Continuity of Care in Chronic Diseases: A Concept Analysis by Literature Review

Lessons Learned From a Retrospective Analysis of Medicolegal Risks for Physicians Treated Adolescents and Young Adults With Medical Complexity

PURPOSE

Adolescent and young adult patients occupy a clinically transitional space between pediatric and adult care. Youth with chronic conditions and special healthcare needs may have trouble accessing and receiving appropriate care in this transition, which may lead to patient safety issues and medicolegal risks for physicians. The objectives of this article were to explore patient safety issues and identify medicolegal risks for physicians.

METHODS

A national repository was retrospectively searched for medicolegal cases (MLCs) involving complaints from youth. The study included MLCs closed at the Canadian Medical Protective Association between 2013 and 2022 involving youth. The study participants were adolescents and young adults aged ≥ 15 and ≤ 21 years with medical complexity. The frequencies and proportions of patient safety events and medicolegal risks for physicians were calculated by exploring factors that contributed to each incident using established frameworks.

RESULTS

A total of 182 eligible MLCs were identified. Of 206 involved physicians, 55 were psychiatrists. The most common reasons for patient complaints were deficient assessment, diagnostic error, and communication breakdown with the patient and/or family. More than half of the cases were related to a harmful incident. Peer experts reviewed the cases and identified factors such as a deficient assessment, a failure to perform a test or intervention, failure to refer the patient, and insufficient provider knowledge/skill as contributing to the patient safety event.

DISCUSSION

The impact of our findings is to identify gaps in care delivery to youth that can inform practitioners of ways to mitigate the gaps and improve patient care and health outcomes.

Care needs of chronically ill patients with intellectual disabilities in Dutch general practice: patients' and providers' perspectives

BACKGROUND

To reduce the impact of chronic diseases (cardiovascular disease, diabetes mellitus type 2, and chronic lung disease (asthma or chronic obstructive pulmonary disease (COPD)), it is imperative that care is of high quality and suitable to patients' needs. Patients with intellectual disabilities (ID) differ from the average patient population in general practice because of their limitations in adaptive behaviour and intellectual functioning, and concomitant difficulties recognising and reacting to disease symptoms, proactively searching health information, and independently managing diseases effectively. Because of these differences, information on their care needs is essential for suitable chronic disease management (CDM). Inadequate recognition of the care needs of this vulnerable population may hamper the harmonisation of evidence-based and person-centred care, compounded by issues such as stigma, misconceptions, and diagnostic overshadowing. This study therefore aimed to explore the needs of patients with ID from perspectives of both patients and of healthcare providers (HCPs) in the context of CDM in general practice.

METHODS

This qualitative study recruited patients with ID for face-to-face individual interviews and HCPs for focus groups. With the Chronic Care Model as the underlying framework, semi-structured interviews and focus-group guides were defined to explore patients' care needs and HCPs' perspectives. All interviews and focus groups were audio-recorded and transcribed verbatim. Using Atlas.ti software, data were analysed using reflexive thematic analysis.

RESULTS

Between June and September 2022, 14 patients with ID and cardiovascular disease, diabetes mellitus type 2, and/or asthma/COPD were interviewed; and 32 general practitioners and practice nurses participated in seven focus groups. We identified six care needs underpinning suitable CDM: trusting relationship between patient and HCP; clear expectations about the CDM process; support in disease management; directive decision-making; support in healthy lifestyle; accessible medical information.

CONCLUSIONS

This vulnerable patient population has complex care needs that must be acknowledged for suitable CDM. Although HCPs largely recognise these needs, organisational factors and lack of training or experience with patients with ID hamper HCPs' ability to fully adjust care provision to these needs. Access to, and knowledge of, easy-language information on chronic diseases and communication guidelines could aid HCPs to facilitate patients in managing their diseases more adequately.

Assessing multidisciplinary follow-up pattern efficiency and cost in follow-up care for patients in cervical spondylosis surgery: a non-randomized controlled study

Background

The use of multidisciplinary treatment programs in out-of-hospital healthcare is a new area of research. Little is known about the benefits of this method in the management of discharged patients undergoing cervical spondylosis surgery.

Objective

This study aimed to explore the effect of a contracted-based, multidisciplinary follow-up plan in patients after cervical spondylosis surgery.

Methods

This non-blinded non-randomized controlled study was conducted with 88 patients (44 in the intervention group, 44 in the control group). The clinical outcomes, including Neck Disability Index (NDI), pain score (VAS), Self-Efficacy for Managing Chronic Disease 6-item Scale (SECD-6), and 12-Item Short-Form Health Survey (SF-12) score were assessed at the time of discharge, 24-72 h, 1 month, and 3 months post-discharge. The complications, patient satisfaction, and economic indicators were assessed at the final follow-up (3 months).

Results

Patients who received contracted follow-up showed greater improvement in neck dysfunction at 24-72 h, 1 month, and 3 months after discharge compared to those who received routine follow-up (p < 0.001). At 1 month after discharge, the intervention group exhibited better self-efficacy (p = 0.001) and quality of life (p < 0.001) than the control group, and these improvements lasted for 3 months. The intervention group reported lower pain scores at 24-72 h and 1 month (p = 0.008; p = 0.026) compared to the control group. The incidence of complications was significantly lower in the intervention group (11.4%) compared to the control group (40.9%). The total satisfaction score was significant difference between the two groups (p < 0.001). Additionally, the intervention group had lower direct medical costs (p < 0.001), direct non-medical costs (p = 0.035), and total costs (p = 0.04) compared to the control group. However, there was no statistically significant difference in indirect costs between the two groups (p = 0.59).

Conclusion

A multidisciplinary contract follow-up plan has significant advantages regarding neck disability, self-efficacy, quality of life, postoperative complications, patient satisfaction, and direct costs compared with routine follow-up.

Measuring patients' experiences of continuity of care in a primary care context-Development and evaluation of a patient-reported experience measure

BACKGROUND

Continuity of care is viewed as a hallmark of high-quality care in the primary care context. Measures to evaluate the quality of provider performance are scarce, and it is unclear how the assessments correlate with patients' experiences of care as coherent and interconnected over time, consistent with their preferences and care needs.

AIM

To develop and evaluate a patient-reported experience measure of continuity of care in primary care for patients with complex care needs.

METHOD

The study was conducted in two stages: (1) development of the instrument based on theory and empirical studies and reviewed for content validity (16 patients with complex care needs and 8 experts) and (2) psychometric evaluation regarding factor structure, test-retest reliability, internal consistency reliability, and convergent validity. In all, 324 patients participated in the psychometric evaluation.

RESULTS

The Patient Experienced Continuity of care Questionnaire (PECQ) contains 20 items clustered in four dimensions of continuity of care measuring Information (four items), Relation (six items), Management (five items), and Knowledge (five items). Overall, the hypothesized factor structure was indicated. The PECQ also showed satisfactory convergent validity, internal consistency, and stability.

CONCLUSION/IMPLICATIONS

The PECQ is a multidimensional patient experience instrument that can provide information on various dimensions useful for driving quality improvement strategies in the primary care context for patients with complex care needs.

PATIENT OR PUBLIC CONTRIBUTION

Patients have participated in the content validation of the items.

The meaning of continuity of care from the perspective of older people with complex care needs-A scoping review

People aged 65 years or older with complex care needs are at risk of fragmented care. This may jeopardise patient safety. Complex care needs are defined as care needs that require the performance of time-consuming processes such as reviewing medical history, providing counselling, and prescribing medications. A scoping review was conducted with the aim of mapping the literature regarding continuity of care from the perspective of older people with complex care needs. Search results from seven databases (PubMed, Cinahl, PsycInfo, ASSIA, Web of Science, Google Scholar, Scopus, DOAJ), grey literature (BASE), and a hand-search search of key journals were used. A deductive analysis based on aspects of continuity of care was performed. The search resulted in 5704 records. After a title and abstract screening, 93 records remained. In total, 18 articles met the inclusion criteria and were included in the scoping review. Older people´s sense of continuity of care increases when fewer healthcare workers are involved in their care but help from skilled professionals is more important than meeting the same person. It is vital for older people's feeling of continuity of care that discharge planning involves them, their families, and care providers in an organised way.

Implementation and evaluation of a complex intervention to improve information availability at the interface between inpatient and outpatient care in older patients with multimorbidity and polypharmacy (HYPERION-TransCare) - study protocol for a pilot and feasibility cluster-randomized controlled trial in general practice in Germany

BACKGROUND

Despite attempts to improve the cross-sectoral flow of information, difficulties remain in routine healthcare. The resulting negative impact on continuity of care is often associated with poor health outcomes, especially in older patients. Our intervention aims to increase information availability with respect to medications and health conditions at the interface between inpatient and outpatient care and to contribute towards improving the quality of care in older patients. This pilot study focuses on feasibility and implementability.

METHODS

The idea of the complex intervention has been developed in a previous study. This intervention will be tested in a prospective, multicenter, cluster-randomized (via web tool), controlled pilot trial with two parallel study arms (intervention and control group). The pilot study will be conducted in 20 general practices in Hesse and Saxony (Germany) and include 200 patients (≥ 65 years of age with multimorbidity and polypharmacy) recruited by the practices. Practice staff and patients will be blinded. We will use qualitative and quantitative methods to assess the feasibility and implementability of the intervention and the study design in a process evaluation covering topics ranging from expectations to experiences. In addition, the feasibility of proposed outcome parameters for the future definitive trial will be explored. The composite endpoint will include health-related patient outcomes (hospitalization, falls, and mortality using, e.g., the FIMA questionnaire), and we will assess information on medications (SIMS questionnaire), symptoms and side effects of the medication (pro-CTCAE questionnaire), and health literacy (HLQ questionnaire). Data will be collected at study begin (baseline) and after 6 months. Furthermore, the study will include surveys and interviews with patients, general practitioners, and healthcare assistants.

DISCUSSION

The intervention was developed using a participatory approach involving stakeholders and patients. It aims to empower general practice teams as they provide patient-centered care and play a key role in the coordination and continuity of care. We aim to encourage patients to adopt an active role in their health care. Overall, we want to increase the availability of health-related information for patients and healthcare providers. The results of the pilot study will be used in the design and implementation of the future definitive trial.

TRIAL REGISTRATION

The study was registered in DRKS-German Clinical Trials Register: registration number DRKS00027649 (date: 19 January 2022). Date and version identifier 10.07.2023; Version 1.3.

Young adults with eating disorders perspectives on educational resources to support the transition into adult medicine: a thematic analysis

Background

Eating disorders (EDs) commonly develop in adolescence and can be a chronic condition. Once patients reach the age when it is no longer permitted or appropriate for them to be seen in a children’s healthcare setting, they will need to transition into adult-focused care. This transition period can be challenging, with increased risks of negative health outcomes and disruptions in care. Appropriate educational resources could be an effective support for patients during this transition. Our objectives were to engage patients about the value of developing educational supports and determine how these supports should be structured to be most useful to young adults with EDs.

Methods

Patients who had transitioned out of a hospital-based ED program between 2017 and 2020 were invited to participate in a semi-structured interview. Data were analyzed using thematic analysis and qualitative description.

Results

Six young adults (5 females and 1 male) with EDs were interviewed. All participants thought it would be helpful to have an educational resource. Three main themes and seven subthemes were identified. Themes identified related to the unique challenges of transition for ED patients given the age of onset and cycle of symptoms; issues in adult care related to comorbidities and new level of autonomy; and the value of educational resources as both a connection tool and a benchmark. Participants also thought it would be useful to include in any educational resource a summary of their previous treatments, information regarding the transition process, a list of main healthcare providers they saw for their ED, a description of the differences and expectations of the adult system, a list of their follow up appointments, and a list of community and emergency mental health resources.

Conclusions

Participants said that educational supports can play a useful role for young adults with EDs during their transition into adult care. They also provided valuable insights into the desired contents of such supports and expanded on the roles that educational resources could serve for ED patients.

Most adolescents who have an eating disorder will reach an age when it is no longer appropriate for them to receive care in a children’s health program. They will then need to transition to an adult-focused program. This transition period can be challenging, with increased risks of negative health outcomes and disruptions in care. One approach for better supporting patients during transition is through the development of appropriate educational resources. Before developing these resources, it is important to hear from patients about how they should be structured to be as useful as possible. We interviewed six patients who had recently transitioned out of a pediatric eating disorder program about the value of an educational transition resource and what should be included in it. Patients identified several unique transition issues for young adults with eating disorders. We identified valuable insights and seven key themes from these interviews. While all patients recognized the value of educational resources, rather than being just a static source of information, they envisioned a resource that could also be a dynamic record of their previous care and a tool for engaging with their new adult-focused health care providers.

Effect of medical care linkage-continuous management mode in patients with posterior circulation cerebral infarction undergoing endovascular interventional therapy

BACKGROUND

Acute cerebral infarction is a severe type of ischemic stroke that can be divided into anterior circulation cerebral infarction and posterior circulation cerebral infarction (PCCI). PCCI affects the structure of the posterior circulation brain, because posterior part of the brain, which has more complex anatomical structures and more prone to posterior circulation vascular variation. Therefore, improving the prognosis of PCCI patients is necessary.

AIM

To explore the effect of medical care linkage-continuous management mode (MCLMM) on endovascular interventional therapy (EIT) for PCCI.

METHODS

Sixty-nine patients with PCCI who received EIT and conventional nursing intervention were selected as the control group, and 78 patients with PCCI who received EIT and MCLMM intervention were selected as the observation group. The incidence of postoperative complications, compliance and disease self-management behavior after six months of intervention, modified Rankin scale (mRS) and Barthel index (BI) scores in the acute phase and after one year of intervention, and recurrence within one year were compared between the two groups.

RESULTS

The total incidence rate of postoperative complications in the observation group (7.69%) was lower than that in the control group (18.84%) (P < 0.05). The scores for medical compliance behavior (regular medication, appropriate diet, and rehabilitation cooperation rates) and disease self-management behavior (self-will, disease knowledge, and self-care ability) in the observation group were higher than those in the control group (P < 0.05). After one year of intervention, in the observation group, the mRS score was significantly lower, and the BI score was significantly higher than those in the control group (P < 0.05). The recurrence rate within one year in the observation group (3.85%) was significantly lower than that in the control group (13.04%) (P < 0.05).

CONCLUSION

MCLMM can reduce the incidence of complications after EIT for PCCI, improve patient compliance behavior and disease self-management ability, and promote the recovery of neurological function.

Effect of continuous nursing on angina attack and quality of life in patients with coronary artery disease: A protocol for systematic review and meta-analysis

BACKGROUND

Coronary Artery Disease is an ischemic or necrotic heart disease caused by myocardial hypoxia caused by coronary artery stenosis or occlusion. The main symptoms are heart failure and recurrent angina pectoris. Continuous nursing refers to the nursing mode from in-hospital nursing to out-of-hospital nursing, including guiding patients' follow-up treatment and lifestyle, which can effectively improve the quality of life in patients with Coronary Artery Disease and reduce the number of angina attacks. The study implemented in this program will systematically evaluate the efficacy and safety of continuous nursing intervention on an angina attack and quality of life in Coronary Artery Disease, and provide evidence-based basis for clinical application of continuous nursing intervention in Coronary Artery Disease.

METHOD

The 2 researchers search the databases of China Knowledge Network, VP Information Chinese Journal Service Platform, PubMed, Embase, the Cochrane Library and Web of Science. From the establishment of the database in December 2020, all the randomized controlled trials on continuous nursing intervention for Coronary Artery Disease are collected. The relevant data are extracted and the quality is evaluated. meta-analysis is performed on the included literature using Stata15.0 software.

RESULT

In this study, the efficacy and safety of continuous nursing intervention on Coronary Artery Disease are evaluated by Seattle angina questionnaire and other indicators.

CONCLUSION

This study will provide reliable evidence for the clinical application of nursing intervention in Coronary Artery Disease.

ETHICS AND DISSEMINATION

Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval will not be required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/7QRKV.