6%). We found no difference in any mental disorder between patients with high, medium or low SES. Multivariate logistic regression analyses revealed higher proportion of patients with any mental disorder in patients younger than 60 years [odds ratio (OR) 0.42; P < 0.001], in patients without a partner (OR 1.84; P < 0.001), in women with tumor in female genital organs (OR 2.45; P < 0.002) and in those with a higher level of impairment (OR 1.05, 95% CI 1.03-1.07; P < 0.001).

CONCLUSIONS

SES had no significant influence on mental comorbidity in early cancer survivorship.

A Randomized Controlled Trial Testing the Effects of a Social Needs Navigation Intervention on Health Outcomes and Healthcare Utilization among Medicaid Members with Type 2 Diabetes

Health systems are increasingly assessing and addressing social needs with referrals to community resources. The objective of this randomized controlled trial was to randomize adult Medicaid members with type 2 diabetes to receive usual care (n = 239) or social needs navigation (n = 234) for 6 months and compare HbA1c (primary outcome), quality of life (secondary outcome), and other exploratory outcomes with t-tests and mixed-effects regression. Eligible participants had an HbA1c test in claims in the past 120 days and reported 1+ social needs. Data were collected from November 2019 to July 2023. Surveys were completed at baseline and at 3-, 6-, and 12-month follow-up. Health plan data included care management records and medical and pharmacy claims. The sample was from Louisiana, USA, M = 51.6 (SD = 9.5) years old, 76.1% female, 66.5% Black, 29.4% White, and 3.0% Hispanic. By design, more navigation (91.5%) vs. usual care (6.7%) participants had a care plan. Social needs persisted for both groups. No group differences in HbA1c tests and values were observed, though the large amount of missing HbA1c lab values reduced statistical power. No group differences were observed for other outcomes. Proactively eliciting and attempting to provide referrals and resources for social needs did not demonstrate significant health benefits or decrease healthcare utilization in this sample.

Facilitators and barriers to eliciting physical function goals before and after surgery: A qualitative study with clinicians

OBJECTIVE

Describe clinicians' perspectives of facilitators and barriers to eliciting physical function goals from patients with multiple chronic conditions pre- and post-surgery.

METHODS

Semi-structured qualitative interviews were conducted with clinicians, recruited from an academic medical center, who treat adult patients with multiple chronic conditions. Purposive sampling ensured multiple provider types were represented. Interviews were conducted in person or via web conference and were audio recorded. Findings were summarized using descriptive qualitative content analysis.

RESULTS

Of the 12 participating clinicians, 92% were female and 83% specialized in geriatrics. Clinicians had a mean of 10.7 (min-max: 1-30) years of experience. Key facilitators to goal-setting conversations were sufficient time, familial support, and patient cognitive ability. Barriers included lack of time, lack of training, patient challenges in choosing realistic and specific actionable goals, emotional barriers, and cognitive challenges.

CONCLUSION

Some facilitators and barriers are modifiable, including time, inclusion of family members in the clinical encounter, and clinician training to enable actionable goal setting. These results highlight areas for intervention to facilitate goal elicitation for physical function in clinical care settings.

PRACTICE IMPLICATIONS

Clinicians should be aware of the barriers impacting eliciting goals. Healthcare organizations could consider providing effective goal elicitation training and tools to facilitate goal setting conversation.

Scoping Review of Measures of Comorbidities in Heart Failure

BACKGROUND

Comorbidities are risk factors for poor clinical outcomes in patients with heart failure. However, no consensus has been reached on how to assess comorbidities related to clinical outcomes in patients with heart failure.

OBJECTIVE

The aims of this study were to review (1) how comorbidities have been assessed, (2) what chronic conditions have been identified as comorbidities and (3) the rationale for choosing the comorbidity instruments and/or specific comorbidities when exploring clinical outcomes in patients with heart failure.

METHODS

The clinical outcomes of interest were mortality, hospitalization, quality of life, and self-care. Three electronic databases and reference list searches were used in the search.

RESULTS

In this review, we included 39 articles using 3 different ways to assess comorbidities in the relationship with clinical outcomes: using an instrument (ie, Charlson Comorbidity Index), disease count, and including individual comorbidities. A total of 90 comorbidities were investigated in the 39 articles; however, definitions and labels for the diseases were inconsistent across the studies. More than half of the studies (n = 22) did not provide a rationale for selecting the comorbidity instruments and/or all of the specific comorbidities. Some of the rationale for choosing the instruments and/or specific comorbidities was inappropriate.

CONCLUSIONS

We found several issues related to measuring comorbidities when examining clinical outcomes in patients with heart failure. Researchers need to consider these methodological issues when measuring comorbidities in patients with heart failure. Further efforts are needed to develop guidelines on how to choose proper measures for comorbidities.

Feasibility and outcomes of using DIALOG+ in primary care to improve quality of life and mental distress of patients with long-term physical conditions: an exploratory non-controlled study in Bosnia and Herzegovina, Colombia and Uganda

INTRODUCTION

The management of long-term physical conditions is a challenge worldwide, absorbing a majority resources despite the importance of acute care. The management of these conditions is done largely in primary care and so interventions to improve primary care could have an enormous impact. However, very little data exist on how to do this. Mental distress is frequently comorbid with long term physical conditions, and can impact on health behaviour and adherence, leading to poorer outcomes. DIALOG+ is a low-cost, patient-centred and solution-focused intervention, which is used in routine patient-clinician meetings and has been shown to improve outcomes in mental health care. The question arises as to whether it could also be used in primary care to improve the quality of life and mental health of patients with long-term physical conditions. This is particularly important for low- and middle-income countries with limited health care resources.

METHODS

An exploratory non-controlled multi-site trial was conducted in Bosnia and Herzegovina, Colombia, and Uganda. Feasibility was determined by recruitment, retention, and session completion. Patient outcomes (quality of life, anxiety and depression symptoms, objective social situation) were assessed at baseline and after three approximately monthly DIALOG+ sessions.

RESULTS

A total of 117 patients were enrolled in the study, 25 in Bosnia and Herzegovina, 32 in Colombia, and 60 in Uganda. In each country, more than 75% of anticipated participants were recruited, with retention rates over 90% and completion of the intervention exceeding 92%. Patients had significantly higher quality of life and fewer anxiety and depression symptoms at post-intervention follow-up, with moderate to large effect sizes. There were no significant improvements in objective social situation.

CONCLUSION

The findings from this exploratory trial suggest that DIALOG+ is feasible in primary care settings for patients with long-term physical conditions and may substantially improve patient outcomes. Future research may test implementation and effectiveness of DIALOG+ in randomized controlled trials in wider primary care settings in low- and middle-income countries.

TRIAL REGISTRATION

All studies were registered prospectively within the ISRCTN Registry. ISRCTN17003451, 02/12/2020 (Bosnia and Herzegovina), ISRCTN14018729, 01/12/2020 (Colombia) and ISRCTN50335796, 02/12/2020 (Uganda).

Self-reports by persons with multiple sclerosis are an adequate surrogate for healthcare provider data on disease-modifying therapy and multiple sclerosis type

INTRODUCTION

Self-reports are a valuable and cost-effective method of data collection, though they can be influenced by bias. Limited evidence exists on the quality of self-reports by persons with multiple sclerosis (pwMS), particularly since more potent disease-modifying therapies (DMTs) have been introduced. This study aimed to assess the reliability and validity of self-reported DMT use and multiple sclerosis (MS) type in the Swiss Multiple Sclerosis Registry (SMSR) by comparing self-reports with reimbursement approval requests from the Swiss Association for Joint Tasks of Health Insurers.

METHODS

The self-reported and reimbursement approval data were linked using privacy-preserving methods based on information available in both databases, i.e., date of birth, canton of residence, sex, and year of MS diagnosis. The SMSR baseline questionnaire data was utilized for the main analysis, while the SMSR follow-up survey data was utilized for the sensitivity analysis. For both analyses, we compared self-reported data with reimbursement approval data that corresponded to the respective periods of the SMSR data collection. Thus, the main analysis included the entirety of the data over the six-year period, while the sensitivity analysis captured a more recent snapshot of the data. To assess reliability, we estimated agreement using Cohen's kappa, and for validity, we estimated accuracy parameters using reimbursement approvals as the reference standard. Univariable and multivariable logistic regression models were employed to investigate factors associated with discordance between self-reports and reimbursement approvals in the main analysis.

RESULTS

The main analysis included 446 participants, and the sensitivity analysis included 193 participants. The agreement between self-reported and reimbursement approval data for medication use was near-perfect in both analyses (κ = 0.87, 95% confidence interval (CI) 0.85, 0.90 and κ = 0.82, 95% CI 0.76, 0.88). However, the agreement between self-reported and reimbursement approval-documented MS types ranged from fair to moderate (κ = 0.37, 95% CI 0.25, 0.48 to κ = 0.61, 95% CI 0.46, 0.77). The accuracy estimates for self-reported DMT use were generally high (≥ 0.80) with narrow CIs, except for less frequently reported drugs. While the sensitivity and specificity for RRMS were high, there was a notable possibility of false-negative self-reports for RRMS (NPV = 0.33, 95% CI 0.22, 0.45), and false-positive reports for SPMS (PPV = 0.36, 95% CI 0.21, 0.54). Multivariable logistic regression models showed that age (OR = 1.07, 95% CI 1.04, 1.10 per year) and education level (OR = 0.27, 95% CI 0.11, 0.65) were associated with discordance in reported and documented MS types, whereas possession of Swiss citizenship (OR = 0.32, 95% CI 0.14, 0.72) was associated with discordance in DMT use.

CONCLUSION

Self-reported DMT use in pwMS is a reliable and valid information source, with near-perfect agreement and high accuracy. Self-reported MS types showed fair to moderate agreement and varying accuracy, likely reflecting the complexity of diagnosing progressive forms of MS and access to DMTs. In population-based MS research, self-reports of MS types, and particularly DMT use, can serve as a suitable surrogate for healthcare provider data.

Development of an individual index of social vulnerability that predicts negative healthcare events: a proposed tool to address healthcare equity in primary care research and practice

PURPOSE

Socially disadvantaged patients may lack self-efficacy to navigate a complex health system making them vulnerable to healthcare inequity. We aimed to develop an Index of social vulnerability that predicts increased risk of negative healthcare events (e.g. emergency hospitalization), independent of chronic disease burden. The analysis illustrates the conceptual and practical steps leading to the development of a pragmatic Index of social vulnerability to limited healthcare self-efficacy.

METHODS

Using data from a 3-year cohort of 2507 adult primary care patients in Québec (Canada), we applied two complementary structural equation modelling approaches-Partial Least Squares Path Modelling (PLS-PM) and Multiple indicators and Multiple Causes (MIMIC) modelling-to identify a minimal set of social characteristics that could be summed into an Index related to limited healthcare self-efficacy. We then used logistic regression to determine if the Index predicted: hospital emergency department use; hospital admissions; unmet need for care, and others. We privileged parsimony over explanatory capacity in our analytic decisions to make the Index pragmatic for epidemiologic and clinical use.

RESULTS

The Individual Social Vulnerability Index is the weighted sum of five indicators: two indicators of social support; educational achievement; financial status; limited language proficiency. The Index predicts increased likelihood of all negative healthcare outcomes except unmet need, with a clear threshold at Index ≥ 2. The effect is independent of chronic disease burden.

CONCLUSION

When social deficits outweigh social assets by two or more (Index ≥ 2), there is an increased risk of negative healthcare events beyond the risk attributable to poor health. The Index is a pragmatic tool to identify a minority of patients who will require additional support to receive equitable healthcare.

Diabetes distress in a Medicaid sample: The role of psychosocial and health-related factors

AIMS

Diabetes-related distress can negatively affect disease management leading to worse complications, especially among marginalized populations. Prior studies mostly focus on distress' impact on diabetes outcomes, with few examining distress predictors. The current study examined the impact of social needs on distress on its own and after controlling for other socio-demographic, psychosocial, and health factors.

METHODS

Adult Medicaid beneficiaries with type 2 diabetes and a recent HbA1c test documented in claims data (<120 days) were recruited for a 12-month social needs intervention trial. Baseline survey data assessed diabetes distress, social needs, psychosocial factors and health factors. Descriptive statistics were obtained, and bivariate and multivariable logistic regression analyses were used to identify predictors of moderate to severe distress.

RESULTS

Bivariate analyses revealed social needs, stress, depression, comorbidity and comorbidity burden, poor self-rated health, insulin use, a self-reported HbA1c ≥ 9.0, and difficulty remembering to take diabetes medications were all positively associated with greater odds of diabetes distress; greater social support, diabetes self-efficacy, and age were negatively associated. Four variables remained significant in the multivariate model: depression, diabetes self-efficacy, self-reported HbA1c ≥ 9.0, and younger age.

CONCLUSIONS

Targeted distress screening efforts might prioritize people with HbA1c values >9.0, greater depression, and worse diabetes self-efficacy.

Prevalence of mental disorders, psychosocial distress, and perceived need for psychosocial support in cancer patients and their relatives stratified by biopsychosocial factors: rationale, study design, and methods of a prospective multi-center observational cohort study (LUPE study)

Background

Despite remarkable progress, cancer remains a life-threatening disease for millions of people worldwide, also resulting in significant psychosocial limitations. High-quality, comprehensive cancer care requires patient and family involvement and the provision of needs-based, targeted psychosocial services. Although progress has been made in understanding the occurrence of mental comorbidity and psychosocial distress in cancer patients, comparatively little is known about the course of psychological comorbidity and psychosocial distress in early survivorship among patients and their families. We therefore aim to estimate the prevalence of mental disorders according to the DSM-5, psychosocial distress, perceived needs for psychosocial support and utilization of psychosocial support offers in newly diagnosed cancer patients and their relatives, taking into account potential contributing biopsychosocial factors for the occurrence of psychological comorbidity.

Methods/design

This study follows a prospective multi-center observational cohort design across four measurement time points: within 2 months after cancer diagnosis (t1), and in the follow-up period at 6 months (t2), at 12 months (t3), and at 18 months (t4) after t1. Patients older than 18 years who have a confirmed initial diagnosis of a malignant solid tumor and are scheduled for cancer treatment at one of the participating cancer centers are eligible for study participation. Relatives of eligible patients are also eligible for study participation if they are older than 18 years. Patients are interviewed using the Structured Clinical Interview for DSM-5 Disorders (SCID-5-CV). In addition, patients and relatives receive a set of validated questionnaires at each measurement time point, covering comorbid conditions and functional performance, perceived psychological distress and quality of life, partnership aspects and social relationships, supportive care needs and use of psychosocial support services, health literacy, and health behavior and meaning in life.

Discussion

This prospective multi-center observational cohort study has a major focus on increasing quality of care and quality of life in cancer survivors through providing rigorous longitudinal data for the development and implementation of target group-specific psychosocial support services.

Trial registration

NCT04620564, date of registration 9/11/2020; DKG OnkoZert: Registrier-No.: ST-U134, date of registration 5/11/2021.

Obesity, multiple chronic conditions, and the relationship with physical function: Data from the national health and aging trends survey

BACKGROUND

The population of older adults living with multiple chronic conditions (MCC) continues to grow. MCC is independently associated with functional limitation and obesity. The aim of our study was to evaluate the association between obesity and MCC, and secondarily, the combined presence of obesity and functional limitations with MCC.

METHODS

We analyzed cross-sectional survey data from the National Health and Aging Trends Survey (NHATS) 2011 baseline data, a nationally representative Medicare beneficiary cohort of adults in the United States. We evaluated the coexistent prevalence of obesity and MCC overall, and by standard body mass index (BMI) categories. We then evaluated the prevalence of functional limitations (mobility, self-care, and household activities) and Fried-defined frailty status in persons with a BMI ≥ 30 kg/m2. Logistic regression was used to measure the association between MCC and BMI, and functional limitations and MCC among those with obesity.

RESULTS

In the 6,600 participants, the prevalence of concurrent obesity and MCC was 30.4%. Of those with obesity, the prevalence of MCC was 84.0%, and were more likely to have MCC (adjusted OR: 2.17, 95% CI 1.86, 2.54) compared to a normal BMI. Obesity and functional limitations or frailty were more likely have MCC than individuals with obesity alone.

CONCLUSIONS

We found that individuals with obesity is strongly associated with MCC and that functional limitations and frailty status have a greater association with having MCC than individuals with obesity without MCC. Future longitudinal analyses are needed to ascertain this relationship.

Integrated case management between primary care clinics and hospitals for people with complex needs who frequently use healthcare services: A multiple-case embedded study

INTRODUCTION

Case management (CM) is recognized to improve care integration and outcomes of people with complex needs who frequently use healthcare services, but challenges remain regarding interaction between primary care clinics and hospitals. This study aimed to implement and evaluate an integrated CM program for this population where nurses in primary care clinics worked with a hospital case manager.

METHODS

A multiple embedded case study was conducted in the Saguenay-Lac-Saint-Jean region (Québec, Canada), in four dyads including a clinic and a hospital. Mixed data collection included, at baseline and 6 months, interviews and focus groups with stakeholders, patient questionnaires (patient experience of integrated care and self-management), and emergency department (ED) visits in the previous 6 months.

RESULTS

Integrated CM implementation was optimal when all stakeholders provided collective leadership, and were supportive of the program, particularly the physicians. The 6-month program enabled the observation of positive qualitative outcomes in most clinic-hospital dyads where implementation occurred. Full implementation was associated with improved care integration.

DISCUSSION AND CONCLUSION

Integrated CM between primary care clinics and hospitals is a promising innovation to improve care integration for people with complex needs who frequently use healthcare services. Collective leadership and physicians' buy-in to integrated CM are important to foster the implementation.

The association between comorbidities and self-care of heart failure: a cross-sectional study

BACKGROUND

Because heart failure (HF) is a debilitating chronic cardiac condition and increases with age, most patients with HF experience a broad range of coexisting chronic morbidities. Comorbidities present challenges for patients with HF to successfully perform self-care, but it is unknown what types and number of comorbidities influence HF patients' self-care. The purpose of this study was to explore whether the number of cardiovascular and non-cardiovascular conditions are associated with HF self-care.

METHODS

Secondary data analysis was performed with 590 patients with HF. The number of cardiovascular and non-cardiovascular conditions was calculated using the list of conditions in the Charlson Comorbidity Index. Self-care was measured with the European HF self-care behavior scale. Multivariable linear regression was performed to explore the relationship between the types and number of comorbidities and self-care.

RESULTS

Univariate analysis revealed that a greater number of non-cardiovascular comorbidities was associated with poorer HF self-care(β=-0.103), but not of more cardiovascular comorbidities. In the multivariate analysis, this relationship disappeared after adjusting for covariates. Perceived control and depressive symptoms were associated with HF self-care.

CONCLUSION

The significant relationship between the number of non-cardiovascular comorbidities and HF self-care was not independent of perceived control and depressive symptoms. This result suggests a possible mediating effect of perceived control and depressive symptoms on the relationship between HF self-care and the number and type of comorbidities.

Physical and psychosocial factors associated with sexual satisfaction in long-term cancer survivors 5 and 10 years after diagnosis

Our study provides data on sexual satisfaction among long-term cancer survivors 5 and 10 years after diagnosis, and identifies factors detrimental (e.g. psychosocial and physical symptom burden) or beneficial (e.g. social support) to survivors' sexual satisfaction. We measured sexual satisfaction among cancer survivors recruited via the local clinical cancer registry across a wide range of tumor sites 5 years (cohort 1) and 10 years (cohort 2) after diagnosis. We further assessed chronic comorbidity index (CCI) and symptom scales (EORTC QLQ-C30), depression (PHQ-9) and anxiety (GAD-7), satisfaction with partnership (PFB), quality of life (EORTC QLQ-C30), and social support (OSSS). 924 patients (5-year cohort = 608/10-year cohort = 316) participated in the study (53% men, 80% cohabiting, mean age 66 years, range 18-85). We found that nearly half of the respondents perceived their sexual life as less satisfying than before cancer. High sexual satisfaction was associated with a low chronic comorbidities index (r = - 0.27, p < .001),  less fatigue (r = - 0.35, p<.001), less nausea/vomiting (r = - 0.13, p<.001) and less pain (r = - 0.23, p<.001), r ; less depression (r = - 0.24, p < .001), less anxiety(r = - 0.23, p < .001); a high level of social support (r = 0.16, p < .001), a high level of satisfaction with their relationship (r = 0.24, p < .001), and high quality of life (r = 0.33, p < .001). Sexual satisfaction may be affected by both psychosocial and physical symptom burden, with the latter having a greater impact on sexual satisfaction. It is essential for health care providers that sexual health issues are understood, evaluated, and treated, including those of long-term cancer survivors.

Long-term bowel dysfunction and decision regret in diverticulitis: A mixed methods study

BACKGROUND

This study had aimed to describe long-term decision regret, bowel dysfunction, and the overall quality of life in patients with diverticulitis, and to determine if elective colectomy was associated with these patient-reported outcome measures.

METHODS

This mixed-methods, survey-based study was administered to a national cohort of patients in the United States with diverticulitis. We measured decision regret (Brehaut Decision Regret), bowel dysfunction (Low Anterior Resection Syndrome score), and the overall quality of life (EuroQol 5 Dimension) in this population. We asked open-ended questions to elucidate factors that influenced patients' choices between elective colectomy and observation.

RESULTS

Among the 614 respondents, 294 (48%) chose between colectomy and observational management, 94 (15%) had surgery, and 157 (26%) had major Low Anterior Resection Syndrome. Of the 294 that chose between colectomy and observational management, 51 (17%) experienced decision regret. Colectomy was associated with an average decrease in the Brehaut Decision Regret score by 6 points but was not associated with a categorical measure of decision regret (Brehaut Score ≥50). Bowel dysfunction and overall quality of life were not significantly associated with colectomy. Disease-related factors, psychosocial factors, and interactions with physicians were commonly cited as reasons for pursuing colectomy or observational management.

CONCLUSION

Patients with self-reported diverticulitis describe high levels of decision regret and bowel dysfunction regardless of chosen management strategy. Physicians should be aware that psychosocial factors can strongly influence a patient's choice between colectomy and observational management. We advocated for future prospective studies using patient reported outcome metrics to improve outcomes in diverticulitis.

Improving multimorbidity measurement using individualized disease-specific quality of life impact assessments: predictive validity of a new comorbidity index

BACKGROUND

Interpretation of health-related quality of life (QOL) outcomes requires improved methods to control for the effects of multiple chronic conditions (MCC). This study systematically compared legacy and improved method effects of aggregating MCC on the accuracy of predictions of QOL outcomes.

METHODS

Online surveys administered generic physical (PCS) and mental (MCS) QOL outcome measures, the Charlson Comorbidity Index (CCI), an expanded chronic condition checklist (CCC), and individualized QOL Disease-specific Impact Scale (QDIS) ratings in a developmental sample (N = 5490) of US adults. Controlling for sociodemographic variables, regression models compared 12- and 35-condition checklists, mortality vs. population QOL-weighting, and population vs. individualized QOL weighting methods. Analyses were cross-validated in an independent sample (N = 1220) representing the adult general population. Models compared estimates of variance explained (adjusted R2) and model fit (AIC) for generic PCS and MCS across aggregation methods at baseline and nine-month follow-up.

RESULTS

In comparison with sociodemographic-only regression models (MCS R2 = 0.08, PCS = 0.09) and Charlson CCI models (MCS R2 = 0.12, PCS = 0.16), increased variance was accounted for using the 35-item CCC (MCS R2 = 0.22, PCS = 0.31), population MCS/PCS QOL weighting (R2 = 0.31-0.38, respectively) and individualized QDIS weighting (R2 = 0.33 & 0.42). Model R2 and fit were replicated upon cross-validation.

CONCLUSIONS

Physical and mental outcomes were more accurately predicted using an expanded MCC checklist, population QOL rather than mortality CCI weighting, and individualized rather than population QOL weighting for each reported condition. The 3-min combination of CCC and QDIS ratings (QDIS-MCC) warrant further testing for purposes of predicting and interpreting QOL outcomes affected by MCC.

Measuring Health Literacy in Primary Healthcare: Adaptation and Validation of a French-Language Version of the Brief Health Literacy Screening among Patients with Chronic Conditions Seen in Primary Care

Background: The Brief Health Literacy Screening (BHLS) is a short self-report instrument developed to identify patients with inadequate health literacy. This study aimed to translate the BHLS into French Canadian (BHLS-FCv) and to evaluate its psychometric properties among patients with chronic conditions in primary care. Methods: The BHLS was translated into French using the Hawkins and Osborne’s method. Content validity was evaluated through cognitive interviews. A validation study of the BHLS-FCv was conducted in two primary care clinics in the province of Quebec (Canada) among adult patients with chronic conditions. Psychometric properties evaluated included: internal consistency (Cronbach’s alpha); test–retest reliability (intraclass correlation coefficient); and concurrent validity (Spearman’s correlations with the Health Literacy Questionnaire (HLQ)). Results: 178 participants completed the questionnaire at baseline and 47 completed the questionnaire two weeks later over the telephone. The average score was 13.3. Cronbach’s alpha for internal consistency was 0.77. The intraclass correlation coefficient for test–retest reliability was 0.69 (95% confidence interval: 0.45–0.83). Concurrent validity with Spearman’s correlation coefficient with three subscales of HLQ ranged from 0.28 to 0.58. Conclusions: The BHLS-FCv demonstrated acceptable psychometric properties and could be used in a population with chronic conditions in primary care.

Health Literacy Among Adults With Multiple Chronic Health Conditions

Low health literacy (HL) is associated with poorer health outcomes. We examined HL among adults with multiple chronic conditions (CCs), using 2016 Behavioral Risk Factor Surveillance System data. Health literacy was measured by 3 subjective questions about difficulty with the following tasks: (1) obtaining health information or advice; (2) understanding spoken health information; and (3) understanding written health information. We estimated the prevalence of low HL (difficulty with ≥1 HL tasks) and used multiple logistic regression analysis to examine associations between HL and number of CCs. The prevalence of low HL was 13.8% overall and increased with the number of CCs from 10.6% among those with no CC to 24.7% among those with 3 or more CCs, with the latter having more than twice the adjusted odds of low HL compared with the former (adjusted odds ratio = 2.65; 95% confidence interval, 2.36-2.97). Efforts to improve HL in this population are needed.

A pragmatic randomized controlled trial of a group self-management support program versus treatment-as-usual for anxiety disorders: study protocol

BACKGROUND

The integration of a personal recovery-oriented practice in mental health services is an emerging principle in policy planning. Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse, and promoting well-being. While SMS is well established for chronic physical conditions, there is a lack of evidence to support the implementation of structured SMS programs for common mental disorders, and particularly for anxiety disorders. This study aims to examine the effectiveness of a group-based self-management support program for anxiety disorders as an add-on to treatment-as-usual in community-based care settings.

METHODS/DESIGN

We will conduct a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment (4-month post-randomization), and follow-ups at 8, 12 and 24-months. TREATMENT AND CONTROL GROUPS: a) group self-management support (10 weekly 2.5-h group web-based sessions with 10-15 patients with two trained facilitators); b) treatment-as-usual. Participants will include adults meeting DSM-5 criteria for Panic Disorder, Agoraphobia, Social Anxiety Disorder, and/or Generalized Anxiety Disorder. The primary outcome measure will be the Beck Anxiety Inventory; secondary outcome measures will comprise self-reported instruments for anxiety and depressive symptoms, recovery, self-management, quality of life, and service utilisation.

STATISTICAL ANALYSIS

Data will be analysed based on intention-to-treat with a mixed effects regression model accounting for between and within-subject variations in the effects of the intervention.

DISCUSSION

This study will contribute to the limited knowledge base regarding the effectiveness of structured group self-management support for anxiety disorders. It is expected that changes in patients' self-management behaviour will lead to better anxiety management and, consequently, to improved patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05124639 . Prospectively registered 18 November 2021.

Better understanding care transitions of adults with complex health and social care needs: a study protocol

Background

Adults with chronic conditions who also suffer from mental health comorbidities and/or social vulnerability require services from many providers across different sectors. They may have complex health and social care needs and experience poorer health indicators and high mortality rates while generating considerable costs to the health and social services system. In response, the literature has stressed the need for a collaborative approach amongst providers to facilitate the care transition process. A better understanding of care transitions is the next step towards the improvement of integrated care models. The aim of the study is to better understand care transitions of adults with complex health and social care needs across community, primary care, and hospital settings, combining the experiences of patients and their families, providers, and health managers.

Methods/design

We will conduct a two-phase mixed methods multiple case study (quantitative and qualitative). We will work with six cases in three Canadian provinces, each case being the actual care transitions across community, primary care, and hospital settings. Adult patients with complex needs will be identified by having visited the emergency department at least three times over the previous 12 months. To ensure they have complex needs, they will be invited to complete INTERMED Self-Assessment and invited to enroll if positive. For the quantitative phase, data will be obtained through questionnaires and multi-level regression analyses will be conducted. For the qualitative phase, semi-structured interviews and focus groups will be conducted with patients, family members, care providers, and managers, and thematic analysis will be performed. Quantitative and qualitative results will be compared and then merged.

Discussion

This study is one of the first to examine care transitions of adults with complex needs by adopting a comprehensive vision of care transitions and bringing together the experiences of patients and family members, providers, and health managers. By using an integrated knowledge translation approach with key knowledge users, the study’s findings have the potential to inform the optimization of integrated care, to positively impact the health of adults with complex needs, and reduce the economic burden to the health and social care systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07588-0.

Charlson Comorbidity Index: A Critical Review of Clinimetric Properties

The present critical review was conducted to evaluate the clinimetric properties of the Charlson Comorbidity Index (CCI), an assessment tool designed specifically to predict long-term mortality, with regard to its reliability, concurrent validity, sensitivity, incremental and predictive validity. The original version of the CCI has been adapted for use with different sources of data, ICD-9 and ICD-10 codes. The inter-rater reliability of the CCI was found to be excellent, with extremely high agreement between self-report and medical charts. The CCI has also been shown either to have concurrent validity with a number of other prognostic scales or to result in concordant predictions. Importantly, the clinimetric sensitivity of the CCI has been demonstrated in a variety of medical conditions, with stepwise increases in the CCI associated with stepwise increases in mortality. The CCI is also characterized by the clinimetric property of incremental validity, whereby adding the CCI to other measures increases the overall predictive accuracy. It has been shown to predict long-term mortality in different clinical populations, including medical, surgical, intensive care unit (ICU), trauma, and cancer patients. It may also predict in-hospital mortality, although in some instances, such as ICU or trauma patients, the CCI did not perform as well as other instruments designed specifically for that purpose. The CCI thus appears to be clinically useful not only to provide a valid assessment of the patient's unique clinical situation, but also to demarcate major diagnostic and prognostic differences among subgroups of patients sharing the same medical diagnosis.

Exploring the ability of self-report measures to identify risk of high treatment burden in chronic disease patients: a cross-sectional study

Background

Effective self-management of chronic health conditions is key to avoiding disease escalation and poor health outcomes, but self-management abilities vary. Adequate patient capacity, in terms of abilities and resources, is needed to effectively manage the treatment burden associated with chronic health conditions. The ability to measure different elements of capacity, as well as treatment burden, may assist to identify those at risk of poor self-management. Our aims were to: 1. Investigate correlations between established self-report tools measuring aspects of patient capacity, and treatment burden; and 2. Explore whether individual questions from the self-report tools will correlate to perceived treatment burden without loss of explanation. This may assist in the development of a clinical screening tool to identify people at risk of high treatment burden.

Methods

A cross-sectional survey in both a postal and online format. Patients reporting one or more chronic diseases completed validated self-report scales assessing social, financial, physical and emotional capacity; quality of life; and perceived treatment burden. Logistic regression analysis was used to explore relationships between different capacity variables, and perceived high treatment burden.

Results

Respondents (n = 183) were mostly female (78%) with a mean age of 60 years. Most participants were multimorbid (94%), with 45% reporting more than five conditions. 51% reported a high treatment burden. Following logistic regression analyses, high perceived treatment burden was correlated with younger age, material deprivation, low self-efficacy and usual activity limitation. These factors accounted for 50.7% of the variance in high perceived treatment burden. Neither disease burden nor specific diagnosis was correlated with treatment burden.

Conclusions

This study supports previous observations that psychosocial factors may be more influential than specific diagnoses for multimorbid patients in managing their treatment workload. A simple capacity measure may be useful to identify those who are likely to struggle with healthcare demands.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12579-1.

Patients' openness to discussing implantable cardioverter defibrillator deactivation at end of life: a cross-sectional study

AIMS

It is recommended that patients and clinicians discuss end-of-life deactivation of their implantable cardioverter defibrillator (ICD) prior to device implantation and throughout the illness trajectory to facilitate shared decision-making. However, such discussions rarely occur, and little is known about patients' openness to this discussion. The purpose of this study was to explore factors associated with patients' openness to discussing end-of-life ICD deactivation with clinicians.

METHODS AND RESULTS

This cross-sectional study recruited 293 patients with an ICD from outpatient clinics in the USA, Australia, and South Korea. Patients were classified into an open or resistant group based on their desire to discuss device deactivation at end of life with clinicians. Multivariable logistic regression was used to explore factors related to patients' openness to this discussion.About half of the participants (57.7%) were open to discussing such issues with their clinicians. Factors related to patients' openness to discussing device deactivation at end of life were living with someone, not having severe comorbid conditions (cancer and/or chronic kidney disease), greater ICD knowledge, and more experience discussing end-of-life issues with clinicians (odds ratio: 0.479, 0.382, 1.172, 1.332, respectively).

CONCLUSION

Approximately half of the ICD recipients were reluctant to discuss device deactivation at end of life with clinicians. Unmodifiable factors were their living arrangement and severe comorbidity. ICD knowledge and prior experience discussing end-of-life issues were potentially modifiable factors in the future. These factors should be addressed when assessing patients' readiness for a shared discussion about device deactivation at end of life.

Using projective exercises to identify patient perspectives of living with comorbid type 2 diabetes and asthma

OBJECTIVE

Patient self-management of a single chronic condition can be challenging, but few studies have examined the emotional impact of living with comorbid conditions and how that differs from a single chronic condition. This study examined patient perspectives of the emotional impact of living with asthma or asthma with comorbid type 2 diabetes (asthma+diabetes).

METHODS

Data were collected from 41 adults (asthma only n = 22, asthma+diabetes n = 19) using semi-structured interviews on two separate online bulletin boards. Respondents engaged in discussions that leveraged two projective exercises: describing their health condition(s) as an animal, and selecting one of eight images that best illustrated how they were living with and managing their health condition(s).

RESULTS

Respondents described physical and emotional challenges related to managing asthma or asthma+diabetes. Animal- and image- projective exercises were categorized by response and health condition. Thematic analysis across both projective exercises identified four themes: (1) frustrations with dual diagnosis, (2) juggling the dual diagnosis, (3) anticipating the future, and (4) unpredictability.

DISCUSSION

Projective exercises are one way to elicit feelings about living with chronic conditions. Healthcare providers can improve support for patients with more than one health condition by providing education on how to manage comorbid conditions.

Elevated customary alcohol consumption attenuates opioid effects

BACKGROUND

Regular alcohol consumption is on the rise among older adults and has the potential of altering the subjective experience of pain and response to pain medications. This study examined the cognitive, analgesic and side effect response to oxycodone in middle age and older adults with elevated levels of customary alcohol consumption in a human laboratory setting.

METHODS

After refraining from alcohol for one day, eligible participants underwent baseline assessment cognition and side effects by means of questionnaires that were repeated at three time points (90 min, 5 and 8 h) following administration of a 10 mg oral dose of oxycodone. Response to pain stimulus (Cold Pressor Test (CPT)), pupil size, and plasma oxycodone were also measured.

RESULTS

One hundred twenty-eight adults (age 35-85) completed the study day. Compared to those with lower customary alcohol consumption, participants with elevated alcohol consumption showed attenuated opioid-induced pupil constriction and cognitive decline on objective measures of working memory, sustained attention, inhibitory control, coordination on a simulated driving task, and subjective dysphoric effects with enhanced subjective euphoric effects. Oxycodone pharmacokinetics, pain tolerance to CPT, and Berg balance were impacted comparably between alcohol consumption groups. Women endorsed greater negative drug effects, whereas men endorsed positive drug effects.

CONCLUSION

Independent of subject's age, elevated customary alcohol consumption attenuates opioid central effects (i.e., pupil miosis, impaired cognition) and gender influences subjective drug effects. Clinicians should consider alcohol consumption and gender when prescribing opioid medications.

Reconciling validity and challenges of patient comfort and understanding: Guidelines to patient-oriented questionnaires

Background

Patient‐reported outcome measures (PROMs) are widely recognized as important tools for achieving a patient‐centred approach in health research. While PROMs are subject to several stages of validation during development, even questionnaires with robust psychometric properties may challenge patient comfort and understanding.

Aim

Building on the experience of patient engagement in the PriCARE research programme, this paper outlines the team's response to concerns raised by patient partners regarding the administration of the questionnaire.

Methods

Based on a participatory action research design and the patient engagement framework in the Strategy for Patient‐Oriented Research of the Canadian Institutes of Health Research, PriCARE team members worked together to discuss concerns, review the questionnaires and come up with solutions. Data were collected through participant observation of team meetings.

Results

This paper demonstrates how patient partners were engaged in PriCARE and integrated into the programme's governance structure, focusing on the challenges that they raised regarding the questionnaires and how these were addressed by PriCARE team members in a six‐step approach: (1) Recognizing patient partner concerns, discussing concerns and reframing the challenges; (2) Detailing and sharing evidence of the validity of the questionnaires; (3) Evaluating potential solutions; (4) Searching the literature for guidelines; (5) Creating guidelines; and (6) Sharing and refining guidelines.

Conclusion

This six‐step approach demonstrates how research teams can integrate patient partners as equal members, develop meaningful collaboration through recognition of individual experiences and expertise and ensure that the patient perspective is taken into consideration in research and healthcare innovation.

Patient or Public Contribution

All patient partners from the PriCARE programme were actively involved in the six‐step approach. They were also involved in the preparation of the manuscript.

An exploration of the sociodemographic and health conditions associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults

Objective

To identify sociodemographic factors and health conditions associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults. Participants were recruited via investigator networks and an online panel provider with an established nationwide panel of Aboriginal and Torres Strait Islander adults. Those interested were invited to complete a survey that included an assessment of wellbeing using a visual analogue scale. Data was collected from October–November 2019 and August–September 2020. Exploratory analyses were conducted to ascertain factors associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults.

Results

Having more than enough money to last until next pay day, full-time employment, completion of grade 12, having a partner, and living with others were significantly associated with higher wellbeing among Aboriginal and Torres Strait Islander adults. A self-reported history of depression, anxiety, other mental health conditions, heart disease, or disability were associated with lower self-rated wellbeing scores. Our findings indicate a need for further investigation among these socioeconomic and patient groups to identify how to improve and support the wellbeing of Aboriginal and Torres Strait Islander adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05794-3.

Feasibility, experiences and outcomes of using DIALOG+ in primary care to improve quality of life and mental distress of patients with chronic conditions: an exploratory non-controlled trial in Bosnia and Herzegovina, Colombia and Uganda

BACKGROUND

DIALOG+ is a resource-oriented and evidence-based intervention to improve quality of life and reduce mental distress. While it has been extensively studied in mental health care, there is little evidence for how to use it in primary care settings for patients with chronic physical conditions. Considering that DIALOG+ is used in existing routine patient-clinician meetings and is very low cost, it may have the potential to help large numbers of patients with chronic physical conditions, mental distress and poor quality of life who are treated in primary care. This is particularly relevant in low- and middle-income countries (LMICs) where resources for specialised services for such patients are scarce or non-existent.

METHODS

An exploratory non-controlled trial will be conducted to primarily assess the feasibility and acceptability and, secondarily, outcomes of delivering DIALOG+ to patients with chronic physical conditions and poor quality of life in primary care settings in Bosnia and Herzegovina, Colombia and Uganda. Thirty patients in each country will receive DIALOG+ up to three times in monthly meetings over a 3-month period. Feasibility will be assessed by determining the extent to which the intervention is implemented as planned. Experiences will be captured in interviews and focus groups with care providers and participants to understand acceptability. Quality of life, symptoms of anxiety and depression, objective social situation and health status will be assessed at baseline and again after the three-session intervention.

DISCUSSION

This study will inform our understanding of the extent to which DIALOG+ may be used in the routine care of patients with chronic physical conditions in different primary care settings. The findings of this exploratory trial can inform the design of future full randomised controlled trials of DIALOG+ in primary care settings in LMICs.

TRIAL REGISTRATION

All studies were registered prospectively (on 02/12/2020 for Uganda and Bosnia and Herzegovina, and 01/12/2020 for Colombia) within the ISRCTN Registry. ISRCTN17003451 (Bosnia and Herzegovina), ISRCTN14018729 (Colombia) and ISRCTN50335796 (Uganda). Protocol version and date: v2.0; 28/07/2020 (Bosnia and Herzegovina), v0.3 02/08/2020 (Colombia) and v1.0, 05/11/2020 (Uganda).

Feasibility of an Automated Bidet Intervention to Decrease Caregiver Burden

IMPORTANCE

Informal caregivers often receive limited training and support, especially in providing assistance with toileting, a physically and emotionally demanding activity of daily living. This increases caregivers' risk for physical injury and burnout and jeopardizes older adults' ability to age in place.

OBJECTIVE

To assess the feasibility, acceptability, and preliminary efficacy of a toileting intervention using an automated bidet to reduce the amount of physical assistance required from caregivers.

DESIGN

Randomized wait-list control feasibility study.

SETTING

Caregiver's home.

PARTICIPANTS

Ten informal caregivers.

INTERVENTION

An occupational therapy intervention to educate and train caregiving dyads to use an automated bidet system. Outcomes and Measures: Feasibility was measured in terms of recruitment and retention, bidet installation, ability to operate the bidet, acceptability (a process evaluation), preliminary efficacy (physical barriers and impact on caregiver outcomes of performance, satisfaction, and self-efficacy), and adverse events.

RESULTS

All bidets were installed successfully. All caregivers reported that the intervention made toileting easier and increased their confidence. Physical barriers decreased for the treatment group. The bidet had a large effect on self-efficacy for the treatment group.

CONCLUSIONS AND RELEVANCE

The results suggest that the automated bidet intervention is feasible and acceptable and can have a positive impact on caregiver outcomes when assisting with toileting. What This Article Adds: A toileting intervention using an automated bidet is feasible and acceptable for caregivers of older adults and can reduce the amount of physical assistance required from caregivers.

Multimorbidity and its effect on perceived burden, capacity and the ability to self-manage in a low-income rural primary care population: A qualitative study

INTRODUCTION

Multimorbidity is increasing in prevalence, especially in low-income settings. Despite this, chronic conditions are often managed in isolation, potentially leading to burden-capacity imbalance and reduced treatment adherence. We aimed to explore, in a low-income population with common comorbidities, how the specific demands of multimorbidity affect burden and capacity as defined by the Cumulative Complexity Model.

MATERIALS AND METHODS

Qualitative interviews with thirteen rural community health centre patients in Victoria, Australia. Participants were aged between 47-72 years and reported 3-10 chronic conditions. We asked about perceived capacity and burden in managing health. The Theory of Patient Capacity was used to analyse capacity and Normalisation Process Theory to analyse burden. All data specifically associated with the experience of multimorbidity was extracted from each burden and capacity domain.

RESULTS

The capacity domains of biography, resource mobilisation and work realisation were important in relation to multimorbidity. Conditions causing functional impairment (e.g. chronic pain, depression) interacted with physical, psychological and financial capacity, leading to biographical disruption and an inability to realise treatment and life work. Despite this, few people had a treatment plan for these conditions. Participants reported that multimorbidity affected all burden domains. Coherence and appraisal were especially challenging due to condition interactions, with clinicians providing little guidance.

DISCUSSION

The capacity and burden deficits highlighted by participants were not associated with any specific diagnosis, but were due to condition interactions, coupled with the lack of health provider support to navigate interactions. Physical, psychological and financial capacities were inseparable, but rarely addressed or understood holistically. Understanding and managing condition and treatment interactions was a key burden task for patients but was often difficult, isolating and overwhelming. This suggests that clinicians should become more aware of linkages between conditions, and include generic, synergistic or cross-disciplinary approaches, to build capacity, reduce burden and encourage integrated chronic condition management.

Examining variation in the measurement of multimorbidity in research: a systematic review of 566 studies

BACKGROUND

A systematic understanding of how multimorbidity has been constructed and measured is unavailable. This review aimed to examine the definition and measurement of multimorbidity in peer-reviewed studies internationally.

METHODS

We systematically reviewed studies on multimorbidity, via a search of nine bibliographic databases (Ovid [PsycINFO, Embase, Global Health, and MEDLINE], Web of Science, the Cochrane Library, CINAHL Plus, Scopus, and ProQuest Dissertations & Theses Global), from inception to Jan 21, 2020. Reference lists and tracked citations of retrieved articles were hand-searched. Eligible studies were full-text articles measuring multimorbidity for any purpose in community, primary care, care home, or hospital populations receiving a non-specialist service. Abstracts, qualitative research, and case series were excluded. Two reviewers independently reviewed the retrieved studies with conflicts resolved by discussion or a third reviewer, and a single researcher extracted data from published papers. To assess our objectives of how multimorbidity has been measured and examine variation in the chronic conditions included (in terms of number and type), we used descriptive analysis (frequencies, cross-tabulation, and negative binomial regression) to summarise the characteristics of multimorbidity studies and measures (study setting, source of morbidity data, study population, primary study purpose, and multimorbidity measure type). This systematic review is registered with PROSPERO, CRD420201724090.

FINDINGS

566 studies were included in our review, of which 206 (36·4%) did not report a reference definition for multimorbidity and 73 (12·9%) did not report the conditions their measure included. The number of conditions included in measures ranged from two to 285 (median 17 [IQR 11-23). 452 (79·9%) studies reported types of condition within a single multimorbidity measure; most included at least one cardiovascular condition (441 [97·6%] of 452 studies), metabolic and endocrine condition (440 [97·3%]), respiratory condition (422 [93·4%]), musculoskeletal condition (396 [87·6%]), or mental health condition (355 [78·5%]) in their measure of multimorbidity. Chronic infections (123 [27·2%]), haematological conditions (110 [24·3%]), ear, nose, and throat conditions (107 [23·7%]), skin conditions (70 [15·5%]), oral conditions (19 [4·2%]), and congenital conditions (14 [3·1%]) were uncommonly included. Only eight individual conditions were included by more than half of studies in the multimorbidity measure used (diabetes, stroke, cancer, chronic obstructive pulmonary disease, hypertension, coronary heart disease, chronic kidney disease, and heart failure), with individual mental health conditions under-represented. Of the 566 studies, 419 were rated to be of moderate risk of bias, 107 of high risk of bias, and 40 of low risk of bias according to the Effective Public Health Practice Project quality assessment tool.

INTERPRETATION

Measurement of multimorbidity is poorly reported and highly variable. Consistent reporting of measure definitions should be required by journals, and consensus studies are needed to define core and study-dependent conditions to include in measures of multimorbidity.

FUNDING

Health Data Research UK.

The Influence of Contextual Factors on the Process of Formulating Strategies to Improve the Adoption of Care Manager Activities by Primary Care Nurses

Background:

Primary care nurses are well-suited to provide care management for common mental disorders, but their practices depend on context. Various strategies can be considered to improve the adoption of nursing care manager activities, but data from implementation studies rarely address strategy formulation.

Aim:

To analyze the influence of contextual factors on strategy formulation to improve the adoption of care manager activities by primary care nurses.

Method:

A qualitative multiple case study in three primary care clinics was carried out. Data were collected through individual interviews (n = 32) and observations (n = 7), working group meetings, and relevant documents. Thematic analysis was conducted.

Results:

Contextual factors influenced strategy formulation through organizational readiness for change, which resulted from tension for change and perceived organizational ability to implement change. Tension for change was generated through the perceived gap between patient needs and service availability, perceived compatibility with the nurses work environment, and their assessment of their capacity to perform care manager activities or acquire the necessary skills.

Conclusion:

Future studies should give sufficient attention to implementation strategy formulation and consider the dynamic role of organizational readiness for change when facilitating the adoption of evidence-based practices for common mental disorders in primary care.

Psychometric properties of the WHOQOL-BREF(PT) in a sample of elderly citizens

Background

The goal of this article was to research the psychometric properties of the WHOQOL-BREF(PT) instrument in a sample of elderly citizens residing in a rural area in their own homes or at family members’ or friends’ homes and to compare the results: (i) to those reported by the team of Portuguese researchers that undertaken the instrument's translation/validation to the Portuguese language and (ii) to those reported internationally by the World Health Organization Quality of Life group. An overall quality of life scoring (QOL₂₄—all facets) is also proposed in this article as novelty. The correlation level between QOL₂₄ and the instrument’s general facet was also investigated.

Methods

This was a cross-sectional study with a sample of 351 elderly citizens (46.4% males and 53.6% females) randomly selected from the official dataset of the Local Health Unit of Baixo Alentejo. All the data were collected by health professionals at the participants’ homes following the structured interview methodology and using the WHOQOL-BREF(PT) instrument. Three different structural equation models were developed: (i) a first-order confirmatory factor analysis, to assess the instrument’s psychometric properties; (ii) a hierarchical second-order confirmatory factor analysis model, to allow determining the QOL₂₄ scoring; and (iii) a more generic structural equation model, to investigate the correlation level between QOL₂₄ and the instrument’s general facet.

Results

The WHOQOL-BREF(PT) showed an “almost very good” goodness of fit (comparative fit index of 0.949 and Tucker-Lewis index of 0.943), an adequate internal consistency (Cronbach’s alpha: from 0.64 to 0.90; composite reliability: from 0.59 to 0.88) and tolerable convergent validity (average variance extracted: from 0.374 to 0.614). However, discriminant validity was not reached because strong correlations between the first-order factors (four QOL domains) were obtained, together with low values of the average variance extracted. The scoring of QOL domains and QOL₂₄, determined as weighted averages (proposed in this article as novelty) were significantly different than those determined as unweighted averages. The standardized correlation coefficient between QOL₂₄ and the instrument’s general facet was of 0.89 (statistically highly significant).

Conclusions

The WHOQOL-BREF(PT) is a psychometrically sound instrument to assess the QOL of the considered population sample. However, the QOL domains were found strongly intertwined. More studies are necessary to validate the weighted average scoring strategy of QOL domains and QOL₂₄. Concurrent validity between QOL₂₄ and the instrument’s general facet was considered as “strong”.

Systematic review on the instruments used for measuring the association of the level of multimorbidity and clinically important outcomes

OBJECTIVES

There are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are suitable for use in studies aiming to measure the association of a specific outcome with different levels of multimorbidity as the main independent variable in community-dwelling individuals. The secondary objective was to provide details of the requirements, strengths and limitations of these instruments, and the chosen outcomes.

METHODS

We conducted the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO registration number: CRD42018105297). We searched MEDLINE, Embase and CINAHL electronic databases published in English and manually searched the Journal of Comorbidity between 1 January 2010 and 23 October 2020 inclusive. Studies also had to select adult patients from primary care or general population and had at least one specified outcome variable. Two authors screened the titles, abstracts and full texts independently. Disagreements were resolved with a third author. The modified Newcastle-Ottawa Scale was used for quality assessment.

RESULTS

Ninety-six studies were identified, with 69 of them rated to have a low risk of bias. In total, 33 unique instruments were described. Disease Count and weighted indices like Charlson Comorbidity Index were commonly used. Other approaches included pharmaceutical-based instruments. Disease Count was the common instrument used for measuring all three essential core outcomes of multimorbidity research: mortality, mental health and quality of life. There was a rise in the development of novel weighted indices by using prognostic models. The data obtained for measuring multimorbidity were from sources including medical records, patient self-reports and large administrative databases.

CONCLUSIONS

We listed the details of 33 instruments for measuring the level of multimorbidity as a resource for investigators interested in the measurement of multimorbidity for its association with or prediction of a specific outcome.

Robust classification from noisy labels: Integrating additional knowledge for chest radiography abnormality assessment

Chest radiography is the most common radiographic examination performed in daily clinical practice for the detection of various heart and lung abnormalities. The large amount of data to be read and reported, with more than 100 studies per day for a single radiologist, poses a challenge in consistently maintaining high interpretation accuracy. The introduction of large-scale public datasets has led to a series of novel systems for automated abnormality classification. However, the labels of these datasets were obtained using natural language processed medical reports, yielding a large degree of label noise that can impact the performance. In this study, we propose novel training strategies that handle label noise from such suboptimal data. Prior label probabilities were measured on a subset of training data re-read by 4 board-certified radiologists and were used during training to increase the robustness of the training model to the label noise. Furthermore, we exploit the high comorbidity of abnormalities observed in chest radiography and incorporate this information to further reduce the impact of label noise. Additionally, anatomical knowledge is incorporated by training the system to predict lung and heart segmentation, as well as spatial knowledge labels. To deal with multiple datasets and images derived from various scanners that apply different post-processing techniques, we introduce a novel image normalization strategy. Experiments were performed on an extensive collection of 297,541 chest radiographs from 86,876 patients, leading to a state-of-the-art performance level for 17 abnormalities from 2 datasets. With an average AUC score of 0.880 across all abnormalities, our proposed training strategies can be used to significantly improve performance scores.

CONECT-6: a case-finding tool to identify patients with complex health needs

Background

Early identification of patients with chronic conditions and complex health needs in emergency departments (ED) would enable the provision of services better suited to their needs, such as case management. A case-finding tool would ultimately support ED teams to this end and could reduce the cost of services due to avoidable ED visits and hospitalizations. The aim of this study was to develop and validate a short self-administered case-finding tool in EDs to identify patients with chronic conditions and complex health needs in an adult population.

Methods

This prospective development and initial validation study of a case-finding tool was conducted in four EDs in the province of Quebec (Canada). Adult patients with chronic conditions were approached at their third or more visit to the ED within 12 months to complete a self-administered questionnaire, which included socio-demographics, a comorbidity index, the reference standard INTERMED self-assessment, and 12 questions to develop the case-finding tool. Significant variables in bivariate analysis were included in a multivariate logistic regression analysis and a backward elimination procedure was applied. A receiver operating characteristic (ROC) curve was developed to identify the most appropriate threshold score to identify patients with complex health needs.

Results

Two hundred ninety patients participated in the study. The multivariate analysis yielded a six-question tool, COmplex NEeds Case-finding Tool – 6 (CONECT-6), which evaluates the following variables: low perceived health; limitations due to pain; unmet needs; high self-perceived complexity; low income; and poor social support. With a threshold of two or more positive answers, the sensitivity was 90% and specificity 66%. The positive and negative predictive values were 49 and 75% respectively.

Conclusions

The case-finding process is the essential characteristic of case management effectiveness. This study presents the first case-finding tool to identify adult patients with chronic conditions and complex health needs in ED.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06154-4.

Who Is Willing to Engage in Social Gatherings During the Coronavirus Disease 2019 Lockdown? A Curvilinear Relationship Between Age and Heuristic Processing

BACKGROUND

The Chinese government implemented a lockdown to contain the coronavirus disease 2019 (COVID-19) pandemic during the Chinese Lunar New Year when people have the tradition to visit families and friends. Previous research suggested that heuristic processing increased risky behavioral willingness (e.g., desire to have social gatherings despite the pandemic) and that people's tendency to use heuristic processing varied across different adulthood stages. This study thus investigated the relationships among age, heuristic processing of COVID-19-related information, and the willingness to have social gatherings during the lockdown.

METHODS

A sample of 1,651 participants was recruited from an online crowdsourcing platform between January 31 and February 04 in 2020, with a mean age of 30.69, 47.9% being women. Participants completed an online questionnaire about heuristic processing of COVID-19-related information, willingness to engage in social gatherings during the lockdown, age, and other demographic information.

RESULTS

Age was found to have a U-shaped curvilinear relationship with heuristic processing, and heuristic processing was positively correlated with the willingness to have social gatherings. Further analyses showed that heuristic processing curvilinearly mediated the relationship between age and the willingness to have social gatherings.

CONCLUSION

Compared with young adults, emerging and older adults are more likely to engage in heuristic processing, which in turn, increases the willingness to have social gatherings. Heuristic processing serves as an underlying mechanism to explain the relationship between age and risky behavioral willingness.

Relationship of Phosphatidylethanol Biomarker to Self-Reported Alcohol Drinking Patterns in Older and Middle-Age Adults

BACKGROUND

Risky alcohol consumption is on the rise among older adults. Biomarkers such as phosphatidylethanol (PEth) have been used to evaluate the correspondence between an objective, laboratory-based biomarker and self-report of alcohol consumption. This study examined the relationship between PEth, self-report of alcohol consumption, and health indices in a sample of community-dwelling older to middle-age adults (aged 35 to 89) with healthy and risky levels of alcohol consumption.

METHODS

Self-reports of alcohol consumption were collected using the Alcohol Use Disorders Identification Test (AUDIT) and Form 30. In addition, indices of health along with a blood sample to determine PEth values were collected (N = 183).

RESULTS

PEth was correlated with age, AUDIT-C, AUDIT total, alcohol consumption, mood, and liver function measures but not with medical comorbidity or body mass index (J Gerontol B Psychol Sci Soc Sci 73, 2018, 633). Alcohol consumption over the past 30 days measured with Form 30 was the strongest predictor of PEth levels for both middle-age and older adults, with age a small contributing predictor. General alcohol consumption patterns for amount of alcohol consumed over a 30-day period revealed middle-age adults consumed larger amounts of alcohol compared with older adults, but older adults consumed alcohol on more days than middle-age adults. Middle-age participants evidenced higher PEth levels than older adults at comparable drinking rates.

CONCLUSIONS

Overall, findings suggest a strong relationship between alcohol consumption and PEth levels with age a small but contributing factor to predicting PEth levels.

Rasch analysis of the long-term conditions questionnaire (LTCQ) and development of a short-form (LTCQ-8)

Background

The aim of the current study was to evaluate the structural validity of the 20-item long-term conditions questionnaire (LTCQ) and to explore a potential short-form version of the scale using Rasch analysis.

Methods

Data were collected through postal surveys (February 2016–January 2017) from a sample of 1,211 participants diagnosed with at least one long-term condition (LTC). Identified participants were invited through either local authorities for a social care cohort (n = 294) or primary care practices for a health care cohort (n = 917). Participants were mailed a survey, including the LTCQ, demographic questions, a comorbidities measure, and other validated outcome measures. Respondents were invited to complete a follow-up survey including the LTCQ for assessment of reproducibility.

Results

The main assumptions of the Rasch model from the LTCQ were fulfilled, although infit and outfit indices indicated some items showed misfit. Misfitted items, items that did not have a preceding set or showed some local dependence were removed one at a time, with the remaining candidate items to form an 8-item short version, the LTCQ-8. The Rasch model for the LTCQ-8 explained 64% variance and had a reliability estimate greater than 0.80. Several items in the LTCQ showed uniform differential item function (DIF) in relation to the number of reported LTCs, age, cohort and type of LTCs, but fewer items exhibited DIF in the LTCQ-8. Spearman’s rho correlations between the LTCQ and the LTCQ-8 were strong across the total sample and various subgroups. Correlations between the LTCQ-8 and all reference measures were moderate to strong, and comparable to correlations found between the LTCQ and these measures.

Conclusions

The LTCQ measures a unidimensional construct, and it is therefore acceptable to use a summed total score. The LTCQ-8 also met the assumption of unidimensionality and had comparable construct validity with the LTCQ. Additional validation is required in an independent sample.

Barriers to Low-Dose CT Lung Cancer Screening among Middle-Aged Chinese

PURPOSE

The current study aims to explore the barriers for middle-aged Chinese to learn about and uptake low-dose computed tomography (LDCT) lung cancer screening.

METHODS

Data were collected via an online survey in December 2019. Final valid sample included 640 respondents, aged 40-60 years old, from 21 provinces of China. We performed multiple linear regressions to test the potential barriers to LDCT scan.

FINDINGS

Cost concerns, distrust in doctors, fears of disease, lack of knowledge, and optimistic bias are negatively associated with the intention to learn about and uptake LDCT scan.

IMPLICATIONS

Our study contributes to understanding the negative predictors of middle-aged Chinese to get LDCT lung cancer scans. Future campaign programs should help audiences to build comprehensive understandings about lung cancer and LDCT scan. To better promote LDCT scan in China, the government should fund more trial programs continuously and public efforts should be made to rebuild the patient-doctor trust.

Health TAPESTRY Ontario: protocol for a randomized controlled trial to test reproducibility and implementation

BACKGROUND

Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening qualitY) aims to help people stay healthier for longer where they live by providing person-focused care through the integration of four key program components: (1) trained volunteers who visit clients in their homes, (2) an interprofessional primary health care team, (3) use of technology to collect and share information, and (4) improved connections to community health and social services. The initial randomized controlled trial of Health TAPESTRY found promising results in terms of health care use and patient outcomes, indicating a shift from reactive to preventive care. The trial was based on one clinical academic center, thus limiting generalizability. The study objectives are (1) to test reproducibility of the established effectiveness of Health TAPESTRY on physical activity and hospitalizations, (2) to test the feasibility of, and understand the contributing factors to, the implementation of Health TAPESTRY in six diverse communities across Ontario, Canada, and (3) to determine the value for money of implementing Health TAPESTRY.

METHODS

This planned study is a pragmatic parallel randomized controlled trial with a delayed intervention for control participants at 6 months. This trial will simultaneously assess effectiveness and implementation in a real-world setting (type II hybrid) in six diverse communities across Ontario. Participants 70 years of age and older will be randomized into the Health TAPESTRY intervention or the control group (usual care). Intervention clients will receive an individualized plan of care from an interprofessional care team. The plan will be based on a client's goals and current health risks identified through volunteer visits. The study's outcomes are mapped onto the RE-AIM framework, with levels of physical activity and number of hospitalizations as the co-primary outcomes. The main analysis will be a comparison at 6 months.

DISCUSSION

It is important to evaluate the effectiveness and implementation of Health TAPESTRY in multiple communities prior to scaling or widespread adoption.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03397836 . Registered on 12 January 2018.

Access to hip and knee replacement surgery in patients with chronic diseases according to patient-reported pain and functional status

BACKGROUND

An increasing number of patients undergoing hip or knee replacement have chronic diseases. It has been suggested that the presence of chronic diseases may affect access to this type of surgery in the English National Health Service (NHS). We examined the access to hip and knee replacement surgery in patients with and without chronic diseases according to preoperative patient-reported pain, functional status and symptom duration.

METHODS

We analysed data of 640,832 patients who had hip or knee surgery between 2009 and 2016 in England. Multivariable regression was used to estimate the impact of 11 chronic diseases on severity of joint problems as measured on a scale from 0 to 48 by Oxford Hip (OHS) and Knee Scores (OKS) just before surgery and on likelihood of long-standing joint problems (> 5 years pre-operatively).

RESULTS

Patients with chronic diseases reported more severe joint problems than patients without (OHS differences ranged from 1.1 [95% CI 0.93, 1.2] to 2.5 [95% CI 2.3, 2.7] and OKS differences from 0.5 [95% CI 0.3, 0.7] to 2.6 [95% CI 2.4, 2.7] for the 11 chronic diseases) but the differences remain small. When analysed separately, patients with chronic diseases reported both more severe pain and poorer functional status. Six chronic diseases in hip patients and two in knee patients increased the likelihood that they had long-standing joint problems. The severity of joint problems just before surgery increased with the number of chronic diseases (OHS differences; one chronic disease (1.5 [95% CI 1.4, 1.5]) to four or more (5.8 [95% CI 5.6, 6.0])).

CONCLUSIONS

Patients with chronic diseases reported more severe joint problems immediately before hip or knee replacement surgery suggesting they have hip or knee replacement later in the course of their joint disease.

Initial validation of the German version of the Attentional Function Index in a sample of haematological cancer survivors

OBJECTIVE

To date, no German instrument exists to assess subjective levels of cancer-related cognitive impairments (CRCI) in cancer survivors. We translated the validated Attentional Function Index (AFI) into German and explored its psychometric properties.

METHODS

The validation sample consisted of 1,111 haematological cancer survivors mainly recruited from two cancer registries. Factorial structure was explored using principal component analysis, internal consistency via Cronbach's α, construct validity through correlational analyses (Pearson's r) and associations of patient characteristics with the AFI score via regression analyses.

RESULTS

In line with the original version, we revealed three factors, that is "effective action" (seven items), "attentional lapses" (three items) and "interpersonal effectiveness" (three items). The overall reliability α was .91. Verifying construct validity, the AFI score correlated positively with cognitive functioning (r = .64, p ≤ .01) and global QoL (r = .44, p ≤ .01), but negatively with fatigue (r = -.60, p ≤ .01) and depressive symptomatology (r = -.6, p ≤ .01). Older age (β = .12, p < .001), higher comorbidity (β = -.07, p = .02) and being male patient (β = .07, p = .01) were significantly associated with the AFI scores, but effect sizes were small.

CONCLUSION

The German translation of the AFI shows good psychometric properties and thus may be reasonably applied to measure the subjective level of CRCI in German-speaking oncological populations.

La littératie en santé chez les personnes présentant des troubles mentaux graves

Le Plan d’action 2015-2020 en santé mentale du Québec vise, chez les personnes présentant des troubles mentaux graves, le développement d’une autonomie optimale dans la société et l’utilisation adéquate des services de santé. Néanmoins, à ce jour, un manque de données est rapporté au Québec, sur la capacité des personnes présentant des troubles mentaux à accéder, à comprendre et à utiliser l’information relative à la santé, ce qui correspond au concept de littératie en santé (LS). Une étude descriptive quantitative a été menée pour décrire la LS chez les personnes présentant des troubles mentaux graves et demeurant dans la communauté de Dolbeau-Mistassini, au Saguenay–Lac-Saint-Jean (Québec). Les données ont été collectées à l’aide de trois questionnaires autorapportés, incluant le Questionnaire sur la littératie en santé (QLS). Ce questionnaire permet de décrire la LS à partir de 9 dimensions, afin de soulever les besoins individuels, organisationnels et sociaux en lien avec la LS des personnes ciblées. Les résultats obtenus auprès des participants (n = 30) ont montré que la LS était plus faible dans la dimension « Comprendre l’information relative à la santé ». Les résultats de cette étude mettent en évidence la nécessité d’adapter les interventions éducatives chez cette population. Cette adaptation pourrait permettre à cette population de mieux intégrer le contenu de l’enseignement reçu, tout en privilégiant l’accompagnement d’un proche lors de la rencontre avec un professionnel de la santé.

Protocol for a mixed-method analysis of implementation of case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs

INTRODUCTION

Case management (CM) in a primary care setting is a promising approach to integrating and improving healthcare services and outcomes for patients with chronic conditions and complex care needs who frequently use healthcare services. Despite evidence supporting CM and interest in implementing it in Canada, little is known about how to do this. This research aims to identify the barriers and facilitators to the implementation of a CM intervention in different primary care contexts (objective 1) and to explain the influence of the clinical context on the degree of implementation (objective 2) and on the outcomes of the intervention (objective 3).

METHODS AND ANALYSIS

A multiple-case embedded mixed-methods study will be conducted on CM implemented in ten primary care clinics across five Canadian provinces. Each clinic will represent a subunit of analysis, detailed through a case history. Cases will be compared and contrasted using multiple analytical approaches. Qualitative data (objectives 1 and 2) from individual semistructured interviews (n=130), focus group discussions (n=20) and participant observation of each clinic (36 hours) will be compared and integrated with quantitative (objective 3) clinical data on services use (n=300) and patient questionnaires (n=300). An evaluation of intervention fidelity will be integrated into the data analysis.

ETHICS AND DISSEMINATION

This project received approval from the CIUSSS de l'Estrie - CHUS Research Ethic Board (project number MP-31-2019-2830). Results will provide the opportunity to refine the CM intervention and to facilitate effective evaluation, replication and scale-up. This research provides knowledge on how to resp ond to the needs of individuals with chronic conditions and complex care needs in a cost-effective way that improves patient-reported outcomes and healthcare use, while ensuring care team well-being. Dissemination of results is planned and executed based on the needs of various stakeholders involved in the research.

Patient-Reported Morbidity Instruments: A Systematic Review

OBJECTIVES

Although comorbidities play an essential role in risk adjustment and outcomes measurement, there is little consensus regarding the best source of this data. The aim of this study was to identify general patient-reported morbidity instruments and their measurement properties.

METHODS

A systematic review was conducted using multiple electronic databases (Embase, Medline, Cochrane Central, and Web of Science) from inception to March 2018. Articles focusing primarily on the development or subsequent validation of a patient-reported morbidity instrument were included. After including relevant articles, the measurement properties of each morbidity instrument were extracted by 2 investigators for narrative synthesis.

RESULTS

A total of 1005 articles were screened, of which 34 eligible articles were ultimately included. The most widely assessed instruments were the Self-Reported Charlson Comorbidity Index (n = 7), the Self-Administered Comorbidity Questionnaire (n = 3), and the Disease Burden Morbidity Assessment (n = 3). The most commonly included conditions were diabetes, hypertension, and myocardial infarction. Studies demonstrated substantial variability in item-level reliability versus the gold standard medical record review (κ range 0.66-0.86), meaning that the accuracy of the self-reported comorbidity data is dependent on the selected morbidity.

CONCLUSIONS

The Self-Reported Charlson Comorbidity Index and the Self-Administered Comorbidity Questionnaire were the most frequently cited instruments. Significant variability was observed in reliability per comorbid condition of patient-reported morbidity questionnaires. Further research is needed to determine whether patient-reported morbidity data should be used to bolster medical records data or serve as a stand-alone entity when risk adjusting observational outcomes data.