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Paul C, Schöttker B, Hartmann M, Friederich HC, Brenner H, Wild B. Gender-specific factors associated with case complexity in middle-aged and older adults-Evidence from a large population-based study. Int J Geriatr Psychiatry 2024; 39:e6113. [PMID: 38877644 DOI: 10.1002/gps.6113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 05/29/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVES To investigate gender-specific factors associated with case complexity in a population-based sample of middle-aged and older adults using a holistic approach to complexity. METHODS Data were derived from the 8-year follow-up home visits of the ESTHER study-a German population-based study in middle-aged and older adults. Cross-sectional analyses were conducted for 2932 persons (aged 57-84). Complexity was assessed by the well-established INTERMED for the elderly interview, which uses a holistic approach to the definition of case complexity. The association between various bio-psycho-social variables and case complexity was analyzed using gender-specific logistic regression models, adjusted for sociodemographic factors (age, marital status, education). RESULTS Prevalence of complexity was 8.3% with significantly higher prevalence in female (10.6%) compared to male (5.8%) participants (p < 0.001). Variables associated with increased odds for complexity in both, women and men were: being divorced (odds ratio [OR] women: 1.86, 95% CI 1.05-3.30; OR men: 3.19, 1.25-8.12), higher total somatic morbidity (women: 1.08, 1.04-1.12; men: 1.06, 1.02-1.11), higher depression severity (women: 1.34, 1.28-1.40; men: 1.35, 1.27-1.44), and higher loneliness scores (women: 1.19, 1.05-1.36; men: 1.23, 1.03-1.47). Women (but not men) with obesity (Body mass index [BMI] ≥30) had higher odds (1.79, 1.11-2.89) for being complex compared to those with a BMI <25. High oxidative stress measured by derivatives of reactive oxygen metabolites in serum was associated with 2.02 (1.09-3.74) higher odds for complexity only in men. CONCLUSIONS This study provides epidemiological evidence on gender differences in prevalence and factors associated with case complexity in middle-aged and older adults. Moreover, this study adds to the holistic understanding of complexity by identifying novel variables linked to complexity among middle-aged and older individuals. These factors include loneliness for both genders, and high oxidative stress for men. These findings should be confirmed in future longitudinal studies.
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Affiliation(s)
- Cinara Paul
- Department of General Internal Medicine and Psychosomatics, Medical University Hospital, Heidelberg, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Mechthild Hartmann
- Department of General Internal Medicine and Psychosomatics, Medical University Hospital, Heidelberg, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, Medical University Hospital, Heidelberg, Germany
- DZPG German Centre for Mental Health-Partner Site Heidelberg/Mannheim/Ulm, Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
- Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Beate Wild
- Department of General Internal Medicine and Psychosomatics, Medical University Hospital, Heidelberg, Germany
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Vallet F, Ludwig C, Ashikali EM, Busnel C. First Evidence on the Validity of the Complexity Index Derived from the Resident Assessment Instrument for Home Care in Home Care Patients. J Am Med Dir Assoc 2024:105046. [PMID: 38825323 DOI: 10.1016/j.jamda.2024.105046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVES Recently, a Complexity Index (CI), based on the multidimensional complexity model and derived from the Resident Assessment Instrument for Home Care (interRAI HC) was proposed as a decision-support tool to help frontline health care professionals in their clinical evaluation to identify and analyze complex situations. This study aims to test the CI: (1) concurrent validity with another measure of complexity (ie, the COMID), (2) convergent validity with related constructs assessed by interRAI HC scales (eg, depression), (3) divergent validity (comparison between CI-COMID and scales-COMID correlations), and (4) predictive validity on coordination meetings. DESIGN A cross-sectional observational design was used for a secondary analysis of interRAI HC and COMID data collected in routine home care nursing practice (July-December 2021). SETTING AND PARTICIPANTS Participants were community-dwelling adults receiving home care, with full interRAI HC and COMID assessments (N = 3533). METHODS Correlational analyses were conducted to test the concurrent validity of the CI (with the COMID) and the convergent and divergent validity of the CI (with interRAI HCSwitzerland scales, eg, Depression Rating Scale, Method for Assigning Priority Levels, and a Frailty Index). A receiver operating characteristic (ROC) analysis was conducted to test the discriminative ability of CI on specific professional team coordination meetings. RESULTS Results showed that the CI correlated positively and strongly with the COMID (ρ = 0.691, P < .001, concurrent validity), positively with all the tested scales (P < .001, convergent validity), whereas the CI-COMID correlation was higher than the interRAI HC scales-COMID correlations (divergent validity). The ROC analysis showed the CI had a high area under the curve (AUC = 0.719, predictive validity). CONCLUSIONS AND IMPLICATIONS The CI demonstrates good validity properties with a strong correlation with the COMID and a high predictive value for coordination meeting. It is distinct from the other interRAI HC scales and has its place among them to support the clinical analysis of complex situations.
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Affiliation(s)
- Fanny Vallet
- Research and Development Unit, Geneva Institution for Homecare and Assistance (IMAD), Grand-Lancy, Switzerland.
| | - Catherine Ludwig
- Geneva School of Health Sciences, HES-SO, University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Eleni-Marina Ashikali
- Research and Development Unit, Geneva Institution for Homecare and Assistance (IMAD), Grand-Lancy, Switzerland
| | - Catherine Busnel
- Research and Development Unit, Geneva Institution for Homecare and Assistance (IMAD), Grand-Lancy, Switzerland
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Bogner MS, Eschevins C, Faulks D. Identifying people requiring special care dentistry: A scoping review. SPECIAL CARE IN DENTISTRY 2024; 44:269-279. [PMID: 37254590 DOI: 10.1111/scd.12880] [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: 03/05/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 06/01/2023]
Abstract
AIMS This scoping review aimed to document tools designed to identify persons requiring special care dentistry (SCD) and to provide a better understanding of the factors that justify adaptation in the provision of care. METHODS A scoping review methodology was applied. An electronic search was performed in April 2021 using Pubmed and Embase. Additional tools were sought using hand searches and informal professional networking. RESULTS Ten tools were identified that either predict the complexity of dental management or that retrospectively judge the complexity of care, of which two are as yet unpublished. Some had been developed for a specific population (e.g., patients with Alzheimer's disease, with learning disability, elderly persons) whilst others were applicable for any population (case mix tools). Factors considered included the patient's medical history, ability to cooperate, physical and cognitive autonomy, communication skills, anxiety, need for sedation, oral risk factors, ability to consent and the administrative burden for the dentist. CONCLUSION Identifying persons requiring SCD is possible by looking at various factors that influence the provision of dental care. There may be need for adaptation of tools to local circumstances and to the intended usage of the tool at a health services, systems or policy level.
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Affiliation(s)
- Marie-Sophie Bogner
- Centre de Recherche en Odontologie Clinique (CROC), Université Clermont Auvergne, Clermont-Ferrand, France
| | - Caroline Eschevins
- Centre de Recherche en Odontologie Clinique (CROC), Université Clermont Auvergne, Clermont-Ferrand, France
| | - Denise Faulks
- Centre de Recherche en Odontologie Clinique (CROC), Université Clermont Auvergne, Clermont-Ferrand, France
- Service d'Odontologie, CHU Clermont-Ferrand, CHU Estaing, Clermont-Ferrand, France
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Sheehan KA, Chaput J, Bond V, Alloo J, Bonta M, Soklaridis S, Zhang M, Sockalingam S. Exploring the Impact of ECHO Ontario Integrated Mental and Physical Health on Participants' Approach and Attitude Toward the Care of Patients With Complex Needs. J Acad Consult Liaison Psychiatry 2023; 64:512-520. [PMID: 37536441 DOI: 10.1016/j.jaclp.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To examine how project Extension for Community Healthcare Outcomes-Integrated Mental and Physical Health (ECHO-IMPH) influences the attitudes and approaches of primary care providers and other participants towards patients. METHODS An exploratory qualitative approach was undertaken using semistructured interviews conducted between August 2020 and March 2021. One hundred and sixty-four individuals from two cycles of ECHO-IMPH were invited to participate, and 22 (n = 22) agreed to participate. Data were analyzed using the Braun and Clarke method for thematic analysis. RESULTS Three major themes were identified: 1) enhanced knowledge and skills; 2) changes in attitude and approach; 3) space for reflection and exploration. When participants were asked about areas for improvement, suggestions were focused on the structure of the sessions. Participants identified that ECHO-IMPH helped them to view patients more holistically, which led to greater patient-centered care in their practice. Additionally, skills gained in ECHO-IMPH gave participants the concrete tools needed to have more empathetic interactions with patients with complex needs. CONCLUSIONS ECHO-IMPH created a safe space for participants to reflect on their practice with patients with complex needs. Participants applied newly acquired knowledge and skills to provide more empathetic and patient-centered care for patients with complex needs. Based on the shift in perspectives described by participants, transformative learning theory was proposed as a model for how ECHO-IMPH created change in participants' practice.
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Affiliation(s)
- Kathleen A Sheehan
- University Health Network (UHN), Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
| | - Jake Chaput
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Victoria Bond
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Javed Alloo
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Ontario College of Family Physicians, Toronto, ON, Canada
| | - Mark Bonta
- University Health Network (UHN), Toronto, ON, Canada
| | | | - Maria Zhang
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Sanjeev Sockalingam
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
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Banadinović M, Vočanec D, Lukačević Lovrenčić I, Lončarek K, Džakula A. Role and perspectives of informal care: a qualitative study of informal caregivers in the Republic of Croatia. BMJ Open 2023; 13:e074454. [PMID: 37827736 PMCID: PMC10582946 DOI: 10.1136/bmjopen-2023-074454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVES Population ageing and the prevalence of multimorbidity represent major challenges for healthcare systems. People who need long-term care have complex conditions requiring both health and social services. Informal caregivers are emerging as an important part of the long-term care ecosystem. This paper aims to explore the position and capacities of informal caregivers in Croatia. DESIGN Health and social care legislative documents were analysed using a structured set of keywords. In addition, focus groups were conducted with informal caregivers who cared for a family member. The qualitative method of thematic analysis was used. SETTING AND PARTICIPANTS Two focus groups were conducted with 15 caregivers (13 women and 2 men). Geographically, participants came from all four NUTS2 Croatian regions. All participants cared for a close family member. The length of care provision ranged from 3 to 35 years. Focus groups were conducted using the Zoom platform. RESULTS The analysis of the documents indicates the fragmentation of national policy into health and social policy. Long-term care as a term is recognised only in health policy. However, some components related to long-term care are part of social policy. Caregivers are recognised in social policy, although not in healthcare. In focus groups, three main themes were identified as follows: (1) position and role of the caregivers in the system and society; (2) types of care based on the recipient's need and (3) support for the caregivers. CONCLUSION The research showed that the process of exercising certain rights and services for caregivers is not sufficiently clear and feasible in practice. There is a lack of a clearly defined role of caregivers and relationships towards professional care providers in the system. The key to improving long-term care is connecting community services, including health and social services, both formal and informal, with the process of providing care.
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Affiliation(s)
- Maja Banadinović
- Firefly - Association for Helping Children and Families Facing Malignant Diseases, Zagreb, Croatia
| | - Dorja Vočanec
- Department of Social Medicine and Organization of Health Care, Andrija Štampar School of Public Health, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Iva Lukačević Lovrenčić
- Department of Social Medicine and Organization of Health Care, Andrija Štampar School of Public Health, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Karmen Lončarek
- Department of Integrated and Palliative Care, Rijeka University Hospital Center, Rijeka, Croatia
| | - Aleksandar Džakula
- Department of Social Medicine and Organization of Health Care, Andrija Štampar School of Public Health, University of Zagreb School of Medicine, Zagreb, Croatia
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Shikino K, Mito T, Ohira Y, Yokokawa D, Katsuyama Y, Ota T, Sato E, Hirose Y, Yamashita S, Suzuki S, Noda K, Uehara T, Ikusaka M. Frequency of Difficult Patient Encounters in a Japanese University Hospital and Community Hospitals: A Cross-sectional Study. Intern Med 2023; 62:533-537. [PMID: 35793958 PMCID: PMC10017258 DOI: 10.2169/internalmedicine.0085-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Difficult patient encounters (DPEs) are defined as encounters with patients causing strong negative feelings in physicians. In primary care settings, DPEs account for approximately 15% of visits among outpatients. To our knowledge, this is the first epidemiological study of DPEs in Japan. Methods We conducted a survey of 8 physicians (5.0±2 years of clinical experience) who examined first-visit patients ≥15 years old with clinical symptoms at the Department of General Medicine in Chiba University Hospital and 4 community hospitals over a 2-month period since December 2015. Materials We evaluated 10-Item Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10) scores (DPE ≥31 points; non-DPE ≤30 points) and patient age, sex, and presence of psychological or social problems. Results The valid response rate was 98.9% (94/95) and 98.4% (189/192) in the university and community hospitals, respectively. The percentage of DPEs was 39.8% (37/93) and 15.0% (26/173) in the university and community hospitals, respectively; the percentage of DPEs was significantly higher at the university hospital than at the community hospitals (p<0.001). The proportion of patients with psychosocial problems was significantly higher in the DPE group than in the non-DPE group (93.7% vs. 40.4%, p<0.001). Conclusion Our findings were similar to those reported in primary care settings in other countries in community hospital outpatient and general internal medicine departments, where patients are mostly non-referrals, although the values were higher in university hospital general medicine departments, where patients were mostly referrals. Patients involved in DPEs have a high rate of psychological and social problems.
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Affiliation(s)
- Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Japan
- Department of Community-based Medical Education, Graduate School of Medicine, Chiba University, Japan
| | - Tsutomu Mito
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yoshiyuki Ohira
- Department of General Medicine, Chiba University Hospital, Japan
- Department of General Medicine, International University of Health and Welfare Narita Hospital, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yota Katsuyama
- Department of General Medicine, Chiba University Hospital, Japan
- Department of Community-based Medical Education, Graduate School of Medicine, Chiba University, Japan
- Department of General Medicine, Sanmu Medical Center, Japan
| | - Takahiro Ota
- Department of General Medicine, Chiba University Hospital, Japan
| | - Eri Sato
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yuta Hirose
- Department of General Medicine, Chiba University Hospital, Japan
| | - Shiho Yamashita
- Department of General Medicine, Chiba University Hospital, Japan
| | - Shingo Suzuki
- Department of General Medicine, Chiba University Hospital, Japan
- Department of Internal Medicine, Chiba Central Medical Center, Japan
| | - Kazutaka Noda
- Department of General Medicine, Chiba University Hospital, Japan
| | - Takanori Uehara
- Department of General Medicine, Chiba University Hospital, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, Japan
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Geese F, Schmitt KU. Interprofessional Collaboration in Complex Patient Care Transition: A Qualitative Multi-Perspective Analysis. Healthcare (Basel) 2023; 11:healthcare11030359. [PMID: 36766934 PMCID: PMC9914692 DOI: 10.3390/healthcare11030359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/16/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
Healthcare professionals often feel challenged by complex patients and the associated care needs during care transition. Interprofessional collaboration (IPC) is considered an effective approach in such situations. However, a fragmented healthcare system can limit IPC. This study explored experiences of Swiss healthcare professionals regarding complex patient care transition and the potential of IPC. Professionals from nursing, medicine, psychology, physiotherapy, dietetics and nutrition, social service, occupational therapy, and speech therapy were included. A qualitative between-method triangulation design was applied, with two focus group discussions and ten individual interviews. The combination of different data-collection methods allowed us to explore complex patient care transition and to systematically add perspectives of healthcare professionals from different care settings. Three main themes were identified: (1) Participants described their vision of an ideal complex patient care transition, i.e., the status they would like to see implemented; (2) participants reported challenges in complex patient care transition as experienced today; and (3) participants suggested ways to improve complex patient care transition by IPC. This study highlighted that healthcare professionals regarded IPC as an effective intervention to improve complex patient care transition. It emerged that sustainable implementation of IPC across care organizations is currently limited in Switzerland. In the absence of strong and direct promotion of IPC by the healthcare system, professionals in clinical practice can further promote IPC by finding hands-on solutions to overcome organizational boundaries.
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Kaneko H, Hanamoto A, Yamamoto-Kataoka S, Kataoka Y, Aoki T, Shirai K, Iso H. Evaluation of Complexity Measurement Tools for Correlations with Health-Related Outcomes, Health Care Costs and Impacts on Healthcare Providers: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16113. [PMID: 36498188 PMCID: PMC9741446 DOI: 10.3390/ijerph192316113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/24/2022] [Accepted: 11/24/2022] [Indexed: 06/17/2023]
Abstract
Various tools to measure patient complexity have been developed. Primary care physicians often deal with patient complexity. However, their usefulness in primary care settings is unclear. This study explored complexity measurement tools in general adult and patient populations to investigate the correlations between patient complexity and outcomes, including health-related patient outcomes, healthcare costs, and impacts on healthcare providers. We used a five-stage scoping review framework, searching MEDLINE and CINAHL, including reference lists of identified studies. A total of 21 patient complexity management tools were found. Twenty-five studies examined the correlation between patient complexity and health-related patient outcomes, two examined healthcare costs, and one assessed impacts on healthcare providers. No studies have considered sharing information or action plans with multidisciplinary teams while measuring outcomes for complex patients. Of the tools, eleven used face-to-face interviews, seven extracted data from medical records, and three used self-assessments. The evidence of correlations between patient complexity and outcomes was insufficient for clinical implementation. Self-assessment tools might be convenient for conducting further studies. A multidisciplinary approach is essential to develop effective intervention protocols. Further research is required to determine these correlations in primary care settings.
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Affiliation(s)
- Hiromitsu Kaneko
- Faculty of Medicine, Osaka University, Suita, Osaka 565-0871, Japan
| | | | - Sachiko Yamamoto-Kataoka
- Department of Health Informatics, Kyoto University Graduate School of Medicine/School of Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Tanaka Asukai-cho 89, Kyoto 606-8226, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka 541-0043, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Shogoin Kawara-cho 54, Kyoto 606-8507, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Yoshida Konoe-cho, Kyoto 606-8501, Japan
| | - Takuya Aoki
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Shogoin Kawara-cho 54, Kyoto 606-8507, Japan
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Kokoro Shirai
- Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Hiroyasu Iso
- Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
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Assessing multidimensional complexity in home care: congruencies and discrepancies between patients and nurses. BMC Nurs 2022; 21:166. [PMID: 35751082 PMCID: PMC9230082 DOI: 10.1186/s12912-022-00942-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
Background Person-centered care allows for the inclusion of the totality of a person’s needs and preferences, beyond just the clinical or medical aspect. This approach requires the development of tools to allow for the integration of the patient in his/her healthcare. Based on a 30-item tool developed for nurses to evaluate the complexity of home care situations (COMID), this study proposed a version for the patients (i.e. COMID-P). Both instruments were used, independently by nurses and patients, to rate the complexity of individual situations, in order to compare ratings. Methods The COMID-P and the COMID were completed during the fraXity study at the patients’ homes, independently by patients (aged 65 and over) and nurses. Item-level and scale-level analyses were performed using, Kappa and McNemar tests, and intra-class correlation (ICC). Results A total of 159 pairs of COMID and COMID-P ratings were retained for analyses. Results demonstrated a high degree of patient/nurse agreement for 12/30 items, a moderate agreement for 10/30 items, and a low degree of agreement for 7/30 items. The intra-class correlation between the COMID-P and the COMID was high (ICC= .826, 95%CI [.761-.873]). Conclusions The results demonstrate that patients and nurses can assess complexity using tools that have comparable structural properties. They also reveal congruencies and discrepancies in scoring the components of complexity, highlighting the need of reaching consensus in designing care plans. Further work is needed to demonstrate the benefits of joint assessment in developing care plans that truly meet patients’ needs. Trial registration The fraXity study was registered in ClinicalTrials.gov, NCT03883425, on March 20, 2019.
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Haruta J, Goto R, Sachiko O, Kimura S, Teruyama J, Hama Y, Maeno T. How do general practitioners handle complexities? A team ethnographic study in Japan. BMC PRIMARY CARE 2022; 23:133. [PMID: 35624417 PMCID: PMC9137137 DOI: 10.1186/s12875-022-01741-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 05/09/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND General practitioners (GPs) are often faced with complex problems, including patients with socio-economic and medical problems. However, the methods they use to approach these complexities are still not understood. We speculated that elucidating these methods using complex adaptive systems (CAS) methodology to comprehensively assess GPs' daily activities would contribute to improving the professional development of GPs. This study aimed to clarify how expert GPs handle complex problems and adapt to their community context through the ethnography of GPs and other healthcare professionals in terms of CAS. METHODS We adopted the interdisciplinary team-ethnographic research approach. Five hospitals and four clinics in Japan which were considered to employ expert GPs were selected by purposive sampling. 62 individuals of various backgrounds working in these nine facilities were interviewed. Using field notes and interview data, the researchers iteratively discussed the adequacy of our interpretations. The first author (JH) prepared a draft report, which was reviewed by the GPs at the participating facilities. Through critical and iterative consideration of the different insights obtained, the final findings emerged together with representative data. RESULTS We identified four approaches used by GPs to deal with complexities. First, GPs treat patients with complex problems as a whole being and address their problems multi-directionally. Second, GPs build horizontal, trusting relationships with other healthcare professionals and stakeholders, and thereby reduce the degree of complexity of problems. Third, GPs change the learning climate while committing to their own growth based on societal needs and by acting as role models for other professionals through daily interpersonal facilitation. Fourth, GPs share community vision with multi-professionals and thereby act as a driving force for organizational change. These various interactions among GPs, healthcare professionals, organizations and communities resulted in systematization of the healthcare and welfare network in their community. CONCLUSIONS Expert GPs developed interconnected multidimensional systems in their community health and welfare networks to adapt to fluctuating social realities using four approaches. GPs' work environment may be considered as a complex adaptive system (CAS) and the approach of GPs to complexities is CAS-based. Our findings are expected to have practical applications for GPs.
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Affiliation(s)
- Junji Haruta
- Medical Education Center, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku ku, Tokyo, 160-8582, Japan.
- Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
| | - Ryohei Goto
- Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Ozone Sachiko
- Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shuhei Kimura
- Faculty of Humanities and Social Sciences, University of Tsukuba, Tsukuba, Japan
| | - Junko Teruyama
- Faculty of Library, Information and Media Science, University of Tsukuba, Tsukuba, Japan
| | - Yusuke Hama
- Tokyo Junior College of Transportation, Tokyo, Japan
| | - Tetsuhiro Maeno
- Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Bunting SR, Calabrese SK, Spigner ST, Goetz TG, Morrison SD, Zucker SM, Ritchie TD, Garber SS, Batteson TJ. Evaluating Medical Students' Views of the Complexity of Sexual Minority Patients and Implications for Care. LGBT Health 2022; 9:348-358. [DOI: 10.1089/lgbt.2021.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Samuel R. Bunting
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Sarah K. Calabrese
- Department of Psychological and Brain Sciences, George Washington University, Washington, District of Columbia, USA
| | - Sabina T. Spigner
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Teddy G. Goetz
- Vagelos College of Physicians and Surgeons, Columbia University, New York City, New York, USA
| | - Shane D. Morrison
- Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Shana M. Zucker
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Timothy D. Ritchie
- Department of Psychology, Saint Xavier University, Chicago, Illinois, USA
| | - Sarah S. Garber
- Department of Pharmaceutical Sciences, College of Pharmacy, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Tamzin J. Batteson
- DeWitt C. Baldwin Institute for Interprofessional Education, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
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12
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Nicolaus S, Crelier B, Donzé JD, Aubert CE. Definition of patient complexity in adults: A narrative review. JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2022; 12:26335565221081288. [PMID: 35586038 PMCID: PMC9106317 DOI: 10.1177/26335565221081288] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 01/31/2022] [Indexed: 11/17/2022]
Abstract
Background Better identification of complex patients could help to improve their care. However, the definition of patient complexity itself is far from obvious. We conducted a narrative review to identify, describe, and synthesize the definitions of patient complexity used in the last 25 years. Methods We searched PubMed for articles published in English between January 1995 and September 2020, defining patient complexity. We extended the search to the references of the included articles. We assessed the domains presented in the definitions, and classified the definitions as based on (1) medical aspects (e.g., number of conditions) or (2) medical and/or non-medical aspects (e.g., socio-economic status). We assessed whether the definition was based on a tool (e.g., index) or conceptual model. Results Among 83 articles, there was marked heterogeneity in the patient complexity definitions. Domains contributing to complexity included health, demographics, behavior, socio-economic factors, healthcare system, medical decision-making, and environment. Patient complexity was defined according to medical aspects in 30 (36.1%) articles, and to medical and/or non-medical aspects in 53 (63.9%) articles. A tool was used in 36 (43.4%) articles, and a conceptual model in seven (8.4%) articles. Conclusion A consensus concerning the definition of patient complexity was lacking. Most definitions incorporated non-medical factors in the definition, underlining the importance of accounting not only for medical but also for non-medical aspects, as well as for their interrelationship.
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Affiliation(s)
- Stefanie Nicolaus
- Department of General Internal Medicine, Biel Hospital, Biel, Switzerland
| | - Baptiste Crelier
- Department of General Internal Medicine, Bern University Hospital, Inselspital, University of Bern, Inselspital, Bern, Switzerland
| | - Jacques D Donzé
- Department of Medicine, Neuchâtel Hospital Network, Neuchâtel, Switzerland
- Division of General Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Carole E Aubert
- Department of General Internal Medicine, Bern University Hospital, Inselspital, University of Bern, Inselspital, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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13
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Ben-Menahem S, Sialm A, Hachfeld A, Rauch A, von Krogh G, Furrer H. How do healthcare providers construe patient complexity? A qualitative study of multimorbidity in HIV outpatient clinical practice. BMJ Open 2021; 11:e051013. [PMID: 34810186 PMCID: PMC8609934 DOI: 10.1136/bmjopen-2021-051013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Patient complexity is an increasingly used concept in clinical practice, policy debates and medical research. Yet the literature lacks a clear definition of its meaning and drivers from the health provider's perspective. This shortcoming is problematic for clinical practice and medical education in the light of a rising number of multimorbid patients and the need for future healthcare providers that are adequately trained in treating complex patients. OBJECTIVES To develop an empirically grounded framework of healthcare providers' perceptions of patient complexity and to characterise the relationship between case complexity, care complexity and provider experience as complexity-contributing factors. DESIGN Qualitative study based on semistructured in-depth interviews with healthcare practitioners. SETTING A Swiss hospital-based HIV outpatient clinic. PARTICIPANTS A total of 31 healthcare providers participated. Participants volunteered to take part and comprised 17 nurses, 8 junior physicians (interns) and 6 senior physicians (residents, fellows and attendings). RESULTS Perceived patient complexity arises from the combination of case complexity drivers, the provider's perceived controllability, and a set of complexity moderators at the levels of the patient, the care provider and the broader care context. We develop a conceptual framework that outlines key relationships among these complexity-contributing factors and present 10 key questions to help guide medical professionals in making complexity more explicit and more manageable in daily practice. CONCLUSIONS The framework presented in this study helps to advance a shared understanding of patient complexity. Our findings inform curriculum design and the teaching of essential skills to medical students in areas characterised by high patient complexity such as general internal medicine and geriatrics. From a policy perspective, our findings have important implications for the design of more effective healthcare interventions for complex patients.
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Affiliation(s)
- Shiko Ben-Menahem
- Department of Management, Technology and Economics, ETH Zurich, Zurich, Switzerland
| | - Anastassja Sialm
- Department of Management, Technology and Economics, ETH Zurich, Zurich, Switzerland
| | - Anna Hachfeld
- Department of Infectious Diseases, Inselspital University Hospital Bern, Bern, Switzerland
| | - Andri Rauch
- Department of Infectious Diseases, Inselspital University Hospital Bern, Bern, Switzerland
| | - Georg von Krogh
- Department of Management, Technology and Economics, ETH Zurich, Zurich, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital University Hospital Bern, Bern, Switzerland
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14
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Lim ZZB, Mohamed Kadir M, Ginting ML, Vrijhoef HJM, Yoong J, Wong CH. Early Implementation of a Patient-Centered Medical Home in Singapore: A Qualitative Study Using Theory on Diffusion of Innovations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111160. [PMID: 34769680 PMCID: PMC8583400 DOI: 10.3390/ijerph182111160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022]
Abstract
Patient-Centered Medical Home (PCMH) has been found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. This study explored the ground-up implementation of a PCMH in Singapore by describing change strategies and unpacking initial experience and perception. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners, and other providers. “Diffusion of innovations” emerged as an overarching theory to contextualize PCMH in its early implementation. Three core “innovations” differentiated the PCMH from usual primary care: (i) team-based and integrated care; (ii) empanelment; and (iii) shared care with other general practitioners. Change strategies employed to implement these innovations included repurposing pre-existing resources, building a partnership to create supporting infrastructure and pathways in the delivery system, and doing targeted outreach to introduce the PCMH. Initial experience and perception were characterized by processes to “adopt” and “assimilate” the innovations, which were identified as challenging due to less predictable, self-organizing behaviors by multiple players. To work with the inherent complexity and novelty of the innovations, time, leadership, standardized methods, direct communication, and awareness-building efforts are needed. This study was retrospectively registered (Protocol ID: NCT04594967).
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Affiliation(s)
- Zoe Zon Be Lim
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
- Correspondence:
| | - Mumtaz Mohamed Kadir
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
| | - Mimaika Luluina Ginting
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
| | | | - Joanne Yoong
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
- Center for Economic and Social Research, University of Southern Carolina, Los Angeles, CA 90089, USA
- Research for Impact, Singapore 159964, Singapore
| | - Chek Hooi Wong
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
- Tsao Foundation, Singapore 168730, Singapore
- Health Services & Systems Research, Duke-NUS, Singapore 169857, Singapore
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15
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Tuzzio L, Berry AL, Gleason K, Barrow J, Bayliss EA, Gray MF, Delate T, Bermet Z, Uratsu CS, Grant RW, Ralston JD. Aligning care with the personal values of patients with complex care needs. Health Serv Res 2021; 56 Suppl 1:1037-1044. [PMID: 34363205 PMCID: PMC8515216 DOI: 10.1111/1475-6773.13862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To identify opportunities to align care with the personal values of patients from three distinct groups with complex medical, behavioral, and social needs. DATA SOURCES/STUDY SETTING Between June and August 2019, we conducted semi-structured interviews with individuals with complex care needs in two integrated health care delivery systems. STUDY DESIGN Qualitative study using semi-structured interviews. DATA COLLECTION METHODS We interviewed three groups of patients at Kaiser Permanente Washington and Kaiser Permanente Colorado representing three distinct profiles of complex care needs: Group A ("obesity, opioid prescription, and low-resourced neighborhood"), Group B ("older, high medical morbidity, emergency department, and hospital use"), and Group C ("older, mental and physical health concerns, and low-resourced neighborhood"). These profiles were identified based on prior work and prioritized by internal primary care stakeholders. Interview transcripts were analyzed using thematic analysis. PRINCIPAL FINDINGS Twenty-four patients participated; eight from each complex needs profile. Mean age across groups was 71 (range 48-86) years. We identified five themes common across the three groups that captured patients' views regarding values-aligned care. These themes focused on the importance of care teams exploring and acknowledging a patient's values, providing access to nonphysician providers who have different perspectives on care delivery, offering values-aligned mental health care, ensuring connection to community-based resources that support values and address needs, and providing care that supports the patient plus their family and caregivers. CONCLUSIONS Our results suggest several opportunities to improve how care is delivered to patients with different complex medical, behavioral, and social needs. Future research is needed to better understand how to incorporate these opportunities into health care.
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Affiliation(s)
- Leah Tuzzio
- Kaiser Permanente Washington Health Research InstituteSeattleWAUSA
| | - Andrew L. Berry
- Department of Biomedical Informatics & Medical EducationUniversity of WashingtonSeattleWashingtonUSA
| | - Kathy Gleason
- Kaiser Permanente Colorado Institute for Health ResearchAuroraColoradoUSA
| | - Jennifer Barrow
- Kaiser Permanente Colorado Institute for Health ResearchAuroraColoradoUSA
| | | | | | - Thomas Delate
- Pharmacy Outcomes Research Group, Kaiser Permanente National PharmacyAuroraColoradoUSA
| | - Zoe Bermet
- Kaiser Permanente Washington Health Research InstituteSeattleWAUSA
| | - Connie S. Uratsu
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Richard W. Grant
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - James D. Ralston
- Kaiser Permanente Washington Health Research InstituteSeattleWAUSA
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16
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Characteristics and Service Utilization by Complex Chronic and Advanced Chronic Patients in Catalonia: A Retrospective Seven-Year Cohort-Based Study of an Implemented Chronic Care Program. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189473. [PMID: 34574394 PMCID: PMC8464881 DOI: 10.3390/ijerph18189473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/02/2021] [Accepted: 09/06/2021] [Indexed: 12/23/2022]
Abstract
The Chronic Care Program introduced in Catalonia in 2011 focuses on improving the identification and management of complex chronic (CCPs) and advanced chronic patients (ACPs) by implementing an individualized care model. Its first stage is their identification based on chronicity, difficult clinical management (i.e., complexity), and, in ACPs, limited life prognosis. Subsequent stages are individual evaluation and implementation of a shared personalized care plan. This retrospective study, including all CCPs and ACPs identified in Catalonia between 2013 and 2019, was aimed at describing the characteristics and healthcare service utilization among these patients. Data were obtained from an administrative database and included sociodemographic, clinical, and service utilization variables and morbidity-associated risk according to the Adjusted Morbidity Groups (GMA) stratification. During the study period, CCPs’ and ACPs’ prevalence increased and was higher in lower-income populations; most cases were women. CCPs and ACPs had all comorbidities at higher frequencies, higher utilization of healthcare services, and were more frequently at high risk (63% and 71%, respectively) than age-, sex-, and income level-adjusted non-CCP (23%) and non-ACP populations (30%). These results show effective identification of the program’s target population and demonstrate that CCPs and ACPs have a higher burden of multimorbidity and healthcare needs.
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17
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Roskos SE, Fitzpatrick L, Arnetz B, Arnetz J, Shrotriya S, Hengstebeck E. Complex patients' effect on family physicians: high cognitive load and negative emotional impact. Fam Pract 2021; 38:454-459. [PMID: 33367637 DOI: 10.1093/fampra/cmaa137] [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] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Complex patients present an increasing challenge to the health care system and family physicians play an important role in their care. As part of a larger project exploring family physicians' perceptions of complex patients, we sought to understand how complex patients affect family physicians and if these effects might be related to physician burnout. METHODS We conducted a qualitative study involving interviews with family physicians from various practice settings. We invited the physicians to choose three of their patients between the ages of 18 and 64 whom they considered to have complex medical problems and to have access to their medical records during a telephone interview using a semi-structured interview guide. Interviews were audio-recorded, professionally transcribed and coded. Using qualitative analytical software, research team members worked together to analyse the interview data and determine emerging themes. RESULTS Eleven family physicians participated in the interviews and described 29 unique complex patients, including challenges and effects on them personally. Analysis of the available 10 family physicians' interviews revealed two themes related to complexity's impact on physicians: (i) high cognitive load and (ii) negative emotional impact. CONCLUSION Although preliminary, this study offers a previously unconsidered understanding of drivers of physician burnout, including high cognitive load and negative emotional impact on family physicians created by caring for complex patients. Interventions to improve health care, including addressing physician wellness and burnout, should include the provision of resources to assist them with decreasing cognitive load and negative emotional impact when caring for complex patients.
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Affiliation(s)
- Steven E Roskos
- Department of Family Medicine, Michigan State University, East Lansing, MI, USA.,Department of Family Medicine, Sparrow Hospital, Lansing, MI, USA
| | - Laurie Fitzpatrick
- Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University, East Lansing, MI, USA
| | - Bengt Arnetz
- Department of Family Medicine, Michigan State University, East Lansing, MI, USA.,Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Judy Arnetz
- Department of Family Medicine, Michigan State University, East Lansing, MI, USA
| | - Shiva Shrotriya
- Department of Medicine, Michigan State University, East Lansing, MI, USA
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18
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Justesen K, Smith JD, Swanson K, Yeazel M, Pacala JT. Michelle's Story: The Complexity of Patient Care in a Family Medicine Residency Clinic. Ann Fam Med 2021; 19:362-364. [PMID: 34264840 PMCID: PMC8282285 DOI: 10.1370/afm.2652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Family medicine covers all ages and specializes in chronic disease management as well as acute care medicine. As the health of the population continues to grow in complexity, treating patients appropriately and efficiently is imperative to improving health outcomes and managing health care costs. Family medicine physicians are uniquely poised to provide this type of care. A patient story plus a look at the patients seen over the course of a day within a family medicine residency clinic explores the complexity of care and the ability of family medicine physicians to provide the necessary care. Taking a close look at who comes through our door on a particular day highlights 3 points: primary care physicians are seeing patients with an increasing complexity of needs, our society is witnessing an extreme increase in patients suffering with mental health problems and substance use disorders, and addressing social determinants of health must be part of the solution.
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Affiliation(s)
- Kathryn Justesen
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - James D Smith
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Katherine Swanson
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Mark Yeazel
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - James T Pacala
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
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19
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Maree P, Hughes R, Radford J, Stankovich J, Van Dam PJ. Integrating patient complexity into health policy: a conceptual framework. AUST HEALTH REV 2021; 45:199-206. [PMID: 33208225 DOI: 10.1071/ah19290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/19/2020] [Indexed: 11/23/2022]
Abstract
Objective Clinicians across all health professions increasingly strive to add value to the care they deliver through the application of the central tenets of people-centred care (PCC), namely the 'right care', in the 'right place', at the 'right time' and 'tailored to the needs of communities'. This ideal is being hampered by a lack of a structured, evidence-based means to formulate policy and value the commissioning of services in an environment of increasing appreciation for the complex health needs of communities. This creates significant challenges for policy makers, commissioners and providers of health services. Communities face a complex intersection of challenges when engaging with healthcare. Increasingly, complexity is gaining prominence as a significant factor in the delivery of PCC. Based on the World Health Organization (WHO) components of health policy, this paper proposes a policy framework that enables policy makers, commissioners and providers of health care to integrate a model of complexity into policy, subsequent service planning and development of models of care. Methods The WHO components of health policy were used as the basis for the framework. Literature was drawn on to develop a policy framework that integrates complexity into health policy. Results Within the framework, complexity is juxtaposed between the WHO components of 'vision', 'priorities' and 'roles'. Conclusion This framework, supported by the literature, provides a means for policy makers and health planners to conduct analyses of and for policy. Further work is required to better model complexity in a manner that integrates consumer needs and provider capabilities. What is known about the topic? There is a growing body of evidence regarding patient complexity and its impact on the delivery of health services, but there is little consideration of patient complexity in policy, which is an important consideration for service provision. What does this paper add? This paper presents an argument for the inclusion of patient complexity in health policy and provides a framework for how that might occur. What are the implications for practitioners? The inclusion of patient complexity in policy could provide a means for policy makers to consider the factors that contribute to patient complexity in service provision decisions.
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Affiliation(s)
- Peter Maree
- Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia. ; ; and Department of Health, 22 Elizabeth Street, Hobart, Tas. 7000, Australia; and Corresponding author.
| | - Roger Hughes
- Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia. ;
| | - Jan Radford
- General Practice, Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia.
| | - Jim Stankovich
- Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia. ; ; and Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Vic. 3004, Australia.
| | - Pieter Jan Van Dam
- Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia. ;
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20
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Gabrielian S, Jones AL, Hoge AE, deRussy AJ, Kim YI, Montgomery AE, Blosnich JR, Gordon AJ, Gelberg L, Austin EL, Pollio D, Holmes SK, Varley AL, Kertesz SG. Enhancing Primary Care Experiences for Homeless Patients with Serious Mental Illness: Results from a National Survey. J Prim Care Community Health 2021; 12:2150132721993654. [PMID: 33543675 PMCID: PMC7871055 DOI: 10.1177/2150132721993654] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objectives: Patients experiencing homelessness (PEH) with serious mental illness (SMI) have poor satisfaction with primary care. We assessed if primary care teams tailored for homeless patients (Homeless-Patient Aligned Care Teams (H-PACTs)) provide this population with superior experiences than mainstream primary care and explored whether integrated behavioral health and social services were associated with favorable experiences. Methods: We surveyed VA PEH with SMI (n = 1095) to capture the valence of their primary care experiences in 4 domains (Access/Coordination, Patient-Clinician Relationships, Cooperation, and Homeless-Specific Needs). We surveyed clinicians (n = 52) from 29 H-PACTs to elucidate if their clinics had embedded mental health, addiction, social work, and/or housing services. We counted these services in each H-PACT (0-4) and classified H-PACTs as having high (3-4) versus low (0-2) service integration. We controlled for demographics, housing history, and needs in comparing H-PACT versus mainstream experiences; and experiences in high versus low integration H-PACTs. Results: Among respondents, 969 (91%) had complete data and 626 (62%) were in H-PACTs. After covariate adjustment, compared to mainstream respondents, H-PACT respondents were more likely (P < .01) to report favorable experiences (AORs = 1.7-2.1) and less likely to report unfavorable experiences (AORs = 0.5-0.6) in all 4 domains. Of 29 H-PACTs, 27.6% had high integration. High integration H-PACT respondents were twice as likely as low integration H-PACT respondents to report favorable access/coordination experiences (AOR = 1.7). Conclusions: Homeless-tailored clinics with highly-integrated services were associated with better care experiences among PEH with SMI. These observational data suggest that tailored primary care with integrated services may improve care perceptions among complex patients.
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Affiliation(s)
- Sonya Gabrielian
- VA Greater Los Angeles Health Care System, Los Angeles, CA, USA.,University of California Los Angeles, Los Angeles, CA, USA
| | - Audrey L Jones
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - April E Hoge
- Birmingham VA Medical Center, Birmingham, AL, USA
| | | | - Young-Il Kim
- Birmingham VA Medical Center, Birmingham, AL, USA.,University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Ann Elizabeth Montgomery
- Birmingham VA Medical Center, Birmingham, AL, USA.,University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
| | - John R Blosnich
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,University of Southern California, Los Angeles, CA, USA
| | - Adam J Gordon
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lillian Gelberg
- VA Greater Los Angeles Health Care System, Los Angeles, CA, USA.,University of California Los Angeles, Los Angeles, CA, USA
| | - Erika L Austin
- Birmingham VA Medical Center, Birmingham, AL, USA.,University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
| | - David Pollio
- University of Alabama at Birmingham College of Letters and Sciences, Birmingham, AL, USA
| | | | | | - Stefan G Kertesz
- Birmingham VA Medical Center, Birmingham, AL, USA.,University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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21
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Lalloo D, Gallagher J, Macdonald E, McDonnell C. Clinical Case Complexity in Occupational Health: Contributing Factors and a Proposed Conceptual Framework Model. J Occup Environ Med 2021; 63:e352-e361. [PMID: 33950037 DOI: 10.1097/jom.0000000000002215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Clinical case complexity is an inherent factor in occupational health (OH), yet it is poorly defined and understood. Our aim was to identify the multiple sources of complexity in OH and propose a conceptual complexity framework model for clinical OH practice. METHODS Through a scoping review, expert panel consensus, and content analysis of OH clinical case reports, we identified relevant complexity-contributing factors (CCFs) specifically tailored to the OH setting, which we defined and validated. RESULTS The proposed model consists of three primary domains (PDs); health factors, workplace factors and biopsychosocial factors. Twenty-seven CCFs are described and defined within these PDs. CONCLUSIONS This work lays the foundation for improved understanding, identification, and assessment of complexity in OH. This is imperative for ensuring high quality clinical practice standards, identifying training needs and appropriate triaging/resource allocation.
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Affiliation(s)
- Drushca Lalloo
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8RZ, UK (Dr Lalloo and Dr Macdonald); School of Public Health, University College Cork, Cork T12 YN60, Ireland (Dr Gallagher); Mid-West Region, Limerick V94 7X9, Ireland (Dr McDonnell)
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22
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Measuring the complexity of general practice consultations: a Delphi and cross-sectional study in English primary care. Br J Gen Pract 2021; 71:e423-e431. [PMID: 33824162 PMCID: PMC8049201 DOI: 10.3399/bjgp.2020.0486] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 11/13/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The complexity of general practice consultations may be increasing and varies in different settings. A measure of complexity is required to test these hypotheses. AIM To develop a valid measure of general practice consultation complexity applicable to routine medical records. DESIGN AND SETTING Delphi study to select potential indicators of complexity followed by a cross-sectional study in English general practices to develop and validate a complexity measure. METHOD The online Delphi study over two rounds identified potential indicators of consultation complexity. The cross-sectional study used an age-sex stratified random sample of patients and general practice face-to-face consultations from 2013/2014 in the Clinical Practice Research Datalink. The authors explored independent relationships between each indicator and consultation duration using mixed-effects regression models, and revalidated findings using data from 2017/2018. The proportion of complex consultations in different age-sex groups was assessed. RESULTS A total of 32 GPs participated in the Delphi study. The Delphi panel endorsed 34 of 45 possible complexity indicators after two rounds. After excluding factors because of low prevalence or confounding, 17 indicators were retained in the cross-sectional study. The study used data from 173 130 patients and 725 616 face-to-face GP consultations. On defining complexity as the presence of any of these 17 factors, 308 370 consultations (42.5%) were found to be complex. Mean duration of complex consultations was 10.49 minutes, compared to 9.64 minutes for non-complex consultations. The proportion of complex consultations was similar in males and females but increased with age. CONCLUSION The present consultation complexity measure has face and construct validity. It may be useful for research, management and policy, and for informing decisions about the range of resources needed in different practices.
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23
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Clustering Complex Chronic Patients: A Cross-Sectional Community Study From the General Practitioner's Perspective. Int J Integr Care 2021; 21:4. [PMID: 33976594 PMCID: PMC8064281 DOI: 10.5334/ijic.5496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: Characterize subgroups of Complex Chronic Patients (CCPs) with cluster analysis from the general practitioner’s perspective. Study design: Cross-sectional population-based study. Setting: Three Primary Care urban centres for a reference population of 43,647 inhabitants over 14 years old in Sabadell, Catalonia, Spain. Methods: Complexity is defined by the independent clinical judgment of general practitioners with the aid of complexity domains (both clinical and social). We used a Two-Step Cluster method to identify relevant subgroups of CCPs. Results: Three relevant subgroups were identified. The first one was mainly managed by primary care professionals, and 63% of its CCPs belonged to the high-risk stratum of the Adjusted Morbidity Groups (GMA). The second subgroup included younger patients than the other two clusters, and showed the highest ratios of social deprivation and severe mental disease; 48% of its CCPs belonged to the high-risk stratum of the GMA. A third cluster included patients who belonged to the high-risk stratum of the GMA. Their age was similar to that of the patients in the first cluster, but they showed the highest values in the following areas: (i) risk of admission; (ii) proportion of advanced chronic disease and limited-life prognosis; (iii) functional loss and (iv) geriatric syndromes, along with special uncertainty in decision-making and clinical management. Conclusions: Characterization of CCPs shows clearly distinct profiles of needs, which provides an improved epidemiological picture by identifying clusters of patients who are likely to benefit from targeted interventions.
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Yoshioka-Maeda K, Fujii H. Characteristics of Departments That Provided Primary Support for Households with Complex Care Needs in the Community: A Preliminary Cross-Sectional Study. Healthcare (Basel) 2021; 9:healthcare9040403. [PMID: 33916173 PMCID: PMC8065787 DOI: 10.3390/healthcare9040403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/19/2021] [Accepted: 03/26/2021] [Indexed: 11/16/2022] Open
Abstract
To prevent emergency admissions and save medical costs, support should be provided to households that include people with complex care needs to allow them to continue living in their own homes. This community-based, cross-sectional study was conducted to (1) identify which departments that public health nurses (PHNs) worked have been the primary providers of support for households with complex care needs and (2) clarify the length of time required by each department to resolve primary health problems. We analyzed 148 households with complex care needs that were registered in City A from April 2018 to July 2019. Four types of departments were the primary support providers for complex care households: the department supporting persons with disabilities (n = 54, 36.5%), public/community health centers (n = 47, 31.8%), department of older adults (n = 29, 19.6%), and welfare offices (n = 18, 12.2%). The Mantel–Cox test showed that welfare offices mainly supported households in economic distress and needed significantly less time to resolve their primary health issues than other departments. For early detection and resolution of primary health problems for households with complex care needs, PHNs and healthcare professionals should focus on their economic distress and enhanced multidisciplinary approaches.
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Affiliation(s)
- Kyoko Yoshioka-Maeda
- Department of Health Promotion, National Institute of Public Health, 2-3-6, Minami, Wako-shi, Saitama 351-0197, Japan
- Correspondence: ; Tel.: +81-48-458-6111
| | - Hitoshi Fujii
- Department of Medical Statistics, School of Nursing, Mejiro University, 320 Ukiya, Iwatsuki-ku, Saitama-shi, Saitama 339-8501, Japan;
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Experiences of the Medication Use Process by People with Intellectual Disabilities. What a Pharmacist Should Know! PHARMACY 2021; 9:pharmacy9010024. [PMID: 33494475 PMCID: PMC7838794 DOI: 10.3390/pharmacy9010024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/08/2020] [Accepted: 01/04/2021] [Indexed: 11/16/2022] Open
Abstract
There is a scarcity of information about the experience of people with intellectual disabilities in the medication use process. Six people with intellectual disabilities consented to be interviewed by a pharmacist to determine their knowledge and views of medication use. Data from semi-structured interviews were analysed using a grounded theory approach. Self-determination and risk to the quality of the medication use process were identified as theories. Literature review provided two explanations—vulnerabilities of people with intellectual disabilities in healthcare and pharmacists have a role to play in ensuring a quality medication use process for people with intellectual disabilities. People with intellectual disabilities may be ‘expert patients’ and can provide valuable insights into their experience of medication use. They may be ‘high risk’ patients but may not be recognized as such by pharmacists.
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Grant RW, McCloskey J, Hatfield M, Uratsu C, Ralston JD, Bayliss E, Kennedy CJ. Use of Latent Class Analysis and k-Means Clustering to Identify Complex Patient Profiles. JAMA Netw Open 2020; 3:e2029068. [PMID: 33306116 PMCID: PMC7733156 DOI: 10.1001/jamanetworkopen.2020.29068] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Medically complex patients are a heterogeneous group that contribute to a substantial proportion of health care costs. Coordinated efforts to improve care and reduce costs for this patient population have had limited success to date. OBJECTIVE To define distinct patient clinical profiles among the most medically complex patients through clinical interpretation of analytically derived patient clusters. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed the most medically complex patients within Kaiser Permanente Northern California, a large integrated health care delivery system, based on comorbidity score, prior emergency department admissions, and predicted likelihood of hospitalization, from July 18, 2018, to July 15, 2019. From a starting point of over 5000 clinical variables, we used both clinical judgment and analytic methods to reduce to the 97 most informative covariates. Patients were then grouped using 2 methods (latent class analysis, generalized low-rank models, with k-means clustering). Results were interpreted by a panel of clinical stakeholders to define clinically meaningful patient profiles. MAIN OUTCOMES AND MEASURES Complex patient profiles, 1-year health care utilization, and mortality outcomes by profile. RESULTS The analysis included 104 869 individuals representing 3.3% of the adult population (mean [SD] age, 70.7 [14.5] years; 52.4% women; 39% non-White race/ethnicity). Latent class analysis resulted in a 7-class solution. Stakeholders defined the following complex patient profiles (prevalence): high acuity (9.4%), older patients with cardiovascular complications (15.9%), frail elderly (12.5%), pain management (12.3%), psychiatric illness (12.0%), cancer treatment (7.6%), and less engaged (27%). Patients in these groups had significantly different 1-year mortality rates (ranging from 3.0% for psychiatric illness profile to 23.4% for frail elderly profile; risk ratio, 7.9 [95% CI, 7.1-8.8], P < .001). Repeating the analysis using k-means clustering resulted in qualitatively similar groupings. Each clinical profile suggested a distinct collaborative care strategy to optimize management. CONCLUSIONS AND RELEVANCE The findings suggest that highly medically complex patient populations may be categorized into distinct patient profiles that are amenable to varying strategies for resource allocation and coordinated care interventions.
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Affiliation(s)
- Richard W. Grant
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jodi McCloskey
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Meghan Hatfield
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Connie Uratsu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - James D. Ralston
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | | | - Chris J. Kennedy
- Division of Research, Kaiser Permanente Northern California, Oakland
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley
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Packer T, Kephart G, Audulv Å, Keddy A, Warner G, Peacock K, Sampalli T. Protocol for development, calibration and validation of the Patient-Reported Inventory of Self-Management of Chronic Conditions (PRISM-CC). BMJ Open 2020; 10:e036776. [PMID: 32998919 PMCID: PMC7528366 DOI: 10.1136/bmjopen-2020-036776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Assessing and measuring patients' chronic condition self-management needs are critical to quality health care and to related research. One in three adults around the world live with multiple chronic conditions. While many patient-reported measures of self-management have been developed, none has emerged as the gold standard, and all have one or more of the following limitations: (1) they fail to measure the different domains of self-management important to patients, (2) they lack sufficient specificity to support patient-centred care or identify the specific components of self-management interventions that work and/or (3) they lack suitability for patients with multiple chronic conditions. METHODS AND ANALYSIS The Patient-Reported Inventory of Self-Management of Chronic Conditions (PRISM-CC) is being developed to overcome these shortcomings. It will measure respondents' perceived success (or difficulty) in self-managing seven domains important to patients. The protocol has three phases. Phase 1 is conceptual model development and item generation. Phase 2 is assessment of the relevance and understanding of items by people with chronic conditions. Phase 3 is item analysis, dimensionality assessment, scaling and preliminary validation of the PRISM-CC using an online survey of people with chronic conditions (n~750). The expected completion date is early 2021. ETHICS AND DISSEMINATION This study will adhere to the Canadian Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans. Ethics approval for all phases has been obtained from the Nova Scotia Health Authority Research Ethics Board. Once completed, the PRISM-CC will be made available for research and healthcare at minimal to no cost.
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Affiliation(s)
- Tanya Packer
- Schools of Occupational Therapy and Health Administration, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
- Rehabilitation Department, Radboud Unversity Medical Centre, Nijmegen, Gelderland, The Netherlands
| | - George Kephart
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Åsa Audulv
- Department of Nursing, Umeå Universitet Medicinska fakulteten, Umea, Sweden
| | - America Keddy
- School of Occupational Therapy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Grace Warner
- School of Occupational Therapy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kylie Peacock
- School of Occupational Therapy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tara Sampalli
- Research, Innovation and Discovery, Nova Scotia Health, Halifax, Nova Scotia, Canada
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Vaisman A, Barry P, Flood J. Assessing Complexity Among Patients With Tuberculosis in California, 1993-2016. Open Forum Infect Dis 2020; 7:ofaa264. [PMID: 32793763 PMCID: PMC7415303 DOI: 10.1093/ofid/ofaa264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/03/2020] [Indexed: 12/27/2022] Open
Abstract
Background Although the number of patients with active tuberculosis (TB) has decreased in the last 25 years, anecdotal reports suggest that the complexity of these patients has increased. However, this complexity and its components have never been quantified or defined. We therefore aimed to describe the complexity of patients with active TB in California during 1993–2016. Methods We analyzed data on patient comorbidities, clinical features, and demographics from the California Department of Public Health TB Registry. All adult patients who were alive at the time of TB diagnosis in California during 1993–2016 were included in the analyses. Factors deemed by an expert panel to increase complexity (ie, increased resources or expertise requirement for successful management) were analyzed and included the following: age >75 years, HIV infection, multidrug resistance (MDR), and extrapulmonary TB disease. Second, using additional information on other comorbidities available starting in 2010, we performed exploratory factor analysis on 25 variables in order to define the dimensions of complexity. Results Among the 67 512 patients analyzed, the proportion of patients with extrapulmonary disease, age >75 years, or MDR-TB each increased over the study period (P < .001), while the proportion of patients with HIV decreased. Furthermore, the proportion of patients with at least 1 factor of those increased, rising from 38.8% to 45.3% (P < .001) from 1993 to 2016. Dimensions of complexity identified in the exploratory factor analysis included the following: race/immigration, social features, elderly/institutionalized, advanced TB, comorbidity, and drug resistance risk. Conclusions In this first description of complexity in the setting of TB, we found that the complexity of patients with active TB has risen over the last 25 years in California. These findings suggest that despite the overall decline in active TB cases, effective management of more complex patients may require additional attention and resource investment.
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Affiliation(s)
- Alon Vaisman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Infection Prevention and Control Department, University Health Network, Toronto, Ontario, Canada
| | - Pennan Barry
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA
| | - Jennifer Flood
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA
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Busnel C, Ludwig C, Da Rocha Rodrigues MG. [Complexity in nursing practice : Toward a new conceptual framework in nursing care]. Rech Soins Infirm 2020; 140:7-16. [PMID: 32524804 DOI: 10.3917/rsi.140.0007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
While complexity theory has gradually influenced the field of health and social sciences, it has also had an impact on nursing care by introducing a wealth of terminology into the field. The terms “complex patient,” “complex case,” “complex care,” “complex practice,” and “complex needs” have been proposed to describe different aspects of complexity in nursing care. As these qualifiers reflect, nurses become actors in multidefined care and must integrate complexity into their reflective practice. By way of a narrative literature review, this article aims to offer a new perspective on nursing by explaining the different terms used in the discipline, using a multi-level approach. At the end of this review, the authors propose a new integrative conceptual framework for complexity in nursing practice.
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Beemster TT, van Velzen JM, van Bennekom CAM, Reneman MF, Frings-Dresen MHW. Usefulness and feasibility of comprehensive and less comprehensive vocational rehabilitation for patients with chronic musculoskeletal pain: perspectives from patients, professionals, and managers. Disabil Rehabil 2020; 44:754-767. [PMID: 32588666 DOI: 10.1080/09638288.2020.1780481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To explore the usefulness and feasibility of a comprehensive vocational rehabilitation (C-VR) program and less comprehensive (LC-VR) program for workers on sick leave due to chronic musculoskeletal pain, from the perspective of patients, professionals, and managers. MATERIALS AND METHODS Semi-structured interviews were held with patients, professionals, and managers. Using topic lists, participants were questioned about barriers to and facilitators of the usefulness and feasibility of C-VR and LC-VR. Thirty interviews were conducted with thirteen patients (n = 6 C-VR, n = 7 LC-VR), eight professionals, and nine managers. All interviews were transcribed verbatim. Data were analyzed by systematic text condensation using inductive thematic analysis. RESULTS Three themes emerged for usefulness ("patient factors," "content," "dosage") and six themes emerged for feasibility ("satisfaction," "intention to continue use," "perceived appropriateness," "positive/negative effects on target participants," "factors affecting implementation ease or difficulty," "adaptations"). The patients reported that both programs were feasible and generally useful. The professionals preferred working with the C-VR, although they disliked the fixed and uniform character of the program. They also mentioned that this program is too extensive for some patients, and that the latter would probably benefit from the LC-VR program. Despite their positive intentions, the managers stated that due to the Dutch healthcare system, implementation of the LC-VR program would be financially unfeasible. CONCLUSIONS The main conclusion of this study is that it is not useful to have one VR program for all patients with CMP and reduced work participation, and that flexible and tailored-based VR are warranted.Implications for rehabilitationBoth comprehensive and less comprehensive vocational rehabilitation are deemed useful for patients with chronic musculoskeletal pain and reduced work participation. Particular patient factors, for instance information uptake, discipline, willingness to change, duration of complaints, movement anxiety, obstructing thoughts, and willingness to return to work might guide the right program for the right patient.Both comprehensive and less comprehensive vocational rehabilitation are deemed feasible in practice. However, factors such as center logistic (schemes, rooms, professionals available) and country-specific healthcare insurance and sickness compensation systems should foster the implementation of less comprehensive programs.
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Affiliation(s)
- Timo T Beemster
- Department of Rehabilitation Medicine, Center for Rehabilitation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Research and Development, Heliomare Rehabilitation Center, Wijk aan Zee, The Netherlands.,Amsterdam UMC, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Judith M van Velzen
- Department of Research and Development, Heliomare Rehabilitation Center, Wijk aan Zee, The Netherlands.,Amsterdam UMC, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Coen A M van Bennekom
- Department of Research and Development, Heliomare Rehabilitation Center, Wijk aan Zee, The Netherlands.,Amsterdam UMC, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Michiel F Reneman
- Department of Rehabilitation Medicine, Center for Rehabilitation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Monique H W Frings-Dresen
- Amsterdam UMC, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health research institute, Amsterdam, The Netherlands
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Langton JM, Wong ST, Burge F, Choi A, Ghaseminejad-Tafreshi N, Johnston S, Katz A, Lavergne R, Mooney D, Peterson S, McGrail K. Population segments as a tool for health care performance reporting: an exploratory study in the Canadian province of British Columbia. BMC FAMILY PRACTICE 2020; 21:98. [PMID: 32475339 PMCID: PMC7262753 DOI: 10.1186/s12875-020-01141-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 04/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary care serves all age groups and individuals with health states ranging from those with no chronic conditions to those who are medically complex, or frail and approaching the end of life. For information to be actionable and guide planning, there must be some population disaggregation based on differences in expected needs for care. Promising approaches to segmentation in primary care reflect both the breadth and severity of health states, the types and amounts of health care utilization that are expected, and the roles of the primary care provider. The purpose of this study was to assess population segmentation as a tool to create distinct patient groups for use in primary care performance reporting. METHODS This cross-sectional study used administrative data (patient characteristics, physician and hospital billings, prescription medicines data, emergency department visits) to classify the population of British Columbia (BC), Canada into one of four population segments: low need, multiple morbidities, medically complex, and frail. Each segment was further classified using socioeconomic status (SES) as a proxy for patient vulnerability. Regression analyses were used to examine predictors of health care use, costs and selected measures of primary care attributes (access, continuity, coordination) by segment. RESULTS Average annual health care costs increased from the low need ($ 1460) to frail segment ($10,798). Differences in primary care cost by segment only emerged when attributes of primary care were included in regression models: accessing primary care outside business hours and discontinuous primary care (≥5 different GP's in a given year) were associated with higher health care costs across all segments and higher continuity of care was associated with lower costs in the frail segment (cost ratio = 0.61). Additionally, low SES was associated with higher costs across all segments, but the difference was largest in the medically complex group (cost ratio = 1.11). CONCLUSIONS Population segments based on expected need for care can support primary care measurement and reporting by identifying nuances which may be lost when all patients are grouped together. Our findings demonstrate that variables such as SES and use of regression analyses can further enhance the usefulness of segments for performance measurement and reporting.
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Affiliation(s)
- Julia M Langton
- Centre for Health Services and Policy Research, The University of British Columbia (UBC), 201-2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Sabrina T Wong
- Centre for Health Services and Policy Research, The University of British Columbia (UBC), 201-2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
- School of Nursing, UBC, Vancouver, Canada
| | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Alexandra Choi
- Centre for Health Services and Policy Research, The University of British Columbia (UBC), 201-2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Niloufar Ghaseminejad-Tafreshi
- Centre for Health Services and Policy Research, The University of British Columbia (UBC), 201-2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Sharon Johnston
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alan Katz
- Department of Family Medicine and Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ruth Lavergne
- Faculty of Health Science, Simon Fraser University, Burnaby, BC, Canada
| | - Dawn Mooney
- Centre for Health Services and Policy Research, The University of British Columbia (UBC), 201-2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Sandra Peterson
- Centre for Health Services and Policy Research, The University of British Columbia (UBC), 201-2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, The University of British Columbia (UBC), 201-2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
- School of Population and Public Health, UBC, Vancouver, BC, Canada.
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Cohen DJ, Wyte-Lake T, Dorr DA, Gold R, Holden RJ, Koopman RJ, Colasurdo J, Warren N. Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs. J Am Med Inform Assoc 2020; 27:690-699. [PMID: 32134456 PMCID: PMC7647291 DOI: 10.1093/jamia/ocaa010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/06/2020] [Accepted: 01/16/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To identify the unmet information needs of clinical teams delivering care to patients with complex medical, social, and economic needs; and to propose principles for redesigning electronic health records (EHR) to address these needs. MATERIALS AND METHODS In this observational study, we interviewed and observed care teams in 9 community health centers in Oregon and Washington to understand their use of the EHR when caring for patients with complex medical and socioeconomic needs. Data were analyzed using a comparative approach to identify EHR users' information needs, which were then used to produce EHR design principles. RESULTS Analyses of > 300 hours of observations and 51 interviews identified 4 major categories of information needs related to: consistency of social determinants of health (SDH) documentation; SDH information prioritization and changes to this prioritization; initiation and follow-up of community resource referrals; and timely communication of SDH information. Within these categories were 10 unmet information needs to be addressed by EHR designers. We propose the following EHR design principles to address these needs: enhance the flexibility of EHR documentation workflows; expand the ability to exchange information within teams and between systems; balance innovation and standardization of health information technology systems; organize and simplify information displays; and prioritize and reduce information. CONCLUSION Developing EHR tools that are simple, accessible, easy to use, and able to be updated by a range of professionals is critical. The identified information needs and design principles should inform developers and implementers working in community health centers and other settings where complex patients receive care.
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Affiliation(s)
- Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Department of Medical Informatics and Clinical Epidemiology, OregonHealth and Science University, Portland, Oregon, USA
| | - Tamar Wyte-Lake
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - David A Dorr
- Department of Medical Informatics and Clinical Epidemiology, OregonHealth and Science University, Portland, Oregon, USA
| | - Rachel Gold
- Center for Health Research, Kaiser Permanente, Portland, Oregon, USA
- Department of Research, OCHIN Inc, Portland, Oregon, USA
| | - Richard J Holden
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richelle J Koopman
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Joshua Colasurdo
- Department of Medical Informatics and Clinical Epidemiology, OregonHealth and Science University, Portland, Oregon, USA
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Vallet F, Busnel C, Ludwig C. [Analysis of the reliability of a multidimensional complexity scale instrument (COMID) for home care nurses]. Rech Soins Infirm 2020; 138:53-64. [PMID: 31959242 DOI: 10.3917/rsi.138.0053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Introduction : The increasingly frequent mention of complexity by different health care actors challenges the measurement of this construct. The COMID, a tool that helps home nurses to identify complex situations, provides a multidimensional and operational definition of complexity.Context : While an acceptability study showed that nurses took a keen interest in the COMID, its psychometric properties have not yet been examined.Objective : This article reports on two studies testing the reliability of the scale.Method : Study 1 focuses on 5,401 COMIDs completed by home care nurses in their usual practice. The internal consistency was estimated using Cronbach's alpha. Study 2 focuses on 38 COMIDs, completed by home care nurses (rater group 1) and specialized nurses (rater group 2). Inter-rater agreement was examined using an intraclass correlation coefficient (ICC).Results : The COMID has an acceptable internal consistency α = 0.797 and an excellent inter-rater agreement ICC = 0.839.Discussion : The metrological properties of the COMID will need to be complemented by an analysis of its validity. Conclusion : The COMID has good measurement accuracy and therefore has good potential for identifying complexity in nursing practice.
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Chan B, Hulen E, Edwards S, Mitchell M, Nicolaidis C, Saha S. "It's Like Riding Out the Chaos": Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU). Ann Fam Med 2019; 17:495-501. [PMID: 31712287 PMCID: PMC6846277 DOI: 10.1370/afm.2464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 05/13/2019] [Accepted: 05/24/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE High-need high-cost (HNHC) patients consume a large proportion of health resources but often receive suboptimal care in traditional primary care. Intensive ambulatory care interventions attempt to better meet these patients' needs, but we know little about how teams delivering these interventions in clinics serving socially complex patient populations perceive their work. METHODS We performed a qualitative study of multidisciplinary staff experiences at a Federally Qualified Health Center (FQHC) caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit (A-ICU) intervention. We conducted semistructured interviews with 9 ambulatory intensive care team members and 6 "usual care" members. We conducted a thematic analysis, using an inductive approach, at a semantic level. RESULTS Staff viewed complexity as a combination of social, behavioral, and medical challenges that lead to patient-health care system mismatch. Staff perceive the following as key ingredients in caring for HNHC patients: addressing both psychosocial and clinical needs together; persistence in staying connected to patients through chaotic periods; shared commitment and cohesion among interdisciplinary team members; and flexibility to tailor care to patients' individual situations. Participants' definitions of success focused more on improving patient engagement than reducing utilization or cost. CONCLUSION FQHC staff working with HNHC patients perceive mismatch between the health care system and patients' clinical and social needs as the key driver of poor outcomes for these patients. Intensive ambulatory care teams may bridge mismatch through provision of psychosocial supports, flexible care delivery, and fostering team cohesion to support patient engagement.
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Affiliation(s)
- Brian Chan
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon .,Central City Concern, Portland, Oregon
| | - Elizabeth Hulen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Sociology, Portland State University, Portland, Oregon
| | - Samuel Edwards
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | | | - Christina Nicolaidis
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon.,School of Social Work, Portland State University, Portland, Oregon.,School of Public Health, Oregon Health & Science University and Portland State University, Portland, Oregon
| | - Somnath Saha
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
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Shukor AR, Joe R, Sincraian G, Klazinga N, Kringos DS. A Multi-sourced Data Analytics Approach to Measuring and Assessing Biopsychosocial Complexity: The Vancouver Community Analytics Tool Complexity Module (VCAT-CM). Community Ment Health J 2019; 55:1326-1343. [PMID: 31177480 PMCID: PMC6823655 DOI: 10.1007/s10597-019-00417-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 05/16/2019] [Indexed: 01/09/2023]
Abstract
Operationalization of the fundamental building blocks of primary care (i.e. empanelment, team-based care and population management) within the context of Community Health Centers requires accurate and real-time measures of biopsychosocial complexity, at both client and population-levels. This article describes the conceptualization, design and development of a novel software tool (the VCAT-Complexity Module) that can calculate and report real-time person-oriented biopsychosocial complexity profiles, using multiple data sources. The tool aligns with a profile approach to conceptualizing health outcomes, and represents a potentially significant advance over disease-oriented complexity assessment tools. The results and face validity of the software's complexity score outputs are discussed, along with their practical implications on functions related to the development of primary care within Vancouver Coastal Health, a Canadian Regional Health Authority.
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Affiliation(s)
- Ali Rafik Shukor
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Ronald Joe
- Vancouver Coastal Health (VCH), 520 West 6th Ave, Vancouver, BC Canada
| | | | - Niek Klazinga
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Dionne Sofia Kringos
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Loeb DF, Monson SP, Lockhart S, Depue C, Ludman E, Nease DE, Binswanger IA, Kline DM, de Gruy FV, Good DG, Bayliss EA. Mixed method evaluation of Relational Team Development (RELATED) to improve team-based care for complex patients with mental illness in primary care. BMC Psychiatry 2019; 19:299. [PMID: 31615460 PMCID: PMC6792180 DOI: 10.1186/s12888-019-2294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with mental illness are frequently treated in primary care, where Primary Care Providers (PCPs) report feeling ill-equipped to manage their care. Team-based models of care improve outcomes for patients with mental illness, but multiple barriers limit adoption. Barriers include practical issues and psychosocial factors associated with the reorganization of care. Practice facilitation can improve implementation, but does not directly address the psychosocial factors or gaps in PCP skills in managing mental illness. To address these gaps, we developed Relational Team Development (RELATED). METHODS RELATED is an implementation strategy combining practice facilitation and psychology clinical supervision methodologies to improve implementation of team-based care. It includes PCP-level clinical coaching and a team-level practice change activity. We performed a preliminary assessment of RELATED with a convergent parallel mixed method study in 2 primary care clinics in an urban Federally Qualified Health Center in Southwest, USA, 2017-2018. Study participants included PCPs, clinic staff, and patient representatives. Clinic staff and patients were recruited for the practice change activity only. Primary outcomes were feasibility and acceptability. Feasibility was assessed as ease of recruitment and implementation. Acceptability was measured in surveys of PCPs and staff and focus groups. We conducted semi-structured focus groups with 3 participant groups in each clinic: PCPs; staff and patients; and leadership. Secondary outcomes were change in pre- post- intervention PCP self-efficacy in mental illness management and team-based care. We conducted qualitative observations to better understand clinic climate. RESULTS We recruited 18 PCPs, 17 staff members, and 3 patient representatives. We ended recruitment early due to over recruitment. Both clinics developed and implemented practice change activities. The mean acceptability score was 3.7 (SD=0.3) on a 4-point Likert scale. PCPs had a statistically significant increase in their mental illness management self-efficacy [change = 0.9, p-value= <.01]. Focus group comments were largely positive, with PCPs requesting additional coaching. CONCLUSIONS RELATED was feasible and highly acceptable. It led to positive changes in PCP self-efficacy in Mental Illness Management. If confirmed as an effective implementation strategy, RELATED has the potential to significantly impact implementation of evidence-based interventions for patients with mental illness in primary care.
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Affiliation(s)
- Danielle F. Loeb
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | | | - Steven Lockhart
- 0000 0001 0703 675Xgrid.430503.1Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO USA
| | - Cori Depue
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | - Evette Ludman
- 0000 0004 0615 7519grid.488833.cKaiser Permanente Washington Health Research Institute, Seattle, WA USA
| | - Donald E. Nease
- 0000 0001 0703 675Xgrid.430503.1Department of Family Medicine, University of Colorado, Aurora, USA
| | - Ingrid A. Binswanger
- 0000 0000 9957 7758grid.280062.eKaiser Permanente Colorado Institute for Health Research, Aurora, CO USA
| | - Danielle M. Kline
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | - Frank V. de Gruy
- 0000 0001 0703 675Xgrid.430503.1Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Dixie G. Good
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | - Elizabeth A. Bayliss
- 0000 0000 9957 7758grid.280062.eKaiser Permanente Colorado Institute for Health Research, Aurora, CO USA
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Winship JM, Ivey CK, Etz RS. Opportunities for Occupational Therapy on a Primary Care Team. Am J Occup Ther 2019; 73:7305185010p1-7305185010p10. [PMID: 31484020 DOI: 10.5014/ajot.2019.030841] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Leaders in the occupational therapy profession have called for occupational therapy's inclusion in primary care, but little is known about the occupational needs of patients in this setting. OBJECTIVE To explore the need for and potential role of occupational therapy in a team-based primary care clinic. DESIGN A qualitative descriptive study using a convenience sample of clinicians and patients. Meetings and semistructured interviews were recorded, transcribed, and coded by multiple coders using a general immersion-crystallization approach to identify relevant themes. SETTING Outpatient complex care clinic of an urban academic medical center. PARTICIPANTS The study included a voluntary sample of clinicians and patients from the complex care clinic. Patients were recruited from a staff-provided list; eligible patients had attended the clinic for at least 1 yr. All patients had multiple chronic conditions and were uninsured or received Medicaid. RESULTS Researchers attended 10 clinician team meetings and conducted 13 patient interviews and 10 clinician interviews. Four domains of patient need were identified by both patients and clinicians: complex medical management, patients' limited resources, mental health needs, and challenges to occupation. Clinicians also identified cognitive-behavioral challenges affecting care, including lack of engagement and poor problem solving. CONCLUSIONS AND RELEVANCE The makeup of the clinic team reflected their intent to address medical, socioeconomic, and mental health domains. However, cognitive-behavioral challenges and patients' occupational limitations were not consistently addressed. Thus, patients had unmet needs that occupational therapy practitioners were qualified to address. WHAT THIS ARTICLE ADDS This study adds to the available literature examining patient needs and clinician challenges in a primary care clinic. Patients have occupational needs that are not being addressed in primary care, indicating a need for occupational therapy in this setting.
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Affiliation(s)
- Jodi M Winship
- Jodi M. Winship, MS, OTR/L, is PhD Candidate, Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond;
| | - Carole K Ivey
- Carole K. Ivey, PhD, OTR/L, is Associate Professor, Department of Occupational Therapy, Virginia Commonwealth University, Richmond
| | - Rebecca S Etz
- Rebecca S. Etz, PhD, is Associate Professor, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond
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Loeb DF, Kline DM, Kroenke K, Boyd C, Bayliss EA, Ludman E, Dickinson LM, Binswanger IA, Monson SP. Designing the relational team development intervention to improve management of mental health in primary care using iterative stakeholder engagement. BMC FAMILY PRACTICE 2019; 20:124. [PMID: 31492096 PMCID: PMC6728939 DOI: 10.1186/s12875-019-1010-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/19/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Team-based models of care are efficacious in improving outcomes for patients with mental and physical illnesses. However, primary care clinics have been slow to adopt these models. We used iterative stakeholder engagement to develop an intervention to improve the implementation of team-based care for this complex population. METHODS We developed the initial framework for Relational Team Development (RELATED) from a qualitative study of Primary Care Providers' (PCPs') experiences treating mental illness and a literature review of practice facilitation and psychology clinical supervision. Subsequently, we surveyed 900 Colorado PCPs to identify factors associated with PCP self-efficacy in management of mental illness and team-based care. We then conducted two focus groups for feedback on RELATED. Lastly, we convened an expert panel to refine the intervention. RESULTS We developed RELATED, a two-part intervention delivered by a practice facilitator with a background in clinical psychology. The facilitator observes PCPs during patient visits and provides individualized coaching. Next, the facilitator guides the primary care team through a practice change activity with a focus on relational team dynamics. CONCLUSION The iterative development of RELATED using stakeholder engagement offers a model for the development of interventions tailored to the needs of these stakeholders. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Danielle F. Loeb
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave, Aurora, CO 80045 USA
| | - Danielle M. Kline
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave, Aurora, CO 80045 USA
| | - Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN USA
| | - Cynthia Boyd
- John Hopkins University School of Medicine, Baltimore, MD USA
| | | | - Evette Ludman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA USA
| | - L. Miriam Dickinson
- Department of Biostatistics & Informatics, Colorado School of Public Health; Department of Family Medicine, University of Colorado, Aurora, CO USA
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Boehmer KR, Dobler CC, Thota A, Branda M, Giblon R, Behnken E, Organick P, Allen SV, Shaw K, Montori VM. Changing conversations in primary care for patients living with chronic conditions: pilot and feasibility study of the ICAN Discussion Aid. BMJ Open 2019; 9:e029105. [PMID: 31481553 PMCID: PMC6731832 DOI: 10.1136/bmjopen-2019-029105] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To pilot test the impact of the ICAN Discussion Aid on clinical encounters. METHODS A pre-post study involving 11 clinicians and 100 patients was conducted at two primary care clinics within a single health system in the Midwest. The study examined clinicians' perceptions about ICAN feasibility, patients' and clinicians' perceptions about encounter success, videographic differences in encounter topics, and medication adherence 6 months after an ICAN encounter. RESULTS 39/40 control encounters and 45/60 ICAN encounters yielded usable data. Clinicians reported ICAN use was feasible. In ICAN encounters, patients discussed diet, being active and taking medications more. Clinicians scored themselves poorer regarding visit success than their patients scored them; this effect was more pronounced in ICAN encounters. ICAN did not improve 6-month medication adherence or lengthen visits. CONCLUSION This pilot study suggests that using ICAN in primary care is feasible, efficient and capable of modifying conversations. With lessons learned in this pilot, we are conducting a randomised trial of ICAN versus usual care in diverse clinical settings. TRIAL REGISTRATION NUMBER NCT02390570.
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Affiliation(s)
- Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Claudia C Dobler
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anjali Thota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan Branda
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rachel Giblon
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Emma Behnken
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Paige Organick
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Summer V Allen
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin Shaw
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
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Kasthurirathne SN, Biondich PG, Grannis SJ, Purkayastha S, Vest JR, Jones JF. Identification of Patients in Need of Advanced Care for Depression Using Data Extracted From a Statewide Health Information Exchange: A Machine Learning Approach. J Med Internet Res 2019; 21:e13809. [PMID: 31333196 PMCID: PMC6681643 DOI: 10.2196/13809] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/01/2019] [Accepted: 06/12/2019] [Indexed: 01/02/2023] Open
Abstract
Background As the most commonly occurring form of mental illness worldwide, depression poses significant health and economic burdens to both the individual and community. Different types of depression pose different levels of risk. Individuals who suffer from mild forms of depression may recover without any assistance or be effectively managed by primary care or family practitioners. However, other forms of depression are far more severe and require advanced care by certified mental health providers. However, identifying cases of depression that require advanced care may be challenging to primary care providers and health care team members whose skill sets run broad rather than deep. Objective This study aimed to leverage a comprehensive range of patient-level diagnostic, behavioral, and demographic data, as well as past visit history data from a statewide health information exchange to build decision models capable of predicting the need of advanced care for depression across patients presenting at Eskenazi Health, the public safety net health system for Marion County, Indianapolis, Indiana. Methods Patient-level diagnostic, behavioral, demographic, and past visit history data extracted from structured datasets were merged with outcome variables extracted from unstructured free-text datasets and were used to train random forest decision models that predicted the need of advanced care for depression across (1) the overall patient population and (2) various subsets of patients at higher risk for depression-related adverse events; patients with a past diagnosis of depression; patients with a Charlson comorbidity index of ≥1; patients with a Charlson comorbidity index of ≥2; and all unique patients identified across the 3 above-mentioned high-risk groups. Results The overall patient population consisted of 84,317 adult (aged ≥18 years) patients. A total of 6992 (8.29%) of these patients were in need of advanced care for depression. Decision models for high-risk patient groups yielded area under the curve (AUC) scores between 86.31% and 94.43%. The decision model for the overall patient population yielded a comparatively lower AUC score of 78.87%. The variance of optimal sensitivity and specificity for all decision models, as identified using Youden J Index, is as follows: sensitivity=68.79% to 83.91% and specificity=76.03% to 92.18%. Conclusions This study demonstrates the ability to automate screening for patients in need of advanced care for depression across (1) an overall patient population or (2) various high-risk patient groups using structured datasets covering acute and chronic conditions, patient demographics, behaviors, and past visit history. Furthermore, these results show considerable potential to enable preventative care and can be easily integrated into existing clinical workflows to improve access to wraparound health care services.
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Affiliation(s)
- Suranga N Kasthurirathne
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, United States.,Indiana University Fairbanks School of Public Health, Indianapolis, IN, United States
| | - Paul G Biondich
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, United States.,Indiana University School of Medicine, Indianapolis, IN, United States
| | - Shaun J Grannis
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, United States.,Indiana University School of Medicine, Indianapolis, IN, United States
| | - Saptarshi Purkayastha
- Indiana University School of Informatics and Computing, Indianapolis, IN, United States
| | - Joshua R Vest
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, United States.,Indiana University Fairbanks School of Public Health, Indianapolis, IN, United States
| | - Josette F Jones
- Indiana University School of Informatics and Computing, Indianapolis, IN, United States
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Webster F, Rice K, Bhattacharyya O, Katz J, Oosenbrug E, Upshur R. The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings. Int J Equity Health 2019; 18:107. [PMID: 31272466 PMCID: PMC6611020 DOI: 10.1186/s12939-019-1010-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 06/24/2019] [Indexed: 12/21/2022] Open
Abstract
Purpose Chronic disease is a global concern. While ample research has aimed to identify the epidemiology of multimorbidity and patient complexity using administrative data, little attention has been paid to the processes of care that treating complex patients entail. Consequently, the concept of patient complexity itself does not directly speak to how challenging it may be to care for a given patient. The purpose of this study was to investigate how primary care providers define, encounter, and manage complex patients, especially those with chronic pain. To our knowledge, this is the first study to move beyond general narrative descriptions of complexity towards an interrogation that is grounded in the work practices of caring for these patients. Methods We undertook an institutional ethnography (IE) in Ontario, Canada. IE uses people’s everyday work problems as the starting point for an exploration of the often-invisible social relations that orient experiences. Grounded in the everyday experience of primary care providers, we draw here on 51 interviews that were collected as part of our larger IE study, to interrogate the utility of definitions of patient complexity as medical multimorbidity. Findings Care providers consider patients challenging due to their socio-economic status more so than their medical problems alone. Our data shows that patients’ issues are often bound up with poverty, trauma, and mental health concerns, and are challenging for health care providers in part because the interventions needed exceed the scope of their medical expertise, while social issues render the treatment of potentially straightforward medical problems complicated. This was especially so for patients with chronic pain. Conclusion Defining patient complexity as morbidity alone is inadequate; such models neglect syndromes and conditions that are not included in formal disease classifications. Chronic pain should be included among the chronic conditions that are considered to constitute multimorbidity. In order to provide effective patient-centered care, discussions of patient complexity must also attend to the complex social and economic circumstances in which many patients live and include broader issues of inequity and social justice. This approach would enable policies to better support primary care providers who struggle to manage their patients with complex needs across domains of physiological health, mental health, and the quality of their living conditions, and in so doing improve the care that patients receive.
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Affiliation(s)
- Fiona Webster
- Arthur and Sonia Labatt Family School of Nursing, Faculty of Health Sciences, Western University, 1151 Richmond Street, Room 2373, London, Ontario, N6A 3K7, Canada.
| | - Kathleen Rice
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Onil Bhattacharyya
- Women's College Research Institute, 790 Bay St, 7th Floor, Toronto, Ontario, M5G 1N8, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th floor, Toronto, Ontario, Canada
| | - Joel Katz
- Department of Psychology, York University, 4700 Keele St., BSB 232, Toronto, Ontario, M3J 1P3, Canada
| | - Eric Oosenbrug
- Department of Psychology, York University, 4700 Keele St., BSB 232, Toronto, Ontario, M3J 1P3, Canada
| | - Ross Upshur
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th floor, Toronto, Ontario, Canada.,Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Room, Toronto, Ontario, 632, Canada
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Yoshida S, Matsushima M, Wakabayashi H, Mutai R, Sugiyama Y, Yodoshi T, Horiguchi R, Watanabe T, Fujinuma Y. Correlation of patient complexity with the burden for health-related professions, and differences in the burden between the professions at a Japanese regional hospital: a prospective cohort study. BMJ Open 2019; 9:e025176. [PMID: 30796125 PMCID: PMC6398801 DOI: 10.1136/bmjopen-2018-025176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES An ageing society includes high patient complexity. Various biopsychosocial problems result in a high burden for health-related professionals. The direct relationship between the burden and patient complexity, however, has not been reported. We aimed to examine correlations between the burden for the attending physicians and nurses, and Patient Centred Assessment Method (PCAM) scores of patient complexity. DESIGN Prospective cohort study. SETTING A regional secondary care hospital in Japan. PARTICIPANTS We included all inpatients admitted to our acute care unit between 1 July 2014 and 30 September 2014. Exclusion criteria were age <20 years, refusal to participate in the study and length of stay fixed at the time of admission. MAIN PREDICTOR PCAM total score in the initial phase of hospital admission. MAIN OUTCOME The burden for each profession (measured on a Visual Analogue Scale). RESULTS In total, 201 inpatients participated [female/male=98/103, mean (SD) age of 77.4±11.9 years]. Spearman's rank correlation coefficients between the burden and the PCAM score ranged from 0.23 to 0.32. All p values were <0.05. Multivariate analysis was conducted using multilevel mixed-effects linear regression to determine the association between the burden and the PCAM score in two models. Model 1 used the total PCAM score as the predictive variable. Model 2 used the PCAM factors, patient-oriented complexity and medicine-oriented complexity, as predictive variables. In Model 2, with the burden of physicians, medicine-oriented complexity was statistically significant, whereas with the burden of nurses, both age and patient-oriented complexity were statistically significant. CONCLUSIONS PCAM scores correlated with the burden for physicians and nurses. Individual PCAM factors affected the burden for each profession differently.
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Affiliation(s)
- Shuhei Yoshida
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative, Tokyo, Japan
- Department of Community-Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masato Matsushima
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan
| | - Hidetaka Wakabayashi
- Department of Rehabilitation Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Rieko Mutai
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshifumi Sugiyama
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan
- Tarama Clinic, Okinawa Miyako Hospital, Miyakojima, Japan
| | - Toshifumi Yodoshi
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryoko Horiguchi
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan
| | - Takamasa Watanabe
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative, Tokyo, Japan
| | - Yasuki Fujinuma
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative, Tokyo, Japan
- Interprofessional Education Research Center (IPERC), Chiba University, Chiba, Japan
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Clèries M, Monterde D, Vela E, Guarga À, García Eroles L, Pérez Sust P. [Clinical validation of 2 morbidity groups in the primary care setting]. Aten Primaria 2019; 52:96-103. [PMID: 30765102 PMCID: PMC7025994 DOI: 10.1016/j.aprim.2018.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 09/18/2018] [Accepted: 09/25/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Adjusted Morbidity Groups (GMAs) and the Clinical Risk Groups (CRGs) are population morbidity based stratification tools which classify patients into mutually exclusive categories. OBJETIVE To compare the stratification provided by the GMAs, CRGs and that carried out by the evaluators according to the levels of complexity. DESIGN Random sample stratified by morbidity risk. LOCATION Catalonia. PARTICIPANTS Forty paired general practitioners in the primary care, matched pairs. INTERVENTIONS Each pair of evaluators had to review 25 clinical records. MAIN OUTPUTS The concordance by evaluators, and between the evaluators and the results obtained by the 2 morbidity tools were evaluated according to the kappa index, sensitivity, specificity, and positive and negative predicted values. RESULTS The concordance between general practitioners pairs was around the kappa value 0.75 (mean value=0.67), between the GMA and the evaluators was similar (mean value=0.63), and higher than for the CRG (mean value=0.35). The general practitioners gave a score of 7.5 over 10 to both tools, although for the most complex strata, according to the professionals' assignment, the GMA obtained better scores than the CRGs. The professionals preferred the GMAs over the CRGs. These differences increased with the complexity level of the patients according to clinical criteria. Overall, less than 2% of serious classification errors were found by both groupers. CONCLUSION The evaluators considered that both grouping systems classified the studied population satisfactorily, although the GMAs showed a better performance for more complex strata. In addition, the clinical raters preferred the GMAs in most cases.
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Affiliation(s)
- Montse Clèries
- Unidad de Información y Conocimiento, Servicio Catalán de la Salud, Departamento de Salud de la Generalidad de Cataluña, Barcelona, España.
| | - David Monterde
- Oficina de Estadística, Sistemas de Información, Instituto Catalán de la Salud, Departamento de Salud de la Generalidad de Cataluña, Barcelona, España
| | - Emili Vela
- Unidad de Información y Conocimiento, Servicio Catalán de la Salud, Departamento de Salud de la Generalidad de Cataluña, Barcelona, España
| | - Àlex Guarga
- Área de Atención Sanitaria, Servicio Catalán de la Salud, Departamento de Salud de la Generalidad de Cataluña, Barcelona, España
| | - Luis García Eroles
- Gerente de Sistemas de Información, Servicio Catalán de la Salud, Departamento de Salud de la Generalidad de Cataluña, Barcelona, España
| | - Pol Pérez Sust
- Coordinador general de las tecnologías de la información y comunicación, Departamento de Salud de la Generalidad de Cataluña, Barcelona, España
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Schrauben SJ, Hsu JY, Wright Nunes J, Fischer MJ, Srivastava A, Chen J, Charleston J, Steigerwalt S, Tan TC, Fink JC, Ricardo AC, Lash JP, Wolf M, Feldman HI, Anderson AH. Health Behaviors in Younger and Older Adults With CKD: Results From the CRIC Study. Kidney Int Rep 2019; 4:80-93. [PMID: 30596171 PMCID: PMC6308910 DOI: 10.1016/j.ekir.2018.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 09/04/2018] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION A cornerstone of kidney disease management is participation in guideline-recommended health behaviors. However, the relationship of these health behaviors with outcomes, and the identification of barriers to health behavior engagement, have not been described among younger and older adults with chronic kidney disease. METHODS Data from a cohort study of 5499 individuals with chronic kidney disease was used to identify health behavior patterns with latent class analysis stratified by age <65 and ≥65 years. Cox models, stratified by diabetes, assessed the association of health behavior patterns with chronic kidney disease (CKD) progression, atherosclerotic events, and death. Logistic regression was used to assess for barriers to health behavior engagement. RESULTS Three health behavior patterns were identified: 1 "healthy" pattern, and 2 "less healthy" patterns comprising 1 pattern with more obesity and sedentary activity and 1 with more smoking and less obesity. Less healthy patterns were associated with an increased hazard of poor outcomes. Among participants <65 years of age, the less healthy patterns (vs. healthy pattern) was associated with an increased hazard of death in diabetic individuals (hazard ratio [HR] = 2.17, 95% confidence interval [CI] = 1.09-4.29; and HR = 2.50, 95% CI = 1.39-4.50) and cardiovascular events among nondiabetic individuals (HR = 1.49, 95% CI = 1.04-2.43; and HR = 2.97, 95% CI = 1.49-5.90). Individuals with the more obese/sedentary pattern had an increased risk of CKD progression in those who were diabetic (HR = 1.34, 95% CI = 1.13-1.59). Among older adults, the less healthy patterns were associated with increased risk of death (HR = 2.97, 95% CI = 1.43-6.19; and HR = 3.47, 95% CI = 1.48-8.11) in those who were nondiabetic. Potential barriers to recommended health behaviors include lower health literacy and self-efficacy. CONCLUSION Identifying health behavior patterns and barriers may help target high-risk groups for strategies to increase participation in health behaviors.
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Affiliation(s)
- Sarah J. Schrauben
- Division of Renal, Electrolyte, and Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julie Wright Nunes
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael J. Fischer
- Department of Medicine, University of Illinois at Chicago, and Center of Management for Complex Chronic Healthcare, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, USA
| | - Anand Srivastava
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, Louisiana, USA
| | | | - Susan Steigerwalt
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jeffrey C. Fink
- Department of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, and Center of Management for Complex Chronic Healthcare, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, USA
| | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, and Center of Management for Complex Chronic Healthcare, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, USA
| | - Myles Wolf
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Harold I. Feldman
- Division of Renal, Electrolyte, and Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amanda H. Anderson
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Busnel C, Marjollet L, Perrier-Gros-Claude O. Complexité des prises en soins à domicile : développement d’un outil d’évaluation infirmier et résultat d’une étude d’acceptabilité. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.refiri.2018.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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46
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Haidar OM, Lamarche PA, Levesque JF, Pampalon R. The Influence of Individuals' Vulnerabilities and Their Interactions on the Assessment of a Primary Care Experience. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2018; 48:798-819. [PMID: 29807483 DOI: 10.1177/0020731418768186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examines the relationship between the vulnerabilities of individuals and their assessments of their primary care experiences in the setting of a universal care system. It focuses on 2 specific objectives: (1) evaluating the influence of each of the 5 vulnerabilities on the assessment of the care experience; (2) evaluating the influence of the interactions between the different types of vulnerabilities on the assessment of the care experience. The study identifies the primary care experience of 9,206 people. The health-related, biological, material, relational, and cultural vulnerabilities are also evaluated. Generally, individuals' vulnerabilities are associated with a positive assessment of the primary care experience except for the cultural vulnerability. Material vulnerability is most frequently associated with a positive assessment of the primary care experience. The interactions between the multiple vulnerabilities present for one individual often modify the effect of vulnerability on the assessment of the experience of care. The positive effect of a vulnerability on the assessment of the care experience often increases in the presence of a second vulnerability, especially the health-related vulnerability. The simultaneous presence of health-related vulnerability cancels the negative influence of cultural vulnerability on the assessment of the primary care experience.
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Affiliation(s)
- Ola M Haidar
- 1 University of Montreal, School of Public Health, Montreal, Canada
| | - Paul A Lamarche
- 2 University of Montreal, School of Public Health, Montreal, Canada
| | - Jean-Frederic Levesque
- 3 Bureau of Health Information and Center for Primary Health Care and Equity, University of New South Wales, New South Wales, Australia
| | - Robert Pampalon
- 4 National Institute of Public Health of Quebec and Department of Social and Preventive Medicine, University of Laval, Quebec, Canada
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47
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Complex Care Needs in Multiple Chronic Conditions: Population Prevalence and Characterization in Primary Care. A Study Protocol. Int J Integr Care 2018; 18:16. [PMID: 30127700 PMCID: PMC6095050 DOI: 10.5334/ijic.3292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Chronicity, and particularly complex care needs for people with chronic diseases is one of the main challenges of health systems. Objective: To determine the population prevalence of people with chronic diseases and complex care needs and to characterize these needs considering features of health and social complexity in Primary Care. Design: Cross-sectional population-based study. Scope: Patients who have one or more chronic health conditions from three Primary Care urban centres of a reference population of 43.647 inhabitants older than 14 years old. Methodology: Data will be obtained from the review of electronical medical records. Complexity will be defined by: 1) the independent clinical judgment of primary care physicians and nurses and 2) the aid of three complexity domains (clinical and social). Patients with advanced chronic disease and limited life prognosis will be also described. Conclusions: This research protocol intends to describe and analyse complex care needs from a primary care professional perspective in order to improve knowledge of complexity beyond multimorbidity and previous consumption of health resources. Knowing about health and social complexity with a more robust empirical basis could help for a better integration of social and health policies and a more proactive and differentiated care approach in this most vulnerable population.
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48
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Colaco B, Herold D, Johnson M, Roellinger D, Naessens JM, Morgenthaler TI. Analyses of the Complexity of Patients Undergoing Attended Polysomnography in the Era of Home Sleep Apnea Tests. J Clin Sleep Med 2018; 14:631-639. [PMID: 29609716 DOI: 10.5664/jcsm.7060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/08/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Health care complexity includes dimensions of patient comorbidity and the level of services needed to meet patient demands. Home sleep apnea tests (HSAT) are increasingly used to test medically uncomplicated patients suspected of having moderate to severe obstructive sleep apnea (OSA). Patients with significant comorbidities or other sleep disorders are not candidates for HSAT and require attended in-center polysomnography. We hypothesized that this trend would result in increasingly complex patients being studied in sleep centers. METHODS Our study had two parts. To ascertain trends in sleep patient comorbidity, we used administrative diagnostic codes from patients undergoing polysomnography at the Mayo Clinic Center for Sleep Medicine from 2005 to June 2015 to calculate the Charlson and the Elixhauser comorbidity indices. We measured the level of services provided in two ways: (1) in a subset of patients from the past 2 months of 2015, we evaluated correlation of these morbidity indices with an internally developed Polysomnogram Clinical Index (PSGCI) rating anticipated patient care needs from 0 to 3 and (2) we measured the sleep study complexity based on polysomnography protocol design. RESULTS In 43,780 patients studied from 2005 to June 2015, the Charlson index increased from a mean of 1.38 to 1.88 (3.1% per year, P < .001) and the mean Elixhauser index increased from 2.61 to 3.35 (2.5% per year, P < .001). Both comorbidity indices were significantly higher at the highest (Level 3) level of the PSGCI (P < .001), and sleep study complexity increased over time. CONCLUSIONS The complexity of patients undergoing attended polysomnography has increased by 28% to 36% over the past decade as measured by validated comorbidity indices, and these indices correlate with the complexity of rendered care during polysomnography. These findings have implications for increasing requirements for staffing, monitoring capabilities, and facility design of future sleep centers. COMMENTARY A commentary on this article appears in this issue on page 499.
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Affiliation(s)
- Brendon Colaco
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Daniel Herold
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew Johnson
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Daniel Roellinger
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - James M Naessens
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Health Care Policy & Research, Mayo Clinic, Rochester, Minnesota
| | - Timothy I Morgenthaler
- Mayo Clinic Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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49
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Grier E, Abells D, Casson I, Gemmill M, Ladouceur J, Lepp A, Niel U, Sacks S, Sue K. Managing complexity in care of patients with intellectual and developmental disabilities: Natural fit for the family physician as an expert generalist. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2018; 64:S15-S22. [PMID: 29650740 PMCID: PMC5906780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To delineate the factors inherent in caring for patients with intellectual and developmental disabilities (IDD) that lead to complexity and to provide perspectives and techniques mapped to the phases of the clinical encounter. SOURCES OF INFORMATION The authors of the physical health section of the 2018 Canadian consensus guidelines on the primary care of adults with IDD consisted of family physicians, all of whom practise comprehensive family medicine with additional clinical experience in care of adults with IDD. These authors reviewed evidence on which their recommendations are based and these recommendations have undergone a rigorous peer review to ensure that they deserve special attention because they highlight what is different from what a family physician would consider to constitute "normal care" for the general population. MAIN MESSAGE Additional factors across the phases of clinical encounters with patients with IDD include the need for the following: an initial assessment that identifies genetic or neurologic conditions to guide anticipatory care and isolates unique barriers to health promotion and chronic disease management; adaptations to history taking, particularly for patients who are unable to describe symptoms owing to cognitive and communication deficits; overcoming challenges to performing physical examinations and certain investigations; addressing uncertainty in the formulation of hypotheses to establish an appropriate diagnosis; and involvement of resources of the developmental services sector to provide a management plan as well as an adapted empathetic approach in order to integrate the patient's illness experience. CONCLUSION Although each patient with IDD is unique, and care of patients with IDD requires knowledge of certain conditions, these considerations are readily identifiable, and family physicians as expert generalists are well equipped to provide excellent care to patients with IDD.
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Affiliation(s)
- Elizabeth Grier
- Assistant Professor in the Department of Family Medicine at Queen's University in Kingston, Ont.
| | - Dara Abells
- Family physician at Forest Hill Family Health Centre in Toronto, Ont, and the Integrated Services for Autism and Neurodevelopmental Disorders, and Lecturer in the Department of Family and Community Medicine at the University of Toronto
| | - Ian Casson
- Associate Professor in the Department of Family Medicine at Queen's University
| | - Meg Gemmill
- Assistant Professor, in the Department of Family Medicine at Queen's University
| | - Jessica Ladouceur
- Adjunct Professor in the Belleville Queen's University Family Medicine Centre
| | - Amanda Lepp
- Resident in the Discipline of Family Medicine at McMaster University in Hamilton, Ont
| | - Ullanda Niel
- Family physician at the Scarborough Centre for Healthy Communities in Ontario
| | - Samantha Sacks
- Clinical Faculty Lecturer in the Department of Family Medicine at McGill University in Montreal, Que, and a family physician at See Things My Way Centre for Innovation in Autism and Intellectual Disabilities
| | - Kyle Sue
- Clinical Assistant Professor in the Discipline of Family Medicine at Memorial University of Newfoundland in St John's
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50
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Bandini F, Guidi S, Blaszczyk S, Fumarulo A, Pierini M, Pratesi P, Spolveri S, Padeletti M, Petrone P, Zoppi P, Landini G. Complexity in internal medicine wards: A novel screening method and implications for management. J Eval Clin Pract 2018; 24:285-292. [PMID: 29318709 DOI: 10.1111/jep.12875] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 11/29/2017] [Accepted: 12/11/2017] [Indexed: 12/22/2022]
Abstract
RATIONALE Complexity is increasingly recognized as a critical variable in health care. However, there is still lack of practical tools to assess it and tackle the challenges that stem from it, particularly within hospitals. AIMS AND OBJECTIVE To validate a simple novel screening method based on both objective and subjective criteria to identify patients with clinically complex hospitalization events. To evaluate the prevalence of patients with complex events, identify their features, and compare them with those of the other patients and to those of patients with multimorbidities. METHOD We monitored the level of complexity of the hospitalization events of 240 patients admitted to an internal medicine ward in Tuscany over the course of 56 days. We compared the demographic features, the length of stay, and the prognosis of patients with and without complex events. RESULTS Sixty-nine patients (28.8% of the sample) had a complex episode during their stay, and 115 (47.9%) had phases of low complexity. Patients with complex episodes were younger and more comorbid than patients without. They stayed longer in-hospital (+4.5 days; 95% CI: 2.5-6.5) and had higher mortality (OR: 24.93; 95% CI: 6.97-171.63) and a lower probability of home discharge (OR: 0.25; 95% CI: 0.13-0.48). CONCLUSIONS The results show that using a simple screening method is possible to identify complex patients within IM wards and that every day, about one-third of the patients are complex. The results are discussed in implications for the dynamic management of patients with complex and simple phases during hospitalization.
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Affiliation(s)
- Fabrizio Bandini
- Cardiology Unit Borgo San Lorenzo and Serristori, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Stefano Guidi
- Cardiology Unit Borgo San Lorenzo and Serristori, Local Healthcare Unit Tuscany Centre, Florence, Italy.,Department of Social, Political and Cognitive Sciences, University of Siena, Siena, Italy
| | - Silvia Blaszczyk
- Internal Medicine Unit, Local Healthcare Unit Tuscany Centre, Ospedale del Mugello, Florence, Italy
| | | | - Michela Pierini
- Department of Nursing, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Paolo Pratesi
- Department of Nursing, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Stefano Spolveri
- Internal Medicine Unit, Local Healthcare Unit Tuscany Centre, Ospedale del Mugello, Florence, Italy
| | - Margherita Padeletti
- Cardiology Unit Borgo San Lorenzo and Serristori, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Pasquale Petrone
- Cardiology Unit Borgo San Lorenzo and Serristori, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Paolo Zoppi
- Department of Nursing, Local Healthcare Unit Tuscany Centre, Florence, Italy
| | - Giancarlo Landini
- Department of Medicine and Medical Specialties, Local Healthcare Unit Tuscany Centre, Florence, Italy
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