Can team-based care improve patient satisfaction? A systematic review of randomized controlled trials

Measuring the Impact of Primary Care Team Composition on Patient Activation Utilizing Electronic Health Record Big Data Analytics

Purpose

Team-based care has been linked to key outcomes associated with the Quadruple Aim and a key driver of high-value patient-centered care. Use of the electronic health record (EHR) and machine learning have significant potential to overcome previous barriers to studying the impact of teams, including delays in accessing data to improve teamwork and optimize patient outcomes.

Methods

This study utilized a large EHR dataset (n=316,542) from an urban health system to explore the relationship between team composition and patient activation, a key driver of patient engagement. Teams were operationalized using consensus definitions of teamwork from the literature. Patient activation was measured using the Patient Activation Measure (PAM). Results from multilevel regression analyses were compared to machine learning analyses using multinomial logistic regression to calculate propensity scores for the effect of team composition on PAM scores. Under the machine learning approach, a causal inference model with generalized overlap weighting was used to calculate the average treatment effect of teamwork.

Results

Seventeen different team types were observed in the data from the analyzed sample (n=12,448). Team sizes ranged from 2 to 5 members. After controlling for confounding variables in both analyses, more diverse, multidisciplinary teams (team size of 4 or more) were observed to have improved patient activation scores.

Conclusions

This is the first study to explore the relationship between team composition and patient activation using the EHR and big data analytics. Implications for further research using EHR data and machine learning to study teams and other patient-centered care are promising and could be used to advance team science.

Nurse and midwife involvement in task-sharing and telehealth service delivery models in primary care: A scoping review

AIM

To synthesise and map current evidence on nurse and midwife involvement in task-sharing service delivery, including both face-to-face and telehealth models, in primary care.

DESIGN

This scoping review was informed by the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews.

DATA SOURCE/REVIEW METHODS

Five databases (Ovid MEDLINE, Embase, PubMed, CINAHL and Cochrane Library) were searched from inception to 16 January 2024, and articles were screened for inclusion in Covidence by three authors. Findings were mapped according to the research questions and review outcomes such as characteristics of models, health and economic outcomes, and the feasibility and acceptability of nurse-led models.

RESULTS

One hundred peer-reviewed articles (as 99 studies) were deemed eligible for inclusion. Task-sharing models existed for a range of conditions, particularly diabetes and hypertension. Nurse-led models allowed nurses to work to the extent of their practice scope, were acceptable to patients and providers, and improved health outcomes. Models can be cost-effective, and increase system efficiencies with supportive training, clinical set-up and regulatory systems. Some limitations to telehealth models are described, including technological issues, time burden and concerns around accessibility for patients with lower technological literacy.

CONCLUSION

Nurse-led models can improve health, economic and service delivery outcomes in primary care and are acceptable to patients and providers. Appropriate training, funding and regulatory systems are essential for task-sharing models with nurses to be feasible and effective.

IMPACT

Nurse-led models are one strategy to improve health equity and access; however, there is a scarcity of literature on what these models look like and how they work in the primary care setting. Evidence suggests these models can also improve health outcomes, are perceived to be feasible and acceptable, and can be cost-effective. Increased utilisation of nurse-led models should be considered to address health system challenges and improve access to essential primary healthcare services globally.

REPORTING METHOD

This review is reported against the PRISMA-ScR criteria.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

PROTOCOL REGISTRATION

The study protocol is published in BJGP Open (Moulton et al., 2022).

Integrated care teams in primary care improve clinical outcomes and care processes in patients with non-communicable diseases

Introduction

Primary care physicians face the increasing burden of managing multimorbidities in an ageing population. Implementing an integrated care team (ICT) with defined roles and accountability to share consultation tasks is an emerging care model to address this issue. This study compared outcomes with ICT versus usual care for patients with multimorbidities in primary care.

Methods

Data was retrospectively extracted from the electronic medical records (EMRs) of consecutive adult Asian patients empanelled to ICT and those in UC at a typical primary care clinic (polyclinic) in eastern Singapore in 2018. The study population had hypertension, and/or hyperlipidaemia and/or type 2 diabetes mellitus (T2DM). Clinical outcomes included the proportion of patients (ICT vs. UC) who attained their treatment goals after 12 months. Process outcomes included the proportion of patients who completed annual diabetic eye and foot screenings, where applicable.

Results

Data from 3,302 EMRs (ICT = 1,723, UC = 1,579) from January 2016 to September 2017 was analysed. The ICT cohort was more likely to achieve treatment goals for systolic blood pressure (SBP) (adjusted odds ratio [AOR] = 1.52, 95% confidence interval [CI] = 1.38-1.68), low-density lipoprotein cholesterol (AOR = 1.72, 95% CI = 1.49-1.99), and glycated haemoglobin (AOR = 1.28, 95% CI = 1.09-1.51). The ICT group had higher uptake of diabetic retinal screening (89.1% vs. 83.0%, P < 0.001) and foot screening (85.2% vs. 77.9%, P < 0.001).

Conclusion

The ICT model yielded better clinical and process outcomes than UC, with more patients attaining treatment goals.

Nurses' Priorities for Perioperative Research in Africa

BACKGROUND

Mortality rates among surgical patients in Africa are double those of surgical patients in high-income countries. Internationally, there is a call to improve access to and safety of surgical and perioperative care. Perioperative research needs to be coordinated across Africa to positively impact perioperative mortality.

METHODS

The aim of this study was to determine the top 10 perioperative research priorities for perioperative nurses in Africa, using a research priority-setting process. A Delphi technique with 4 rounds was used to establish consensus on the top 10 perioperative research priorities. In the first round, respondents submitted research priorities. Similar research priorities were amalgamated into single priorities when possible. In round 2, respondents ranked the priorities using a scale from 1 to 10 (of which 1 is the first/highest priority, and 10 is the last/lowest priority). The top 20 (of 31) were determined after round 2. In round 3, respondents ranked their top 10 priorities. The final round was an online discussion to reach consensus on the top 10 perioperative research priorities.

RESULTS

A total of 17 perioperative nurses representing 12 African countries determined the top research priorities, which were: (1) strategies to translate and implement perioperative research into clinical practice in Africa, (2) creating a perioperative research culture and the tools, resources, and funding needed to conduct perioperative nursing research in Africa, (3) optimizing nurse-led postoperative pain management, (4) survey of operating theater and critical care resources, (5) perception of, and adherence to sterile field and aseptic techniques among surgeons in Africa (6) surgical staff burnout, (7) broad principles of infection control in surgical wards, (8) the role of interprofessional communication to promote clinical teamwork when caring for surgical patients, (9) effective implementation of the surgical safety checklist and measures of its impact, and (10) constituents of quality nursing care.

CONCLUSIONS

These research priorities provide the structure for an intermediate-term research agenda for perioperative research in Africa.

Advancing digital patient-centered measurement methods for team-based care

Objectives

To conceptualize new methods for integrating patient-centered measurement into team-based care.

Methods

A standalone portal was introduced into a rural clinic to support conceptualization of new methods for integration of patient-centered measurement in team-based care. The portal housed mental health-related online resources, three patient-reported measures and a self-action plan. Six providers and four patients used the portal for four months. Our data collection techniques included clinic discussions, one-on-one interviews, workflow diagrams and data generated through the portal. Analysis was supported through coding interview transcripts, looking across multiple sources of research data and research team discussions.

Results

Our research team conceptualized five team-based patient-centered measurement methods through this study. Patient-centered measurement Team Mapping offfers a technique to provide greater clarity of care-team roles and responsibilities in data collected through patient-centered measurement. Longitudinal Care Alignment can guide the care-team on incorporating patient-centered measurement into ongoing provider-patient interactions. Digital Tool Exploration can be used to evaluate a team's readiness toward digital tool adoption, and the impact of these tools. Team-based quality improvement serves as a framework for engaging teams in patient-centered quality improvement. Shared learning is a method that promotes patientprovider interactions that validate patient's perspectives of their care.

Conclusion

The portal illuminated new methods for the integration of patient-centered measurement in team-based care. The first three proposed patient-centered measurement methods provides ways to assess how a clinic can incorporate patient-centered measurement methods into team-based care. The latter two methods focus on the aim of patient-generated data in which patient's values and perspectives are represented and quality of patient-centered care can be evaluated. Further testing is needed to assess the utility of these patient-centered measurement methods across different clinical settings and domains.

Addressing Hypertension Outcomes Using Telehealth and Population Health Managers: Adaptations and Implementation Considerations

Purpose of Review

There is a growing evidence base describing population health approaches to improve blood pressure control. We reviewed emerging trends in hypertension population health management and present implementation considerations from an intervention called Team-supported, Electronic health record-leveraged, Active Management (TEAM). By doing so, we highlight the role of population health managers, practitioners who use population level data and to proactively engage at-risk patients, in improving blood pressure control.

Recent Findings

Within a population health paradigm, we discuss telehealth-delivered approaches to equitably improve hypertension care delivery. Additionally, we explore implementation considerations and complementary features of team-based, telehealth-delivered, population health management. By leveraging the unique role and expertise of a population health manager as core member of team-based telehealth, health systems can implement a cost-effective and scalable intervention that addresses multi-level barriers to hypertension care delivery.

Summary

We describe the literature of telehealth-based population health management for patients with hypertension. Using the TEAM intervention as a case study, we then present implementation considerations and intervention adaptations to integrate a population health manager within the health care team and effectively manage hypertension for a defined patient population. We emphasize practical considerations to inform implementation, scaling, and sustainability. We highlight future research directions to advance the field and support translational efforts in diverse clinical and community contexts.

Nurse-led service delivery models in primary care: A scoping review protocol

Background

Ensuring equitable access to health care is reliant on the strengthening of primary care services. Increasing the utilisation of task-sharing and telehealth models is one strategy to improve patient access and outcomes in primary care. This protocol details the methodology of a proposed scoping review of nurse and midwife involvement in task-sharing and telehealth models in primary care.

Aim

Undertaking this review will identify what models have been utilised in the primary care setting globally, the characteristics and health and economic outcomes of the models and whether these models are acceptable and feasible.

Design and setting

This protocol was developed in line with Joanna Briggs Institute Methodology for Scoping Reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis protocols (PRISMA-P).

Methods and analysis

Five databases (Ovid MEDLINE, Embase, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Library) will be searched for relevant studies published in English. Articles will be screened for inclusion in Covidence by three authors, with data extracted and synthesised using a chart designed for this review. Evidence will be mapped in both tabular and narrative forms to show characteristics, outcomes and acceptability of the models of care. Ethical approval is not required as data utilised is publicly available.

Conclusions

Understanding how nurse and midwife-led models of care may operate is crucial to strengthening service provision in primary care. Evidence on nurse and midwife led primary care models will be collated and synthesised to inform future models

Interprofessional primary care: indispensable for family physicians yet invisible to older patients

There is growing consensus that interprofessional primary care is key to delivering timely, coordinated, and comprehensive care, especially in the older patient population who often live with complex and chronic needs. Despite significant investments in reforming health systems toward interprofessional primary care, there is a paucity of evidence describing the importance of interprofessional primary care for older patients and physicians. This qualitative descriptive study aimed to understand the use and utility of interprofessional primary care for older patients and family physicians from the perspective of different stakeholders within primary care in Ontario, Canada. Twenty-five semi-structured interviews (including 16 older patients, six family physicians, three primary care managers) and a focus group with 13 patient representatives were conducted. Our study found that while the benefits of interprofessional primary care teams for family physicians were clearly emphasized, stakeholders consistently reported that older patients often appeared to be unaware of the presence of, or roles played by, non-physician healthcare professionals in their clinic. Better transparency and education regarding available services and roles of different care providers may allow for more optimal use of interprofessional family medicine clinics by patients.

Impact of State Nurse Practitioner Regulations on Potentially Inappropriate Medication Prescribing Between Physicians and Nurse Practitioners: A National Study in the United States

BACKGROUND

The American Geriatrics Society regularly updates the Beers Criteria for Potentially Inappropriate Medication (PIM) to improve prescribing safety.

PURPOSE

This study assessed the impact of nurse practitioner (NP) practices on PIM prescribing across states in the United States and compared the change in PIM prescribing rates between 2016 and 2018.

METHODS

We used data from a random selection of 20% of Medicare beneficiaries (66 years or older) from 2015 to 2018 to perform multilevel logistic regression. A PIM prescription was classified as initial or refill on the basis of medication history 1 year before a visit. PIM use after an outpatient visit was the primary study outcome.

RESULTS

We included 9 000 224 visits in 2016 and 9 310 261 in 2018. The PIM prescription rate was lower in states with full NP practice and lower among NPs than among physicians; these rates for both physicians and NPs decreased from 2016 to 2018.

CONCLUSIONS

Changes could be due to individual state practices.

Developing a team-based assessment strategy: direct observation of interprofessional team performance in an ambulatory teaching practice

Background: High functioning interprofessional teams may benefit from understanding how well (or not so well) a team is functioning and how teamwork can be improved. A team-based assessment can provide team insight into performance and areas for improvement. Though individual assessment via direct observation is common, few residency programs in the United States have implemented strategies for interprofessional team (IPT) assessments. Methods: We piloted a program evaluation via direct observation for a team-based assessment of an IPT within one Internal Medicine residency program. Our teams included learners from medicine, pharmacy, physician assistant and psychology graduate programs. To assess team performance in a systematic manner, we used a Modified McMaster-Ottawa tool to observe three types of IPT encounters: huddles, patient interactions and precepting discussions with faculty. The tool allowed us to capture team behaviors across various competencies: roles/responsibilities, communication with patient/family, and conflict resolution. We adapted the tool to include qualitative data for field notes by trained observers that added context to our ratings. Results: We observed 222 encounters over four months. Our results support that the team performed well in measures that have been iteratively and intentionally enhanced – role clarification and conflict resolution. However, we observed a lack of consistent incorporation of patient-family preferences into IPT discussions. Our qualitative results show that team collaboration is fostered when we look for opportunities to engage interprofessional learners. Conclusions: Our observations clarify the behaviors and processes that other IPTs can apply to improve collaboration and education. As a pilot, this study helps to inform training programs of the need to develop measures for, not just individual assessment, but also IPT assessment.

Mental health care integration and primary care patient experience in the Veterans Health Administration

BACKGROUND

Mental health specialists and care managers facilitate comprehensive care provision within medical homes. Despite implementation challenges, mental health integration is thought to improve patient-centered primary care.

OBJECTIVES

To examine the relationship between primary care patient experience and mental health integration.

RESEARCH DESIGN

Cross-sectional surveys from 168 primary care clinicians (PCPs) (n = 226) matched with assigned patients' surveys (n = 1734) in one Veterans Health Administration (VA) region, fiscal years 2012-2013. Multilevel regression models examined patient experience and mental health integration, adjusting for patient and PCP characteristics.

MEASURES

Patient experience outcomes were (1) experience with PCP and (2) receipt of comprehensive care, such as talked about "stress". Independent variables represented mental health integration- (1) PCP-rated communication with mental health and (2) proportion of clinic patients who saw integrated specialists.

RESULTS

50% and 43% of patients rated their PCPs 10/10 and reported receiving comprehensive care, respectively. Neither patient experience or receipt of comprehensive care was significantly associated with PCP's ratings of communication with mental health, nor with proportion of clinic patients who saw integrated specialists. Among a subsample of patients who rated their mental health as poor/fair, however, we detected an association between proportion of clinic patients who saw integrated specialists and patient experience (odds ratio = 1.05, 95% confidence interval = 1.01-1.09, p = .01).

CONCLUSIONS

No association was observed between mental health integration and primary care patients' reported care experiences, but a significant association existed among patients who reported poor/fair mental health. More research is needed to understand patient experiences with regard to care model implementation.

Clinical decision support systems with team-based care on type 2 diabetes improvement for Medicaid patients: A quality improvement project

BACKGROUND

The prevalence of clinical inertia, the failure of appropriate treatment intensification in diabetes treatment, is a well-documented worldwide phenomenon. This project addresses the problem of clinical inertia through three interrelated activities, clinical decision support (CDSS), team-based care, and patient engagement in diabetes management.

OBJECTIVES

The purpose of this research is to provide analysis under the State-University Partnership Learning Network regarding the impact of an electronic decision support tool combined with team-based care workflow on provider decision-making and patient outcomes for the treatment of poorly controlled diabetes mellitus (diabetes) among patients receiving Kentucky Medicaid. The objectives of this study are to 1) assess clinical outcomes of type 2 diabetes in the Medicaid population with team-based care using CDSS, 2) evaluate physicians' and pharmacists' experience on CDSS.

METHODS

This is a quality improvement project using a mixed-method - longitudinal and control group comparison of outcomes based upon clinical measures and online surveys of providers and pharmacists involved in this project.

RESULTS

Patients treated by providers who changed the treatment regimen to one that either fully or partially followed the recommendation of the CDSS tool had a statistically significant reduction in HbA1c with an average initial HbA1c of 10.1 and the final HbA1c of 8. The online survey of physicians shows that more than 80% of physicians agree the use of CDSS will support improved patient outcomes. The use of a team-based care approach that includes pharmacists in implementing treatment changes was broadly supported by both physicians and pharmacists.

CONCLUSION

CDSS combined with team-based care can be effective in reducing HbA1c to targeted therapeutic levels. The use of CDSS provides a way to efficiently assess more than 160 potential frontline drugs and properly accelerate treatment. Consistent with the research literature, the inclusion of pharmacists can play a key role in team-based care to assess treatment alternatives and provide for improvement in outcomes and patient adherence for diabetes. The user surveys show both physicians and pharmacists have a positive attitude toward CDSS.

Strategies to Improve the Quality of Team-Based Care for Neonatal Abstinence Syndrome

BACKGROUND

Prioritizing nonpharmacologic care for neonatal abstinence syndrome (NAS) requires a team-based care (TBC) approach to facilitate staff and family engagement. We aimed to identify the important structures and processes of care for TBC of infants with NAS and quality of care outcomes that are meaningful to care team members (including parents).

METHODS

Using a Donabedian framework, we conducted semistructured interviews from May to October 2019 with care team members at 3 community hospitals, including parents, nurses, social workers, physicians, lactation nurses, child protective services, volunteers, and hospital administrators. We used thematic analysis to identify important structures, processes of care, and outcomes.

RESULTS

We interviewed 45 interprofessional care team members: 35 providers and 10 parents. Structures critical to providing TBC included (1) building a comprehensive network of interprofessional team members and (2) creating an NAS specialized unit. Necessary processes of care included (1) prioritizing early involvement of interprofessional team members, (2) emphasizing nonjudgmental incorporation of previous experience with addiction, (3) establishing clear roles and expectations, and (4) maintaining transparency with social services. Lastly, we identified 9 outcomes resulting from these identified structures and processes that are meaningful to care team members to assess the quality of care for infants with NAS.

CONCLUSIONS

In this study, we identify important structures, processes of care, and meaningful outcomes to enhance and evaluate TBC for infants with NAS. Hospitals that adopt and implement these structures and processes have the potential to improve the quality of care for infants, caregivers, and providers who care for these infants.

Team-based primary health care for non-communicable diseases: complexities in South India

Chronic non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases, have reached epidemic proportions worldwide. Health systems, especially those in low- and middle-income countries, such as India, struggle to deliver quality chronic care. A reorganization of healthcare service delivery is needed to strengthen care for chronic conditions. In this study, we evaluated the implementation of a package of tailored interventions to reorganize care, which were identified following a detailed analysis of gaps in delivering quality NCD care at the primary care level in India. Interventions included a redesign of the workflow at primary care clinics, a redistribution of tasks, the introduction of patient information records and the involvement of community health workers in the follow-up of patients with NCDs. An experimental case study design was chosen to study the implementation of the quality improvement measures. Three public primary care facilities in rural South India were selected. Qualitative methods were used to gain an in-depth understanding of the implementation process and outcomes of implementation. Observations, field notes and semi-structured interviews with staff at these facilities (n = 15) were thematically analysed to identify contextual factors that influenced implementation. Only one of the primary health centres implemented all components of the intervention by the end of 9 months. The main barriers to implementation were hierarchical arrangements that inhibited team-based care, the amount of time required for counselling and staff transfers. Team cohesion, additional staff and staff motivation seem to have facilitated implementation. This quality improvement research highlights the importance of building relational leadership to enable team-based care at primary care clinics in India. Redesigned organization of care and task redistribution is important solutions to deliver quality chronic care. However, implementing these will require capacity building of local primary care teams.

Associations of patient-centered medical home with quality of care, patient experience, and health expenditures: A STROBE-compliant cross-sectional study

In efforts to improve the delivery of quality primary care, patient-centered medical home (PCMH) model has been promoted. However, evidence on its association with health outcomes has been mixed. The aim of this study was to assess the performance of PCMH model on quality of care, patient experience, health expenditures.This was a cross-sectional study of the 2015-2016 Medical Expenditure Panel Survey-Medical Organization Survey linked data, including 5748 patient-provider pairs. We examined twenty-four quality of care measures (18 high-value and 6 low-value care services), health service utilization, patient experience (patient-provider communication, satisfaction), and health expenditure.Of 5748 patients, representing a weighted population of 56.2 million American adults aged 18 years and older, 44.2% were cared for by PCMH certified providers. 9.3% of those with PCMHs had at least one inpatient stay in the past year, which was comparable to the 11.4% among those with non-PCMHs. Similarly, 17.4% of respondents cared for by PCMH and 18.5% cared for by non-PCMH had at least one ED visit. Overall, we found no significant differences in quality of care measures (neither high-nor low-value of care) between the two groups. The overall satisfaction, the experience of access to care, and communication with providers were also comparable. Patients who were cared for by PCMHs had less total health expenditure (difference $217) and out-of-pocket spending (difference $91) than those cared for by non-PCMHs; however, none of these differences reached the statistical significance (adjusted P > 0.05 for all).This study found no meaningful difference in quality of care, patient experience, health care utilization, or health care expenditures between respondents cared for by PCMH and non-PCMH. Our findings suggest that the PCMH model is not superior in the quality of care delivered to non-PCMH providers.

Interprofessional Education: Current State in Psychology Training

Healthcare reform has led to the consideration of interprofessional team-based, collaborative care as a way to provide comprehensive, high-quality care to patients and families. Interprofessional education is the mechanism by which the next generation health professional workforce is preparing for the future of health care-team-based, collaborative care. This literature review explored the extent and content of published studies documenting Interprofessional Education (IPE) activities with psychology trainees across learner level. A systematic review following PRISMA guidelines was conducted of studies describing IPE involving psychology learners. Electronic databases (MEDLINE, CINAHL, PsychINFO, and EMBASE) were searched for the following terms: inter/multi-professional education/practice, inter/multidisciplinary education/practice, and psychology/psychologists. Thirty-seven articles were identified that included psychology in clinical outcome studies or other reviews of interprofessional education initiatives. The review addresses the nature of current IPE learning activities, the impact of IPE activities on participating trainees, opportunities for, and challenges of, involving psychology trainees in IPE, and future directions for research. This review illuminates the relative paucity of the literature about IPE in psychology training. Given the trend toward increasing team-based collaborative care, the limited inclusion of psychology in the IPE literature is concerning. The next generation of health professional trainees is learning about, from, and with each other with the objective of building collaboration and teamwork. Given the few articles documenting psychology trainees' involvement in IPE, future health professionals quite possibly will have limited understanding of, and contact with, psychologists. Our findings are a call to action for greater psychology involvement in IPE.

Development of a Novel and Scalable Simulation-Based Teamwork Training Model Using Within-Group Debriefing of Observed Video Simulation

THE CHALLENGE

Effective teamwork and communication skills are essential for safe and reliable health care. These skills require training and practice. Experiential learning is optimal for training adults, and the industry has recognized simulation training as an exemplar of this approach. Yet despite decades of investment, this training is inaccessible and underutilized for most of the more than 12 million health care professionals in the United States.

DESIGNING A SOLUTION

This report describes the design process of an adapted simulation training created to overcome the key barriers to scaling simulation-based teamwork training: access to technology, time away from clinical work, and availability of trained simulation educators. The prototype training is designed for delivery in one-hour segments and relies on observation of video simulation scenarios and within-group debriefing, which are promising variations on traditional simulation training. To our knowledge, these two simulation approaches have not been previously combined. The resulting prototype minimizes the need for an on-site trained simulation educator. This report details the development of a training model, its subsequent modification based on pilot testing, and the evaluation of the resulting redesigned prototype.

PRELIMINARY EVALUATION

Participant evaluations of the redesigned prototype were highly positive, with 92% reporting that they would like to participate in additional, similar training sessions. Positive results were also found in assessment of feasibility, acceptability, psychological safety, and behavioral intention (reported intention to alter behavior).

Assessing Association Between Team Structure and Health Outcome and Cost by Social Network Analysis

BACKGROUND/OBJECTIVE

To assess the impact of team structure composition and degree of collaboration among various providers on process and outcomes of primary care.

DESIGN

Cross-sectional study.

SETTING

Data from 20% randomly selected primary care service areas in the 2015 Medicare claims were used to identify primary care practices.

PARTICIPANTS

449,460 patients with diabetes, heart failure, or chronic obstructive pulmonary disease cared for by the identified primary care practices.

MEASUREMENTS

Social network analysis measures, including edge density, degree centralization, and betweenness centralization for each practice.

RESULTS

When compared with practices with MDs and nurse practitioners (NPs) or/and physicians assistants (PAs), the practices with MDs had only lower degree of centralization and higher MD-to-MD connectedness. Within the primary care practices comprising MDs, NPs, or/and PAs, the nonphysician providers were more connected (measured as edge density) to all providers in the practice but with higher degree of centralization compared with the MDs in the practice. After adjusting for patient characteristics and type of practice, higher edge density was associated with lower odds of hospitalization (odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-0.99), emergency department (ER) admission (OR = 0.80, 95% CI = 0.70-0.92), and total spending (cost ratio (CR) = 0.86, standard error of the mean (SE) = 0.038). Conversely, higher degree centralization was associated with higher rates of hospitalization (OR = 1.15, 95% CI = 1.03-1.28), ER admission (OR = 1.23, 95% CI = 1.08-1.40), and total spending (CR = 1.14, SE = 0.037). However, higher degree centralization was associated with lower rates of potentially inappropriate medications (OR = 0.90, 95% CI = 0.81-0.99). Team leadership by an NP versus an MD was similar in the rate of ER admissions, hospitalizations, or total spending.

CONCLUSION

Our findings showed that highly connected primary care practices with high collaborative care and less top-down MD-centered authority have lower odds of hospitalization, fewer ER admissions, and less total spending; findings likely reflecting better communication and more coordinated care of older patients.

Optimal staffing in community health centers to improve quality of care

OBJECTIVE

To explore optimal workforce configurations in the production of care quality in community health centers (CHCs), accounting for interactions among occupational categories, as well as contributions to the volume of services.

DATA SOURCES

We linked the Uniform Data System from 2014 to 2016 with Internal Revenue Service nonprofit tax return data. The final database contained 3139 center-year observations from 1178 CHCs.

STUDY DESIGN

We estimated a system of two generalized linear production functions, with quality of care and volume of services as outputs, using the average percent of diabetic patients with controlled A1C level and hypertensive patients with controlled blood pressure as quality measures. To explore the substitutability and complementarity between staffing categories, we estimated a revenue function.

FINDINGS

Primary care physicians and advanced practice clinicians achieve similar quality outcomes (3.2 percent and 3.0 percent improvement in chronic condition management per full-time equivalent (FTE), respectively). Advanced practice clinicians generate less revenue per FTE but are generally less costly to employ.

CONCLUSION

As quality incentives are further integrated into payment systems, CHCs will need to optimize their workforce configuration to improve quality. Given the relative efficiency of advanced practice clinicians in producing quality, further hiring of these professionals is a cost-effective investment for CHCs.

Multidisciplinary aortopathy clinics: A systematic scoping review of the literature and evaluation of patient experiences from a newly started clinic in Norway

Background

International guidelines recommend hereditary thoracic aortic diseases (HTADs) to be managed in multidisciplinary aorta clinics.

Aim

To study HTAD patient's experiences with a aortopathy clinic in Norway and to review the literature on aortopathy clinics.

Methods

(a) A systematic scoping review of research on multidisciplinary clinics for HTADs. (b) A cross‐sectional postal questionnaire study to investigate patient experiences with the health‐services. Fifty consecutive patients from the aortopathy clinic and 50 controls in usual care were invited to participate.

Results

The review identified eight publications on aortopathy clinics. Although the papers were not judged for quality, these showed promising results from such clinics in terms of diagnostics and increased adherence to guideline‐directed therapy. The survey constituted thirty‐seven (74%) patients and 22 (44%) controls who responded to postal questionnaires. Both groups reported delays in diagnostics and follow‐up appointments prior to the start of the clinic. Patients indicated high satisfaction with the aortopathy clinic, whereas controls reported poor coordination of medical follow‐up. Individuals in both groups struggled with disease self‐management.

Conclusion

Norwegian patient experiences found the aortopathy clinic beneficial. According to studies included in the review, disease management in aortopathy clinics may improve patient satisfaction, diagnostics and follow‐up. Effect studies may further document the benefits of clinic organization, treatment, cost‐efficiency and patient experiences.

Multidisciplinary approach to degenerative cervical myelopathy

INTRODUCTION

Degenerative cervical myelopathy (DCM) is a prevalent condition causing significant impairment spanning several domains of health. A multidisciplinary approach to the care of DCM would be ideal in utilizing complex treatments from different disciplines to address broad patient needs.

AREAS COVERED

In this article the authors will discuss the importance of multidisciplinary care and establish a general framework for its use. The authors will then highlight the potential role of a multidisciplinary team in each aspect of DCM care including assessment, diagnosis, decision-making, surgical intervention, non-operative therapy, monitoring, and postoperative care.

EXPERT OPINION

In order to provide comprehensive personalized care to DCM patients, it is necessary to have a multidisciplinary team composed by a combination of the patient, surgeon, primary care practitioner, neurologist, anesthesiologist, radiologist, physiatrist, nurses, physiotherapist, occupational therapist, pain specialist, and social workers all functioning independently and communicating to achieve a common goal.

Improved patient-reported outcomes after interprofessional training in mental health: a nonrandomized intervention study

BACKGROUND

Collaborative interprofessional practices are essential in caring for people with complex mental health problems. Despite the difficulties of demonstrating positive impacts of interprofessional education (IPE), it is believed to enhance interprofessional practices. We aimed to assess impacts on patient satisfaction, self-reported psychological distress and mental health status in a psychiatric ward.

METHODS

We conducted a nonrandomized intervention study with patient satisfaction, psychological distress, and health status as outcomes. Mental health inpatients were referred to either an interprofessional training unit (intervention group) or to a conventionally organized ward (comparison group). Outcomes were assessed using the Short Form Health Survey (SF-36), the Kessler Psychological Distress Scale (K10), and the Client Satisfaction Questionnaire (CSQ-8).

RESULTS

The intervention group included 129 patients, the comparison group 123. The former group reported better mental health status than the latter; the postintervention mean difference between them being 5.30 (95% CI 2.71-7.89; p = 0.001; SF-36), with an effect size of 0.24. The intervention group patients also scored higher on satisfaction (mean difference 1.01; 95% CI 0.06-1.96; p = 0.04), with an effect size of 0.31. The groups' mean scores of psychological distress were identical.

CONCLUSION

Our results support the hypothesized value of interprofessional training: intervention group patients reported higher scores regarding mental health status and satisfaction than did comparison group patients. As IPE interventions have rarely involved patients and fewer have taken place in practice settings, further research into both the processes and the long-term effects of IPE in mental healthcare is needed.

TRIAL REGISTRATION

The study was registered in ClinicalTrials.gov: NCT03070977 on March 6, 2017.

Integration of nurses in general practice: A thematic synthesis of the perspectives of general practitioners, practice nurses and patients living with chronic illness

AIMS AND OBJECTIVES

To explore the views of general practitioners, practice nurses and patients on interprofessional collaboration in general practice and to understand to what extent the nurse-doctor relationship meets their needs and expectations.

BACKGROUND

To address future challenges of primary health care, there is a need for integrated interprofessional collaboration care systems with a patient-centred focus. Worldwide, there is an integration of nurses in general practice. However, in a transitioning Belgian context little is known about the perspectives of three key stakeholder groups.

DESIGN

The results of four qualitative descriptive primary studies were triangulated and a secondary analysis resulted in a thematic synthesis within a pragmatic research paradigm.

METHODS

Primary data were collected through individual, semi-structured interviews with 7 general practitioners, 19 practice nurses and 21 patients living with chronic illness in 26 primary care centres with different nurse integration levels. We conducted a secondary analysis for the thematic synthesis of the different stakeholders' perspectives. This study was reported in accordance with the COREQ checklist.

RESULTS

Four overarching themes were found as follows: vision and mission at general practice level, patient-centred care, practice nurse role development and interprofessional collaboration. Interprofessional collaboration within general practice ensures better response to patient needs. Evolution of the practice nurse role to autonomous decision-making can be facilitated by clear vision and mission, team communication, complementarity of responsibilities and trust-based professional relationships.

CONCLUSIONS

The key for patient-centred care in a well-organised practice is a clear vision and mission and well-defined task description for interprofessional collaboration. General practice is urging for systematic guidance for the sustainable integration of a practice nurse.

RELEVANCE TO CLINICAL PRACTICE

Our study highlights opportunities and challenges to nurse integration in general practice from key stakeholders' perspectives, which can inform other transitioning contexts.

Outcomes of trimodality bladder-sparing therapy for muscle-invasive bladder cancer

INTRODUCTION

Although radical cystectomy is considered the standard of care for muscle-invasive bladder cancer (MIBC), recent data has suggested comparable survival outcomes for bladder-sparing trimodality therapy (TMT). We conducted a retrospective, single-institution analysis of MIBC patients to evaluate the efficacy of TMT as an alternative, curative approach to surgical intervention.

METHODS

We conducted a retrospective analysis of MIBC patients assessed by a multidisciplinary team at the Juravinski Cancer Centre from 2010-2016. Patients underwent transurethral resection of bladder tumor (TURBT) followed by radiotherapy with or without concurrent chemotherapy. Patients could receive neoadjuvant treatment. Clinical data and response rates were summarized, and overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method.

RESULTS

Our analytic cohort included 115 patients, of whom 53 underwent TMT and 62 underwent radiotherapy alone following TURBT. Median age at diagnosis was 79 years and median followup was 21 months. Complete response rates in those receiving TMT and radiation without chemotherapy were 84.4% and 66.7%, respectively. For TMT patients, three-year OS and DFS were 68.5% and 49.6%, respectively. Patients who received TMT had reduction in risk of mortality (hazard ratio [HR] 0.49; p=0.026) and disease recurrence (HR 0.55; p=0.017) compared to those who had radiation without chemotherapy. Overall, four patients had grade 3 or higher late toxicity.

CONCLUSIONS

In this single-institution analysis, TMT appears to be a safe and effective approach in the short-term management of MIBC in appropriately selected patients. Extended followup and analysis are necessary to validate these results.

Implementation of Case Conferences to Improve Interprofessional Collaboration in Resident Continuity Clinic

OBJECTIVES

Residents must be trained in skills for interprofessional collaboration and team-based care in the outpatient setting, and successful models are needed to achieve this aim. A longitudinal curriculum was developed to enhance residents' knowledge of interprofessional team members' roles, residents' attitudes toward team-based care, and patient referrals to team members.

METHODS

Postgraduate year 1 through postgraduate year 3 internal medicine residents with continuity clinic at a large hospital-based practice received the curriculum. Residents with continuity clinic at another site did not receive the curriculum and served as controls. Intervention residents attended five small-group conferences during the course of 1 year, each dedicated to a specific interprofessional discipline: pharmacy, psychology, diabetes/nurse education, social work, and case management. Conferences involved interactive, case-based discussions of patients who benefit from an interprofessional approach. Control and intervention residents were surveyed with pre- and posttests. The rates of patient referrals to interprofessional team members were assessed.

RESULTS

Seventy-one residents received the curriculum. Intervention residents' knowledge of team members' names and roles, indications for patient referral, and communication methods improved after curriculum implementation. Attitudes toward team-based care did not change but were positive at baseline. Following curriculum implementation, new patient referrals increased for the pharmacist (0.1-1/100 patient visits, P = 0.015) and psychologist (1.1-2.2/100 patient visits, P = 0.032).

CONCLUSIONS

Case-based interprofessional conferences improved residents' knowledge regarding interprofessional care and increased referrals to team members. This curriculum addresses barriers to team-based care experienced by residents in continuity clinic and is adaptable to other clinic settings.

Team-Based Care and Patient Satisfaction in the Hospital Setting: A Systematic Review

Purpose

Limited research examining the relationship between team-based models of care and patient satisfaction in the hospital setting is available. The purpose of this literature review was to explore this relationship as well as the relationships between team composition, team-based interventions, patient satisfaction, and other outcomes of care when measured as part of the study.

Methods

A systematic appraisal of research studies published through February 2017 was conducted using PubMed, Cochrane Library, CINAHL, Embase, Ovid, gray literature and Google Scholar. Inclusion criteria were 1) experimental (randomized control trials), quasi-experimental, or non-experimental (cross-sectional) study design; 2) team-based care interventions; 3) hospital setting; 4) patient satisfaction measured as an outcome; and 5) published in English.

Results

The literature search yielded 15,247 citations. In total, 142 articles were retrieved for full-text screening; 21 studies met inclusion criteria. Overall, 57% of the studies identified a statistically significant improvement in patient satisfaction associated with team-based care. Team-based care interventions ranged from single team activities such as multidisciplinary rounds to comprehensive team-based models of care. Patient satisfaction scores were greater with teams that had more than two professions and more comprehensive team-based models. About one-quarter of studies that measured patient satisfaction and at least one additional outcome demonstrated improvement in both.

Conclusions

Team-based care may positively affect patient satisfaction. Team composition and type of team intervention appears to influence the strength of the relationship. Improvements in satisfaction are not consistently accompanied by improvements in other outcomes.

An evaluation of an advanced practice role in palliative radiation therapy

Introduction

The purpose of the study was to evaluate the palliative advanced practice radiation therapy (APRT) role with respect to the impact on waiting times for patients from referral to radiation treatment delivery, the ability of the APRT to define palliative radiation therapy fields and patient satisfaction. The evaluation of the impact of the APRT role and referral pathway on patient waiting times has been previously published.

Methods

Patients were allocated to two different pathways; APRT and standard. Patients in the APRT pathway had their radiotherapy treatment managed by the APRT including defining their palliative fields blinded to the radiation oncologist (RO).

Results

Of the 150 palliative patients, 94 had their radiation therapy managed by the APRT and 56 were managed through the standard pathway. 82/92 APRT defined fields were accepted by the RO.

Conclusions

Inter‐observer variability between the APRT and the RO in defining palliative radiation therapy fields is similar to that reported in the literature between clinicians. With previously published reduced wait times from referral to treatment for palliative patients, the establishment of the APRT role is justified.

Multidisciplinary collaborative care in the management of patients with uncontrolled diabetes: A systematic review and meta-analysis

BACKGROUND

Diabetes is a chronic and complex disease that requires a multidisciplinary collaborative care approach.

OBJECTIVE

The primary objective was to evaluate the clinical outcomes of patients with uncontrolled diabetes within a multidisciplinary collaborative care model. The secondary objective was to evaluate the humanistic and economic outcomes of this model of care.

METHODS

A search using PubMed, SCOPUS, and CINAHL from 2007 to 2017 was conducted. Articles selected included randomised controlled studies on multidisciplinary collaborative care (defined as care provision by ≥ two different care providers) vs usual care (defined as standard care provided solely by physicians) for patients with uncontrolled diabetes. In addition, the eligible article had to report at least two of the three outcomes such as clinical (glycated haemoglobin [HbA1c], systolic blood pressure [SBP], low-density lipoprotein [LDL], and triglyceride [TG]), humanistic (patient-reported measures), and economic (healthcare costs and utilisations) outcomes. Parameters examined included study characteristics, care interventions, patient characteristics, and study outcomes. Primary outcomes using mean differences (MDs) with 95% confidence intervals (CIs) were analysed either by fixed- or random-effects models.

RESULTS

A total of 16 studies were included in the review. Multidisciplinary collaborative care significantly improved HbA1c (MD = -0.55%, 95% CI = -0.65% to -0.45%, P < 0.001, I²  = 35%) and SBP (MD = -4.89 mm Hg, 95% CI = -6.64 to -3.13 mm Hg, P < 0.001, I²  = 46%) over 3-12 months. The humanistic outcomes in the multidisciplinary collaborative care model were either improved or maintained over time. In comparison to usual care, the healthcare costs and utilisations in the multidisciplinary collaborative care model were comparable without incurring excessive costs.

CONCLUSIONS

Multidisciplinary collaborative care appeared to positively impact on the clinical, humanistic, and economic outcomes of patients with uncontrolled diabetes.

How teams impact patient satisfaction: A review of the empirical literature

BACKGROUND

The increased use of health care teams merits further investigation in terms of their impact on patient satisfaction. Patient satisfaction and patient experience generally have come front-and-center given trends within the health care industry around "patient-centered care" and "consumer engagement."

PURPOSE

This review examines research published between 2000 and 2017 that includes analysis of potential team-patient satisfaction linkages, taking the conceptual perspective that both the mere presence of health care teams and specific team features like cohesion may each be impactful.

METHODS

A systematic, PRISMA-guided literature review across four databases (PubMed, CINAHL, Business Source Complete, and ScienceDirect) to examine potential team-patient satisfaction linkages in the existing team literature was performed.

RESULTS

In-depth review of 24 relevant studies found the following: (a) The extant literature examining the team-patient satisfaction relationship currently suffers from limitations around study design, construct definition, and variable operationalization, which render less confidence overall in the body of work, and (b) despite the limitations, extant work does suggest that there may be instances where the presence of a health care team does favorably impact patient satisfaction.

PRACTICE IMPLICATIONS

Future research should attend to several issues related to study design improvements, more precise operationalization and measurement of both teams and patient satisfaction, expansion of focus beyond patient satisfaction within the same study, and inclusion of more ambulatory care delivery settings in team-satisfaction research.

Evaluation of the quality of acute pain management in a pediatric surgical setting: Validation of a parent proxy modified version of the revised American Pain Society Patient Outcome Questionnaire

BACKGROUND

Effective pain management involves a cycle of continual pain assessment, good pain control strategies, and assessment of a standard quality improvement measures. A validated questionnaire that focuses on the quality of postoperative pain management in pediatric surgical patients and parental satisfaction on pain treatment is lacking. We, therefore, modified the revised American Pain Society Patient Outcome Questionnaire to evaluate the quality of postoperative pain management in a pediatric surgical setting. The primary aim of this study was to validate the modified version of revised American Pain Society Patient Outcome Questionnaire.

METHODS

Parents whose children aged below 12 years and were scheduled for elective surgery in a teaching hospital, were approached to participate in this survey. The reliability of the modified version of revised American Pain Society Patient Outcome Questionnaire was evaluated using Cronbach's alpha test, while the construct validity was assessed with a principal component analysis using a varimax rotation. The parental satisfaction with pain treatment received was measured.

RESULTS

A total of 108 parents completed the questionnaire. The internal consistency of the questionnaire shows a Cronbach's alpha of 0.798. Principal component analysis revealed a four-factor structure of the 12 items which explained 69.7% of the total variance. The factors are "Interference of sleep and activity," "Pain severity and drowsiness," "Perception of care," and "Adverse effects," respectively. Our study showed that this questionnaire is a valid and reliable measure for "Interference of sleep and activity" and "Pain severity and drowsiness" factors, but not for "Perception of care" and "Adverse effects." The results for "Perception of care" and "Adverse effects," therefore, should be reported as individual items instead of total score. The parental satisfaction with pain treatment given was good (median 8.0; IQR 3.0).

CONCLUSION

The modified version of revised American Pain Society Patient Outcome Questionnaire is a feasible and easy instrument to administer. The questionnaire can be used to obtain feedback from parents about the outcomes and experiences of pain management and is helpful in continuous quality evaluation and improvement in the postoperative care in a pediatric setting.

Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients

IMPORTANCE

Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions.

OBJECTIVE

To evaluate the association of establishing team-based primary care with patient health care use and costs.

DESIGN, SETTING, AND PARTICIPANTS

We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018.

EXPOSURES

Practices participated in a 4-year learning collaborative that created and supported team-based primary care.

MAIN OUTCOMES AND MEASURES

Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care.

RESULTS

Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n = 51 155 [37.0%] vs n = 186 954 [46.6%]), more participants younger than 18 years (n = 337 931 [27.5%] vs n = 74 691 [18.6%]), higher Medicaid enrollment (n = 39 541 [28.6%] vs n = 81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P < .001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P = .03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P = .007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P = .009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P < .001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P = .003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P = .02).

CONCLUSIONS AND RELEVANCE

While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.

The Elephant in the Room: The Need for Increased Integrative Therapies in Conventional Medical Settings

Pediatric integrative therapy programs are essential to the treatment and well-being of patients. Identifying an effective integrative therapy model within conventional pediatric medical settings, however, often proves difficult. Our goal in this article is to explore varied solutions to increase access and inclusion of integrative therapies in an effort to promote best practice and holistic care. The main methods applied in this article are vignettes that illustrate how the integrative therapies in a metropolitan academic hospital successfully treat the patient by complementing conventional medicine. This leads to comprehensive care. The central finding of the article proposes viable solutions to increase interdisciplinary collaboration both internally within the institution and externally. Integrative therapists detail how they were able to increase visibility and yield best practice through increased educational initiatives and interdisciplinary collaboration.

Nurse Practitioner-Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain

PURPOSE

Various models of care delivery have been investigated to meet the increasing demands in primary care. One proposed model is comanagement of patients by more than 1 primary care clinician. Comanagement has been investigated in acute care with surgical teams and in outpatient settings with primary care physicians and specialists. Because nurse practitioners are increasingly managing patient care as independent clinicians, our study objective was to propose a model of nurse practitioner-physician comanagement.

METHODS

We conducted a literature search using the following key words: comanagement; primary care; nurse practitioner OR advanced practice nurse. From 156 studies, we extracted information about nurse practitioner-physician comanagement antecedents, attributes, and consequences. A systematic review of the findings helped determine effects of nurse practitioner-physician comanagement on patient care. Then, we performed 26 interviews with nurse practitioners and physicians to obtain their perspectives on nurse practitioner-physician comanagement. Results were compiled to create our conceptual nurse practitioner-physician comanagement model.

RESULTS

Our model of nurse practitioner-physician comanagement has 3 elements: effective communication; mutual respect and trust; and clinical alignment/shared philosophy of care. Interviews indicated that successful comanagement can alleviate individual workload, prevent burnout, improve patient care quality, and lead to increased patient access to care. Legal and organizational barriers, however, inhibit the ability of nurse practitioners to practice autonomously or with equal care management resources as primary care physicians.

CONCLUSIONS

Future research should focus on developing instruments to measure and further assess nurse practitioner-physician comanagement in the primary care practice setting.

The key questions in rehabilitation in thoracic surgery

Enhancing the recovery of patients undergoing Thoracic Surgery is the raison d'être of a pulmonary rehabilitation (PR) process. Benefits of a PR program have been shown to include reduced postoperative complications, hospital length of stay (LOS) and improved exercise and lung function parameters. Identifying which groups of patients benefit most and the constituency of the perfect PR program is subject to ongoing research. Providing PR to patients in a manner acceptable to their lifestyle and disease timeline within economic limitations is the challenge.

Job-related stress in psychiatric assistant nurses

Aim

We aimed to clarify how stress among psychiatric assistant nurses (PANs) differed from Registered Nurses (PRNs).

Design

Cross-sectional survey study was conducted with PRNs and PANs working in six psychiatric hospitals in Japan.

Methods

The Psychiatric Nurse Job Stressor Scale (PNJSS) and the job stressor and stress reaction subscales of the Brief Job Stress Questionnaire measured stress in 68 PANs and 140 PRNs. The results were statistically analysed.

Results

Psychiatric assistant nurses had significantly higher scores than PRNs on the job stressor subscales in psychiatric nursing ability, interpersonal relations and in the stress reaction subscales of irritability and somatic symptoms. "Psychiatric nursing ability," "Communication" and "Use of techniques" were associated with almost all stress reactions in PANs than in PRNs.

Patients' perceptions of healthcare professionalism-a Romanian experience

Background

The main objective of this cross sectional study was to assess the psychometric properties of a new research instrument. The secondary aim was to analyze patients’ levels of dissatisfaction with the professionalism of medical staff.

Methods

A social survey questionnaire was created and administered online. The instrument consisted of two scales: the 30-item patient dissatisfaction scale and the 10 items institutional scale. In this article, we assessed only the patient dissatisfaction scale. The research population includes 1838 subjects. The statistical procedures used were descriptive statistics, Pearson’s correlation, and factorial analyses with the SPSS.19 software. The internal consistency of the instrument was determined using the Cronbach’s alpha coefficient. We used a principal component analysis to investigate the factorial validity of the scale.

Results

The patients’ scale of dissatisfaction obtained an alpha Cronbach score of 0.81. Three latent factors corresponding to three dimensions of dissatisfaction emerged from the data: medical staff’s ability to communicate, medical staff’s hygiene, as well as sanitary and privacy conditions within the hospital. The first factor explained 43.47% of the variance in patient dissatisfaction, the second factor explained 10.24%, and the third factor explained 7.59%; overall, the three factors explained 61.30% of the total variance.

Conclusion

The Romanian healthcare system has an organization and management structure which has shown few changes since the communist period. Our study indicates that although more than 25 years have passed since the political regime changed in Romania and the introduction of a different system of social care, there have been no corresponding changes in the medical staff’s mentality or in the way that patients are approached. The present assessment of patient dissatisfaction is not a strictly theoretical exercise; it also represents a valuable instrument for healthcare system management.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2412-z) contains supplementary material, which is available to authorized users.

The collaboration of general practitioners and nurses in primary care: a comparative analysis of concepts and practices in Slovenia and Spain

Aim A comparative analysis of concepts and practices of GP-nurse collaborations in primary health centres in Slovenia and Spain.

BACKGROUND

Cross-professional collaboration is considered a key element for providing high-quality comprehensive care by combining the expertise of various professions. In many countries, nurses are also being given new and more extensive responsibilities. Implemented concepts of collaborative care need to be analysed within the context of care concepts, organisational structures, and effective collaboration.

METHODS

Background review of primary care concepts (literature analysis, expert interviews), and evaluation of collaboration in 'best practice' health centres in certain regions of Slovenia and Spain. Qualitative content analysis of expert interviews, presentations, observations, and group discussions with professionals and health centre managers. Findings In Slovenian health centres, the collaboration between GPs and nurses has been strongly shaped by their organisation in separate care units and predominantly case-oriented functions. Conventional power structures between professions hinder effective collaboration. The introduction of a new cross-professional primary care concept has integrated advanced practice nurses into general practice. Conventional hierarchies still exist, but a shared vision of preventive care is gradually strengthening attitudes towards team-oriented care. Formal regulations or incentives for teamwork have yet to be implemented. In Spain, health centres were established along with a team-based care concept that encompasses close physician-nurse collaboration and an autonomous role for nurses in the care process. Nurses collaborate with GPs on more equal terms with conflicts centring on professional disagreements. Team development structures and financial incentives for team achievements have been implemented, encouraging teams to generate their own strategies to improve teamwork.

CONCLUSION

Clearly defined structures, shared visions of care and team development are important for implementing and maintaining a good collaboration. Central prerequisites are advanced nursing education and greater acceptance of advanced nursing practice.

Interprofessional Teamwork Education: Moving Toward the Patient-Centered Approach

HOW TO OBTAIN CONTACT HOURS BY READING THIS ISSUE Instructions: 1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded after you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. In order to obtain contact hours you must: 1. Read the article, "Interprofessional Teamwork Education: Moving Toward the Patient-Centered Approach," found on pages 449-460, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website to register for contact hour credit. You will be asked to provide your name, contact information, and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until September 30, 2019. CONTACT HOURS This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. OBJECTIVES Explain the recommended framework in teaching and implementing interprofessional competencies. Identify suggested core competencies to implement interprofessional collaborative practice. DISCLOSURE STATEMENT Neither the planners nor the author have any conflicts of interest to disclose.

BACKGROUND

The aim of this study is to develop and contextualize a competency framework for interprofessional teamwork in Iran.

METHOD

The study was conducted in three phases. First, the competencies of interprofessional teamwork were extracted from the literature. In the second phase, the content validity of the initial framework was assessed by the experts through the Delphi rounds. Content validity ratio (CVR) and item-level content validity index (I-CVI) were used for quantitative analysis. Finally, in the third phase, the importance and utility of interprofessional teamwork competencies were assessed by the experts.

RESULTS

Initial framework was constructed with 28 competencies. Quantitative analysis by CVR indicated a score of less than .49 for three items. These items were excluded from the framework. The I-CVI for all items in the framework was higher than .78. The final framework was developed and validated with 16 competencies.

DISCUSSION

The developed framework is recommended for teaching and assessment of interprofessional teamwork competencies. J Contin Educ Nurs. 2016;47(10):449-460.

Is the co-location of GPs in primary care centres associated with a higher patient satisfaction? Evidence from a population survey in Italy

Background

Several countries have co-located General Practitioners (GPs) in Primary Care Centres (PCCs) with other health and social care professionals in order to improve integrated care. It is not clear whether the co-location of a multidisciplinary team actually facilitates a positive patient experience concerning GP care. The aim of this study was to verify whether the co-location of GPs in PCCs is associated positively with patient satisfaction with their GP when patients have experience of a multidisciplinary team. We also investigated whether patients who frequently use health services, due to their complex needs, benefitted the most from the co-location of a multidisciplinary team.

Methods

The study used data from a population survey carried out in Tuscany (central Italy) at the beginning of 2015 to evaluate the patients’ experience and satisfaction with their GPs. Multilevel linear regression models were implemented to verify the relationship between patient satisfaction and co-location. This key explanatory variable was measured by considering both the list of GPs working in PCCs and the answers of surveyed patients who had experienced the co-location of their GP in a multidisciplinary team. We also explored the effect modification on patient satisfaction due to the use of hospitalisation, access to emergency departments and visits with specialists, by performing the multilevel modelling on two strata of patient data: frequent and non-frequent health service users.

Results

A sample of 2025 GP patients were included in the study, 757 of which were patients of GPs working in a PCC. Patient satisfaction with their GP was generally positive. Results showed that having a GP working within a PCC and the experience of the co-located multidisciplinary team were associated with a higher satisfaction (p < 0.01). For non-frequent users of health services on the other hand, the co-location of multidisciplinary team in PCCs was not significantly associated with patient satisfaction, whereas for frequent users, the strength of relationships identified in the overall model increased (p < 0.01).

Conclusion

The co-location of GPs with other professionals and their joint working as experienced in PCCs seems to represent a greater benefit for patients, especially for those with complex needs who use primary care, hospitals, emergency care and specialized care frequently.

It 'makes you feel more like a person than a patient': patients' experiences receiving home-based primary care (HBPC) in Ontario, Canada

The lack of effective systems to appropriately manage the health and social care of frail older adults - especially among those who become homebound - is becoming all the more apparent. Home-based primary care (HBPC) is increasingly being promoted as a promising model that takes into account the accessibility needs of frail older adults, ensuring that they receive more appropriate primary and community care. There remains a paucity of literature exploring patients' experiences with HBPC programmes. The purpose of this study was to explore the experiences of patients accessing HBPC delivered by interprofessional teams, and their perspectives on the facilitators and barriers to this model of care in Ontario, Canada. Using certain grounded theory principles, we conducted an inductive qualitative content analysis of in-depth patient interviews (n = 26) undertaken in the winter of 2013 across seven programme sites exploring the lived experiences and perspectives of participants receiving HBPC. Themes emerged in relation to patients' perceptions regarding the preference for and necessity of HBPC, the promotion of better patient care afforded by the model in comparison to office-based care, and the benefits of and barriers to HBPC service provision. Underlying patterns also surfaced related to patients' feelings and emotions about their quality of life and satisfaction with HBPC services. We argue that HBPC is well positioned to serve frail homebound older adults, ensuring that patients receive appropriate primary and community care - which the office-based alternative provides little guarantee - and that they will be cared for, pointing to a model that may not only lead to greater patient satisfaction but also likely contributes to bettering the quality of life of a highly vulnerable population.

Does a complex intervention increase patient knowledge about oral anticoagulation? - a cluster-randomised controlled trial

Background

Oral anticoagulation therapy (OAT) is a challenge in general practice, especially for high-risk groups such as the elderly. Insufficient patient knowledge about safety-relevant aspects of OAT is considered to be one of the main reasons for complications. The research question addressed in this manuscript is whether a complex intervention that includes practice-based case management, self-management of OAT and additional patient and practice team education improves patient knowledge about anticoagulation therapy compared to a control group of patients receiving usual care (as a secondary objective of the Primary Care Management for Optimised Antithrombotic Treatment (PICANT) trial).

Methods

The cluster-randomised controlled PICANT trial was conducted in 52 general practices in Germany, between 2012 and 2015. Trial participants were patients with a long-term indication for oral anticoagulation. A questionnaire was used to assess knowledge at baseline, after 12, and after 24 months. The questionnaire consists of 13 items (with a range of 0 to 13 sum-score points) covering topics related to intervention. Differences in the development of patient knowledge between intervention and control groups compared to baseline were assessed for each follow-up by means of linear mixed-effects models.

Results

Seven hundred thirty-six patients were included at baseline, of whom 95.4% continued to participate after 12 months, and 89.3% after 24 months. The average age of patients was 73.5 years (SD 9.4), and they mainly suffered from atrial fibrillation (81.1%). Patients in the intervention and control groups had similar knowledge about oral anticoagulation at baseline (5.6 (SD 2.3) in both groups). After 12 months, the improvement in the level of knowledge (compared to baseline) was significantly larger in the intervention group than in the control group (0.78 (SD 2.5) vs. 0.04 (SD 2.3); p = 0.0009). After 24 months, the difference between both groups was still statistically significant (0.6 (SD 2.6) vs. -0.3 (SD 2.3); p = 0.0001).

Conclusion

Since this intervention was effective, it should be established in general practice as a means of improving patient knowledge about oral anticoagulation.

Trial registration

Current controlled trials ISRCTN41847489; Date of registration: 13/04/2012

Validation of the scale on Satisfaction of Adolescents with Postoperative pain management - idiopathic Scoliosis (SAP-S)

Background

Spinal fusion is a common orthopedic surgery in children and adolescents and is associated with high pain levels postoperatively. If the pain is not well managed, negative outcomes may ensue. To our knowledge, there is no measure in English that assesses patient’s satisfaction with postoperative pain management following idiopathic scoliosis surgery. The aim of the present study was to assess the psychometric properties of the satisfaction subscale of the English version of the Satisfaction of Adolescents with Postoperative pain management – idiopathic Scoliosis (SAP-S) scale.

Methods

Eighty-two participants aged 10–18 years, who had undergone spinal fusion surgery, fully completed the SAP-S scale at 10–14 days postdischarge. Construct validity was assessed through a principal component analysis using varimax rotation.

Results

Principal component analysis indicated a three-factor structure of the 13-item satisfaction subscale of the SAP-S scale. Factors referred to satisfaction regarding current medication received (Factor 1), actions taken by nurses and doctors to manage pain (Factor 2) and information received after surgery (Factor 3). Cronbach’s alpha was 0.91, showing very good internal consistency. Data on satisfaction and clinical outcomes were also reported.

Conclusion

The SAP-S is a valid and reliable measure of satisfaction with postoperative pain management that can be used in both research and clinical settings to improve pain management practices. Although it was developed and validated with adolescents who had undergone spinal fusion surgery, it can be used, with further validation, to assess adolescents’ satisfaction with pain management in other postoperative contexts.

When less is more: validating a brief scale to rate interprofessional team competencies

BACKGROUND

There is a need for validated and easy-to-apply behavior-based tools for assessing interprofessional team competencies in clinical settings. The seven-item observer-based Modified McMaster-Ottawa scale was developed for the Team Objective Structured Clinical Encounter (TOSCE) to assess individual and team performance in interprofessional patient encounters.

OBJECTIVE

We aimed to improve scale usability for clinical settings by reducing item numbers while maintaining generalizability; and to explore the minimum number of observed cases required to achieve modest generalizability for giving feedback.

DESIGN

We administered a two-station TOSCE in April 2016 to 63 students split into 16 newly-formed teams, each consisting of four professions. The stations were of similar difficulty. We trained sixteen faculty to rate two teams each. We examined individual and team performance scores using generalizability (G) theory and principal component analysis (PCA).

RESULTS

The seven-item scale shows modest generalizability (.75) with individual scores. PCA revealed multicollinearity and singularity among scale items and we identified three potential items for removal. Reducing items for individual scores from seven to four (measuring Collaboration, Roles, Patient/Family-centeredness, and Conflict Management) changed scale generalizability from .75 to .73. Performance assessment with two cases is associated with reasonable generalizability (.73). Students in newly-formed interprofessional teams show a learning curve after one patient encounter. Team scores from a two-station TOSCE demonstrate low generalizability whether the scale consisted of four (.53) or seven items (.55).

CONCLUSION

The four-item Modified McMaster-Ottawa scale for assessing individual performance in interprofessional teams retains the generalizability and validity of the seven-item scale. Observation of students in teams interacting with two different patients provides reasonably reliable ratings for giving feedback. The four-item scale has potential for assessing individual student skills and the impact of IPE curricula in clinical practice settings.

ABBREVIATIONS

IPE: Interprofessional education; SP: Standardized patient; TOSCE: Team objective structured clinical encounter.

Team-Based Care: A Concept Analysis

AIM

The purpose of this concept analysis is to clarify and analyze the concept of team-based care in clinical practice.

BACKGROUND

Team-based care has garnered attention as a way to enhance healthcare delivery and patient care related to quality and safety. However, there is no consensus on the concept of team-based care; as a result, the lack of common definition impedes further studies on team-based care.

METHODS

This analysis was conducted using Walker and Avant's strategy. Literature searches were conducted using PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO, with a timeline from January 1985 to December 2015.

RESULTS

The analysis demonstrates that the concept of team-based care has three core attributes: (a) interprofessional collaboration, (b) patient-centered approach, and (c) integrated care process. This is accomplished through understanding other team members' roles and responsibilities, a climate of mutual respect, and organizational support. Consequences of team-based care are identified with three aspects: (a) patient, (b) healthcare professional, and (c) healthcare organization.

CONCLUSION

This concept analysis helps better understand the characteristics of team-based care in the clinical practice as well as promote the development of a theoretical definition of team-based care.

A human factors systems approach to understanding team-based primary care: a qualitative analysis

BACKGROUND

Research shows that high-functioning teams improve patient outcomes in primary care. However, there is no consensus on a conceptual model of team-based primary care that can be used to guide measurement and performance evaluation of teams.

OBJECTIVE

To qualitatively understand whether the Systems Engineering Initiative for Patient Safety (SEIPS) model could serve as a framework for creating and evaluating team-based primary care.

METHODS

We evaluated qualitative interview data from 19 clinicians and staff members from 6 primary care clinics associated with a large Midwestern university. All health care clinicians and staff in the study clinics completed a survey of their communication connections to team members. Social network analysis identified key informants for interviews by selecting the respondents with the highest frequency of communication ties as reported by their teammates. Semi-structured interviews focused on communication patterns, team climate and teamwork.

RESULTS

Themes derived from the interviews lent support to the SEIPS model components, such as the work system (Team, Tools and Technology, Physical Environment, Tasks and Organization), team processes and team outcomes.

CONCLUSIONS

Our qualitative data support the SEIPS model as a promising conceptual framework for creating and evaluating primary care teams. Future studies of team-based care may benefit from using the SEIPS model to shift clinical practice to high functioning team-based primary care.

Sharing Responsibilities within the General Practice Team - A Cross-Sectional Study of Task Delegation in Germany

BACKGROUND

Expected growth in the demand for health services has generated interest in the more effective deployment of health care assistants. Programs encouraging German general practitioners (GPs) to share responsibility for care with specially qualified health care assistants in the family practice (VERAHs) have existed for several years. But no studies have been conducted on the tasks German GPs are willing to rely on specially qualified personnel to perform, what they are prepared to delegate to all non-physician practice staff and what they prefer to do themselves.

METHODS

As part of an evaluation study on the deployment of VERAHs in GP-centered health care, we used a questionnaire to ask about task delegation within the practice team. From a list of tasks that VERAHs are specifically trained to carry out, GPs were asked to indicate which they actually delegate. We also asked GPs why they had employed a VERAH in their practice and for their opinions on the benefits and limitations of assigning tasks to VERAHs. The aim of the study was to find out which tasks GPs delegate to their specially qualified personnel, which they permit all HCAs to carry out, and which tasks they do not delegate at all.

RESULTS

The survey was filled in and returned by 245 GPs (83%). Some tasks were exclusively delegated to VERAHs (e.g. home visits), while others were delegated to all HCAs (e.g. vaccinations). About half the GPs rated the assessment of mental health, as part of the comprehensive assessment of a patient's condition, as the sole responsibility of a GP. The possibility to delegate more complex tasks was the main reason given for employing a VERAH. Doctors said the delegation of home visits provided them with the greatest relief.

CONCLUSIONS

In Germany, where GPs are solely accountable for the health care provided in their practices, experience with the transfer of responsibility to other non-physician health care personnel is still very limited. When HCAs have undergone special training, GPs seem to be prepared to delegate tasks that demand a substantial degree of know-how, such as home visits and case management. This "new" role allocation within the practice may signal a shift in the provision of health care by family practice teams in Germany.

What’s Unethical About Interprofessional Collaboration?

In this commentary, the beneficial value of the relational aspects of interprofessional collaboration is emphasized to demonstrate that conflict of interests arising in self-referrals are more complex than presented in classic cases of conflicts of interest. A dialog involving health professionals and ethicists is recommended to better understand the relational aspects that are essential to patient wellness and autonomy, in relation to the various care and organizational contexts across private and public sectors. The goal is to inform policy making on management of conflicts of interests associated with self-referrals.