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Forrester M, Breitenfeld L, Castelo-Branco M, Aperta J. Identification of an oncological clinical pathway through questionnaires to health professionals. BMC Health Serv Res 2023; 23:1011. [PMID: 37726812 PMCID: PMC10510255 DOI: 10.1186/s12913-023-09964-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/25/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Clinical Pathways in Oncology can benefit patients using organized interventions to standardize and increase care efficiency. Healthcare systems should have tools to identify their oncological clinical pathways for a better institutional organization to reduce mortality rates and contain costs without compromising quality. Our objective is to determine the regional Oncology Clinical Pathway from a first basic hypothesis using questionnaires directed to healthcare professionals considered key deciders within the Pathway. METHODS Study design consisted of data analysis of two structured region-wide questionnaires; built using available literature on Oncology Clinical Pathways, in a Portuguese Healthcare context and pre-tested in a focus group of key deciders (Physicians and nurses with management functions) from which a design was created. Queries analyzed the patients: tumor staging at service arrival; time intervals on tumor suspicion/diagnosis confirmation and diagnosis/first treatment; referral pathway; diagnostic networks and patient Follow-up. One questionnaire was sent to key deciders directly involved with Oncology patients at a Regional Hospital. 15 physicians and 18 nurses of this sample answered the questionnaire (approx. response rate = 67%). Another questionnaire sent to healthcare professionals in Primary Healthcare Centers yielded response rate 19.2%, N = 29 physicians and 46 nurses. Finally, we performed a descriptive analysis and a Cronbach Alpha reliability analysis. RESULTS Our findings reveal: different appreciations of tumor staging at arrival in Primary Healthcare Centers and Regional Hospitals (the latter receiving more metastatic cases); approximately 4 weeks between tumor suspicion-diagnostic and divided opinions regarding diagnostic-treatment time intervals. Primary Healthcare Centers depend on private laboratories for diagnostics confirmation, while the Hospitals resolve this locally. Referral pathways indicate almost half of the patients being sent from primary healthcare centers to National Reference Hospitals instead of a Regional Hospital. Patient follow-up is developed throughout the institutions, however, is more established at Regional Hospitals. As patients advance through the Oncology Clinical Pathway and toward treatment stages the number of healthcare professionals involved reduce. CONCLUSION Our questionnaires enable us to understand the real pathway between the different institutions involved and the main entry points of the patients into the Oncology Clinical Pathway.
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Affiliation(s)
- Mario Forrester
- Faculty of Health Sciences Universidade Da Beira Interior, Av. Infante D. Henrique, Covilhã, 6200-506, Portugal.
| | - Luiza Breitenfeld
- Faculty of Health Sciences Universidade Da Beira Interior, Av. Infante D. Henrique, Covilhã, 6200-506, Portugal
| | - Miguel Castelo-Branco
- Faculty of Health Sciences Universidade Da Beira Interior, Av. Infante D. Henrique, Covilhã, 6200-506, Portugal
| | - Jorge Aperta
- Sousa Martins Hospital, Avenida Rainha Dona Amélia, Guarda, 6300-858, Portugal
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Botey AP, Barber T, Robson PJ, O'Neill BM, Green LA. Using care pathways for cancer diagnosis in primary care: a qualitative study to understand family physicians' mental models. CMAJ Open 2023; 11:E486-E493. [PMID: 37279982 DOI: 10.9778/cmajo.20220084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Care pathways are tools that can help family physicians navigate the complexities of the cancer diagnostic process. Our objective was to examine the mental models associated with using care pathways for cancer diagnosis of a group of family physicians in Alberta. METHODS We conducted a qualitative study using cognitive task analysis, with interviews in the primary care setting between February and March 2021. Family physicians whose practices were not heavily oriented toward patients with cancer and who did not work closely with specialized cancer clinics were recruited with the support of the Alberta Medical Association and leveraging our familiarity with Alberta's Primary Care Networks. We conducted simulation exercise interviews with 3 pathway examples over Zoom, and we analyzed data using both macrocognition theory and thematic analysis. RESULTS Eight family physicians participated. Macrocognitive functions (and subthemes) related to mental models were sense-making and learning (confirmation and validation, guidance and support, and sense-giving to patients), care coordination and diagnostic decision-making (shared understanding). Themes related to the use of the pathways were limited use in diagnosis decisions, use in guiding and supporting referral, only relevant and easy-to-process information, and easily accessible. INTERPRETATION Our findings suggest the importance of designing pathways intentionally for streamlined integration into family physicians' practices, highlighting the need for co-design approaches. Pathways were identified as a tool that, used in combination with other tools, may help gather information and support cancer diagnosis decisions, with the goals of improving patient outcomes and care experience.
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Affiliation(s)
- Anna Pujadas Botey
- Cancer Strategic Clinical Network (Pujadas Botey), Alberta Health Services, Calgary, Alta.; School of Public Health (Pujadas Botey, Robson) and Department of Family Medicine (Barber, Green), University of Alberta; Cancer Strategic Clinical Network (O'Neill, Robson), Alberta Health Services, Edmonton, Alta.
| | - Tanya Barber
- Cancer Strategic Clinical Network (Pujadas Botey), Alberta Health Services, Calgary, Alta.; School of Public Health (Pujadas Botey, Robson) and Department of Family Medicine (Barber, Green), University of Alberta; Cancer Strategic Clinical Network (O'Neill, Robson), Alberta Health Services, Edmonton, Alta
| | - Paula J Robson
- Cancer Strategic Clinical Network (Pujadas Botey), Alberta Health Services, Calgary, Alta.; School of Public Health (Pujadas Botey, Robson) and Department of Family Medicine (Barber, Green), University of Alberta; Cancer Strategic Clinical Network (O'Neill, Robson), Alberta Health Services, Edmonton, Alta
| | - Barbara M O'Neill
- Cancer Strategic Clinical Network (Pujadas Botey), Alberta Health Services, Calgary, Alta.; School of Public Health (Pujadas Botey, Robson) and Department of Family Medicine (Barber, Green), University of Alberta; Cancer Strategic Clinical Network (O'Neill, Robson), Alberta Health Services, Edmonton, Alta
| | - Lee A Green
- Cancer Strategic Clinical Network (Pujadas Botey), Alberta Health Services, Calgary, Alta.; School of Public Health (Pujadas Botey, Robson) and Department of Family Medicine (Barber, Green), University of Alberta; Cancer Strategic Clinical Network (O'Neill, Robson), Alberta Health Services, Edmonton, Alta
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Analysis of low resource setting referral pathways to improve coordination and evidence-based services for maternal and child health in Ethiopia. PLoS One 2022; 17:e0273436. [PMID: 36007079 PMCID: PMC9409580 DOI: 10.1371/journal.pone.0273436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/08/2022] [Indexed: 11/30/2022] Open
Abstract
Background In low-resource settings, patient referral to a hospital is an essential part of the primary health care system. However, there is a paucity of study to explore the challenges and quality of referral coordination and communication. Objective The purpose of this research was to analyze the existing paper-based referral registration logbook for maternal and child health in general and women of reproductive age in particular, to improve referral coordination and evidence-based services in Low-Resource Settings. Methods This study analyzed the existing paper-based referral registration logbook (RRL) and card-sheet to explore the documentation of the referral management process, and the mechanism and quality of referrals between the health center (Jimma Health Center-case, Ethiopia) and the Hospital. A sample of 459 paper-based records from the referral registration logbook were digitized as part of a retrospective observational study. For data preprocessing, visualization, and analysis, we developed a python-based interactive referral clinical pathway tool. The data collection was conducted from August to October 2019. Jimma Health Center’s RRL was used to examine how the referral decision was made and what cases were referred to the next level of care. However, the RRL was incomplete and did not contain the expected referral feedback from the hospital. Hence, we defined a new protocol to investigate the quality of referral. We compared the information in the health center’s RRL with the medical records in the hospital to which the patients were referred. A total of 201 medical records of referred patients were examined. Results A total of 459 and 201 RRL records from the health center and the referred hospital, respectively, were analyzed in the study. Out of 459, 86.5% referred cases were between the age of 20 to 30 years. We found that “better patient management”, “further patient management”, and “further investigation” were the main health-center referral reasons and decisions. It accounted for 40.08%, 39.22%, and 16.34% of all 459 referrals, respectively. The leading and most common referral cases in the health center were long labor, prolonged first and second stage labor, labor or delivery complicated by fetal heart rate anomaly, preterm newborn, maternal care with breech presentation, premature rupture of membranes, malposition of the uterus, and antepartum hemorrhage. In the hospital RRL and card-sheet, the main referral-in reasons were technical examination, expert advice, further management, and evaluation. We found it overall impossible to match records from the referral logbook in the health center with the patient files in the hospital. Out of 201, only 13.9% of records were perfect matching entries between health center and referred hospital RRL. We found 84%, 14.4%, and 1.6% were appropriate, unnecessary and unknown referrals respectively. Conclusion The paper illustrates the bottlenecks encountered in the quality assessment of the referrals. We analyzed the current status of the referral pathway, existing communications, guidelines and data quality, as a first step towards an end-to-end effective referral coordination and evidence-based referral service. Accessing, monitoring, and tracking the history of referred patients and referral feedback is challenging with the present paper-based referral coordination and communication system. Overall, the referral services were inadequate, and referral feedback was not automatically delivered, causing unnecessary delays.
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Chong C, Smekal M, Hemmelgarn B, Elliott M, Allu S, Wick J, McBrien K, Jackson W, Bello A, Jindal K, Scott-Douglas N, Manns B, Tonelli M, Donald M. Use of Google Analytics to Explore Dissemination Activities for an Online CKD Clinical Pathway: A Retrospective Study. Can J Kidney Health Dis 2022; 9:20543581221097456. [PMID: 35574262 PMCID: PMC9102205 DOI: 10.1177/20543581221097456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Data on dissemination strategies that generate awareness of clinical pathways for kidney care are limited. Objective: This study reports the application of Google Analytics to describe the reach and use of the Chronic Kidney Disease Pathway (CKD-P) using a multi-faceted dissemination strategy. Design: The design of this study is a retrospective descriptive study. Setting: This study was conducted in Alberta, Canada. Patients: Individuals who accessed the CKD-P Web site between November 5, 2014, and May 31, 2019. Measurements: Dissemination activities included print, electronic, in-person meetings, and a laboratory prompt. We used Google Analytics over a 5-year period to evaluate the following CKD-P Web site user metrics: number of sessions, pageviews, visit duration, user path, and bounce rate (when an individual visits a single page of the Web site and leaves the Web site without interacting with additional pages). Methods: We plotted dissemination activities alongside Web site metrics using control charts and described the data using means and percentages. We performed chi-square test for trends to evaluate year-over-year usage. Results: There were 83 294 users, 90 805 sessions, and 231 684 pageviews. The overall bounce rate was 45.7%. Each user had an average of 1.5 sessions and a session duration of 2 minutes and 8 seconds. There was a significant positive trend for total annual users (P = .008), new users (P = .009), number of sessions (P = .006), and pageviews per day (P = .016). Limitations: We were unable to confirm if users were primary care providers and if word-of-mouth dissemination among providers/researchers drove people to use the CKD-P. Conclusions: Google Analytics was a useful and accessible tool for evaluating CKD-P reach and use trends. It was challenging to identify how individual dissemination activities contributed to CKD-P reach; however, repeated dissemination appeared to play a role in increasing CKD-P use. Trial registration: Not applicable—observational study design.
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Affiliation(s)
- Christy Chong
- Department of Community Health Sciences, University of Calgary, AB, Canada
- Department of Medicine, University of Calgary, AB, Canada
| | | | | | - Meghan Elliott
- Department of Community Health Sciences, University of Calgary, AB, Canada
- Department of Medicine, University of Calgary, AB, Canada
| | - Selina Allu
- Department of Medicine, University of Calgary, AB, Canada
| | - James Wick
- Department of Medicine, University of Calgary, AB, Canada
| | - Kerry McBrien
- Department of Community Health Sciences, University of Calgary, AB, Canada
- Department of Medicine, University of Calgary, AB, Canada
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Wes Jackson
- Department of Medicine, University of Calgary, AB, Canada
| | - Aminu Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Kailash Jindal
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Braden Manns
- Department of Community Health Sciences, University of Calgary, AB, Canada
- Department of Medicine, University of Calgary, AB, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, AB, Canada
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Smekal MD, Donald M, Beanlands H, Straus S, Herrington G, Waldvogel B, Sparkes D, Delgado M, Bello A, Hemmelgarn BR. Development and Preliminary Psychometric Testing of an Adult Chronic Kidney Disease Self-Management (CKD-SM) Questionnaire. Can J Kidney Health Dis 2021; 8:20543581211063981. [PMID: 34925864 PMCID: PMC8671825 DOI: 10.1177/20543581211063981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/20/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Self-management focused interventions to slow chronic kidney disease (CKD) progression are increasingly common. However, valid self-report instruments to evaluate the effectiveness of self-management interventions in CKD are limited. Objective: We sought to develop and conduct preliminary psychometric testing of a patient-informed questionnaire to assess aspects of CKD self-management for patients with CKD categories G2-G5 (not on kidney replacement therapy [KRT]). Design: Self-administered electronic questionnaires (multiphase). Setting: Online. Sample: Canadian adults with CKD categories G2-G5 (not on KRT) Methods: The CKD-SM questionnaire was developed and tested in 4 phases. First, we used a content coverage matrix to identify potential questionnaire items based on existing self-efficacy questionnaires, self-management theories, and patient-identified priorities. Second, the draft questionnaire was reviewed by a multidisciplinary expert panel using percent acceptance to finalize the questionnaire. Third, we tested an electronic version of the questionnaire with patients with CKD, evaluating preliminary psychometric properties including internal consistency, face validity, and content validity. Finally, we tested the questionnaire within a CKD self-management intervention study and collected data on internal consistency, test-retest reliability, and pre-post responsiveness. Results: We identified 22 potential questionnaire items for the first round of expert panel review. Thirteen items were retained in the first round. Eleven additional items were tested in the second review round and all were retained. Of the 24 items retained following expert review of the questionnaire, 21 had greater than 85% acceptance (content validity index [CVI], 0.75-1.00) and 3 items had 75% acceptance (CVI, 0.5). Thirty patients with CKD from across Canada participated in the pilot testing, and 29 patients participated in the CKD self-management intervention study. In the pilot test, several participants requested inclusion of a question that explicitly addressed mental health; consequently, an additional item relating to mental health was included prior to the intervention study (final questionnaire total was 25 items). Internal consistency (Cronbach α) was high for both the pilot (0.921) and intervention study (0.912). Preintervention test-retest reliability, measured with intraclass correlation coefficient, was acceptable (0.732, 95% confidence interval, 0.686-0.771, P < .001), and paired pre/postintervention comparison, measured with Wilcoxon sign-rank, demonstrated significant increases in self-management (P < .05) despite stable preintervention test-retest responses. Participants were satisfied with the content, wording, and design. Limitations: The sample sizes were small for each component of the analysis, and the sampling was consecutive/convenience-based. Conclusions: We used self-management theories, patient-identified self-management needs, expert review, and conducted preliminary psychometric testing to finalize a CKD self-management questionnaire for patients with G2-G5 CKD (not on KRT). The finalized questionnaire assesses aspects of self-management for individuals with CKD and may be particularly helpful as a tool to evaluate self-management interventions among patients with CKD.
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Affiliation(s)
| | - Maoliosa Donald
- Department of Medicine, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Heather Beanlands
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON, Canada
| | - Sharon Straus
- Department of Medicine, University of Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Gwen Herrington
- Can-SOLVE CKD Network-Patient Partner, Vancouver, BC, Canada
| | - Blair Waldvogel
- Can-SOLVE CKD Network-Patient Partner, Vancouver, BC, Canada
| | - Dwight Sparkes
- Can-SOLVE CKD Network-Patient Partner, Vancouver, BC, Canada
| | - Maria Delgado
- Can-SOLVE CKD Network-Patient Partner, Vancouver, BC, Canada
| | - Aminu Bello
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, AB, Canada.,Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
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Smekal MD, Bello AK, Donald M, Zaidi D, McBrien K, Nicholson K, Novak E, Hemmelgarn B. Enhancing primary care capacity in chronic kidney disease management: a quality improvement educational initiative. BMJ Open 2021; 11:e046068. [PMID: 34753751 PMCID: PMC8578991 DOI: 10.1136/bmjopen-2020-046068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Gaps in identification, medical management and appropriate referral for patients with chronic kidney disease (CKD) are evident. OBJECTIVE We designed and implemented an interactive educational intervention (accredited workshop) to improve primary care providers' awareness of tools to support guideline-concordant CKD management. DESIGN We used the Kern method to design the educational intervention and targeted the accredited workshops to primary care team members (physicians, nurses and allied health) in Alberta, Canada. We conducted anonymous pre-workshop and post-workshop surveys to identify practice-specific barriers to care, identify potential solutions, and evaluate provider confidence pre-intervention and post-intervention. We used non-parametric statistics to analyse Likert-type survey data and descriptive content analysis to categorise responses to open-ended survey questions. RESULTS We delivered 12 workshops to 114 providers from September 2017 through March 2019. Significant improvements (p<0.001) in confidence to appropriately identify, manage and refer patients with CKD were observed. Participants identified several patient-level, provider-level, and system-level barriers and potential solutions to care for patients with CKD; the majority of these barriers were addressed in the interactive workshop. CONCLUSIONS The Kern model was an effective methodology to design and implement an educational intervention to improve providers' confidence in managing patients with CKD in primary care. Future research is needed to determine if these perceived knowledge and confidence improvements affect patient outcomes and whether improvements are sustained long term.
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Affiliation(s)
| | - Aminu K Bello
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Deenaz Zaidi
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kerry McBrien
- Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Ellen Novak
- Alberta Kidney Care, Alberta Health Services, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Medicine, University of Calgary, Calgary, Alberta, Canada
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Donald M, Smekal MD, Elliott MJ, McBrien K, Weaver RG, Manns BJ, Tonelli M, Bello A, Straus SE, Scott-Douglas N, Jindal K, Hemmelgarn BR. Online clinical pathway for chronic kidney disease management in primary care: a retrospective cohort study. BMC Nephrol 2021; 22:332. [PMID: 34615462 PMCID: PMC8496057 DOI: 10.1186/s12882-021-02533-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Clinical pathways aim to improve patient care. We sought to determine whether an online chronic kidney disease (CKD) clinical pathway was associated with improvements in CKD management. METHODS We conducted a retrospective pre/post population-based cohort study using linked health data from Alberta, Canada. We included adults 18 years or older with mean estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2. The primary outcome was measurement of an outpatient urine albumin creatinine ratio (ACR) in a 28-day period, among people without a test in the prior year. Secondary outcomes included use of guideline-recommended drug therapies (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statins). RESULTS The study period spanned October 2010 to March 2017. There were 84 independent 28-day periods (53 pre, 31 post pathway implementation) including 345,058 adults. The population was predominantly female (56%) with median age 77 years; most had category 3A CKD (67%) and hypertension (82%). In adjusted segmented regression models, the increase in the rate of change of ACR testing was greatest in Calgary zone (adjusted OR 1.19 per year, 95% CI 1.16-1.21), where dissemination of the pathway was strongest; this increase was more pronounced in those without diabetes (adjusted OR 1.25 per year, 95% CI 1.21-1.29). Small improvements in guideline-concordant medication use were also observed. CONCLUSIONS Following implementation of an online CKD clinical pathway, improvements in ACR testing were evident in regions where the pathway was most actively used, particularly among individuals without diabetes.
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Affiliation(s)
- Maoliosa Donald
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Michelle D Smekal
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Meghan J Elliott
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Kerry McBrien
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Robert G Weaver
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Braden J Manns
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Aminu Bello
- Faculty of Medicine & Dentistry, University of Alberta, 2J2.01 Walter C MacKenzie Health Sciences Centre, Clinical Sciences Building, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada
| | - Sharon E Straus
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Nairne Scott-Douglas
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Kailash Jindal
- Faculty of Medicine & Dentistry, University of Alberta, 2J2.01 Walter C MacKenzie Health Sciences Centre, Clinical Sciences Building, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
- Faculty of Medicine & Dentistry, University of Alberta, 2J2.01 Walter C MacKenzie Health Sciences Centre, Clinical Sciences Building, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada.
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Odendaal WA, Anstey Watkins J, Leon N, Goudge J, Griffiths F, Tomlinson M, Daniels K. Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis. Cochrane Database Syst Rev 2020; 3:CD011942. [PMID: 32216074 PMCID: PMC7098082 DOI: 10.1002/14651858.cd011942.pub2] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Mobile health (mHealth), refers to healthcare practices supported by mobile devices, such as mobile phones and tablets. Within primary care, health workers often use mobile devices to register clients, track their health, and make decisions about care, as well as to communicate with clients and other health workers. An understanding of how health workers relate to, and experience mHealth, can help in its implementation. OBJECTIVES To synthesise qualitative research evidence on health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services, and to develop hypotheses about why some technologies are more effective than others. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, Science Citation Index and Social Sciences Citation Index in January 2018. We searched Global Health in December 2015. We screened the reference lists of included studies and key references and searched seven sources for grey literature (16 February to 5 March 2018). We re-ran the search strategies in February 2020. We screened these records and any studies that we identified as potentially relevant are awaiting classification. SELECTION CRITERIA We included studies that used qualitative data collection and analysis methods. We included studies of mHealth programmes that were part of primary healthcare services. These services could be implemented in public or private primary healthcare facilities, community and workplace, or the homes of clients. We included all categories of health workers, as well as those persons who supported the delivery and management of the mHealth programmes. We excluded participants identified as technical staff who developed and maintained the mHealth technology, without otherwise being involved in the programme delivery. We included studies conducted in any country. DATA COLLECTION AND ANALYSIS We assessed abstracts, titles and full-text papers according to the inclusion criteria. We found 53 studies that met the inclusion criteria and sampled 43 of these for our analysis. For the 43 sampled studies, we extracted information, such as country, health worker category, and the mHealth technology. We used a thematic analysis process. We used GRADE-CERQual to assess our confidence in the findings. MAIN RESULTS Most of the 43 included sample studies were from low- or middle-income countries. In many of the studies, the mobile devices had decision support software loaded onto them, which showed the steps the health workers had to follow when they provided health care. Other uses included in-person and/or text message communication, and recording clients' health information. Almost half of the studies looked at health workers' use of mobile devices for mother, child, and newborn health. We have moderate or high confidence in the following findings. mHealth changed how health workers worked with each other: health workers appreciated being more connected to colleagues, and thought that this improved co-ordination and quality of care. However, some described problems when senior colleagues did not respond or responded in anger. Some preferred face-to-face connection with colleagues. Some believed that mHealth improved their reporting, while others compared it to "big brother watching". mHealth changed how health workers delivered care: health workers appreciated how mHealth let them take on new tasks, work flexibly, and reach clients in difficult-to-reach areas. They appreciated mHealth when it improved feedback, speed and workflow, but not when it was slow or time consuming. Some health workers found decision support software useful; others thought it threatened their clinical skills. Most health workers saw mHealth as better than paper, but some preferred paper. Some health workers saw mHealth as creating more work. mHealth led to new forms of engagement and relationships with clients and communities: health workers felt that communicating with clients by mobile phone improved care and their relationships with clients, but felt that some clients needed face-to-face contact. Health workers were aware of the importance of protecting confidential client information when using mobile devices. Some health workers did not mind being contacted by clients outside working hours, while others wanted boundaries. Health workers described how some community members trusted health workers that used mHealth while others were sceptical. Health workers pointed to problems when clients needed to own their own phones. Health workers' use and perceptions of mHealth could be influenced by factors tied to costs, the health worker, the technology, the health system and society, poor network access, and poor access to electricity: some health workers did not mind covering extra costs. Others complained that phone credit was not delivered on time. Health workers who were accustomed to using mobile phones were sometimes more positive towards mHealth. Others with less experience, were sometimes embarrassed about making mistakes in front of clients or worried about job security. Health workers wanted training, technical support, user-friendly devices, and systems that were integrated into existing electronic health systems. The main challenges health workers experienced were poor network connections, access to electricity, and the cost of recharging phones. Other problems included damaged phones. Factors outside the health system also influenced how health workers experienced mHealth, including language, gender, and poverty issues. Health workers felt that their commitment to clients helped them cope with these challenges. AUTHORS' CONCLUSIONS Our findings propose a nuanced view about mHealth programmes. The complexities of healthcare delivery and human interactions defy simplistic conclusions on how health workers will perceive and experience their use of mHealth. Perceptions reflect the interplay between the technology, contexts, and human attributes. Detailed descriptions of the programme, implementation processes and contexts, alongside effectiveness studies, will help to unravel this interplay to formulate hypotheses regarding the effectiveness of mHealth.
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Affiliation(s)
- Willem A Odendaal
- South African Medical Research CouncilHealth Systems Research UnitCape TownWestern CapeSouth Africa
- Stellenbosch UniversityDepartment of PsychiatryCape TownSouth Africa
| | | | - Natalie Leon
- South African Medical Research CouncilHealth Systems Research UnitCape TownWestern CapeSouth Africa
- Brown UniversitySchool of Public HealthProvidenceRhode IslandUSA
| | - Jane Goudge
- University of the WitwatersrandCentre for Health Policy, School of Public Health, Faculty of Health SciencesJohannesburgSouth Africa
| | - Frances Griffiths
- University of WarwickWarwick Medical SchoolCoventryUK
- University of the WitwatersrandCentre for Health Policy, School of Public Health, Faculty of Health SciencesJohannesburgSouth Africa
| | - Mark Tomlinson
- Stellenbosch UniversityInstitute for Life Course Health Research, Department of Global HealthCape TownSouth Africa
- Queens UniversitySchool of Nursing and MidwiferyBelfastUK
| | - Karen Daniels
- South African Medical Research CouncilHealth Systems Research UnitCape TownWestern CapeSouth Africa
- University of Cape TownHealth Policy and Systems Division, School of Public Health and Family MedicineCape TownWestern CapeSouth Africa7925
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9
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Church DL, Naugler C. Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model. Crit Rev Clin Lab Sci 2020; 57:323-344. [PMID: 32180485 DOI: 10.1080/10408363.2020.1720591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.
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Affiliation(s)
- Deirdre L Church
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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10
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Garlo KG, Bates DW, Seger DL, Fiskio JM, Charytan DM. Lab monitoring and acute care utilization during initiation of renin angiotensin aldosterone inhibitors or diuretics in chronic kidney disease. Medicine (Baltimore) 2019; 98:e17963. [PMID: 31804307 PMCID: PMC6919529 DOI: 10.1097/md.0000000000017963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Renin angiotensin aldosterone system inhibitors (RAASi) and diuretics are among the most frequently prescribed anti-hypertensives. Individuals with chronic kidney disease (CKD) are particularly at risk for electrolyte disturbances and kidney injury but the appropriate use of lab monitoring following RAASi or diuretic initiation is uncertain in CKD.We describe the frequency and time interval of lab monitoring during initiation of RAASi and diuretics in CKD and assess whether close lab monitoring associates with one-year risk of emergency department (ED) visit or hospitalization.We evaluated an observational cohort of 8,217 individuals with stage 3-5 non-dialysis CKD newly prescribed a RAASi (52.3%) or diuretic (47.7%) from thirty-six primary care offices affiliated with Brigham and Women's Hospital and Massachusetts General Hospital between 2009 and 2011.Overall, 3306 (40.2%) individuals did not have pre-prescription labs done within 2 weeks, and 5957 (72.5%) did not have post-prescription labs done within 2 weeks which includes 524 (6.4%) individuals without post-prescription within 1 year. Close monitoring occurred in only 1547 (20.1%) and was more likely in individuals prescribed diuretics compared to RAASi (adjusted OR 1.39; 95%CI 1.20-1.62), with CKD stage 4,5 compared with stage 3 (adjusted OR 1.47; 95%CI 1.16-1.86) and with cardiovascular disease (adjusted OR 1.42; 95%CI 1.21-1.66). Close monitoring was not associated with decreased risk of ED visit or hospitalization.Close lab monitoring during initiation of RAASi or diuretics was more common in participants with cardiovascular disease and advanced CKD suggesting physicians selected high-risk individuals for close monitoring. As nearly 80% of individuals did not receive close lab monitoring there may be value in future research on electronic physician decision tools targeted at lab monitoring.
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Affiliation(s)
| | - David W. Bates
- The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston
- Clinical & Quality Analysis, Partners HealthCare, Somerville, MA
| | - Diane L. Seger
- The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston
- Clinical & Quality Analysis, Partners HealthCare, Somerville, MA
| | - Julie M. Fiskio
- The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston
- Clinical & Quality Analysis, Partners HealthCare, Somerville, MA
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11
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Bello A, Zaidi D, Braam B, Courtney M, Glassford J, Jindal K, Klarenbach S, Kurzawa J, Osman M, Scott-Douglas N, Szigety S, Thompson S, Manns B, Hemmelgarn B, Tonelli M. Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease. Can J Kidney Health Dis 2019; 6:2054358119878715. [PMID: 31631888 PMCID: PMC6769217 DOI: 10.1177/2054358119878715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 08/04/2019] [Indexed: 12/30/2022] Open
Abstract
Background: As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians. Objective: To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD. Design: This is a sequential, mixed methods study that will be conducted in 3 phases. Setting: The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]). Patients: Patients suffering from CKD will be included in the study. Measurements: We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes. Methods: The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes. Results: We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult. Limitations: Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task. Conclusions: Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents. Trial registration: Not required.
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Affiliation(s)
- Aminu Bello
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Deenaz Zaidi
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Branko Braam
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Mark Courtney
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | | | - Kailash Jindal
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | | | - Julia Kurzawa
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Mohammed Osman
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | | | - Sue Szigety
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | | | - Braden Manns
- Division of Nephrology, University of Calgary, AB, Canada
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12
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Tam-Tham H, Clement F, Hemmelgarn BR, Manns BJ, Klarenbach SW, Tonelli M, Tsuyuki RT, Al Hamarneh YN, Penko J, Weaver CGW, Au F, Weaver RG, Jones CA, McBrien KA. A Cost Analysis and Cost-Utility Analysis of a Community Pharmacist-Led Intervention on Reducing Cardiovascular Risk: The Alberta Vascular Risk Reduction Community Pharmacy Project (R xEACH). VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1128-1136. [PMID: 31563255 DOI: 10.1016/j.jval.2019.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 03/23/2019] [Accepted: 05/23/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND A randomized trial (the Alberta Vascular Risk Reduction Community Pharmacy Project) showed that a community pharmacist-led intervention was efficacious for reducing cardiovascular (CV) risk. However, the cost of this strategy is unknown. OBJECTIVES We examined the short- and long-term cost of a pharmacist-led intervention to reduce CV risk compared to usual care. METHODS We conducted a trial-based cost analysis from the perspective of a publicly funded healthcare system. Over 3 and 12 months of follow-up, we examined specific intervention costs (pharmacy claims), related intervention costs (laboratory tests and medications), and ongoing healthcare costs (physician claims, emergency department visits, and hospital admissions). We also used the validated CV Disease Policy Model-Canada to estimate the long-term effects. RESULTS A total of 684 participants (mean age 62, 57% male) were included. Overall, there were no significant differences in healthcare costs at 3 or 12 months between the usual care and intervention groups (P = .127). The CV disease-related healthcare cost of managing a patient over a lifetime was estimated to be Can$45 530 (95% uncertainty interval [UI], 45 460-45 580) and Can$40 750 (95% UI, 37 780-43 620) in usual care and intervention groups, respectively, an incremental cost savings of Can$4770 per patient (95% UI, 1900-7760). The intervention dominated usual care (better outcomes and lower costs) across 3-year, 5-year, 10-year, and lifetime horizons. CONCLUSION This economic analysis suggests that a clinical pathway-driven pharmacist-led intervention (previously shown to reduce CV risk) was associated with similar measured healthcare costs over 1 year, and lower extrapolated healthcare costs over a patient lifetime. This strategy could be broadly implemented to realize its benefits.
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Affiliation(s)
- Helen Tam-Tham
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Braden J Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Scott W Klarenbach
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ross T Tsuyuki
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Department of Pharmacology, University of Alberta, Edmonton, Alberta, Canada
| | - Yazid N Al Hamarneh
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Joanne Penko
- Centre for Vulnerable Populations, Department of Medicine, University of California, San Francisco, CA, USA
| | - Colin G W Weaver
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Flora Au
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert G Weaver
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charlotte A Jones
- Department of Medicine, Southern Medical Program, University of British Columbia, Kelowna, British Columbia, Canada
| | - Kerry A McBrien
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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13
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Smekal MD, Tam-Tham H, Finlay J, Donald M, Thomas C, Weaver RG, Quinn RR, Tam K, Manns BJ, Tonelli M, Bello A, Tangri N, Hemmelgarn BR. Patient and provider experience and perspectives of a risk-based approach to multidisciplinary chronic kidney disease care: a mixed methods study. BMC Nephrol 2019; 20:110. [PMID: 30922254 PMCID: PMC6440153 DOI: 10.1186/s12882-019-1269-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/26/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The Kidney Failure Risk Equation (KFRE) predicts risk of progression to kidney failure and is used to guide clinical decisions for patients with chronic kidney disease (CKD). METHODS The KFRE was implemented to guide access to multidisciplinary care for CKD patients in Alberta, Canada, based on their 2-year risk of kidney failure. We used a mixed methods approach to investigate patients' and providers' perspectives and experiences 1 year following KFRE implementation. We conducted post-implementation interviews with multidisciplinary clinic providers and with low-risk patients who transitioned from multidisciplinary to general nephrology care. We also administered pre- and post-implementation patient care experience surveys, targeting both low-risk patients discharged to general nephrology and high-risk patients who remained in the multidisciplinary clinic, and provider job satisfaction surveys. RESULTS Twenty-seven interviews were conducted (9 patients, 1 family member, 17 providers). Five categories were identified among patients and providers: targeted care; access to resources outside the multidisciplinary clinics; self-efficacy; patient reassurance and reduced stress; and transition process for low-risk patients Two additional categories were identified among providers only: anticipated concerns and job satisfaction. Patients and providers reported that the risk-based approach allowed the clinic to target care to those most likely to experience kidney failure and most likely to benefit from multidisciplinary care. While some participants indicated the risk-based model enhanced the sustainability of the clinics, others expressed concern that care for low-risk patients discharged from multidisciplinary care, or those now considered ineligible, may be inadequate. Overall, 413 patients completed the care experience survey and 73 providers completed the workplace satisfaction survey. The majority of patients were satisfied with their care in both periods with no overall differences. When considering the responses "Always" and "Often" together versus not, there were statistically significant improvements in domains of access to care, caring staff, and safety of care. There were no differences in healthcare providers' job satisfaction following KFRE implementation. CONCLUSIONS Patients and healthcare providers reported that the risk-based approach improved the focus of the multidisciplinary CKD clinics by targeting patients at highest risk, with survey results suggesting no difference in patient care experience or healthcare provider job satisfaction.
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Affiliation(s)
- Michelle D. Smekal
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Helen Tam-Tham
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Juli Finlay
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Maoliosa Donald
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Chandra Thomas
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Robert G. Weaver
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Robert R. Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Kin Tam
- Southern Alberta Renal Program, Alberta Health Services, Calgary, Alberta Canada
| | - Braden J. Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
- Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
- Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta Canada
| | - Aminu Bello
- Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta Canada
| | - Navdeep Tangri
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba Canada
| | - Brenda R. Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
- Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta Canada
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14
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Smekal MD, Tam-Tham H, Finlay J, Donald M, Benterud E, Thomas C, Quinn RR, Tam K, Manns BJ, Tonelli M, Bello A, Tangri N, Hemmelgarn BR. Perceived Benefits and Challenges of a Risk-Based Approach to Multidisciplinary Chronic Kidney Disease Care: A Qualitative Descriptive Study. Can J Kidney Health Dis 2018; 5:2054358118763809. [PMID: 29636981 PMCID: PMC5888822 DOI: 10.1177/2054358118763809] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/04/2018] [Indexed: 11/23/2022] Open
Abstract
Background: The kidney failure risk equation (KFRE) provides an estimate of risk of progression to kidney failure, and may guide clinical care. Objective: We aimed to describe patient, family, and health care provider’s perspectives of the perceived benefits and challenges of using a risk-based approach to guide care delivery for patients with advanced chronic kidney disease (CKD), and refine implementation based on their input. Methods: We used qualitative methodology to explore perceived benefits and challenges of implementing a risk-based approach (using the KFRE) to determine eligibility for multidisciplinary CKD care in Southern Alberta. We obtained perspectives from patients and families through focus groups, as well as input from health care providers through interviews and open-ended responses from an online survey. Twelve patients/family members participated in 2 focus groups, 16 health care providers participated in an interview, and 40 health care providers responded to the survey. Results: Overall, participants felt that a KFRE-based approach had the potential to improve efficiency of the clinics by targeting care to patients at highest risk of kidney failure; however, they also expressed concerns about the impact of loss of services for lower risk individuals. Participants also articulated concerns about a perceived lack of capacity for adequate CKD patient care in the community. Our implementation strategy was modified as a result of participants’ feedback. Conclusions: We identified benefits and challenges to implementation of a risk-based approach to guide care of patients with advanced CKD. Based on these results, our implementation strategy has been modified by removing the category of referral back to primary care alone, and instead having that decision made jointly by nephrologists and patients among low-risk patients.
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Affiliation(s)
- Michelle D Smekal
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Helen Tam-Tham
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Juli Finlay
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Maoliosa Donald
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Eleanor Benterud
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Chandra Thomas
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Robert R Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Kin Tam
- Southern Alberta Renal Program, Alberta Health Services, Alberta, Canada
| | - Braden J Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta, Canada
| | - Aminu Bello
- Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Canada
| | - Navdeep Tangri
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada.,Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta, Canada
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