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Lindemann CH, Burst V, Völker LA, Brähler S, Simic D, Becker I, Hellmich M, Kurscheid C, Scholten N, Krauspe R, Leibel K, Stock S, Brinkkoetter PT. Personalized, interdisciplinary patient pathway for cross-sector care of multimorbid patients (eliPfad trial): study protocol for a randomized controlled trial. Trials 2024; 25:177. [PMID: 38468319 PMCID: PMC10926660 DOI: 10.1186/s13063-024-08026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 02/28/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Multimorbid and frail elderly patients often carry a high burden of treatment. Hospitalization due to the onset of an acute illness can disrupt the fragile balance, resulting in further readmissions after hospital discharge. Current models of care in Germany do not meet the needs of this patient group. Rather lack of coordination and integration of care combined with a lack of interdisciplinary approaches result in fragmented and inadequate care and increase the burden of treatment even more. METHODS eliPfad is a randomized controlled trial conducted in 6 hospitals in Germany. Multimorbid elderly patients aged 55 or older are randomly assigned to the intervention or control group. Patients in the intervention group receive the eliPfad intervention additional to standard care. The core components of eliPfad are: Early assessment of patients' individual treatment burden and support through a specially trained case manager Involvement of the patient's general practitioner (GP) right from the beginning of the hospital stay Preparation of an individual, cross-sectoral treatment plan through the interdisciplinary hospital team with the involvement of the patient's GP Establishment of a cross-sectoral electronic patient record (e-ePA) for documentation and cross-sectoral exchange Support/Promote patient adherence Tailored early rehabilitation during the hospital stay, which is continued at home Close-tele-monitoring of medically meaningful vital parameters through the use of tablets, digital devices, and personal contacts in the home environment The intervention period begins in the hospital and continues 6 weeks after discharge. Patients in the control group will be treated according to standard clinical care and discharged according to current discharge management. The primary aim is the prevention/reduction of readmissions in the first 6 months after discharge. In addition, the impact on health-related quality of life, the burden of treatment, survival, self-management, medication prescription, health literacy, patient-centered care, cost-effectiveness, and process evaluation will be examined. Nine hundred forty-eight patients will be randomized 1:1 to intervention and control group. DISCUSSION If eliPfad leads to fewer readmissions, proves (cost-)effective, and lowers the treatment burden, it should be introduced as a new standard of care in the German healthcare system. TRIAL REGISTRATION The trial was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) on 08/14/2023 under the ID DRKS00031500 .
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Affiliation(s)
- Christoph Heinrich Lindemann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Volker Burst
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Linus Alexander Völker
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Sebastian Brähler
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Dusan Simic
- Cologne Institute for Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Clarissa Kurscheid
- Research Institute for Health and System Development, EUFH University of Applied Sciences, Cologne, Germany
| | - Nadine Scholten
- Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, Chair for Health Services Research, University of Cologne, Cologne, Germany
| | - Ruben Krauspe
- Cologne Institute for Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Kerstin Leibel
- Cologne Institute for Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Stephanie Stock
- Cologne Institute for Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Paul Thomas Brinkkoetter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany.
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De Coninck L, Declercq A, Bouckaert L, Döpp C, Graff MJL, Aertgeerts B. The willingness and barriers to collaborate in the care of frail older adults: perspectives of primary care professionals. BMC Geriatr 2023; 23:488. [PMID: 37568088 PMCID: PMC10422814 DOI: 10.1186/s12877-023-04163-y] [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: 03/11/2023] [Accepted: 07/11/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND This study investigated the perspectives of primary care professionals, in particular general practitioners, registered nurses, physiotherapists and occupational therapists, on inter-professional collaboration, the barriers and the facilitators they perceive in the care of the frail older population. METHODS We conducted a qualitative study. In-depth interviews with healthcare professionals were performed, using open-ended questions about their perceptions on the care of frail older adults and inter-professional collaboration. Data was analyzed following the Basic Logical Model of Abduction and Creswell's coding method. RESULTS Healthcare professionals indicated that when they explored problems complementary to the reasons for older people to contact a healthcare professional, these additional problems often seemed to be the main problem. They also stated that there was too little inter-professional collaboration in the care of complex chronic issues and lack of a shared vision on collaboration. Collaboration is still limited too much to contacting established professions. Health information technology can support both, inter-professional collaboration and working on an evidence-based manner. It can also be a facilitator to inform patients. The availability and use of health information technology differs between the professions. Success factors and barriers for sustainable collaboration were identified on several levels, namely innovation, individual, professional, patient, social context, context of the organization, economic and political context. CONCLUSIONS Our study shed light on the willingness and barriers in collaboration of healthcare professionals in primary care for older adults. There is little inter-professional collaboration, despite the willingness of the healthcare professionals to collaborate.
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Affiliation(s)
- Leen De Coninck
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, Leuven, 3000, Belgium.
- CEBAM Belgian Center for Evidence-based Medicine vzw, Kapucijnenvoer 7, Leuven, 3000, Belgium.
- Department of Occupational Therapy, Artevelde University of Applied Sciences, Voetweg 66, Ghent, 9000, Belgium.
| | - Anja Declercq
- LUCAS Center for Care Research and Consultancy & CESO Center for Sociological Research, KU Leuven, Minderbroedersstraat 8, Leuven, 5310, Belgium
| | - Leen Bouckaert
- Department of Occupational Therapy, Artevelde University of Applied Sciences, Voetweg 66, Ghent, 9000, Belgium
| | - Carola Döpp
- Scientific Institute for Quality of Health Care, Department of Rehabilitation, Radboudumc Research Institute, Radboud University Medical Center, Houtlaan 4, Nijmegen, 6525 XZ, the Netherlands
| | - Maud J L Graff
- Scientific Institute for Quality of Health Care, Department of Rehabilitation, Radboudumc Research Institute, Radboud University Medical Center, Houtlaan 4, Nijmegen, 6525 XZ, the Netherlands
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, Leuven, 3000, Belgium.
- CEBAM Belgian Center for Evidence-based Medicine vzw, Kapucijnenvoer 7, Leuven, 3000, Belgium.
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Sadler E, Khadjesari Z, Ziemann A, Sheehan KJ, Whitney J, Wilson D, Bakolis I, Sevdalis N, Sandall J, Soukup T, Corbett T, Gonçalves-Bradley DC, Walker DM. Case management for integrated care of older people with frailty in community settings. Cochrane Database Syst Rev 2023; 5:CD013088. [PMID: 37218645 PMCID: PMC10204122 DOI: 10.1002/14651858.cd013088.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems. OBJECTIVES To assess the effects of case management for integrated care of older people living with frailty compared with usual care. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care. AUTHORS' CONCLUSIONS We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.
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Affiliation(s)
- Euan Sadler
- School of Health Sciences, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
| | | | - Alexandra Ziemann
- Department of Social & Policy Sciences, University of Bath, Bath, UK
| | - Katie J Sheehan
- School of Life Course & Population Sciences, King's College London, London, UK
| | - Julie Whitney
- School of Life Course & Population Sciences, King's College London, London, UK
- Department of Clinical Gerontology, King's College Hospital NHS Foundation Trust, London, UK
| | - Dan Wilson
- Department of Clinical Gerontology, King's College Hospital NHS Foundation Trust, London, UK
| | - Ioannis Bakolis
- Health Service & Population Research Department, King's College London, London, UK
| | - Nick Sevdalis
- Centre for Behavioural & Implementation Science Interventions (BISI), National University of Singapore, Singapore, Singapore
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, London, UK
| | - Tayana Soukup
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Teresa Corbett
- Faculty of Sport, Health and Social Sciences, Solent University, Southampton, UK
| | | | - Dawn-Marie Walker
- School of Health Sciences, University of Southampton, Southampton, UK
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Alharbi K, Blakeman T, van Marwijk H, Reeves D, Tsang JY. Understanding the implementation of interventions to improve the management of frailty in primary care: a rapid realist review. BMJ Open 2022; 12:e054780. [PMID: 35649605 PMCID: PMC9161080 DOI: 10.1136/bmjopen-2021-054780] [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] [Received: 06/24/2021] [Accepted: 01/24/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Identifying and managing the needs of frail people in the community is an increasing priority for policy makers. We sought to identify factors that enable or constrain the implementation of interventions for frail older persons in primary care. DESIGN A rapid realist review. DATA SOURCES Cochrane Library, SCOPUS and EMBASE, and grey literature. The search was conducted in September 2019 and rerun on 8 January 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We considered all types of empirical studies describing interventions targeting frailty in primary care. ANALYSIS We followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication criteria for our synthesis to systematically analyse and synthesise the existing literature and to identify (intervention-context-mechanism-outcome) configurations. We used normalisation processes theory to illuminate mechanisms surrounding implementation. RESULTS Our primary research returned 1755 articles, narrowed down to 29 relevant frailty intervention studies conducted in primary care. Our review identified two families of interventions. They comprised: (1) interventions aimed at the comprehensive assessment and management of frailty needs; and (2) interventions targeting specific frailty needs. Key factors that facilitate or inhibit the translation of frailty interventions into practice related to the distribution of resources; patient engagement and professional skill sets to address identified need. CONCLUSION There remain challenges to achieving successful implementation of frailty interventions in primary care. There were a key learning points under each family. First, targeted allocation of resources to address specific needs allows a greater alignment of skill sets and reduces overassessment of frail individuals. Second, earlier patient involvement may also improve intervention implementation and adherence. PROSPERO REGISTRATION NUMBER The published protocol for the review is registered with PROSPERO (CRD42019161193).
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Affiliation(s)
- Khulud Alharbi
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Thomas Blakeman
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Harm van Marwijk
- Division of Primary Care and Public Health, University of Brighton, Falmer, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - David Reeves
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jung Yin Tsang
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
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Olson MB, McCreedy EM, Baier RR, Shield RR, Zediker EE, Uth R, Thomas KS, Mor V, Gutman R, Rudolph JL. Measuring implementation fidelity in a cluster-randomized pragmatic trial: development and use of a quantitative multi-component approach. Trials 2022; 23:43. [PMID: 35033176 PMCID: PMC8761354 DOI: 10.1186/s13063-022-06002-8] [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] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In pragmatic trials, on-site partners, rather than researchers, lead intervention delivery, which may result in implementation variation. There is a need to quantitatively measure this variation. Applying the Framework for Implementation Fidelity (FIF), we develop an approach for measuring variability in site-level implementation fidelity. This approach is then applied to measure site-level fidelity in a cluster-randomized pragmatic trial of Music & MemorySM (M&M), a personalized music intervention targeting agitated behaviors in residents living with dementia, in US nursing homes (NHs). METHODS Intervention NHs (N = 27) implemented M&M using a standardized manual, utilizing provided staff trainings and iPods for participating residents. Quantitative implementation data, including iPod metadata (i.e., song title, duration, number of plays), were collected during baseline, 4-month, and 8-month site visits. Three researchers developed four FIF adherence dimension scores. For Details of Content, we independently reviewed the implementation manual and reached consensus on six core M&M components. Coverage was the total number of residents exposed to the music at each NH. Frequency was the percent of participating residents in each NH exposed to M&M at least weekly. Duration was the median minutes of music received per resident day exposed. Data elements were scaled and summed to generate dimension-level NH scores, which were then summed to create a Composite adherence score. NHs were grouped by tercile (low-, medium-, high-fidelity). RESULTS The 27 NHs differed in size, resident composition, and publicly reported quality rating. The Composite score demonstrated significant variation across NHs, ranging from 4.0 to 12.0 [8.0, standard deviation (SD) 2.1]. Scaled dimension scores were significantly correlated with the Composite score. However, dimension scores were not highly correlated with each other; for example, the correlation of the Details of Content score with Coverage was τb = 0.11 (p = 0.59) and with Duration was τb = - 0.05 (p = 0.78). The Composite score correlated with CMS quality star rating and presence of an Alzheimer's unit, suggesting face validity. CONCLUSIONS Guided by the FIF, we developed and used an approach to quantitatively measure overall site-level fidelity in a multi-site pragmatic trial. Future pragmatic trials, particularly in the long-term care environment, may benefit from this approach. TRIAL REGISTRATION Clinicaltrials.gov NCT03821844. Registered on 30 January 2019, https://clinicaltrials.gov/ct2/show/NCT03821844 .
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Affiliation(s)
- Miranda B Olson
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA.
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA.
| | - Ellen M McCreedy
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
| | - Rosa R Baier
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
| | - Renée R Shield
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
| | - Esme E Zediker
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
| | - Rebecca Uth
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
| | - Kali S Thomas
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- US Department of Veterans Affairs Medical Center, 830 Chalkstone Ave., Providence, RI, 02908, USA
| | - Vincent Mor
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- US Department of Veterans Affairs Medical Center, 830 Chalkstone Ave., Providence, RI, 02908, USA
| | - Roee Gutman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Department of Biostatistics, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
| | - James L Rudolph
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main St., Providence, RI, 02912, USA
- US Department of Veterans Affairs Medical Center, 830 Chalkstone Ave., Providence, RI, 02908, USA
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Thomas K, Dannapfel P. Organizational readiness to implement a care model in primary care for frail older adults living at home in Sweden. FRONTIERS IN HEALTH SERVICES 2022; 2:958659. [PMID: 36925790 PMCID: PMC10012617 DOI: 10.3389/frhs.2022.958659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 11/25/2022]
Abstract
Background The demographic change of an aging population constitutes a challenge for primary care organizations worldwide. The systematic implementation of preventative and proactive care models is needed to cope with increased care demands. Objective To investigate the organizational readiness in primary care to implement a new care model to prevent hospitalization among frail older adults. Method Individual qualitative interviews with health care staff investigated organizational readiness at seven primary care units in Sweden. A semi-structured interview guide was used during the interviews and included broad questions on individual and collective readiness to change. Directed content analysis and organizational readiness to change theory were used in data analysis. Results Positive beliefs among staff such as perceived benefits and compatibility with existing values contributed to a strong commitment to implement the new care model. However, perceptions such as unclear task demands, limited resources and concerns about new collaborative structures challenged implementation. Conclusions The findings emphasize implementation as an inter-organizational phenomenon, especially for holistic practices that span across multiple health care providers and disciplines. Furthermore, implementing care models in healthcare may require a change of culture as much as a change of practice.
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Affiliation(s)
- Kristin Thomas
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Petra Dannapfel
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden.,Region Östergötland, Linköping, Sweden
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Lampe D, Hasemann L, Nebling T, Thiem U, Greiner W. Health economic perspective on a community-based intervention for older people at risk of care dependency – results of a prospective quasi-experimental study. Gerontol Geriatr Med 2022; 8:23337214221140222. [DOI: 10.1177/23337214221140222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/20/2022] [Accepted: 11/03/2022] [Indexed: 11/25/2022] Open
Abstract
This prospective, quasi-experimental study aims to compare healthcare resource utilization (HCRU) and costs of a multi-component care approach for older people in a community setting (intervention group (IG)) with usual care in a matched control group (CG) during a 21-month observation period. The reablement-oriented intervention included a geriatric assessment, a case and network management and digital supporting tools. Regression models were applied to determine intervention effects regarding hospitalization, total hospital length of stay (LOS), number of physician consultations, and healthcare costs using claims data. 872 subjects were included in the IG and 1,768 in the CG. The analyses showed that the intervention did not affect hospitalization ( OR = 1.153; 95% CI: 0.971–1.369, p = .105). However, participating in the IG lead to a small but significant increase of physician contacts by a factor of 1.078 (Exp( ß) = 1.078; 95% CI: 1.011–1.149; p = .022). A non-significant mean difference in costs of €1,183 (95% CI: €−261.6 to €2,627.6, p = .108) per participant was identified. Further research is needed to generate robust evidence on the optimal design of care approaches for older people and the health economic implications of such interventions to improve care and resource allocation decision-making. Trial registration: The study was registered at the German Clinical Trials Register (DRKS00027866).
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Affiliation(s)
| | - Lena Hasemann
- AG 5 - Department of Health Economics and Health Care Management, Bielefeld University, School of Public Health, Bielefeld, Germany
| | - Thomas Nebling
- Techniker Krankenkasse, Department Care Management, Hamburg, Germany
| | - Ulrich Thiem
- Centre for Geriatrics and Gerontology, Albertinen-Haus, Hamburg, Germany
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Greiner
- AG 5 - Department of Health Economics and Health Care Management, Bielefeld University, School of Public Health, Bielefeld, Germany
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Brettel JH, Manuwald U, Hornstein H, Kugler J, Rothe U. Chronic-Care-Management Programs for Multimorbid Patients with Diabetes in Europe: A Scoping Review with the Aim to Identify the Best Practice. J Diabetes Res 2021; 2021:6657718. [PMID: 34796236 PMCID: PMC8595013 DOI: 10.1155/2021/6657718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 10/20/2021] [Indexed: 11/29/2022] Open
Abstract
AIM This scoping review is aimed at providing a current descriptive overview of care programs based on the chronic care model (CCM) according to E. H. Wagner. The evaluation is carried out within Europe and assesses the methodology and comparability of the studies. METHODS A systematic search in the databases PubMed, Embase, and MEDLINE via OVID was conducted. In the beginning, 2309 articles were found and 48 full texts were examined, 19 of which were incorporated. Included were CCM-based programs from Belgium, Cyprus, Germany, Italy, Switzerland, and the Netherlands. All 19 articles were presented descriptively whereof 11 articles were finally evaluated in a checklist by Rothe et al. (2020). In this paper, the studies were tabulated and evaluated conforming to the same criteria. RESULTS Due to the complexity of the CCM and the heterogeneity of the studies in terms of setting and implementation, a direct comparison proved difficult. Nevertheless, the review shows that CCM was successfully implemented in various care situations and also can be useful in single practices, which often dominate the primary care sector in many European health systems. The present review was able to provide a comprehensive overview of the current care situation of chronically ill patients with multimorbidities. CONCLUSIONS A unified nomenclature concerning the distinction between disease management programs and CCM-based programs should be aimed for. Similarly, homogeneous quality standards and a Europe-wide evaluation strategy would be necessary to identify best practice models and to provide better care for the steadily growing number of chronically multimorbid patients.
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Affiliation(s)
- Julia Heike Brettel
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
| | - Ulf Manuwald
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
| | - Henriette Hornstein
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
| | - Joachim Kugler
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
| | - Ulrike Rothe
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
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9
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Herrler A, Kukla H, Vennedey V, Stock S. What matters to people aged 80 and over regarding ambulatory care? A systematic review and meta-synthesis of qualitative studies. Eur J Ageing 2021; 19:325-339. [PMID: 36052193 PMCID: PMC9424416 DOI: 10.1007/s10433-021-00633-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 04/23/2023] Open
Abstract
AbstractThe growing percentage of the population aged 80 and over is challenging for healthcare systems, as frailty and other complex health issues are common in this age group. In order to provide patient-centered ambulatory healthcare, their preferences and expectations need to be explored. Therefore, the aim of this study was to systematically search for and synthesize qualitative evidence on how people aged 80 and over believe ambulatory healthcare (medical and nursing care) should be delivered to them. Medline, PsycINFO, CINAHL, Web of Science Core Collection and Google Scholar were searched for full research reports of qualitative studies focusing on the preferences, wishes, needs, expectations and experiences of people aged 80 and over regarding ambulatory medical and nursing care. The results were screened by two independent reviewers using a two-step approach. The included studies were meta-synthesized using Thomas and Harden’s ‘thematic synthesis’ approach in order to gain a new, second-order interpretation of the findings of the primary studies. In the intermediate synthesis step, 14 aspects of healthcare structures and care relationships were identified as relevant. Based on these, three underlying wishes were found: feeling safe, feeling like a meaningful human being, and maintaining control and independence. The results of this review are in line with other research, such as reviews focusing on the preferences of the younger age group (65–80). However, the importance of aspects of care relationships as an integral part of favorable ambulatory healthcare and the wish to be strengthened as a meaningful human being are emphasized more strongly.
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10
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van Olmen J, Menon S, Poplas Susič A, Ir P, Klipstein-Grobusch K, Wouters E, Peñalvo JL, Zavrnik Č, Te V, Martens M, Danhieux K, Chham S, Stojnić N, Buffel V, Yem S, White G, Boateng D, Klemenc-Ketis Z, Prevolnik VR, Remmen R, Van Damme W. Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium (SCUBY): a study design for a quasi-experimental multiple case study. Glob Health Action 2021; 13:1824382. [PMID: 33373278 PMCID: PMC7594757 DOI: 10.1080/16549716.2020.1824382] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.
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Affiliation(s)
- Josefien van Olmen
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium.,Department of Sociology, University of Antwerp , Antwerp, Belgium
| | - Sonia Menon
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium
| | - Antonija Poplas Susič
- Community Health Center Ljubljana , Slovenia.,Department of Family Medicine, Faculty of Medicine, University of Ljubljana , Ljubljana, Slovenia
| | - Por Ir
- National Institute of Public Health , Ljubljana, Cambodia
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University , Utrecht, The Netherlands.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Edwin Wouters
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - José L Peñalvo
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium
| | - Črt Zavrnik
- Community Health Center Ljubljana , Slovenia
| | - Vannarath Te
- National Institute of Public Health , Ljubljana, Cambodia
| | - Monika Martens
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium
| | - Katrien Danhieux
- Department of Sociology, University of Antwerp , Antwerp, Belgium
| | - Savina Chham
- National Institute of Public Health , Ljubljana, Cambodia
| | | | - Veerle Buffel
- Department of Sociology, University of Antwerp , Antwerp, Belgium
| | - Sokunthea Yem
- National Institute of Public Health , Ljubljana, Cambodia
| | - Gareth White
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium
| | - Daniel Boateng
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University , Utrecht, The Netherlands
| | - Zalika Klemenc-Ketis
- Community Health Center Ljubljana , Slovenia.,Department of Family Medicine, Faculty of Medicine, University of Ljubljana , Ljubljana, Slovenia.,Department of Family Medicine, Faculty of Medicine, University of Maribor , Maribor, Slovenia
| | | | - Roy Remmen
- Community Health Center Ljubljana , Slovenia
| | - Wim Van Damme
- National Institute of Public Health , Ljubljana, Cambodia
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11
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Gillard S, Banach N, Barlow E, Byrne J, Foster R, Goldsmith L, Marks J, McWilliam C, Morshead R, Stepanian K, Turner R, Verey A, White S. Developing and testing a principle-based fidelity index for peer support in mental health services. Soc Psychiatry Psychiatr Epidemiol 2021; 56:1903-1911. [PMID: 33606048 PMCID: PMC8429155 DOI: 10.1007/s00127-021-02038-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/29/2021] [Indexed: 11/05/2022]
Abstract
PURPOSE Evidence suggests that the distinctive relational qualities of peer support-compared to clinical-patient relationships-can be eroded in regulated healthcare environments. Measurement of fidelity in trials of peer support is lacking. This paper reports the development and testing of a fidelity index for one-to-one peer support in mental health services, designed to assess fidelity to principles that characterise the distinctiveness of peer support. METHODS A draft index was developed using expert panels of service user researchers and people doing peer support, informed by an evidence-based, peer support principles framework. Two rounds of testing took place in 24 mental health services providing peer support in a range of settings. Fidelity was assessed through interviews with peer workers, their supervisors and people receiving peer support. Responses were tested for spread and internal consistency, independently double rated for inter-rater reliability, with feedback from interviewees and service user researchers used to refine the index. RESULTS A fidelity index for one-to-one peer support in mental health services was produced with good psychometric properties. Fidelity is assessed in four principle-based domains; building trusting relationships based on shared lived experience; reciprocity and mutuality; leadership, choice and control; building strengths and making connections to community. CONCLUSIONS The index offers potential to improve the evidence base for peer support in mental health services, enabling future trials to assess fidelity of interventions to peer support principles, and service providers a means of ensuring that peer support retains its distinctive qualities as it is introduced into mental health services.
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Affiliation(s)
- S. Gillard
- grid.4464.20000 0001 2161 2573Population Health Research Institute, St George’s, University of London, London, UK ,grid.4464.20000 0001 2161 2573School of Health Sciences, City, University of London, London, UK
| | - N. Banach
- grid.4464.20000 0001 2161 2573Population Health Research Institute, St George’s, University of London, London, UK
| | - E. Barlow
- grid.451317.50000 0004 0489 3918Research and Development Department, Sussex Partnership NHS Foundation Trust, Hove, UK
| | - J. Byrne
- grid.451317.50000 0004 0489 3918Research and Development Department, Sussex Partnership NHS Foundation Trust, Hove, UK
| | - R. Foster
- grid.4464.20000 0001 2161 2573Population Health Research Institute, St George’s, University of London, London, UK
| | - L. Goldsmith
- grid.4464.20000 0001 2161 2573Population Health Research Institute, St George’s, University of London, London, UK
| | - J. Marks
- grid.4464.20000 0001 2161 2573Population Health Research Institute, St George’s, University of London, London, UK
| | - C. McWilliam
- grid.4464.20000 0001 2161 2573Population Health Research Institute, St George’s, University of London, London, UK
| | - R. Morshead
- grid.4464.20000 0001 2161 2573Population Health Research Institute, St George’s, University of London, London, UK
| | - K. Stepanian
- grid.15751.370000 0001 0719 6059School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - R. Turner
- grid.4464.20000 0001 2161 2573Population Health Research Institute, St George’s, University of London, London, UK
| | - A. Verey
- grid.4464.20000 0001 2161 2573School of Health Sciences, City, University of London, London, UK
| | - S. White
- grid.4464.20000 0001 2161 2573Population Health Research Institute, St George’s, University of London, London, UK
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12
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Fraze TK, Beidler LB, Briggs ADM, Colla CH. Translating Evidence into Practice: ACOs' Use of Care Plans for Patients with Complex Health Needs. J Gen Intern Med 2021; 36:147-153. [PMID: 33006083 PMCID: PMC7858720 DOI: 10.1007/s11606-020-06122-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 04/23/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Care plans are an evidence-based strategy, encouraged by the Centers for Medicare and Medicaid Services, and are used to manage the care of patients with complex health needs that have been shown to lead to lower hospital costs and improved patient outcomes. Providers participating in payment reform, such as accountable care organizations, may be more likely to adopt care plans to manage complex patients. OBJECTIVE To understand how Medicare accountable care organizations (ACOs) use care plans to manage patients with complex clinical needs. DESIGN A qualitative study using semi-structured interviews with Medicare ACOs. PARTICIPANTS Thirty-nine interviews were conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff. APPROACH Development, structure, use, and management of care plans for complex patients at Medicare ACOs. KEY RESULTS Most (11) of the interviewed ACOs reported using care plans to manage care of complex patients. All care plans include information about patient history, current medical needs, and future care plans. Beyond the core elements, care plans included elements based on the ACO's planned use and level of staff and patient engagement with care planning. Most care plans were developed and maintained by care management (not clinical) staff. CONCLUSIONS ACOs are using care plans for patients with complex needs, but their use of care plans does not always meet the best practices. In many cases, ACO usage of care plans does not align with prescribed best practices: ACOs are adapting use of care plans to better fit the needs of patients and providers.
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Affiliation(s)
- Taressa K Fraze
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA. .,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA.
| | - Laura B Beidler
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Adam D M Briggs
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA.,Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK.,The Health Foundation, London, UK
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
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13
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Grooten L, Fabbricotti IN, Devroey D, Vrijhoef HJM. Assessment of the implementation fidelity of a strategy to scale up integrated care in five European regions: a multimethod study. BMJ Open 2020; 10:e035002. [PMID: 32193271 PMCID: PMC7150600 DOI: 10.1136/bmjopen-2019-035002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The SCaling IntegRated Care in COntext (SCIROCCO) project tested a step-based scaling up strategy to explore what and how to scale up integrated care initiatives in five European regions. To gain a profound understanding of which factors influence the implementation of this strategy, the objective of this study was to assess the extent to which the SCIROCCO strategy was implemented as planned. DESIGN Multimethod study. METHODS The extended version of the conceptual framework for implementation fidelity was used to evaluate what factors influence the implementation of the scaling up strategy. Data were collected in the five participating European regions during the intervention period. Data collection methods included: key informant interviews, focus groups, questionnaire studies and project documents. RESULTS All three main steps of the scaling up strategy were implemented with acceptable fidelity. Variations were observed in the duration of implementing the steps in the regions. Also, variations were observed in the coverage of experts to participate in the steps of the strategy. Several factors were observed to influence the implementation: facilitation conditions (ie, good coordination for implementation) and participant responsiveness (ie, a positive experience of participants in the organised study visits). Factors that may have moderated adherence to the original plan of the strategy were found in facilitating conditions (ie, in the flexible approach), participant recruitment factors (ie, adaptions of the procedure by the regions) and contextual factors (ie, the level of development of integrated care). CONCLUSION This was the first study to assess implementation fidelity of a European project that used a step-based scaling up strategy in five European regions. Similar European projects that are based on collaboration between several European regions can learn from the lessons captured in SCIROCCO and can become more aware of the facilitating factors and pitfalls of implementing such projects.
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Affiliation(s)
- Liset Grooten
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | | | - Dirk Devroey
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Hubertus J M Vrijhoef
- Department of Patient & Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
- Panaxea B.V, Amsterdam, The Netherlands
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14
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Maharani C, Djasri H, Meliala A, Dramé ML, Marx M, Loukanova S. A scoping analysis of the aspects of primary healthcare physician job satisfaction: facets relevant to the Indonesian system. HUMAN RESOURCES FOR HEALTH 2019; 17:38. [PMID: 31146752 PMCID: PMC6543658 DOI: 10.1186/s12960-019-0375-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 05/12/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Although there is extensive literature on the different aspects of physician job satisfaction worldwide, existing questionnaires used to measure job satisfaction in developed countries (e.g., the Job Satisfaction Scale) do not capture the aspects specific to Indonesian primary healthcare physicians. This is especially true considering the 2014 healthcare system reform, which led to the implementation of a national social health insurance scheme in Indonesia that has significantly changed the working conditions of physicians. Therefore, the current study aimed to identify aspects of primary care physician job satisfaction featured in published literature and determine those most suitable for measuring physician job satisfaction in light of Indonesia's recent reforms. METHODS A scoping literature review of full-text articles published in English between 2006 and 2015 was conducted using the PubMed, Psycinfo, and Web of Science databases. All aspects of primary care physician job satisfaction included in these studies were identified and classified. We then selected aspects mentioned in more than 5% of the reviewed papers and identified those most relevant to the post-reform Indonesian context. RESULTS A total of 440 articles were reviewed, from which 23 aspects of physicians' job satisfaction were extracted. Sixteen aspects were deemed relevant to the current Indonesian system: physical working conditions, overall job satisfaction, patient care/treatment, referral systems, relationships with colleagues, financial aspects, workload, time of work, recognition for good work, autonomy, opportunity to use abilities, relationships with patients, their families, and community, primary healthcare facilities' organization and management style, medical education, healthcare systems, and communication with health insurers. CONCLUSION Considering the recent reforms of the Indonesian healthcare system, existing tools for measuring job satisfaction among physicians must be revised. Future research should focus on the development and validation of new measures of physician job satisfaction based on the aspects identified in this study.
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Affiliation(s)
- Chatila Maharani
- Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
- Department of Public Health, Universitas Negeri Semarang, Semarang, Indonesia
| | - Hanevi Djasri
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Andreasta Meliala
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Mohamed Lamine Dramé
- Success in Africa, Conakry University Medical Faculty based think tank, Conakry, Guinea
| | - Michael Marx
- Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Svetla Loukanova
- Department of General Practice and Implementation Research, Medical Faculty, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
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15
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Nurjono M, Shrestha P, Ang IYH, Shiraz F, Yoong JSY, Toh SAES, Vrijhoef HJM. Implementation fidelity of a strategy to integrate service delivery: learnings from a transitional care program for individuals with complex needs in Singapore. BMC Health Serv Res 2019; 19:177. [PMID: 30890134 PMCID: PMC6425607 DOI: 10.1186/s12913-019-3980-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 02/28/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) - RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs. METHODS Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases. RESULTS Most (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs' level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers. CONCLUSION This is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.
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Affiliation(s)
- Milawaty Nurjono
- Centre for Health Services Research and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Pami Shrestha
- Regional Health System Planning Office, National University Health System, Singapore, Singapore
| | - Ian Yi Han Ang
- Regional Health System Planning Office, National University Health System, Singapore, Singapore
| | - Farah Shiraz
- Regional Health System Planning Office, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Joanne Su-Yin Yoong
- Center for Economic and Social Research, University of Southern California, Los Angeles, USA
| | - Sue-Anne Ee Shiow Toh
- Regional Health System Planning Office, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Hubertus Johannes Maria Vrijhoef
- Department of Patient and Care, University Hospital Maastricht, Maastricht, The Netherlands
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussels, Brussels, Belgium
- Panaxea B.V, Amsterdam, The Netherlands
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16
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Blom JW, Van den Hout WB, Den Elzen WPJ, Drewes YM, Bleijenberg N, Fabbricotti IN, Jansen APD, Kempen GIJM, Koopmans R, Looman WM, Melis RJF, Metzelthin SF, Moll van Charante EP, Muntinga ME, Numans ME, Ruikes FGH, Spoorenberg SLW, Stijnen T, Suijker JJ, De Wit NJ, Wynia K, Wind AW, Gussekloo J. Effectiveness and cost-effectiveness of proactive and multidisciplinary integrated care for older people with complex problems in general practice: an individual participant data meta-analysis. Age Ageing 2018. [PMCID: PMC6108387 DOI: 10.1093/ageing/afy091] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose to support older people with several healthcare needs in sustaining adequate functioning and independence, more proactive approaches are needed. This purpose of this study is to summarise the (cost-) effectiveness of proactive, multidisciplinary, integrated care programmes for older people in Dutch primary care. Methods design individual patient data (IPD) meta-analysis of eight clinically controlled trials. Setting primary care sector. Interventions combination of (i) identification of older people with complex problems by means of screening, followed by (ii) a multidisciplinary integrated care programme for those identified. Main outcome activities of daily living, i.e. a change on modified Katz-15 scale between baseline and 1-year follow-up. Secondary outcomes quality of life (visual analogue scale 0–10), psychological (mental well-being scale Short Form Health Survey (SF)-36) and social well-being (single item, SF-36), quality-adjusted life years (Euroqol-5dimensions-3level (EQ-5D-3L)), healthcare utilisation and cost-effectiveness. Analysis intention-to-treat analysis, two-stage IPD and subgroup analysis based on patient and intervention characteristics. Results included were 8,678 participants: median age of 80.5 (interquartile range 75.3; 85.7) years; 5,496 (63.3%) women. On the modified Katz-15 scale, the pooled difference in change between the intervention and control group was −0.01 (95% confidence interval −0.10 to 0.08). No significant differences were found in the other patient outcomes or subgroup analyses. Compared to usual care, the probability of the intervention group to be cost-effective was less than 5%. Conclusion compared to usual care at 1-year follow-up, strategies for identification of frail older people in primary care combined with a proactive integrated care intervention are probably not (cost-) effective.
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Affiliation(s)
- J W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, RC Leiden, The Netherlands
| | - W B Van den Hout
- Department of Biomedical Data Sciences—Medical Decision Making, Leiden University Medical Center, RC Leiden, The Netherlands
| | - W P J Den Elzen
- Department of Public Health and Primary Care, Leiden University Medical Center, RC Leiden, The Netherlands
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Y M Drewes
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, RC Leiden, The Netherlands
| | - N Bleijenberg
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, GA Utrecht, The Netherlands
| | - I N Fabbricotti
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, CA Rotterdam, The Netherlands
| | - A P D Jansen
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, MB Amsterdam, The Netherlands
| | - G I J M Kempen
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, MD Maastricht, The Netherlands
| | - R Koopmans
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, HB Nijmegen, The Netherlands
| | - W M Looman
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, CA Rotterdam, The Netherlands
| | - R J F Melis
- Department of Geriatric Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, HB Nijmegen, The Netherlands
| | - S F Metzelthin
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, MD Maastricht, The Netherlands
| | - E P Moll van Charante
- Department of General Practice, Academic Medical Center, DD Amsterdam, The Netherlands
| | - M E Muntinga
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, MB Amsterdam, The Netherlands
| | - M E Numans
- Department of Public Health and Primary Care, Leiden University Medical Center, RC Leiden, The Netherlands
| | - F G H Ruikes
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, HB Nijmegen, The Netherlands
| | - S L W Spoorenberg
- Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, Internal postal code FA10, AD Groningen, The Netherlands
| | - T Stijnen
- Department of Medical Statistics, Leiden University Medical Center, RC Leiden, The Netherlands
| | - J J Suijker
- Department of General Practice, Academic Medical Center, DD Amsterdam, The Netherlands
| | - N J De Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, GA Utrecht, The Netherlands
| | - K Wynia
- Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, Internal postal code FA10, AD Groningen, The Netherlands
| | - A W Wind
- Department of Public Health and Primary Care, Leiden University Medical Center, RC Leiden, The Netherlands
| | - J Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, RC Leiden, The Netherlands
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, RC Leiden, The Netherlands
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Robusto F, Bisceglia L, Petrarolo V, Avolio F, Graps E, Attolini E, Nacchiero E, Lepore V. The effects of the introduction of a chronic care model-based program on utilization of healthcare resources: the results of the Puglia care program. BMC Health Serv Res 2018; 18:377. [PMID: 29801489 PMCID: PMC5970509 DOI: 10.1186/s12913-018-3075-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 03/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background Ageing is continuously increasing the prevalence of patients with chronic conditions, putting pressure on the sustainability of Healthcare Systems. Chronic Care Models (CCM) have been used to address the needs of frail people in the continuum of care, testifying to an improvement in health outcomes and more efficient access to healthcare services. The impact of CCM deployment has already been experienced in a selected cohort of patients affected by specific chronic illnesses. We have investigated its effects in a heterogeneous frail cohort included in a regional CCM-based program. Methods a retrospective population-based cohort study was carried out involving a non-oncological cohort of adult subjects with chronic diseases included in the CCM-oriented program (Puglia Care). Individuals in usual care with comparable demographic and clinical characteristics were selected for matched pair analysis. Study cohorts were defined by using a record linkage analysis of administrative databases and electronic medical records, including data on the adult population in the 6 local area health authorities of Puglia in Italy (approximately 2 million people). The effects of Puglia Care on the utilizations of healthcare resources were evaluated both in a before-after and in a case-control analysis. Results There were 1074 subjects included in Puglia Care and 2126 matched controls. In before-after analysis of the Puglia Care cohort, 240 unplanned hospitalizations occurred in the pre-inclusion period, while 239 were registered during follow-up. The incidence of unplanned hospitalization was 10.3 per 100 person/year (95% CI, 9.1–11.7) during follow-up and 12.1 per 100 person/year (95% CI, 10.7–13.8) in the pre-inclusion period (IRR, 0.84; 95% CI, 0.80–0.99). During follow-up a significant reduction in costs related to unplanned hospitalizations (IRR, 0.92; 95% CI, 0.91–0.92) was registered, while costs related to drugs (IRR, 1.14; p < 0.01), out-patient specialist visits (IRR, 1.19; p < 0.01), and planned hospitalization (IRR 1.03; p < 0.01) increased significantly. These modifications can be related to the aging of the population and modifications to healthcare delivery; for this reason, a case-control analysis was performed. The results testify to a significantly lower number (IRR, 0.79; 95% CI, 0.68–0.91), length of hospital stay (IRR, 0.80; 95% CI, 0.76–0.84), and costs related to unplanned hospitalizations (IRR, 0.80; 95% CI, 0.80–0.80) during follow-up in the intervention group. However, there was a higher increase in costs of hospitalizations, drugs and out-patients specialist visits during follow-up in Puglia Care when compared with patients in usual care. Conclusion In a population-based cohort, inclusion of chronic patients in a CCM-based program was significantly associated with a lower recourse to unplanned hospital admissions when compared with patients in usual care with comparable clinical and demographic characteristics. Electronic supplementary material The online version of this article (10.1186/s12913-018-3075-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fabio Robusto
- Regional Healthcare Agency of Puglia Region (AReSS Puglia), via Giovanni Gentile n 52 -, 70126, Bari, Italy
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Ruikes FGH, van Gaal BGI, Oudshoorn L, Zuidema SU, Akkermans RP, Assendelft WJJ, Schers HJ, Koopmans RTCM. The association between implementation and outcome of a complex care program for frail elderly people. Fam Pract 2018; 35:47-52. [PMID: 28985296 DOI: 10.1093/fampra/cmx065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Over the last 20 years, the effectiveness of complex care programs aiming to prevent adverse outcomes in frail elderly people has been disappointing. Recently, we found no effectiveness of the CareWell primary care program. It is largely unknown to what extent incomplete implementation of these complex interventions influences their outcomes. OBJECTIVE To examine the association between the degree of implementation of the CareWell program and the prevention of functional decline in frail elderly people. METHODS Quantitative process evaluation conducted alongside a cluster-controlled trial. Two hundred and four frail elderly participants from six general practitioner practices in the Netherlands received care according to the CareWell program, consisting of four key components: multidisciplinary team meetings, proactive care planning, case management and medication reviews. We measured time registrations of team meetings, case management and medication reviews and care plan data as stored in a digital information portal. These data were aggregated into a total implementation score (TIS) representing the program's overall implementation. We measured functional decline with the Katz-15 change score (follow-up score at 12 months minus the baseline score). The association between TIS and functional decline was analyzed with linear mixed model analyses. RESULTS We found no statistically significant differences in functional decline between TIS groups (F = 1.350, P = 0.245). In the groups with the highest TISs, we found more functional decline. CONCLUSION A higher degree of implementation of the CareWell program did not lead to the prevention of functional decline in frail elderly people.
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Affiliation(s)
- Franca G H Ruikes
- Department of Primary and Community Care, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Betsie G I van Gaal
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Liset Oudshoorn
- Department of Primary and Community Care, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Reinier P Akkermans
- Department of Primary and Community Care, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Henk J Schers
- Department of Primary and Community Care, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Joachim and Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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Smit LC, Schuurmans MJ, Blom JW, Fabbricotti IN, Jansen APD, Kempen GIJM, Koopmans R, Looman WM, Melis RJF, Metzelthin SF, Moll van Charante EP, Muntinga ME, Ruikes FGH, Spoorenberg SLW, Suijker JJ, Wynia K, Gussekloo J, De Wit NJ, Bleijenberg N. Unravelling complex primary-care programs to maintain independent living in older people: a systematic overview. J Clin Epidemiol 2017; 96:110-119. [PMID: 29289764 DOI: 10.1016/j.jclinepi.2017.12.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 11/23/2017] [Accepted: 12/14/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Complex interventions are criticized for being a "black box", which makes it difficult to determine why they succeed or fail. Recently, nine proactive primary-care programs aiming to prevent functional decline in older adults showed inconclusive effects. The aim of this study was to systematically unravel, compare, and synthesize the development and evaluation of nine primary-care programs within a controlled trial to further improve the development and evaluation of complex interventions. STUDY DESIGN AND SETTING A systematic overview of all written data on the nine proactive primary-care programs was conducted using a validated item list. The nine proactive primary-care programs involved 214 general practices throughout the Netherlands. RESULTS There was little or no focus on the (1) context surrounding the care program, (2) modeling of processes and outcomes, (3) intervention fidelity and adaptation, and (4) content and evaluation of training for interventionists. CONCLUSIONS An in-depth analysis of the context, modeling of the processes and outcomes, measurement and reporting of intervention fidelity, and implementation of effective training for interventionists is needed to enhance the development and replication of future complex interventions.
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Affiliation(s)
- Linda C Smit
- Research Group for the Chronically Ill and Elderly, Faculty of Health Care, University of Applied Sciences Utrecht, Utrecht 3584 CS, The Netherlands.
| | - Marieke J Schuurmans
- Research Group for the Chronically Ill and Elderly, Faculty of Health Care, University of Applied Sciences Utrecht, Utrecht 3584 CS, The Netherlands; Department of Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht 3508 GA, The Netherlands
| | - Jeanet W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden 2333 ZD, The Netherlands
| | - Isabelle N Fabbricotti
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam 3062 PA, The Netherlands
| | - Aaltje P D Jansen
- Department of General Practice and Elderly Care, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, 1081 BT, The Netherlands
| | - Gertrudis I J M Kempen
- Department of Health Services Research, and Care and Public Health Research Institute (CAPHRI) Maastricht University, Maastricht 6229 GT, The Netherlands
| | - Raymond Koopmans
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre Nijmegen, Nijmegen C500 HB, The Netherlands
| | - Willemijn M Looman
- Department of Geriatric Medicine, Radboud University Nijmegen Medical Centre, Nijmegen 6500 HB, The Netherlands
| | - Rene J F Melis
- Department of General Practice, Academic Medical Center, Amsterdam 1105 AZ, The Netherlands
| | - Silke F Metzelthin
- Department of Health Services Research, and Care and Public Health Research Institute (CAPHRI) Maastricht University, Maastricht 6229 GT, The Netherlands
| | | | - Maaike E Muntinga
- Department of General Practice and Elderly Care, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, 1081 BT, The Netherlands
| | - Franca G H Ruikes
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre Nijmegen, Nijmegen C500 HB, The Netherlands
| | - Sophie L W Spoorenberg
- Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Jacqueline J Suijker
- Department of General Practice, Academic Medical Center, Amsterdam 1105 AZ, The Netherlands
| | - Klaske Wynia
- Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden 2333 ZD, The Netherlands; Department of Geriatrics and Gerontology, Leiden University Medical Center, Leiden 2300 RC, The Netherlands
| | - Niek J De Wit
- Department of General Practice, Division Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht 3508 GA, The Netherlands
| | - Nienke Bleijenberg
- Research Group for the Chronically Ill and Elderly, Faculty of Health Care, University of Applied Sciences Utrecht, Utrecht 3584 CS, The Netherlands; Department of Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht 3508 GA, The Netherlands
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20
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Hoogendijk EO, van der Horst HE, van de Ven PM, Twisk JWR, Deeg DJH, Frijters DHM, van Leeuwen KM, van Campen JPCM, Nijpels G, Jansen APD, van Hout HPJ. Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial. Eur J Intern Med 2016; 28:43-51. [PMID: 26597341 DOI: 10.1016/j.ejim.2015.10.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/27/2015] [Accepted: 10/30/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults. We evaluated the impact of the Geriatric Care Model (GCM) on the quality of life of community-dwelling frail older adults. METHODS A 24-month stepped wedge cluster randomized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practices in the Netherlands, and included 1147 frail older adults. The intervention consisted of a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Reassessment occurred every six months. Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams. Complex patients were reviewed in multidisciplinary consultations. The primary outcome was quality of life (SF-12). Secondary outcomes were health-related quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning and hospitalizations. RESULTS Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes. Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months (B=-0.25, 95%CI=-0.43 to -0.06, p=0.007), but this effect was not statistically significant after correction for multiple comparisons. CONCLUSION The GCM did not show beneficial effects on quality of life in frail older adults in primary care, compared to usual care. This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population. TRIAL REGISTRATION The Netherlands National Trial Register NTR2160.
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Affiliation(s)
- Emiel O Hoogendijk
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Gérontopôle, Department of Internal Medicine and Geriatrics, Toulouse University Hospital, Toulouse, France; Department of Epidemiology & Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Henriëtte E van der Horst
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Peter M van de Ven
- Department of Epidemiology & Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Jos W R Twisk
- Department of Epidemiology & Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Dorly J H Deeg
- Department of Epidemiology & Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Dinnus H M Frijters
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Karen M van Leeuwen
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of Health Sciences, EMGO+ Institute for Health and Care Research, Faculty of Earth & Life Sciences, VU University, Amsterdam, The Netherlands.
| | - Jos P C M van Campen
- Department of Geriatric Medicine, Slotervaart Hospital, Amsterdam, The Netherlands.
| | - Giel Nijpels
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Aaltje P D Jansen
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Hein P J van Hout
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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21
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van Leeuwen KM, Bosmans JE, Jansen APD, Hoogendijk EO, Muntinga ME, van Hout HPJ, Nijpels G, van der Horst HE, van Tulder MW. Cost-Effectiveness of a Chronic Care Model for Frail Older Adults in Primary Care: Economic Evaluation Alongside a Stepped-Wedge Cluster-Randomized Trial. J Am Geriatr Soc 2015; 63:2494-2504. [PMID: 26663424 DOI: 10.1111/jgs.13834] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the cost-effectiveness of the Geriatric Care Model (GCM), an integrated care model for frail older adults based on the Chronic Care Model, with that of usual care. DESIGN Economic evaluation alongside a 24-month stepped-wedge cluster-randomized controlled trial. SETTING Primary care (35 practices) in two regions in the Netherlands. PARTICIPANTS Community-dwelling older adults who were frail according to their primary care physicians and the Program on Research for Integrating Services for the Maintenance of Autonomy case-finding tool questionnaire (N = 1,147). INTERVENTION The GCM consisted of the following components: a regularly scheduled in-home comprehensive geriatric assessment by a practice nurse followed by a customized care plan, management and training of practice nurses by a geriatric expert team, and coordination of care through community network meetings and multidisciplinary team consultations of individuals with complex care needs. MEASUREMENTS Outcomes were measured every 6 months and included costs from a societal perspective, health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey (SF-12) physical (PCS) and mental component summary (MCS) scales), functional limitations (Katz activities of daily living and instrumental activities of daily living), and quality-adjusted life years based on the EQ-5D. RESULTS Multilevel regression models adjusted for time and baseline confounders showed no significant differences in costs ($356, 95% confidence interval = -$488-1,134) and outcomes between intervention and usual care phases. Cost-effectiveness acceptability curves showed that, for the SF-12 PCS and MCS, the probability of the intervention being cost-effective was 0.76 if decision-makers are willing to pay $30,000 per point improvement on the SF-12 scales (range 0-100). For all other outcomes the probability of the intervention being cost-effective was low. CONCLUSION Because the GCM was not cost-effective compared to usual care after 24 months of follow-up, widespread implementation in its current form is not recommended.
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Affiliation(s)
- Karen M van Leeuwen
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Health Sciences, Faculty of Earth & Life Sciences, Emgo+ Institute for Health and Care Research, VU University, Amsterdam, the Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Earth & Life Sciences, Emgo+ Institute for Health and Care Research, VU University, Amsterdam, the Netherlands
| | - Aaltje P D Jansen
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Emiel O Hoogendijk
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Gérôntopole, Toulouse University Hospital, Toulouse, France
| | - Maaike E Muntinga
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Medical Humanities, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Hein P J van Hout
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Giel Nijpels
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Henriette E van der Horst
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth & Life Sciences, Emgo+ Institute for Health and Care Research, VU University, Amsterdam, the Netherlands
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