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Evidence On The Chronic Care Model In The New Millennium
Abstract
Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCM's effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes.
... Patients with chronic disease(s) are the highest users of healthcare services [11]. Proper healthcare access, coordination, and continuity of care are essential to effective chronic disease management [12]. Without sustained care and good self-management, poorly controlled chronic disease may arise and lead to emergency department visitations and hospital admissions [13,14]. ...
... A semi-structured interview guide was initially developed with reference to the chronic care model [12]. The chronic care model describes six components for effective chronic care management. ...
... While it is encouraging that patients were able to adapt their lifestyles, the adoption of poorer habits is concerning. Effective disease control requires good selfmanagement, as recognised in Wagner's chronic care model [12]. Patients with chronic diseases must be supported by healthcare providers to continue healthy selfmanagement practices, even during disease outbreaks. ...
Background
Patients with chronic diseases have seen unprecedented changes to healthcare practices since the emergence of COVID-19. Traditional ‘on-site’ clinics have had to innovate to continue services. Whether these changes are acceptable to patients and are effective for care continuation are largely unreported.
Methods
We evaluated the effectiveness of care provision at a re-structured chronic care clinic and elicited the patient experiences of care and self-management. We conducted a convergent, parallel, mixed-methods study. Adult patients attending a chronic care clinic were included. We extracted data from 4,849 clinic visits before and during the COVID-19 pandemic, including operational metrics and attendee profile. We also conducted fifteen interviews with patients from the same clinic using a semi-structured interview guide.
Results
Re-structuring the chronic clinic, including the introduction of teleconsultations, home-delivery of prescriptions and use of community-based phlebotomy services, served to maintain continuity of care while adhering to COVID-19 containment measures. Qualitatively, five themes emerged. Patients were able to adjust to healthcare practice changes and adapt their own lifestyles, although poor self-management practices were adopted. While most were apprehensive about attending the clinic, they valued ongoing care access and were reassured by the on-site containment measures.
Conclusions
Continuation of routine services is desired by patients and can be achieved through the adoption of containment measures, by greater collaboration with community partners, and the use of technology. Patients adapted to service changes, but poor self-management was evident. To prevent chronic disease relapse, services must strive to innovate rather than suspend services during pandemics.
... They describe how best practice health care is delivered through different stages of a condition, injury or event, ensuring that the right care is delivered at the right time, in the right place, to the right person or group ( ACI, 2013 ). Care for chronic conditions in well-resourced settings has evolved from an acute, often hospital-based, physician-led, disease-focussed care model to an increasingly primary care-based, multi-disciplinary, patient-centred approach, embracing multimorbidity ( Coleman et al., 2009 ;Stokes et al., 2017 ;Low et al., 2011 ). By contrast, NCD care continues to be focussed at hospital-level in many low and middle income country (LMIC) settings. ...
... The intermediate health system goals (responsiveness, quality and safety) and final goals, including improved health outcomes, featured much less in their accounts. Participants clearly aspired to providing patient patient-centred, holistic care, echoing both the evolution of chronic disease care and primary care in higher income settings and the increasing focus on quality of care in LMICs ( Coleman et al., 2009 ;Kruk et al., 2018 ;Kruk et al., 2015 ). Some suggested using a primary care lens as well as level , advocating that care should be provided by generalists, taking a holistic, whole-person approach. ...
... Some suggested using a primary care lens as well as level , advocating that care should be provided by generalists, taking a holistic, whole-person approach. This aligns with the wellestablished Chronic Care Model, person-centred model of care involving a proactive care team, combined with supported self-care and enhanced community resources, to improve quality of healthcare and health outcomes ( Coleman et al., 2009 ;McNatt et al., 2019 ;Ansbro et al., 2021 ). In practice, however, few examples of patient-centred NCD care were described, patient-centredness is not currently measured, relevant indicators do not exist and patient experience has been explored in a very limited fashion ( Ansbro et al., 2021 ). ...
Background
The high and rising global burden of non-communicable diseases (NCDs) is reflected among crisis-affected populations. People living with NCDs are especially vulnerable in humanitarian crises. Limited guidance exists to support humanitarian actors in designing effective models of NCD care for crisis-affected populations in low- and middle-income countries (LMICs). We aimed to synthesise expert opinion on current care models for hypertension and diabetes (HTN/DM) in humanitarian settings in LMICs, to examine the gaps in delivering good quality HTN/DM care and to propose solutions to address these gaps.
Methods
We interviewed twenty global experts, purposively selected based on their expertise in provision of NCD care in humanitarian settings. Data were analysed using a combination of inductive and deductive methods. We used a conceptual framework for primary care models for HTN/DM in humanitarian settings, guided by the WHO health systems model, patient-centred care models and literature on NCD care in LMICs.
Results
HTN/DM care model design was highly dependent on the type of humanitarian crisis, the implementing organisation, the target population, the underlying health system readiness to deal with NCDs and its resilience in the face of crisis. Current models were mainly based at primary-care level, in prolonged crisis settings. Participants focussed on the basic building blocks of care, including training the workforce, and strengthening supply chains and information systems. Intermediate health system goals (responsiveness, quality and safety) and final goals received less attention. There were notable gaps in standardisation and continuity of care, integration with host systems, and coordination with other actors. Participants recommended a health system strengthening approach and aspired to providing patient-centred care. However, more evidence on effective integration and on patients’ priorities and experience is needed. More funding is needed for NCD care and related research.
Conclusions
Comprehensive guidance would foster standardization, continuity, integration and, thus, better quality care. Future models should take a health system strengthening approach, use patient-centred design, and should be co-created with patients and providers. Those designing new models may draw on lessons learned from existing chronic care models in high- and low-income settings.
... Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse and promoting well-being [25][26][27]. SMS is consistent with patient-centered care [28] and has the potential to enhance the efficiency of the health care system for patients by improving health outcomes and reducing overall service utilization [29]. SMS is a promising avenue towards recovery by fostering social inclusion, self-determination, autonomy, hope, and personal responsibility. ...
... While the value of the integration of SMS programs to health care services for chronic physical conditions is well-established [27,29,32] and rapidly growing for depression [25,[33][34][35][36], few studies have examined the added value of structured SMS programs for anxiety disorders as a complement to usual care. In a review by Houle et al. [25], the efficacy of SMS for depression was examined in six studies and promising results were observed for symptom reduction, self-management behaviours and self-efficacy, and mixed results for relapse rates. ...
Background
The integration of a personal recovery-oriented practice in mental health services is an emerging principle in policy planning. Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse, and promoting well-being. While SMS is well established for chronic physical conditions, there is a lack of evidence to support the implementation of structured SMS programs for common mental disorders, and particularly for anxiety disorders. This study aims to examine the effectiveness of a group-based self-management support program for anxiety disorders as an add-on to treatment-as-usual in community-based care settings.
Methods/design
We will conduct a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment (4-month post-randomization), and follow-ups at 8, 12 and 24-months.
Treatment and control groups
a) group self-management support (10 weekly 2.5-h group web-based sessions with 10–15 patients with two trained facilitators); b) treatment-as-usual. Participants will include adults meeting DSM-5 criteria for Panic Disorder, Agoraphobia, Social Anxiety Disorder, and/or Generalized Anxiety Disorder. The primary outcome measure will be the Beck Anxiety Inventory ; secondary outcome measures will comprise self-reported instruments for anxiety and depressive symptoms, recovery, self-management, quality of life, and service utilisation.
Statistical analysis
Data will be analysed based on intention-to-treat with a mixed effects regression model accounting for between and within-subject variations in the effects of the intervention.
Discussion
This study will contribute to the limited knowledge base regarding the effectiveness of structured group self-management support for anxiety disorders. It is expected that changes in patients’ self-management behaviour will lead to better anxiety management and, consequently, to improved patient outcomes.
Trial registration
ClinicalTrials.gov: NCT05124639 . Prospectively registered 18 November 2021.
... A comparison of the ILoC model to the six elements of the chronic care model (CCM) [33,34] in primary care practice and the triple aims, provides an opportunity to target areas for improvement. Four of the six CCM elements (1. ...
... Four of the six CCM elements (1. increasing providers' expertise and skills; 2. educating and supporting patients; 3. making care delivery more team-based and planned; 4. making better use of registry-based information systems) were proved to lead to great improvement in health outcomes [33,35]. The ILoC model addresses 1 and 3 of these domains. ...
Integrated care is expected to improve patient experience, patient outcomes and assist with the increasing demand on health services from those with long term conditions including mental disorder. Few studies have evaluated health care utilization as a consequence of increased integration of mental health care. This study considers the factors known to influence secondary health service utilization and investigated the impact of a locality based mental health integrated model of care (ILoC) providing specialist consultation and liaison advice to primary care, to support early diagnosis and treatment. Using existing hospital databases, the study-cohort was identified (service users supported by ILoC, and then referred within 6 months to specialist mental health services (MHS) care between 2017- 2018) and compared on health services utilization with a matched-cohort (without ILoC support before referral to specialist services). The length-of-care in the non-acute MHS was 71% shorter for the ILoC study-cohort, and differences increased in the subgroup taking antidepressants. The ILoC study-cohort was less likely to be admitted to acute MHS on first referral post ILoC intervention and had a 25% lower relative risk of acute MHS admissions at any time in follow-up. There was no difference in the average MHS inpatient length-of-stay. The risk of general hospital acute inpatient admission was marginally higher in the ILoC study-cohort.
Conclusions:
ILoC appears to shorten non-acute length-of-specialist-care and reduce acute mental health admission. The study provides a first step in understanding the clinical characteristics and specialist services health-care utilization of patients supported by an integrated mental care approach.
... Organisation und Umsetzung von Alltagsaktivitäten der Zugang zu Leistungen der GKV-Versorgung erschwert sein kann (Fret et al. 2019;Schulz et al. 2020 (Wagner et al. 1996;Bodenheimer et al. 2002;Gensichen et al. 2006;Coleman et al. 2009). ...
... Für erwachsene, chronisch kranke Menschen werden etwa signifikante Verbesserungen der gesundheitsbezogenen Lebensqualität bei chronisch obstruktiver Lungenerkrankung (COPD) (Aryani et al. 2016), leitliniengerechter Versorgung und geringere Raten von Krankenhausaufenthalten und Mortalität bei Herzinsuffizienz (Coleman et al. 2009; Ballo et al. 2018), weniger Krankenhausaufenthalte bei psychischen Erkrankungen (Bauer et al. 2019), verbesserte Diabetesversorgung (Nutting et al. 2007; Chmiel et al. 2017) und weniger ungeplante Krankenhausaufenthalte (Robusto et al. 2018) berichtet. Jedoch ermittelten einige Studien auch ausbleibende erwartete Effekte, etwa zur Kosteneffektivität einer Adaption des CCM für geriatrische Populationen (van Leeuwen et al. 2015) oder für den selbstberichteten Gesundheitsstatus psychisch kranker Menschen (Bauer et al. 2019).Für die Leistungserbringenden ist der Einsatz des CCM mit verbesserten Versorgungsprozessen assoziiert(Coleman et al. 2009), wobei der Implementierungserfolg seitens der Leistungserbringenden von dem Gehalt und dem Ausmaß der bereitgestellten Information über das CCM, der Akzeptanz der (Neu-)Konzeption der Versorgungsgestaltung beziehungsweise der CCM-Intervention sowie der Vorbereitung auf die Anwendung des CCM abhängt(Davy et al. 2015). Weiter beeinflussen die Nachvollziehbarkeit des Arguments für die Einführung des CCM oder des Bedarfs und Nutzen der Veränderung der Versorgung, die Qualifikation und Erfahrung der beteiligten Gesundheitsprofessionen und die Haltung und der Einsatz der verantwortlichen Führungspersonen den Implementierungserfolg(Davy et al. 2015).Im Zusammenhang mit Barrieren und Facilitatoren der Anwendung des CCM wird auch die Rollevon Informations-und Kommunikationssystemen hervorgehoben, die ein Monitoring der Versorgung im Vergleich zu bestehenden Behandlungsempfehlungen, die Identifikation von Versorgungslücken und die Dokumentation von Ergebnissen und Erfolgen erlauben (Davy et al. 2015). ...
Menschen mit Pflegebedarf sind oft von Multimorbidität betroffen und ein selbstbestimmter Zugang zu Leistungen der gesetzlichen Krankenversicherung (GKV) kann ihnen erschwert sein. Der Messung und Sicherstellung der ambulanten medizinischen Versorgungsqualität dieser Personengruppe kommt daher eine besondere Bedeutung zu. Ein populationsspezifisches Qualitätsmonitoring existiert in Deutschland bislang nicht. Ursprünglich zu Abrechnungszwecken erhobene GKV-Routinedaten stellen eine potentielle Datenquelle für das Monitoring der ambulanten Versorgungsqualität pflegebedürftiger Menschen dar.
Diese kumulative Dissertation untersucht, welche Möglichkeiten und Grenzen sich für das Monitoring der ambulanten medizinischen Versorgungsqualität von Menschen mit Pflegebedarf anhand von GKV-Routinedaten in Deutschland ergeben. Anhand einer systematischen Übersichtsarbeit und zweier Sekundäranalysen von Routinedaten der AOK wird gezeigt, dass i) eine breite Auswahl international erprobter Qualitätsindikatoren für die Abbildung der ambulanten Versorgungsqualität auf Basis von GKV-Routinedaten zur Verfügung steht, ii) eine populationsspezifische Abbildung ausgewählter Qualitätsaspekte auf Basis von GKV-Routinedaten machbar ist, iii) Versorgungsunterschiede bei Berücksichtigung des Lebensorts und des Pflegestatus zu Ungunsten älterer Menschen vorliegen und iv) Zusammenhänge zwischen der individuellen Versorgungsqualität in pflegebedürftigen, multimorbiden Populationen und einem Heimeintritt bestehen. Zudem beschreibt die Arbeit einen Status-Quo der ambulanten Versorgungsqualität pflegebedürftiger Menschen in Deutschland auf Basis von GKV-Routinedaten. Einen theoretischen Begründungs- und Bezugsrahmen für ein populationsspezifisches Monitoring liefert das Chronic Care-Modell (CCM), das Argumente für die nutzenbringende Einbindung von GKV-Routinedaten in Informationssysteme und die Versorgungsgestaltung bietet.
Möglichkeiten eines populationsspezifischen Monitorings anhand von GKV-Routinedaten ergeben sich aus den Stärken der Datengrundlage, wie einem direktem Alltagsbezug, guter Datenverfügbarkeit, großen Versichertenkollektiven mit Einschluss vulnerabler Personengruppen, versichertenbezogener Bestimmung von Risikofaktoren und Kennzahlen der Versorgungskontinuität sowie der Anwendung unterschiedlich komplexer Studiendesigns. Grenzen des Monitorings liegen in Limitationen der Datengrundlage wie Unschärfe in der Diagnosekodierung, fehlenden Zähler- und Nennerinformationen für die Indikatorbildung, nicht abbildbaren Informationen etwa zu individuellem Verhalten von Leistungserbringenden und Pflegebedürftigen, fehlenden Erkenntnissen zur Validität der Datengrundlage sowie datenschutz- und informationstechnischen Hürden. Zu prüfen bleibt, welche Faktoren seitens der Leistungserbringenden, der Pflegebedürftigen und des Versorgungssystems Einfluss auf Versorgungsprozesse und Endpunkte nehmen, die beeinflusst oder im Rahmen von Risikoadjustierungen berücksichtigt werden sollten.
Um ein populationsspezifisches Monitoring zu etablieren, sind Limitationen der Datengrundlage möglichst zu überwinden. Dazu tragen die Durchführung von Validierungsstudien, die Anreicherung der GKV-Routinedaten mit Daten aus weiteren Datenquellen, die Erweiterung der empirischen Evidenzbasis und die Konsentierung und Erweiterung eines nationalen Indikatorensets sowie die systematische Erhebung und Erklärung von Qualitätsunterschieden bei. Ebenso sind Sektorengrenzen in der Versorgungsforschung abzubauen, formale Versorgungskooperationen und eine am CCM orientierte Versorgungsgestaltung auszubauen sowie eine populationsspezifische Qualitätsarbeit durch gesetzliche Maßnahmen zu stärken. So ließen sich die gezeigten Versorgungsunterschiede zu Ungunsten älterer und pflegebedürftiger Menschen adressieren und der Versorgungsforschung die Evaluation der Auswirkungen populationsspezifischer Qualitätsarbeit und Versorgungsanpassungen unter Berücksichtigung der Präferenzen der Zielgruppe ermöglichen.
... In Japan, the rising number of older adults is projected to increase rates of functional disability [3,4] and dementia [5], raising serious concerns regarding the increasing care burden. The chronic care model is widely adopted worldwide to improve chronic patient outcomes by changing patients' care and managing chronic diseases [6,7]. Meanwhile, the government of Japan implemented the long-term care (LTC) insurance system in 2000, based on several European programs, to help older people with functional disabilities adequately manage their daily lives [8]. ...
... Meanwhile, several care models are applied to the elderly worldwide. For example, the chronic care model is widely used to improve chronic patient outcomes by changing patients' care and managing chronic diseases [6]. The chronic care model is compatible with LTC insurance in terms of availability to take care and services, particularly for functional disability, as one of the major endpoints of LTC in the present review. ...
This study aimed to review evidence on future long-term care associated with pre-existing factors among community-dwelling Japanese older adults. We systematically searched cohort and nested case–control studies published between 2000 and 2019 that assessed long-term care certification using the PubMed, CINAHL, and EMBASE databases. The relationship between long-term care insurance information and risk factors was investigated. The protocol was registered with the Open Science Framework. We extracted 91 studies for synthesis, including 84 prospective cohort studies, 1 retrospective cohort study, and 6 nested case–control studies. Certification for long-term care was classified into two endpoints: onset of functional disability and dementia. There were 72 studies that used long-term care certification as a proxy for functional disability, and 22 used long-term care information to indicate the onset of dementia. Common risk factors related to functional disability were physical function, frailty, and oral condition. Motor function and nutritional status were common risk factors for dementia. We found consistent associations between premorbid risk factors and functional disability and dementia. The accumulation of evidence on the incidence of long-term care and associated factors can aid the development of preventive measures. Future studies should aim to integrate this evidence.
... The sentinel evidence and impetus for chronic care model (CCM) more than a quarter of a century highlighted that patient care requiring multiple services, show the greatest improvement in health outcomes on 4 pillars (Tables 1,2, Ref. [2,7,11,34]): improving health services expertise and skill, patient support and education, team-based care planning and delivery, and enhanced health information systems and registries [34][35][36]. It is fundamental from the outset we define what is the key concept of a chronic illness. ...
... Simultaneously and unfortunately CDSM programs have been demoted from lack of evidence [4]. The CCM is well described [34][35][36], when models are looked at in chronological terms, the Acute Care Model(ACM) in can achieve comparable outcome rates as summarise in consensus guidelines (Fig. 1). In many wellresourced institutions, acute HF needs are met. ...
Background: Enhancing community based Chronic Disease Management (CDM) will make significant impacts on all major chronic disease management outcome measures. There are no successful models of community hubs to triage and manage chronic diseases that significantly reduce readmissions, cost and improve chronic disease knowledge. Chronic heart failure (CHF) management foundations are built on guideline derived medical therapies (GDMT). These consensuses evidenced building blocks have to be interwoven into systems and processes of care which create access, collaboration and coordinate effective and innovative health services. Methods: Perspective and short communication. Conclusions: This review explores: (i) conventional chronic disease management in Australia; (ii) Possible options for future chronic diseases models of care that deliver key components of CHF management.
... 23 In alignment with the chronic care model, the primary objective of the MATS program was the reduction of patients' use of high-cost detoxification and inpatient services. 24 This study has 2 central aims: (1) To examine the 12-month SUD-related outcomes of MATS and (2) to explore whether a predictive algorithm for high future spending (HFS) would have a moderating effect on program outcomes. This post-hoc analysis is consistent with prior CM programs' [20][21][22] case selection based on statistical models that predict who is likely to have greater needs and have high expenditures in the near future. ...
Aims
We examined the effects of a statewide New York (NY) care management (CM) program for substance use disorder (SUD), Managed Addiction Treatment Services (MATS), on SUD treatment services’ utilization and spending among patients with a recent history of high Medicaid spending and among those for whom a predictive algorithm indicates a higher probability of outlier spending in the following year.
Methods
We applied difference-in-difference analyses with propensity score matching using NY Medicaid claims data and a state registry of SUD-treatment episodes from 2006 to 2009. A total of 1263 CM enrollees with high SUD treatment spending (>$10K) in the prior year and a matched comparison group were included in the analysis. Crisis care utilization for SUD (detoxification and hospitalizations), outpatient SUD treatment, and Medicaid spending were examined over 12 months among both groups. CM effects among predicted high-future-spending patients (HFS) were also analyzed.
Results
CM increased outpatient SUD treatment visits by approximately 10.5 days (95% CI = 0.9, 20.0). CM crisis care and spending outcomes were not statistically different from comparison since both conditions had comparable pre-post declines. Conversely, CM significantly reduced SUD treatment spending by approximately $955 (95% CI = −1518, −391) and reduced days of detox utilization by about 1.0 days (95% CI = −1.9, −0.1) among HFS.
Conclusion
Findings suggest that CM can reduce SUD treatment spending and utilization when targeted at patients with a greater likelihood of high future spending, indicating the potential value of predictive models to select CM patients.
... Therefore, personally acquired potentials, which can develop over later courses of life, such as knowledge, skills, positive emotions and engagement are of particular importance from both public health and health economic perspective [9,10]. A number of theories, such as internal locus of control [11], self-efficacy [12], self-management [13] or the transtheoretical model of change [14], have addressed the drivers of change in health behaviours, and a number care delivery models, such as the Chronic Care Model, promoted systematic improvements involving patient centredness, support for self-management, evidence-based proactive interventions, integrated team care and supportive information technology solutions [15]. Digital health interventions have been shown to be effective in promoting healthy behaviours through patient education or supporting behaviour change, and upon the demonstration of adequate supportive evidence, authorities are now considering their adoption among publicly financed health technologies [16,17]. ...
Background
Patient activation comprises the skills, knowledge and motivation necessary for patients’ effective contribution to their care. We adapted and validated the 13-item Patient Activation Measure (PAM-13) in the ≥ 40 years old Hungarian general population.
Methods
A cross-sectional web survey was conducted among 900 respondents selected from an online panel via quota sampling. After 10 days, the survey was repeated on 100 respondents. The distribution, internal consistency, test–retest reliability, factor structure, convergent, discriminant and known-groups validity of PAM-13 were assessed according to the COSMIN guidelines.
Results
The sample comprised 779 respondents. Mean (± SD) age was 60.4 ± 10.6 years, 54% were female and 67% had chronic illness. Mean (± SD) PAM-13 score was 60.6 ± 10.0. We found good internal consistency (Cronbach alpha: 0.77), moderate test–retest reliability (ICC: 0.62; n = 75), a single-factor structure and good content validity: PAM-13 showed moderate correlation with the eHealth Literacy Scale ( r = 0.40), and no correlation with age ( r = 0.02), education ( r = 0.04) or income ( ρ = 0.04). Higher PAM-13 scores were associated with fewer lifestyle risks ( p < 0.001), more frequent health information seeking ( p < 0.001), participation in patient education ( p = 0.018) and various online health-related behaviours. When controlling for health literacy, sociodemographic factors and health status, the association of higher PAM-13 scores with overall fewer lifestyle risks, normal body mass index, physical activity and adequate diet remained significant. Similar properties were observed in the subgroup of participants with chronic morbidity, but not in the age group 65+.
Conclusion
PAM-13 demonstrated good validity in the general population. Its properties in clinical populations and the elderly as well as responsiveness to interventions warrant further research.
... Chronic conditions follow an unpredictable trajectory over a prolonged period and commonly do not achieve a cure, so to provide effective care for people with chronic conditions and to facilitate the shift from a reactive health care system to one which proactively involves patients has been developed in the Chronic Care Model [15,16]. Extensive evidence has shown that the Chronic Care Model improves patient care and provides a framework for improved efficiency and outcomes [17,18], especially in a primary care setting [19]. The Chronic Care Model is based on "patient-centeredness", requiring an interprofessional collaboration approach and taking into account the patients perspectives. ...
The global spread of diabetes poses serious threats to public health requiring a patient-centered approach based both on interprofessional collaboration (IPC) given by the cooperation of several different health professionals, and patients’ perspective through the assessment of Patient-Reported Outcomes (PROs). The aim of the present study is to evaluate the impact of interprofessional collaboration interventions, for the management of type 2 diabetes in primary care settings, through PROs. A systematic review and meta-analysis was conducted querying the PubMed, Scopus and Embase databases. Out of the 1961 papers initially retrieved, 19 met the inclusion criteria. Interprofessional collaboration is significantly associated with an increase in both patient’s satisfaction (SMD 0.32 95% CI 0.05–0.59) and in the mental well-being component of the HRQoL (SMD 0.18; 95% CI 0.06–0.30), and there was also promising evidence supporting the association between an interprofessional approach and an increase in self-care and in generic and specific quality-of-life. No statistical differences were found, supporting the positive impact on IPC interventions on the physical component of the HRQoL, depression, emotional distress, and self-efficacy. In conclusion, the effect of IPC impacts positively on the few areas assessed by PROMs. Policymakers should promote the widespread adoption of a collaborative approach as well as to endorse an active engagement of patients across the whole process of care.
... Because mental and social wellbeing are essential for overall health, the model for chronic disease management includes long-term medical, behavioral, and social care that is coordinated, if not integrated. Chronic disease management incorporates mental health and social support with medical care, and has been shown to improve participant outcomes and QoL [3,4]. Substance use disorder is acknowledged as a chronic illness that negatively impairs the quality of a patient's life, and they therefore would benefit from the application of the chronic disease model of integrated medical, behavioral, and social support [5,6]. ...
Background:
The Houston Emergency Opioid Engagement System was established to create an access pathway into long-term recovery for individuals with opioid use disorder. The program determines effectiveness across multiple dimensions, one of which is by measuring the participant's reported quality of life (QoL) at the beginning of the program and at successive intervals.
Methods:
A visual analog scale was used to measure the change in QoL among participants after joining the program. We then identified sociodemographic and clinical characteristics associated with changes in QoL.
Results:
71% of the participants (n = 494) experienced an increase in their QoL scores, with an average improvement of 15.8 ± 29 points out of a hundred. We identified 10 factors associated with a significant change in QoL. Participants who relapsed during treatment experienced minor increases in QoL, and participants who attended professional counseling experienced the largest increases in QoL compared with those who did not.
Conclusions:
Insight into significant factors associated with increases in QoL may inform programs on areas of focus. The inclusion of counseling and other services that address factors such as psychological distress were found to increase participants' QoL and success in recovery.
... Case management, care coordination, and other similar initiatives that ostensibly focused on patients with multiple chronic conditions including Chronic Care Clinics, the Chronic Care Model, Medicare Coordinated Care, the Guided Care Model, and GRACE used a variety of eligibility criteria but rarely explicitly focused on patients with multiple chronic diseases. (72)(73)(74)(75)(76)(77)(78)(79)(80)(81)(82)(83)(84)(85) Most would agree that these initiatives have elements that are important to address the needs of patients with multiple chronic conditions. Yet, for the most part, they did not improve outcomes or reduce utilization because they did not target the right patients. ...
... A partir de la deuxième moitié des années 2010, la réflexion des pouvoirs publics s'oriente vers le développement de formules de paiement à la coordination plus intégrées. Elle s'appuie sur le constat de l'existence de freins à la coordination et à la coopération induits par des dispositifs de paiement comme la T2A, et s'inspire d'expériences internationales, tels que le Chronic Care Model(Coleman et al., 2009) ou les Accountable Care Organisations mises en place aux Etats-Unis(Hassenteufel et al., 2020). Trois expérimentations nationales lancées par les pouvoirs publics sur la base de l'article 51 de la LFSS 2018 traduisent la recherche de ces nouveaux instruments, alternatifs ou complémentaires au paiement à l'acte et au séjour. ...
Cette thèse est consacrée à la caractérisation de la logique de parcours dans le champ sanitaire. L'usage banalisé de cette notion, qui apparaît cohérent avec le développement des prises en charge ambulatoires et l'émergence de nouveaux besoins, liés au vieillissement de la population et à l’essor des maladies chroniques, tend à éluder la nécessité de définir son périmètre de validité et les modes d’organisation et d'opérationnalisation qu'elle recouvre. La thèse s'attache à traiter cette problématique, en caractérisant la logique de parcours, les enjeux organisationnels et de politiques publiques qu'elle soulève, et en étudiant les modalités de son déploiement et les transformations de l'action publique qu'elle entraîne. Sur un plan théorique, la thèse se situe au croisement de deux champs de la littérature académique, l'un relatif aux enjeux organisationnels des parcours de santé et l'autre relatif au management public, qu'elle articule pour analyser le changement de paradigme associé à l'émergence de cette nouvelle logique. Inscrite dans un partenariat avec l'Agence Régionale de Santé d'Ile-de-France, la recherche s'est fondée sur l'étude et l'accompagnement de différents projets visant à améliorer la gestion des parcours de santé. La thèse propose une typologie des situations des patients et de leurs prises en charge, en fonction des modalités d'évaluation des besoins et de coordination qu'elles mobilisent. Elle montre que derrière l'appellation générique de logique de parcours se déploient différentes approches, selon le degré de complexité des situations auxquelles elle s'applique. Encouragé par les pouvoirs publics, le développement de la logique de parcours nécessite un renouvellement de la doctrine et de l'instrumentation de l'action publique sanitaire, encore en cours de construction.
... The chronic care model was developed specifically for chronic diseases. Considering the context of care, this model is aimed at integrating informed and active patients into the management of their disease with a proactive and multidisciplinary team of healthcare professionals [36,37] . New generations of chronic care models consider broad determinants of health and focus on a system of coordinated interventions across different levels of care [19] through the Innovative Care for Chronic Conditions Framework (World Health Organisation) that is focused on health policies and organisations, as well as resources in the community [38] . ...
Background
Because of the limits in conceptualisation of care coordination linked to the large array of care coordination models and definitions available, a care coordination framework is needed with a particular focus on the micro level.
Objective
To develop an evidence-based reference framework for person-centred care coordination interventions based on international validated definitions.
Methods
This two-step mixed-methods study included first, a scoping review of reviews focus on the impact of care coordination interventions and then, a nominal group technique. The scoping review aimed at identifying the components of the four dimensions of the framework (contexts, activities, actors and tools, and effects). The nominal group technique was to select the relevant components of the dimension ‘activities’ of the reference framework.
Results
The scoping review selected 52 articles from the 1,407 retrieved at first. The nominal group selected the 66 most relevant activities from the 159 retrieved in the literature (28 activities of care organisation, 24 activities of care, and 14 activities of facilitation).
Conclusion
This operational framework focused on care coordination at the micro level, is a useful and innovative tool, applicable in any clinical condition, and in any health care system for describing, implementing and evaluating care coordination programmes.
... integrated models of care; for example, Canada's most populous province, Ontario, is currently undergoing significant restructuring to better integrate its healthcare system [2]; interprofessional and integrated team-based care are at the center of the reform. In the past, much of implementation occurred with a short-term focus on local implementation with limited attention to spread, scale-up, or sustainability [3]. Indeed, there is a lack of guidance in the literature on how to account for, and support, contextual differences while maintaining the fidelity of successful models. ...
Background
In Canada, there is widespread agreement about the need for integrated models of team-based care. However, there is less agreement on how to support the scale-up and spread of successful models, and there is limited empirical evidence to support this process in chronic disease management. We studied the supporting and mitigating factors required to successfully implement and scale-up an integrated model of team-based care in primary care.
Methods
We conducted a collective case study using multiple methods of data collection including interviews, document analysis, living documents, and a focus group. Our study explored a team-based model of care for chronic obstructive pulmonary disease (COPD) known as Best Care COPD (BCC) that has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants included healthcare providers involved in the delivery of the BCC program.
Results
We identified several mechanisms influencing the scale-up and spread of BCC and categorized them as Foundational (e.g., evidence-based program, readiness to implement, peer-led implementation team), Transformative (adaptive process, empowerment and collaboration, embedded evaluation), and Enabling Mechanisms (provider training, administrative support, role clarity, patient outcomes). Based on these results, we developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management. Our framework builds off our empirical work and is framed by local contextual factors.
Conclusions
This study explores the implementation and spread of integrated team-based care in a primary care setting. Despite the study’s focus on COPD, we believe the findings can be applied in other chronic disease contexts. We provide a framework to support the progressive implementation of integrated team-based care for chronic disease management.
... Surveillance without more specific actions to close CM health gaps does not necessarily translate to better health outcomes [11,12]. The ability to close health gaps is mediated, in part, by clinical-level (e.g., knowledge, communication, familiarity of guidelines) and patient-level factors (e.g., environment, health behaviors, genetics, etc.). ...
The objective of this study was to determine the strengths and limitations of using structured electronic health records (EHR) to identify and manage cardiometabolic (CM) health gaps. We used medication adherence measures derived from dispense data to attribute related therapeutic care gaps (i.e., no action to close health gaps) to patient- (i.e., failure to retrieve medication or low adherence) or clinician-related (i.e., failure to initiate/titrate medication) behavior. We illustrated how such data can be used to manage health and care gaps for blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), and HbA1c for 240,582 Sutter Health primary care patients. Prevalence of health gaps was 44% for patients with hypertension, 33% with hyperlipidemia, and 57% with diabetes. Failure to retrieve medication was common; this patient-related care gap was highly associated with health gaps (odds ratios (OR): 1.23–1.76). Clinician-related therapeutic care gaps were common (16% for hypertension, and 40% and 27% for hyperlipidemia and diabetes, respectively), and strongly related to health gaps for hyperlipidemia (OR = 5.8; 95% CI: 5.6–6.0) and diabetes (OR = 5.7; 95% CI: 5.4–6.0). Additionally, a substantial minority of care gaps (9% to 21%) were uncertain, meaning we lacked evidence to attribute the gap to either patients or clinicians, hindering efforts to close the gaps.
... As a hybrid type II trial (Curran et al., 2012), it examined the effectiveness of implementation facilitation in establishing the evidence-based CCM to structure the clinical care delivered by interdisciplinary outpatient mental health provider teams. The CCM organizes health care delivery to be anticipatory, coordinated, and patient-centered (Von Korff et al., 1997;Wagner et al., 1996;Coleman et al., 2009). It comprises six core elements: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. ...
Background: Facilitation is an effective strategy to implement evidence-based practices, often involving external facilitators (EFs) bringing content expertise to implementation sites. Estimating time spent on multifaceted EF activities is complex. Furthermore, collecting continuous time–motion data for facilitation tasks is challenging. However, organizations need this information to allocate implementation resources to sites. Thus, our objectives were to conduct a time–motion analysis of external facilitation, and compare continuous versus noncontinuous approaches to collecting time–motion data. Methods: We analyzed EF time–motion data from six VA mental health clinics implementing the evidence-based Collaborative Chronic Care Model (CCM). We documented EF activities during pre-implementation (4–6 weeks) and implementation (12 months) phases. We collected continuous data during the pre-implementation phase, followed by data collection over a 2-week period (henceforth, “a two-week interval”) at each of three time points (beginning/middle/end) during the implementation phase. As a validity check, we assessed how closely interval data represented continuous data collected throughout implementation for two of the sites. Results: EFs spent 21.8 ± 4.5 h/site during pre-implementation off-site, then 27.5 ± 4.6 h/site site-visiting to initiate implementation. Based on the 2-week interval data, EFs spent 2.5 ± 0.8, 1.4 ± 0.6, and 1.2 ± 0.6 h/week toward the implementation’s beginning, middle, and end, respectively. Prevalent activities were preparation/planning, process monitoring, program adaptation, problem identification, and problem-solving. Across all activities, 73.6% of EF time involved email, phone, or video communication. For the two continuous data sites, computed weekly time averages toward the implementation’s beginning, middle, and end differed from the interval data’s averages by 1.0, 0.1, and 0.2 h, respectively. Activities inconsistently captured in the interval data included irregular assessment, stakeholder engagement, and network development. Conclusions: Time–motion analysis of CCM implementation showed initial higher-intensity EF involvement that tapered. The 2-week interval data collection approach, if accounting for its potential underestimation of irregular activities, may be promising/efficient for implementation studies collecting time–motion data.
... One potential strategy to extend the reach of ABOM Diplomate expertise may be through a team-based, collaborative care approach in which ABOM Diplomates serve as expert consultants to enhance PCPs' delivery of evidence-based obesity care. Collaborative Care Models (CCMs) are widely used in primary care settings to improve outcomes among patients with other complex chronic conditions through patient self-management support, provider guideline dissemination and education, delivery system redesign such as team-based care, and use of population health management strategies using clinical informatics (Coleman et al., 2009;Yeoh et al., 2018). Building upon these components, the highly effective CCM for mental health conditions aims to improve outcomes for patients with depression by integrating mental health experts into the primary care team (Press et al., 2017). ...
Background
Primary care providers (PCPs) are expected to help patients with obesity to lose weight through behavior change counseling and patient-centered use of available weight management resources. Yet, many PCPs face knowledge gaps and clinical time constraints that hinder their ability to successfully support patients’ weight loss. Fortunately, a small and growing number of physicians are now certified in obesity medicine through the American Board of Obesity Medicine (ABOM) and can provide personalized and effective obesity treatment to individual patients. Little is known, however, about how to extend the expertise of ABOM-certified physicians to support PCPs and their many patients with obesity.
Aim
To develop and pilot test an innovative care model – the Weight Navigation Program (WNP) – to integrate ABOM-certified physicians into primary care settings and to enhance the delivery of personalized, effective obesity care.
Methods
Quality improvement program with an embedded, 12-month, single-arm pilot study. Patients with obesity and ≥1 weight-related co-morbidity may be referred to the WNP by PCPs. All patients seen within the WNP during the first 12 months of clinical operations will be compared to a matched cohort of patients from another primary care site. We will recruit a subset of WNP patients ( n = 30) to participate in a remote weight monitoring pilot program, which will include surveys at 0, 6, and 12 months, qualitative interviews at 0 and 6 months, and use of an electronic health record (EHR)-based text messaging program for remote weight monitoring.
Discussion
Obesity is a complex chronic condition that requires evidence-based, personalized, and longitudinal care. To deliver such care in general practice, the WNP leverages the expertise of ABOM-certified physicians, health system and community weight management resources, and EHR-based population health management tools. The WNP is an innovative model with the potential to be implemented, scaled, and sustained in diverse primary care settings.
... Patient engagement has been called the "blockbuster" drug [18,19] of the twenty-first century as motivated patients demonstrate improved well-being and health outcomes [20,21]. Strong theoretical foundations from social cognitive theories of self-efficacy [22,23] and the chronic care model [24] support the importance of patient engagement [25][26][27][28][29] to minimize toxicities of cancer treatment. ...
Background
Many cancer patients experience high symptom burden. Healthcare in the USA is reactive, not proactive, and doctor-patient communication is often suboptimal. As a result, symptomatic patients may suffer between clinic visits. In research settings, systematic assessment of electronic patient-reported outcomes (ePROs), coupled with clinical responses to severe symptoms, has eased this symptom burden, improved health-related quality of life, reduced acute care needs, and extended survival. Implementing ePRO-based symptom management programs in routine care is challenging. To study methods to overcome the implementation gap and improve symptom control for cancer patients, the National Cancer Institute created the Cancer-Moonshot funded Improving the Management of symPtoms during And following Cancer Treatment (IMPACT) Consortium.
Methods
Symptom Management IMplementation of Patient Reported Outcomes in Oncology (SIMPRO) is one of three research centers that make up the IMPACT Consortium. SIMPRO, a multi-disciplinary team of investigators from six US health systems, seeks to develop, test, and integrate an electronic symptom management program (eSyM) for medical oncology and surgery patients into the Epic electronic health record (EHR) system and associated patient portal. eSyM supports real-time symptom tracking for patients, automated clinician alerts for severe symptoms, and specialized reports to facilitate population management. To rigorously evaluate its impact, eSyM is deployed through a pragmatic stepped wedge cluster-randomized trial. The primary study outcome is the occurrence of an emergency department treat-and-release event within 30 days of starting chemotherapy or being discharged following surgery. Secondary outcomes include hospitalization rates, chemotherapy use (time to initiation and duration of therapy), and patient quality of life and satisfaction. As a type II hybrid effectiveness-implementation study, facilitators and barriers to implementation are assessed throughout the project.
Discussion
Creating and deploying eSyM requires collaboration between dozens of staff across diverse health systems, dedicated engagement of patient advocates, and robust support from Epic. This trial will evaluate eSyM in routine care settings across academic and community-based healthcare systems serving patients in rural and metropolitan locations. This trial’s pragmatic design will promote generalizable results about the uptake, acceptability, and impact of an EHR-integrated, ePRO-based symptom management program.
Trial registration
ClinicalTrials.gov NCT03850912. Registered on February 22, 2019. Last updated on November 9, 2021.
... In that study, patients were screened and enrolled before postoperative hospital discharge using the Physical Health Questionnaire-2. A nurse manager performed active follow-up of patients adhering to evidence-based treatment protocols, patient education about their illness, patient history and preferences for treatments while actively involving their primary care physician and transfer of care to a mental health clinician if the patients did not respond to therapy [39,40]. ...
Background
In this study we hypothesize that depression is associated with perioperative neurocognitive dysfunction and altered quality of life one month after surgery.
Methods
Data were obtained as part of a study evaluating cerebral autoregulation monitoring for targeting arterial pressure during cardiopulmonary bypass. Neuropsychological testing was performed before surgery and one month postoperatively. Testing included the Beck Depression Inventory, a depression symptoms questionnaire (0–63 scale), as well as anxiety and quality of life assessments. Depression was defined as a Beck Depression Inventory score > 13.
Results
Beck Depression data were available from 320 patients of whom cognitive domain endpoints were available from 88–98% at baseline and 69–79% after surgery. This range in end-points data was due to variability in the availability of each neuropsychological test results between patients. Depression was present in 50 (15.6%) patients before surgery and in 43 (13.4%) after surgery. Baseline depression was not associated with postoperative domain-specific neurocognitive function compared with non-depressed patients. Those with depression one month after surgery, though, had poorer performance on tests of attention ( p = 0.017), memory ( p = 0.049), verbal fluency ( p = 0.010), processing speed ( p = 0.017), and fine motor speed ( p = 0.014). Postoperative neurocognitive dysfunction as a composite outcome occurred in 33.3% versus 14.5% of patients with and without postoperative depression ( p = 0.040). Baseline depression was associated with higher anxiety and lower self-ratings on several quality of life domains, these measures were generally more adversely affected by depression one month after surgery.
Conclusions
The results of this exploratory analysis suggests that preoperative depression is not associated with perioperative neurocognitive dysfunction, but depression after cardiac surgery may be associated with impairment in in several cognitive domains, a higher frequency of the composite neurocognitive outcome, and altered quality of life.
Trial Registration
www.clinicaltrials.gov, NCT00981474 (parent study).
... Other broader system-level changes suggested by our respondents, such as the need to expand access to effective outpatient treatment for SUD and addressing social determinants of health, may take more concerted efforts on the part of healthcare system leaders and healthcare funders. For instance, an expansion of chronic care models, using a proactive population health approach and comprehensive care coordination to reduce social deterrents to care and engage patients in needed follow-up care [28][29][30] may be increasingly important for patients with complex chronic conditions like IDU-IE. However difficult, these changes could impact the outcomes and long-term costs of a complex and highly vulnerable patient population receiving expensive inpatient care. ...
Background
Despite high morbidity and mortality, patients with injection drug use associated infective endocarditis (IDU-IE) lack standardized care, and experience prolonged hospitalization and variable substance use disorder (SUD) management.
Our study’s objective was to elicit perspectives of health care workers (HCWs) who deliver care to this population by understanding their perceived patient, provider, and system-level resources and barriers.
Methods
This qualitative study included interviews of HCWs providing care to patients with IDU-IE from January 2017 to December 2019 at a single Midwest academic center. Based on electronic medical record queries to determine high and low rates of referral to SUD treatment, HCWs were selected using stratified random sampling followed by convenience sampling of non-physician HCWs and a patient. Study participants were recruited via email and verbal consent was obtained. The final sample included 11 hospitalists, 3 specialists (including 2 cardiovascular surgery providers), 3 case managers, 2 social workers, 1 nurse, and 1 patient. Qualitative semi-structured interviews explored challenges and resources related to caring for this population. Qualitative Data Analysis (QDA) Minor Lite was used for thematic data using an inductive approach.
Results
Three major thematic categories emerged relative to patient-level barriers (e.g., pain control, difficult patient interactions, social determinants of health), provider-level barriers (e.g., inequity, expectations for recovery, varying levels of hope, communication style, prescribing medication for SUD), and system-level barriers (e.g., repeat surgery, placement, resources for SUD and mental health). The need to address underlying SUD was a prominent theme.
Conclusion
Practical steps we can take to improve treatment for this population include training and coaching HCWs on a more person-centered approach to communication and transparent decision-making around pain management, surgery decisions, and expectations for SUD treatment.
... Since the turn of the 21 st century, there has also been a shift from reactive to proactive intervention strategies (Coleman et al., 2009) and delivery of remote interventions (Sørensen et al., 2020b), assuming a more active and evolving role for CYP with LTCs and their families (Coulter et al., 2013). This remote management has been intensified during the COVID-19 pandemic (BSR, 2020). ...
This thesis, titled, 'Innovative approaches to the self- and shared- management of arthritis by children, their families and professionals: A realist approach', was submitted in accordance with the requirements for the degree of Doctor of Philosophy at the University of Leeds in June 2021. The aim of the research presented in the thesis was to explore how self- and shared-management of JIA can be promoted across the lifecourse by children and young people, families, and professionals involved in their healthcare, wellbeing, and education. The thesis is embargoed until 1 March 2024. Please visit https://etheses.whiterose.ac.uk/30220/ to request a copy.
... Therefore, understanding the experiences of patients using OAA, and comparing the similarities and differences of these experiences with those of medication use for other chronic conditions, can help develop management strategies for the cancer patients and their caregivers to use. Because of the potential similarities in their experiences of managing OAA use and medications for managing other chronic illnesses, research that helps to understand patients' and caregivers' experiences with OAA use and their supportive care needs may benefit from the use of the Chronic Care Model (CCM) that has been widely used to understand the experiences of patients with chronic illnesses and their families and to empower them to engage in self-management [4]. The CCM highlights productive interactions between informed, activated patients and a well-prepared, proactive practice health care team to improve outcomes; informed and activated patients can provide meaningful feedback on their experiences and perceptions of safety. ...
Oral anticancer agents (OAA) are increasingly prescribed to treat cancer because they are flexible and convenient to use. However, managing complex OAA regimens and life-threatening toxicities at home can be challenging for patients and their caregivers. It is urgent to better understand the supportive care needs for OAA and develop novel approaches to facilitating self-management and communicating about OAA. Guided by the chronic care model (CCM), we conducted a grounded theory-based study to analyze OAA-related online discussions and potential mHealth interventions. We found that patients and caregivers commonly used the online community to share personal experiences and concerns, exchange emotional and informational support, identify relevant resources, and obtain benefits of peer coaching. The findings deepen the understanding of the needs for OAA self-management and mHealth interventions, contributing to the development of mHealth models to enhance supportive care and improve communication among peer patients and between patients and providers.
... Chronic care management processes are structural capabilities for delivering chronic care as compared with patient engagement strategies, which are more interpersonally focused interventions. 34,35 The greater use of chronic care management practices may be positively associated with the adoption of patient engagement strategies because they provide a strong foundation to measure clinician performance and target patients for engagement using information from disease registries. ...
Background:
Patient engagement strategies can equip patients with tools to navigate treatment decisions and improve patient-centered outcomes. Despite increased recognition about the importance of patient engagement, little is known about the extent of physician practice adoption of patient engagement strategies nationally.
Methods:
We analyzed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on physician practice adoption of patient engagement strategies. Stratified-cluster sampling was used to select physician practices operating under different organizational structures. Multivariable linear regression models estimated the association of practice ownership, health information technology functionality, use of screening activities, patient responsiveness, chronic care management processes, and the adoption of patient engagement strategies, including shared decision-making, motivational interviewing, and shared medical appointments. All regression models controlled for participation in payment reforms, practice size, Medicaid revenue percentage, and geographic region.
Results:
We found modest and varied adoption of patient engagement strategies by practices of different ownership types, with health system-owned practices having the lowest adoption of ownership types. Practice capabilities, including chronic care management processes, routine screening of medical and social risks, and patient care dissemination strategies were associated with greater practice-level adoption of patient engagement strategies.
Conclusions:
This national study is the first to characterize the adoption of patient engagement strategies by US physician practices. We found modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments. Risk-based payment reform has the potential to motivate greater practice-level patient engagement, but the extent to which it occurs may depend on internal practice capabilities.
Objectives: The middle-aged population from rural areas of Pakistan is disproportionately at risk of developing and mismanaging their diabetes. The purpose of this study was to explore the self-management experiences of two focus groups in the middle-aged population with type 2 diabetes mellitus living in rural Pakistan. Methods: The study design is based on the exploratory research using a qualitative approach. Purposive sampling was used to recruit patients with diabetes from the metabolic outpatient clinics of medical centers in rural areas of Pakistan. The data were collected for two focus groups consisting of 20 persons (10 men and 10 women) with type 2 diabetes mellitus, ranging in age from 40 to 65 years, who were receiving diabetic care at a local health facility. Focus group discussions with a sample size of 10 participants each were all recorded, transcribed, and analyzed. The data were evaluated thematically. Results: Participants described diabetes management as emotionally, physically, and socially taxing. The analysis of the data indicated three major themes: (1) diabetes as a challenging disease; (2) understanding diabetes and its challenges; (3) following diabetes self-management practices. Throughout the session, participants discussed the impact of diabetes on their daily life. This study provided new insights into the experiences of the middle-aged population of Pakistan regarding their self-management of diabetes. Conclusions: Healthcare professionals should become involved in diabetes self-management education as soon as feasible to alleviate patient worry and establish better patient-centered, culturally sensitive professional abilities. Along with monitoring patients’ self-management, healthcare professionals should place a greater emphasis on patients’ understanding of the disease and its challenges and associated complications. It is recommended to establish diabetes support groups to encourage patients to share their experiences of diabetes self-management.
This paper examines the role of universal healthcare on patient choice and quality of care. Lack of health insurance is a leading contributor to emergency department (ED) visits from the uninsured. Using a natural experiment from Massachusetts, we follow previously uninsured individuals over time—both before and after the implementation of universal healthcare—to study the effects of insurance availability on their healthcare seeking behavior. We find that the availability of health insurance has a significant impact on the type of healthcare sought by the previously uninsured. Specifically, individuals are less likely to continue visiting the ED and instead more likely to choose hospital inpatient and outpatient services. We find that frequent fliers and patients with chronic conditions, who are both known to account for a substantial share of healthcare costs, exhibit heterogeneity in this behavior. Finally, we examine the effect of the policy on quality of care, as measured by short‐term ED revisits. Although the overall revisit rates remain unchanged, frequent ED users and chronic patients experience a decline in short‐term ED revisits. With key features of the Affordable Care Act being frequently criticized for repeal, understanding how these changes influence patient choice and quality of care is significantly policy relevant.
Objective: The main aim of this study was to implement the Chronic Care Model (CCM) for the self-management of type 2 diabetes in primary health care settings of rural areas of Pakistan and identify its effectiveness and develop strategies for overcoming its challenges. The two core elements of the Chronic Care Model: patient Self-Management Support (SMS) and Delivery System Design (DSD), were implemented to improve the quality of life and risk behaviour of type 2 diabetes patients in the middle-aged population of rural Pakistan. Methods: Thirty patients with type 2 diabetes and 20 healthcare professionals were included in this study consisting of 10 general practitioners and 10 nurses recruited from various clinics (medical centres) of Al-Rehman Hospital in Abbottabad, Pakistan. The quantitative content analysis method was used to identify the frequency of the most recurring statements. A t-test was performed to see the mean difference of HbA1c at baseline after 3-months and 6-months follow-up between male and female patients with diabetes. The hypothesis was tested to identify that diabetes self-management has a gendered dimension in rural areas of Pakistan. Results: The quantitative analysis demonstrated that diabetes self-management has a gendered dimension in the rural areas of Pakistan as the mean difference of HbA1c after a 6-month intervention of the two components of the chronic care model between male and female patients of diabetes was 0.83 (p = 0.039) with 95% CI (−0.05; −1.61). The mean difference in BMI after the intervention of 6 months between males and females was significant (p < 0.05). The mean difference was 4.97 kg/m2, p = 0.040 with 95% CI (−0.24; −9.69). The results have shown that the two components of CCM were effective and improved clinical outcomes for diabetes patients of the rural areas of Pakistan. Conclusions: The application of the two Chronic Care Model’s components provided a viable structure for diabetes self-management education and assistance. As a result, developing systems that incorporate long-term diabetes self-management education has an effect on the health care system’s outcomes.
Bipolar disorder (BD) affects approximately 2% of U.S. adults and is the most costly mental health condition for commercial insurers nationwide. Rates of BD are elevated among persons with depression, anxiety disorders, and substance use disorders-conditions frequently seen by primary care clinicians. In addition, antidepressants can precipitate manic or hypomanic symptoms or rapid cycling in persons with undiagnosed BD. Thus, screening in these high-risk groups is indicated. Effective treatments exist, and many can be safely and effectively administered by primary care clinicians.
The author examines the “User-Centered Approach (UCA),” proposed as remedy for supply-side domination in service provision, paying particular attention to the “empowerment” of service users. First, conceptual and analytical approaches to service transaction and utilization are presented, followed by articulation and classification of the nature of services and conjectures on two types of failures. Second, in discussing the effectiveness of the UCA models (co-production and self-management), typologies of user-provider relations and of user agency are presented. Third, conceptual distinction between and empirical illustrations of the activation and development of user agency are provided and related to different types of empowerment interventions. Based on these arguments, an implicit stage theory of user agency is presented: pre-outreach → outreach → counselling → consulting → independence (full autonomy).
Background: In Canada, there is widespread agreement about the need for integrated models of team-based care. However, there is less agreement on how to support the scale-up and spread of successful models; there is limited empirical evidence to support this process in chronic disease management. We studied the supporting, and mitigating factors required to successfully implement and scale-up an integrated model of team-based care in primary care.
Methods: We conducted a collective case study using multiple methods of data collection including interviews, document analysis, living documents, and a focus group. Our study explored a team-based model of care for chronic obstructive pulmonary disease (COPD) known as Best Care COPD (BCC) that has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants included healthcare providers involved in the delivery of the BCC program.
Results: We identified several mechanisms influencing the scale-up and spread of BCC and categorized them as Foundational (e.g., evidence-based program, readiness to implement, peer-led implementation team), Transformative (adaptive process, empowerment and collaboration, embedded evaluation), and Enabling Mechanisms (provider training, administrative support, role clarity, patient outcomes). Based on these results, we developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management. Our framework builds off our empirical work and is framed by local contextual factors.
Conclusions: This study explores the implementation and spread of integrated team-based care in a primary care setting. Despite the study’s focus on COPD, we believe the findings can be applied in other chronic disease contexts. We provide a framework to support the progressive implementation of integrated team-based care for chronic disease management.
Children with medical complexity (CMC) have extremely high health care needs. Given their chronic complex diagnoses and involvement of multiple care providers, they are often over medicalized and seen as a list of diagnoses rather than as a child. Parents of CMC are extraordinary caregivers and advocates for their children. Parental values and perspectives are critical drivers of medical decision making, therefore highlighting the importance of collaboration between all members of the medical team. For health care providers (HCPs) to holistically guide and support families, an all encompassing, big picture understanding of CMC and their family is needed, and care maps are one such vehicle to provide this insight. Care maps are a parent-created tool that can be used to provide a holistic view of the child and demonstrate the complexity of life and interrelatedness of services for CMC. Previous research has shown that care maps have been used as a resource to promote parental reflection and identify parental priorities of care. Promotion of care maps by HCPs as a valuable tool in understanding the child and family’s goals may help improve holistic understanding and promote collaborative care.
RESUMEN: Los pacientes con enfermedades crónicas, su gestión por procesos y su atención socio-sanitaria integral representa uno de los principales retos actuales para los sistemas de salud de cualquier país. Debido al incremento de la longevidad y la esperanza de vida, el número de personas con pluripatologías que demandan atención por su carácter de cronicidad es cada vez mayor. Esto origina un gran consumo de recursos sanitarios con costes elevados en los países más desarrollados. Se estima que la atención a los procesos crónicos consume entre el 70% y el 75% del gasto sanitario total en los países industrializados. Esta necesidad de atención socio sanitaria a los pacientes crónicos implica la necesidad imperiosa de realizar un cambiar de paradigma del actual modelo de ge stión, desde una atención fragmentada y aislada, a una integración socio sanitaria. Necesitamos rediseñar la organización y optimizar los recursos socio sanitarios. Necesitamos mejorar la atención primaria y reorganizar la gestión hospitalaria. Necesitamos trasladar la gestión de la cronicidad al ámbito familiar y comunitario, con una mayor integración socio sanitaria, más eficiente y de mayor calidad tanto clínica asistencial como percibida por el paciente. El mayor reto actual en salud es poder manejar estos pacientes con enfermedades crónicas desde un enfoque holístico donde la tecnología alrededor del paciente mejora su bienestar, sin necesidad de ingresar en un centro hospitalario. Necesitamos abrir puertas a nuevos modelos de atención socio sanitaria. Necesitamos abrir puertas a un nuevo concepto de Hospital Virtual Digital fuera del hospital, en casa o en Residencias tecnológicamente preparadas. El avance en el manejo de pacientes con patologías crónicas requiere un cambio de paradigma de nuestros conceptos habituales de manejo de pacientes agudos dentro de un ámbito hospitalario. Gracias al desarrollo de biosensores y a la computación ubicua y la inteligencia ambiental (U-Health) todos los datos biológicos: ECG, Sat O2, Presión Arterial, Frecuencia Cardíaca, Temperatura, Raw Data Genómico..., pueden ser registrados y transferidos digitalmente a un "Hospital Virtual" desde casa. Con el "Hospital Virtual" podemos mantener a los pacientes en sus hogares y proteger al personal sanitario y a los pacientes del riesgo de ser infectados. A través de una interfaz intuitiva, es posible acceder a los diferentes servicios de uHealth que van desde la atención médica con videoconsultas, chequeo electrónico y hospitalización a domicilio, como servicios de teleeducación para la salud y sesiones clínicas entre profesionales. De este modo, la creación de un "hospital virtual" sin barreras arquitectónicas y ladrillos, puede aumentar la capacidad de camas hospitalarias, limitar la exposición del personal y de los pacientes a las infecciones como ha sucedido con el COVID-19 durante la pandemia. En conclusión: Las iniciativas de crear un "Hospital Virtual" en el hogar o Residencias tecnológicamente adecuadas, proporciona ahorros de costes y mejora la satisfacción del paciente/usuario. SUMMARY: Patients with chronic diseases, their process management and their integral socio-health care, represents one of the main current challenges for health systems in any country. Due to the increase in longevity and life expectancy, the number of people with multiple pathologies that demand attention to their character of chronicity is continuously increasing. It is estimated an attention to chronic processes between 70% and 75% of total health expenditure in industrialized countries. This attention to chronic patients implies an imperative need to change the paradigm of the actual management model: from fragmented and isolated care, to a socio-health care integration; redesigning the organization and optimizing socio-health resources; enhancing primary care; reorganizing hospital management; transferring the management of chronicity to the family and community environment, with a greater, more efficient and higher quality social-health care integration perceived by the patient. The actual challenge in health is to manage patients with chronic diseases from a holistic approach where technology around the patient enhances their wellness. We need to open doors to new care models. We need to open doors to a new concept of Digital Virtual Hospital at Home. The advance in the management of patients with chronic pathologies requires a paradigm shift of our usual concepts of management of patients. Thanks to the development of biosensors and ubiquitous computing and environmental intelligence all the biological data: ECG, 02 Sat, Blood Pressure, Heart Rate, Temperature, Radiological scans and images, Genomic Raw Data..., can be digitally transferred to a "Virtual Hospital" from home. Advancements in sensor technology, miniaturization and machine learning are allowing for real-time remote monitoring of physiological parameters that traditionally could only be measured with costly hospital-based labs and equipment. Also, with the aid of machine learning and artificial intelligence (AI) we can detect which patients are at risk for decompensation and who might need to be admitted to a traditional hospital setting. With the new model, we will help keep large numbers of patients with frail health and/or chronic conditions safely liberated from the hospital and able to enjoy a far higher quality of life at a much lower cost. In this way, the creation of a "Virtual Hospital" without architectural barriers and bricks can increase the capacity of hospital beds, limit the exposure of staff and patients to infections as has happened with COVID-19 during the pandemic. In conclusion: The
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Health is not an entity or a static definition, but a dynamic and local process. From our clinical perspective on health psychology, we consider health as a multidimensional process that is generated from the connection between several experiential trajectories: bodily, affective, cognitive, relational, cultural, and historic. Chronicity, despite its seemingly meaning of staticity, cannot be considered as a stable illness condition. Our interest is about the construction of a sense of “health” also in nonreversible conditions of disease. In this contribution, we present the clinical perspective of the Sense of Grip on chronic disease (SoGoD, Freda et al., 2019; Savarese et al., 2020). By SoGoD, we refer to the narrative sensemaking processes of the chronic disease by means of five semiotic functions: temporal articulation, integration of disease, emotional regulation, social interaction, and agentive processes. By analyzing the narrative construction of the disease in such functions, we can grasp personalized styles of sensemaking of the disease experience. This evaluation is functional to set up personalized intervention to foster the process of adjustment to the disease/patient engagement in the healthcare setting. By SoGoD our aim is overcoming the dichotomy between evidence and ethics-based approaches by an abductive approach; it is not a matter of refuting evidence-based approaches in health but of integrating normative frames and subjective processes in a semiotic perspective aiming at more effective subjective health trajectories and adjustments to chronic disease.
Background:
Gestational diabetes mellitus (GDM), a common complication of pregnancy, is associated with a 10-fold increased risk of type 2 diabetes mellitus (T2DM) compared to the general population. Evidence-based guidelines recommend that patients with GDM receive postpartum care for T2DM risk reduction including an oral glucose tolerance test (OGTT) 4-12 weeks after delivery, yet half of patients with GDM did not return for their postpartum visits by 12 weeks postpartum. Additionally, only 10% utilize primary care within 12 months of delivery and one-third of GDM patients receive timely postpartum OGTT.
Objective:
To determine if the Mother-Infant Dyad postpartum primary care program provides a framework to link well-child visits with postpartum primary care visits to increase postpartum clinical interactions promoting longitudinal care, such as postpartum visit attendance and T2DM screening.
Study design:
All patients with a diagnosis of GDM that received care at a postpartum mother-infant dyad program at a Midwestern academic medical center internal medicine and pediatrics primary care clinic were enrolled. Clinic level data was obtained by baseline and 6-month post-enrollment surveys and chart review. A comparison population was identified from Medicaid claims data using propensity score matching to enable a comparison of program participants' outcomes to a population comprised of similar individuals diagnosed with GDM that received care at sites not participating in the Dyad program. Our primary outcome was completion of T2DM screening in the 4-12 week postpartum period. The secondary outcomes were postpartum visit attendance with a prenatal provider, and prediabetes diagnoses.
Results:
A total of 75 mother-infant dyads were seen by the clinic. Of the enrolled women, 43% were Non-Hispanic White and 30% were Non-Hispanic Black; mean age was 30.75 years. The matched comparison group (n = 62) had a mean age of 30.75 years, were 43% Non-Hispanic White and 30% Non-Hispanic Black. Women who participated in the program were more likely to receive T2DM screenings than women who did not participate (87 vs. 79%, p<.001) and complete postpartum visits (95 vs. 58%, respectively; p<.001). Additionally, a higher rate of new prediabetes diagnoses was observed (12 vs. 6%, p < .001).
Conclusion:
The Mother-Infant Dyad postpartum primary care program improved T2DM screenings and postpartum visit attendance. In addition, a greater proportion of Dyad program participants experienced new prediabetes diagnoses that those in the comparison group. Our findings suggest that the dyad care model, in which women with GDM engage in postpartum primary care concurrent with well-child visits, can improve longitudinal postpartum care after a GDM diagnosis.
Introdução: O envelhecimento populacional ocorre de forma crescente, e gastos com internações hospitalares em pessoas idosas representam um grande custo nos gastos públicos destinados a internações hospitalares com essa parte da população. Algumas das internações hospitalares em idosos podem ser evitadas com ações efetivas de promoção e prevenção na atenção primária à saúde. Objetivos: Descrever as principais causas de internações hospitalares por condições sensíveis à atenção primária em idosos das regiões de saúde do Espírito Santo (ES). Métodos: Trata-se de um estudo descritivo sobre as internações por condições sensíveis à atenção primária (ICSAP) de população com 60 anos ou mais residentes no ES, ocorridas no período de 2010 a 2015. Resultados: A proporção de internações hospitalares por CSAP no ES foram mais elevadas em decorrência do diabetes mellitus (23,51%), pneumonia (18,95%), insuficiência cardíaca (11,04%), doenças renais túbulo-intersticiais (2,75%), e diarreia e gastroenterite de origem infecciosa (2,21%). Conclusão: A atenção primária é a principal porta de entrada para os idosos e deve atuar na promoção à saúde, na prevenção e controle de doenças, de forma a intervir nas proporções dessas internações que poderiam ser evitadas.
Background: Disease management approach is an effective means in genetic disorders, such as sickle cell disease (SCD). This disease is a neglected chronic disease of increasing global health importance. In this process, acquiring knowledge and information related to the disease plays a critical role in self-efficacy and self-care. Therefore, one of the determinants of health and criteria for enhanced quality of life is health literacy. Objectives: Therefore, the present study aimed to determine the relationship between the quality of life and health literacy associated with disease management among patients with SCD. Methods: This descriptive-correlational study was conducted on 150 patients with SCD in Ahvaz. These patients have been referred to the thalassemia clinic and the thalassemia ward of Shahid Baghaei-2 Hospital and selected via accessible sampling. The study data were collected using WHOQOL-EREF-26 items and a researcher-made questionnaire about information resources whose reliability and validity were confirmed. Then, the data were entered into the SPSS software and analyzed via descriptive statistics, chi-square, regression, and correlation tests. Results: The mean age of the participants was 27.56 ± 9.14 years. The most important resource for increasing knowledge was the physician in 83.3% of the patients. In addition, they had acquired the highest amount of knowledge about the causes and symptoms of the disease. Moreover, the highest and lowest mean scores of quality of life were related to physical health (50.80 ± 9.94) and (45.23 ± 19.91) social health dimensions, respectively. The results showed statistically significant differences between the place of residence with the dimension of social health (P = 0.037, b = -11.05) and sources of knowledge enhancement with the dimension of social health quality of life (P = 0.010, b = -14.96). Conclusions: Since quality of life is a subjective and multifactorial concept, its effective factors have to be explored. The present study results indicated that the patients were eager to acquire knowledge about their disease. The higher the patients’ knowledge level, the higher their ability in disease management, self-care, and social health dimension of quality of life would be.
Introduction
Integrated care is a common approach to leverage scarce psychiatric resources to deliver mental health care in primary care settings. To date, a formal clinical fellowship devoted to professional development for this role has not been described.
Methods
The development of a formal year-long clinical fellowship in integrated care is described. The curriculum consists of an Integrated Care Didactic Series, Integrated Care Clinical Skill Experiences, and Integrated Care System-Based Leadership Experiences. Evaluation of impact was assessed with descriptive statistics.
Results
We successfully recruited three classes of fellows to the Integrated Care Fellowship, with 5 program graduates in the first 3 years. All five graduated fellows were hired into integrated care and/or telepsychiatry positions. Integrated Care fellows had a high participation rate in didactics (mean attendance = 80.6%; n=5). We received a total of 582 didactic evaluations for the 151 didactic sessions. On a scale of 1 (poor) to 6 (fantastic), the mean quality of the interactive learning experience was rated as 5.33 (n=581), and the mean quality of the talk was 5.35 (n=582). Rotations were rated with the mean overall teaching quality of 4.98/5 (n = 76 evaluations from 5 fellows).
Conclusions
The Integrated Care clinical fellowship serves as a model for training programs seeking to provide training in clinical and systems-based skills needed for practicing integrated care. Whether such training is undertaken as a standalone fellowship or incorporated into existing Consultation-Liaison Psychiatry programs, such skills are increasingly valuable as integrated care becomes commonplace in practice.
Using in-depth interviews, we sought to characterize the everyday medical and social needs of pediatric liver transplant caregivers to inform the future design of solutions to improve care processes. Participants (parents/caregivers of pediatric liver transplant recipients) completed a survey (assessing socioeconomic status, economic hardship, health literacy, and social isolation). We then asked participants to undergo a 60-min virtual, semistructured qualitative interview to understand the everyday medical and social needs of the caregiver and their household. We intentionally oversampled caregivers who reported a social or economic hardship on the survey. Transcripts were analyzed using thematic analysis and organized around the Capability, Opportunity, Motivation-Behavior model. A total of 18 caregivers participated. Of the participants, 50% reported some form of financial strain, and about half had less than 4 years of college education. Caregivers had high motivation and capability in executing transplant-related tasks but identified several opportunities for improving care. Caregivers perceived the health system to lack capability in identifying and intervening on specific family social needs. Caregiver interviews revealed multiple areas in which family supports could be strengthened, including (1) managing indirect costs of prolonged hospitalizations (e.g., food, parking), (2) communicating with employers to support families' needs, (3) coordinating care across hospital departments, and (4) clarifying care team roles in helping families reduce both medical and social barriers. This study highlights the caregiver perspective on barriers and facilitators to posttransplant care. Future work should identify whether these themes are present across transplant centers. Caregiver perspectives should help inform future interventions aimed at improving long-term outcomes for children after liver transplantation.
O suicídio é um fenômeno complexo e multicausal que ocorre em todas as regiões do mundo e desafia as sociedades modernas por
ser um óbito evitável. Objetivos: Analisar a tendência temporal da mortalidade por suicídio no Espírito Santo no período de 2007 a 2016. Métodos: Trata-se de um estudo ecológico de série temporal, cuja população compreendeu os óbitos maiores de 10 anos por suicídio nas regiões de saúde do Espírito Santo, no período de 2007 a 2016, tendo como fonte o Sistema de Informação sobre Mortalidade.
Realizou-se estatística descritiva, e para análise da tendência do suicídio foram estimados modelos de regressão polinomial. Resultados: Foram declarados 1.630 óbitos por suicídio no Espírito Santo no período analisado. O modelo que representou a tendência dos óbitos por suicídio foi de 2ª ordem (p<0,007) - acréscimo da taxa de 2007 a 2012 e decréscimo a partir de 2013. As regiões de
saúde com tendência decrescente nos últimos cinco anos foram a Metropolitana (p<0,002) e Sul (p<0,020). Para os homens, a tendência decresceu 10,4% e entre as mulheres cresceu 15,3%. As faixas etárias 10-19 anos (p<0,005) e 20-39 anos (p<0,05) decresceram no último quinquênio, e em todo o período observou-se declínio das taxas de suicídio nas faixas etárias de 60-79 anos (p<0,007) e 80 anos
e mais (p<0,001). Conclusão: A taxa de suicídio no ES, regiões Metropolitana e Sul foram crescentes até a metade do período e depois decresceram, maior entre os homens, porém, com tendência decrescente, enquanto a taxa feminina cresceu. Entre os idosos também houve declínio.
Introdução: Os casos de intoxicações medicamentosas têm aumentado em todo o país e se revelado um grande desafio para a saúde pública, além de gerar preocupações para as autoridades e profissionais de saúde. Objetivos:Caracterizar as intoxicações medicamentosas por circunstância no Espírito Santo, segundo região de saúde, sexo e faixa etária no período de 2011 a 2015. Métodos:Trata-se de um estudo ecológico envolvendo notificações dos casos de intoxicação por medicamentos, no Espírito Santo, no período de 2011 a 2015, tendo como fonte o SINAN. Realizou-se a estatística descritiva dos dados. Resultados: A taxa de incidência no ES para o período foi de 27,7/100.000 habitantes. Em relação às regiões de saúde, a maior taxa foi observada na região Central (50,6/ 100.000 hab.) e a menor na região Metropolitana (19,9/100.000 hab.). As principais circunstâncias de intoxicação envolvem suicídio e acidente. O sexo feminino com faixa etária de 10-39 anos obteve as maiores taxas nas circunstâncias tentativa de suicídio e automedicação, com valores próximos a 35/100.000 hab. e 5/100.000 hab., respectivamente. Na circunstância acidental, verificou-se uma incidência semelhante entre os sexos e principalmente na faixa etária ≤ 9 anos (30/100.000 hab.). Mais de 90% dos casos obtiveram cura. A subnotificação foi elevada para as variáveis raça/cor e escolaridade. Conclusão: Verifica-se a importância do aprimoramento e intensificação de políticas públicas de saúde voltadas para a prevenção e conscientização acerca do armazenamento e uso indiscriminado de medicamentos
Introdução: O suicídio é um fenômeno complexo e multicausal
que ocorre em todas as regiões do mundo e desafia as sociedades modernas por
ser um óbito evitável. Objetivos: Analisar a tendência temporal da mortalidade
por suicídio no Espírito Santo no período de 2007 a 2016. Métodos: Trata-se de
um estudo ecológico de série temporal, cuja população compreendeu os óbitos
maiores de 10 anos por suicídio nas regiões de saúde do Espírito Santo, no período
de 2007 a 2016, tendo como fonte o Sistema de Informação sobre Mortalidade.
Realizou-se estatística descritiva, e para análise da tendência do suicídio foram
estimados modelos de regressão polinomial. Resultados: Foram declarados
1.630 óbitos por suicídio no Espírito Santo no período analisado. O modelo
que representou a tendência dos óbitos por suicídio foi de 2ª ordem (p<0,007)
- acréscimo da taxa de 2007 a 2012 e decréscimo a partir de 2013. As regiões de
saúde com tendência decrescente nos últimos cinco anos foram a Metropolitana
(p<0,002) e Sul (p<0,020). Para os homens, a tendência decresceu 10,4% e entre
as mulheres cresceu 15,3%. As faixas etárias 10-19 anos (p<0,005) e 20-39 anos
(p<0,05) decresceram no último quinquênio, e em todo o período observou-se
declínio das taxas de suicídio nas faixas etárias de 60-79 anos (p<0,007) e 80 anos
e mais (p<0,001). Conclusão: A taxa de suicídio no ES, regiões Metropolitana e
Sul foram crescentes até a metade do período e depois decresceram, maior entre
os homens, porém, com tendência decrescente, enquanto a taxa feminina cresceu.
Entre os idosos também houve declínio.
Introdução: Os casos de intoxicações medicamentosas têm
aumentado em todo o país e se revelado um grande desafio para a saúde pública,
além de gerar preocupações para as autoridades e profissionais de saúde. Objetivos:
Caracterizar as intoxicações medicamentosas por circunstância no Espírito Santo,
segundo região de saúde, sexo e faixa etária no período de 2011 a 2015. Métodos:
Trata-se de um estudo ecológico envolvendo notificações dos casos de intoxicação
por medicamentos, no Espírito Santo, no período de 2011 a 2015, tendo como
fonte o SINAN. Realizou-se a estatística descritiva dos dados. Resultados:
A taxa de incidência no ES para o período foi de 27,7/100.000 habitantes. Em
relação às regiões de saúde, a maior taxa foi observada na região Central (50,6/
100.000 hab.) e a menor na região Metropolitana (19,9/100.000 hab.). As principais
circunstâncias de intoxicação envolvem suicídio e acidente. O sexo feminino com
faixa etária de 10-39 anos obteve as maiores taxas nas circunstâncias tentativa de
suicídio e automedicação, com valores próximos a 35/100.000 hab. e 5/100.000
hab., respectivamente. Na circunstância acidental, verificou-se uma incidência
semelhante entre os sexos e principalmente na faixa etária ≤ 9 anos (30/100.000
hab.). Mais de 90% dos casos obtiveram cura. A subnotificação foi elevada para
as variáveis raça/cor e escolaridade. Conclusão: Verifica-se a importância do
aprimoramento e intensificação de políticas públicas de saúde voltadas para a
prevenção e conscientização acerca do armazenamento e uso indiscriminado de
medicamentos.
Introdução: O envelhecimento populacional ocorre de forma
crescente, e gastos com internações hospitalares em pessoas idosas representam
um grande custo nos gastos públicos destinados a internações hospitalares com
essa parte da população. Algumas das internações hospitalares em idosos podem
ser evitadas com ações efetivas de promoção e prevenção na atenção primária à
saúde. Objetivos: Descrever as principais causas de internações hospitalares por
condições sensíveis à atenção primária em idosos das regiões de saúde do Espírito
Santo (ES). Métodos: Trata-se de um estudo descritivo sobre as internações por
condições sensíveis à atenção primária (ICSAP) de população com 60 anos ou mais
residentes no ES, ocorridas no período de 2010 a 2015. Resultados: A proporção
de internações hospitalares por CSAP no ES foram mais elevadas em decorrência
do diabetes mellitus (23,51%), pneumonia (18,95%), insuficiência cardíaca
(11,04%), doenças renais túbulo-intersticiais (2,75%), e diarreia e gastroenterite de
origem infecciosa (2,21%). Conclusão: A atenção primária é a principal porta de
entrada para os idosos e deve atuar na promoção à saúde, na prevenção e controle
de doenças, de forma a intervir nas proporções dessas internações que poderiam
ser evitadas
Background
The alarming rise in prevalence of hypertension warrants psychosocial methods supplementing pharmacotherapy for better management and prevention of cardiac emergencies. The objective of the study was to assess the differential impact of the form and frequency of knowledge intervention on management of primary hypertension.
Materials and Method
The study was conducted on 256 hypertensive patients recruited through purposive sampling at health centers in Hyderabad, India. Pretest post-test control group quasi-experimental design was adopted for the study. There were two forms of the knowledge intervention, namely ‘Direct Interaction’ and ‘Audio-Visual’. Each form was presented in two frequencies namely ‘single exposure’ and ‘double exposure’. The four groups were labelled as Direct Intervention Single (DIS), Direct Intervention Double (DID), Audio-Visual Single (AVS) and Audio-Visual Double (AVD). Adherence and management of hypertension were assessed at baseline and six weeks post experiment. Analysis of Covariance (ANCOVA) was applied using IBM SPSS Statistics version 20.
Results
ANCOVA followed by Bonferroni Multiple Group Comparison Test revealed significant differences between the four intervention groups and control group on adherence (p<.001). In case of hypertension management significant differences were observed between Control group and DIS, DID (P<.001), Control and AVS (P<.01). Control group did not differ from AVD.
Conclusion
There was a positive impact of Knowledge Intervention on adherence and management of hypertension. Double exposure in audio visual form was counterproductive in hypertension management.
Introduction: Peritoneal carcinomatosis (PC) afflicts women with advanced gynecologic cancers. Patients with PC often require ostomies, gastric tubes, or catheters to palliate symptoms, yet patients and caregivers report feeling unprepared to manage these devices. The purpose of this study was to develop and field test the Building Out Lifelines for Safety, Trust, Empowerment, and Renewal (BOLSTER) intervention to support patients and their caregivers after hospitalization for PC. Materials and Methods: We adapted components of the Standard Nursing Intervention Protocol with stakeholders and topical experts. We developed educational content; built a smartphone application to assess patients' symptoms; and assessed preliminary feasibility and acceptability in two single-arm prepilot studies. Eligible participants were English-speaking adults hospitalized for gynecologic cancer-associated PC and their caregivers. Feasibility criteria were a ≥50% consent-to-approach ratio and ≥80% outcome measure completion. The acceptability criterion was ≥70% of participants recommending BOLSTER. Results: During the first prepilot, BOLSTER was a 10-week intervention. While 7/8 (87.5%) approached patients consented, we experienced high attrition to hospice. Less than half of patients (3/7) and caregivers (3/7) completed outcome measures. For the second prepilot, BOLSTER was a four-week intervention. All (7/7) approached patients consented. Two withdrew before participating in any study activity because they were "too overwhelmed." We excluded data from one caregiver who completed baseline measures with the patient's assistance. All remaining patients (5/5) and caregivers (4/4) completed outcome measures and recommended BOLSTER. Conclusion: BOLSTER is a technology-enhanced, nurse-led intervention that is feasible and acceptable to patients with gynecologic cancer-associated PC and their caregivers.
Unter dem Konzept des Gatekeepingsgatekeeping wird verstanden, dass jede Behandlungsepisode mit Ausnahme von Notfällen und einigen vorab definierten Leistungsbereichen mit einem Besuch bei einem individuell bestimmten Allgemeinarzt beginnt. Entsprechend wird auch von Hausarztmodellen gesprochen. Der Versicherte delegiert die Entscheidung, ob die benötigten Leistungen von diesem selbst erbracht werden, ob ein Facharzt konsultiert werden soll oder gar ein Krankenhausaufenthalt notwendig ist, an seinen Gatekeeper. Sämtliche Leistungen werden somit von diesem erbracht oder zumindest veranlasst.
Purpose
Digital transformation (DT) is a priority for the healthcare sector. In many countries, it is still considered in the early stages with an underestimation of its benefits and potentiality. Especially in Italy, little is known about the impact of digitalization – particularly of the Internet of Things (IoT) – on the healthcare sector, for example, in terms of clinician's jobs and patient's experience. Drawing from such premises, the paper aims to focus on an overlooked healthcare area related to the chronic heart diseases field and its relationship with DT. The authors aim at exploring and framing the main variables of remote Monitoring (RM) adoption as a specific archetype of healthcare digitalization, both on patients and medical staff level, by shedding some lights on its overall implementation.
Design/methodology/approach
The authors empirically inquiry the RM adoption within the context of the Cardiology Department of the Casilino General Hospital of Rome. To answer our research question, the authors reconstruct the salient information by using induction-type reasoning, direct observation and interviewees with 12 key informants, as well as secondary sources analysis related to the hospital (internal documentation, presentations and technical reports).
Findings
According to a socio-technical framework, the authors build a model composed of five main variables related to medical staff and patients. The authors classify such variables into an input-process-output (I-P-O) model. RM adoption driver represents the input; cultural digital divide, structure flexibility and reaction to change serve the process and finally, RM outcome stands for the output. All these factors, interacting together, contribute to understanding the RM adoption process for chronic disease management.
Research limitations/implications
The authors' research presents two main limitations. The first one is related to using a qualitative method, which is less reliable in terms of replication and the interpretive role of researchers. The second limitation, connected to the first one, is related to the study's scale level, which focuses on a mono-centric consistent level of analysis.
Practical implications
The paper offers a clear understanding of the RM attributes and a comprehensive view for improving the overall quality management of chronic diseases by suggesting that clinicians carefully evaluate both hard and soft variables when undertaking RM adoption decisions.
Social implications
RM technologies could impact on society both in ordinary situations, by preventing patient mobility issues and transport costs, and in extraordinary times (such as a pandemic), where telemedicine contributes to supporting hospitals in swapping in-person visits with remote controls, in order to minimize the risk of coronavirus disease (COVID-19) contagion or the spread of the virus.
Originality/value
The study enriches the knowledge and understanding of RM adoption within the healthcare sector. From a theoretical perspective, the authors contribute to the healthcare DT adoption debate by focusing on the main variables contributing to the DT process by considering both medical staff and patient's role. From a managerial perspective, the authors highlight the main issues for RM of chronic disease management to enable the transition toward its adoption. Such issues range from the need for awareness of the medical staff about RM advantages to the need for adapting the organizational structure and the training and education process of the patients.
Context
Because of the additional costs associated with improving diabetes management,
there is interest in whether improved glycemic control leads to reductions
in health care costs, and, if so, when such cost savings occur.Objective
To determine whether sustained improvements in hemoglobin A1c
(HbA1c) levels among diabetic patients are followed by reductions
in health care utilization and costs.Design and Setting
Historical cohort study conducted in 1992-1997 in a staff-model health
maintenance organization (HMO) in western Washington State.Participants
All diabetic patients aged 18 years or older who were continuously enrolled
between January 1992 and March 1996 and had HbA1c measured at least
once per year in 1992-1994 (n = 4744). Patients whose HbA1c decreased
1% or more between 1992 and 1993 and sustained the decline through 1994 were
considered to be improved (n = 732). All others were classified as unimproved
(n = 4012).Main Outcome Measures
Total health care costs, percentage hospitalized, and number of primary
care and specialty visits among the improved vs unimproved cohorts in 1992-1997.Results
Diabetic patients whose HbA1c measurements improved were
similar demographically to those whose levels did not improve but had higher
baseline HbA1c measurements (10.0% vs 7.7%; P<.001). Mean total health care costs were $685 to $950 less each
year in the improved cohort for 1994 (P = .09), 1995
(P = .003), 1996 (P = .002),
and 1997 (P = .01). Cost savings in the improved
cohort were statistically significant only among those with the highest baseline
HbA1c levels (≥10%) for these years but appeared to be unaffected
by presence of complications at baseline. Beginning in the year following
improvement (1994), utilization was consistently lower in the improved cohort,
reaching statistical significance for primary care visits in 1994 (P = .001), 1995 (P<.001), 1996 (P = .005), and 1997 (P = .004) and for specialty
visits in 1997 (P = .02). Differences in hospitalization
rates were not statistically significant in any year.Conclusion
Our data suggest that a sustained reduction in HbA1c level
among adult diabetic patients is associated with significant cost savings
within 1 to 2 years of improvement.
Figures in this Article
Cost models have suggested that better glycemic control will lead to
reductions in the longer-term economic burden of diabetes by preventing expensive
complications.1- 3
Unfortunately, payers and policymakers often demand evidence of more immediate
returns on investments before attempting to improve the quality of diabetes
care. Two recent studies4- 5 suggest
that better glycemic control among type 2 diabetic patients may be followed
by health care cost savings within a short time. Gilmer et al,4
in a staff-model health maintenance organization (HMO), examined the relationship
between baseline levels of hemoglobin A1c (HbA1c) among
type 2 diabetic patients and health care costs over the ensuing 3 years. For
every 1% increase in HbA1c, they found that health care costs rose
significantly over the next 3 years. The authors then used these data to estimate
the reduction in health care costs associated with reductions in HbA1c of 1%. Their model suggests health care cost savings of approximately
$400 to $4000 per patient over the ensuing 3 years, with the savings increasing
with the level of baseline HbA1c and the presence of vascular diseases.
These relative cost savings are estimates and do not reflect the actual experience
of individual patients. Therefore, these data cannot answer 2 critical questions:
(1) Will subsequent health care costs decrease if patients achieve better
glycemic control? and (2) If so, how long does it take before cost savings
are demonstrated?
Demonstration that better glycemic control results in early cost savings
would provide stronger support for more aggressive management of type 2 diabetes6 and for investment in system improvements, such as
computerized diabetes registries7- 8
and nurse case management programs.8- 9
A recent article by Testa and Simonson5 provides
some evidence that short-term cost savings are possible. They compared short-term
effect on symptoms, quality of life, work productivity, and health care use
of active hypoglycemic therapy (glipizide) vs placebo in a randomized trial.
At 15 weeks, patients taking glipizide reported better health and work productivity
and less use of ambulatory care. Whether these changes would persist or be
evident in a less-controlled context is uncertain.
In this article, we compare health care utilization and costs for a
5-year period between 2 cohorts of diabetic patients—a group whose glycemic
control improved and a group in whom it did not improve—receiving care
from the same HMO.
The "patient-centered medical home" has been promoted as an enhanced model of primary care. Based on a literature review and interviews with practicing physicians, we find that medical home advocates and physicians have somewhat different, although not necessarily inconsistent, expectations of what the medical home should accomplish-from greater responsiveness to the needs of all patients to increased focus on care management for patients with chronic conditions. As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.
The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.
To evaluate the Diabetes Health Disparities Collaborative, an initiative by the Bureau of Primary Health Care to reduce health disparities and improve the quality of diabetes care in community health centers.
One year before- after trial. Beginning in 1998, 19 Midwestern health centers undertook a diabetes quality improvement initiative based on a model including rapid Plan-Do-Study-Act cycles from the continuous quality improvement field; a Chronic Care Model emphasizing patient self-management, delivery system redesign, decision support, clinical information systems, leadership, health system organization, and community outreach; and collaborative learning sessions. We reviewed charts of 969 random adults for American Diabetes Association standards, surveyed 79 diabetes quality improvement team members, and performed qualitative interviews.
The performance of several key processes of care assessed by chart review increased, including rates of HbA(1c) measurement (80-90%; adjusted odds ratio 2.1, 95% CI 1.6-2.8), eye examination referral (36-47%; 1.6, 1.1-2.3), foot examination (40-64%; 2.7, 1.8-4.1), and lipid assessment (55-66%; 1.6, 1.1-2.3). Mean value of HbA(1c) tended to improve (8.5-8.3%; difference -0.2, 95% CI -0.4 to 0.03). Over 90% of survey respondents stated that the Diabetes Collaborative was worth the effort and was successful. Major challenges included needing more time and resources, initial difficulty developing computerized patient registries, team and staff turnover, and occasional need for more support by senior management.
The Health Disparities Collaborative improved diabetes care in health centers in 1 year.
The author's dual-purpose evaluation assesses the effectiveness of formal collaboratives in stimulating organizational changes to improve chronic illness care (the chronic care model or CCM). Intervention and comparison sites are compared before and after introduction of the CCM. Multiple data sources are used to measure the degree of implementation, patient-level processes and outcomes, and organizational and team factors associated with success. Despite challenges in timely recruitment of sites and patients, data collection on 37 participating organizations, 22 control sites, and more than 4,000 patients with diabetes, congestive heart failure, asthma, or depression is nearing completion. When analyzed, these data will shed new light on the effectiveness of collaborative improvement methods and the CCM.
To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews.
Literature review from January 1996 to May 2004.
Definitions and components of integrated care programmes and all effects reported on the quality of care.
Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals.
Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.
To use empirical data from previously published literature to address 2 research questions: (1) Do interventions that incorporate at least 1 element of the Chronic Care Model (CCM) result in improved outcomes for specific chronic illnesses? (2) Are any elements essential for improved outcomes?
Meta-analysis.
Articles were identified from narrative literature reviews and quantitative meta-analyses, each of which covered multiple bibliographic databases from inception to March 2003. We supplemented this strategy by searching the MEDLINE database (1998-2003) and by consulting experts. We included randomized and nonrandomized controlled trials of interventions that contained 1 or more elements of the CCM for asthma, congestive heart failure (CHF), depression, and diabetes. We extracted data on clinical outcomes, quality of life, and processes of care. We then used random-effects modeling to compute pooled standardized effect sizes and risk ratios.
Of 1345 abstracts screened, 112 studies contributed data to the meta-analysis: asthma, 27 studies; CHF, 21 studies; depression, 33 studies; and diabetes, 31 studies. Interventions with at least 1 CCM element had consistently beneficial effects on clinical outcomes and processes of care across all conditions studied. The effects on quality of life were mixed, with only the CHF and depression studies showing benefit. Publication bias was noted for the CHF studies and a subset of the asthma studies.
Interventions that contain at least 1 CCM element improve clinical outcomes and processes of care--and to a lesser extent, quality of life--for patients with chronic illnesses.
Aboriginal people in Australia experience the highest prevalence of diabetes in the country, an excess of preventable complications and early death. There is increasing evidence demonstrating the importance of healthcare systems for improvement of chronic illness care. The aims of this study were to assess the status of systems for chronic illness care in Aboriginal community health centres, and to explore whether more developed systems were associated with better quality of diabetes care.
This cross-sectional study was conducted in 12 Aboriginal community health centres in the Northern Territory of Australia. Assessment of Chronic Illness Care scale was adapted to measure system development in health centres, and administered by interview with health centre staff and managers. Based on a random sample of 295 clinical records from attending clients with diagnosed type 2 diabetes, processes of diabetes care were measured by rating of health service delivery against best-practice guidelines. Intermediate outcomes included the control of HbA1c, blood pressure, and total cholesterol.
Health centre systems were in the low to mid-range of development and had distinct areas of strength and weakness. Four of the six system components were independently associated with quality of diabetes care: an increase of 1 unit of score for organisational influence, community linkages, and clinical information systems, respectively, was associated with 4.3%, 3.8%, and 4.5% improvement in adherence to process standards; likewise, organisational influence, delivery system design and clinical information systems were related to control of HbA1c, blood pressure, and total cholesterol.
The state of development of health centre systems is reflected in quality of care outcome measures for patients. The health centre systems assessment tool should be useful in assessing and guiding development of systems for improvement of diabetes care in similar settings in Australia and internationally.
Redesigning the system of care for the management of patients with type 2 diabetes mellitus has not been well studied in rural communities with a significant minority population and limited health care resources. This study assesses the feasibility and potential for cost-effectiveness of restructuring care in rural fee-for-service practices for predominantly minority patients with diabetes mellitus.
This was a feasibility study of implementing case management, group visits, and electronic registry in 5 solo or small group primary care practices in rural North Carolina. The subjects were 314 patients with type 2 diabetes mellitus (mean age = 61 years; 72% African American; 54% female). An advanced practice nurse visited each practice weekly for 12 months, provided intensive diabetes case management, and facilitated a 4-session group visit educational program. An electronic diabetes registry and visit reminder systems were implemented.
There was an improvement in the percentage of patients achieving diabetes management goals and an improvement in productivity and billable encounters. The percentage of patients with a documented self-management goal increased from 0% to 42%, a currently documented lipid panel from 55% to 76%, currently documented aspirin use from 25% to 37%, and currently documented foot examination from 12% to 54%. The average daily encounter rate improved from 20.17 to 31.55 on intervention days.
A redesigned care delivery system that uses case management with structured group visits and an electronic registry can be successfully incorporated into rural primary care practices and appears to significantly improve both care processes and practice productivity.
There have been numerous reports of interventions designed to improve the care of patients with diabetes, but the effectiveness of such interventions is unclear.
To assess the impact on glycemic control of 11 distinct strategies for quality improvement (QI) in adults with type 2 diabetes.
MEDLINE (1966-April 2006) and the Cochrane Collaboration's Effective Practice and Organisation of Care Group database, which covers multiple bibliographic databases. Eligible studies included randomized or quasi-randomized controlled trials and controlled before-after studies that evaluated a QI intervention targeting some aspect of clinician behavior or organizational change and reported changes in glycosylated hemoglobin (HbA1c) values.
Postintervention difference in HbA1c values were estimated using a meta-regression model that included baseline glycemic control and other key intervention and study features as predictors.
Fifty randomized controlled trials, 3 quasi-randomized trials, and 13 controlled before-after trials met all inclusion criteria. Across these 66 trials, interventions reduced HbA(1c) values by a mean of 0.42% (95% confidence interval [CI], 0.29%-0.54%) over a median of 13 months of follow-up. Trials with fewer patients than the median for all included trials reported significantly greater effects than did larger trials (0.61% vs 0.27%, P = .004), strongly suggesting publication bias. Trials with mean baseline HbA1c values of 8.0% or greater also reported significantly larger effects (0.54% vs 0.20%, P = .005). Adjusting for these effects, 2 of the 11 categories of QI strategies were associated with reductions in HbA(1c) values of at least 0.50%: team changes (0.67%; 95% CI, 0.43%-0.91%; n = 26 trials) and case management (0.52%; 95% CI, 0.31%-0.73%; n = 26 trials); these also represented the only 2 strategies conferring significant incremental reductions in HbA1c values. Interventions involving team changes reduced values by 0.33% more (95% CI, 0.12%-0.54%; P = .004) than those without this strategy, and those involving case management reduced values by 0.22% more (95% CI, 0.00%-0.44%; P = .04) than those without case management. Interventions in which nurse or pharmacist case managers could make medication adjustments without awaiting physician authorization reduced values by 0.80% (95% CI, 0.51%-1.10%), vs only 0.32% (95% CI, 0.14%-0.49%) for all other interventions (P = .002).
Most QI strategies produced small to modest improvements in glycemic control. Team changes and case management showed more robust improvements, especially for interventions in which case managers could adjust medications without awaiting physician approval. Estimates of the effectiveness of other specific QI strategies may have been limited by difficulty in classifying complex interventions, insufficient numbers of studies, and publication bias.
The results of 44 studies investigating financial impact and return on investment (ROI) from disease management (DM) programs for asthma, congestive heart failure (CHF), diabetes, depression, and multiple illnesses were examined. A positive ROI was found for programs directed at CHF and multiple disease conditions. Some evidence suggests that diabetes programs may save more than they cost, but additional studies are needed. Results are mixed for asthma management programs. Depression management programs cost more than they save in medical expenses, but may save money when considering productivity outcomes.
The Health Disparities Collaboratives of the Health Resources and Services Administration (HRSA) were designed to improve care in community health centers, where many patients from ethnic and racial minority groups and uninsured patients receive treatment.
We performed a controlled preintervention and postintervention study of community health centers participating in quality-improvement collaboratives (the Health Disparities Collaboratives sponsored by the HRSA) for the care of patients with diabetes, asthma, or hypertension. We enrolled 9658 patients at 44 intervention centers that had participated in the collaboratives and 20 centers that had not participated (external control centers). Each intervention center also served as an internal control for another condition. Quality measures were abstracted from medical records at each health center. We created overall quality scores by standardizing and averaging the scores from all of the applicable measures. Changes in quality were evaluated with the use of hierarchical regression models that controlled for patient characteristics.
Overall, the intervention centers had considerably greater improvement than the external and internal control centers in the composite measures of quality for the care of patients with asthma and diabetes, but not for those with hypertension. As compared with the external control centers, the intervention centers had significant improvements in the measures of prevention and screening, including a 21% increase in foot examinations for patients with diabetes, and in disease treatment and monitoring, including a 14% increase in the use of antiinflammatory medication for asthma and a 16% increase in the assessment of glycated hemoglobin. There was no improvement, however, in any of the intermediate outcomes assessed (urgent care or hospitalization for asthma, control of glycated hemoglobin levels for diabetes, and control of blood pressure for hypertension).
The Health Disparities Collaboratives significantly improved the processes of care for two of the three conditions studied. There was no improvement in the clinical outcomes studied.
There is a need to identify effective practical interventions to decrease cardiovascular disease risk in patients with diabetes.
We examine the impact of participation in a collaborative implementing the chronic care model (CCM) on the reduction of cardiovascular disease risk in patients with diabetes.
Controlled pre- and postintervention study.
Persons with diabetes receiving care at 13 health care organizations exposed to the CCM collaborative and controls receiving care in nonexposed sites.
Ten-year risk of cardiovascular disease; determined using a modified United Kingdom Prospective Diabetes Study risk engine score. A total number of 613 patients from CCM intervention sites and 557 patients from usual care control sites met the inclusion criteria. The baseline mean 10-year risk of cardiovascular disease was 31% for both the intervention group and the control group. Participants in both groups had improved blood pressure, lipid levels, and HbA1c levels during the observation period. Random intercept hierarchical regression models showed that the intervention group had a 2.1% (95% CI -3.7%, -0.5%) greater reduction in predicted risk for future cardiovascular events when compared to the control group. This would result in a reduced risk of one cardiovascular disease event for every 48 patients exposed to the intervention.
Over a 1-year interval, this collaborative intervention using the CCM lowered the cardiovascular disease risk factors of patients with diabetes who were cared for in the participating organization's settings. Further work could enhance the impact of this promising multifactorial intervention on cardiovascular disease risk reduction.
In 1998, the Health Resources and Services Administration's Bureau of Primary Health Care began the Health Disparities Collaboratives (HDC) to improve chronic disease management in community health centers (HCs) nationwide. The HDC incorporates rapid quality improvement, a chronic care model, and best practice learning sessions.
To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further.
Chart review of 2364, 2417, and 2212 randomly selected patients with diabetes from 34 HCs in 17 states in 1998, 2000, and 2002, respectively.
American Diabetes Association standards.
We performed a randomized controlled trial with an embedded prospective longitudinal study. We randomized 34 HCs that had undergone 1-2 years of the HDC. The standard-intensity arm continued the baseline HDC intervention. High-intensity arm centers received 4 additional learning sessions, provider training in behavioral change, and patient empowerment materials. To assess the impact of the HDC, we analyzed changes in clinical processes and outcomes in the standard-intensity centers. To determine the effect of more intensive interventions, we compared the standard- and high-intensity centers.
Between 1998 and 2002, HCs undertaking the standard HDC improved 11 diabetes processes and lowered hemoglobin A1c [-0.45%; 95% confidence interval (CI), -0.72 to -0.17] and low-density lipoprotein cholesterol (-19.7 mg/dL; 95% CI, -25.8 to -13.6). High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors [adjusted odds ratio (OR), 1.47; 95% CI, 1.07-2.01] and aspirin (OR, 2.20; 95% CI, 1.28-3.76), but lower use of dietary (OR, 0.24; 95% CI, 0.08-0.68) and exercise counseling (OR, 0.34; 95% CI, 0.15-0.75).
Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.
To assess the evidence for the effect of disease management on quality of care, disease control, and cost, with a focus on population-based programs.
Literature review.
We conducted a literature search for and a structured review of studies on population-based disease management programs, as well as for reviews and meta-analyses of disease management interventions. We identified 3 evaluations of large-scale population-based programs, as well as 10 meta-analyses and 16 systematic reviews, covering 317 unique studies.
We found consistent evidence that disease management improves processes of care and disease control but no conclusive support for its effect on health outcomes. Overall, disease management does not seem to affect utilization except for a reduction in hospitalization rates among patients with congestive heart failure and an increase in outpatient care and prescription drug use among patients with depression. When the costs of the intervention were appropriately accounted for and subtracted from any savings, there was no conclusive evidence that disease management leads to a net reduction of direct medical costs.
Although disease management seems to improve quality of care, its effect on cost is uncertain. Most of the evidence to date addresses small-scale programs targeting high-risk individuals, while only 3 studies evaluate large population-based interventions, implying that little is known about their effect. Payers and policy makers should remain skeptical about vendor claims and should demand supporting evidence based on transparent and scientifically sound methods.
In the past 10 years, a wide spectrum of chronic care improvement interventions has been tried and evaluated to improve health outcomes and reduce costs for chronically ill individuals. On one end of the spectrum are disease-management interventions--often organized by commercial vendors--that work with patients but do little to engage medical practice. On the other end are quality-improvement efforts aimed at redesigning the organization and delivery of primary care and better supporting patient self-management. This qualitative review finds that carve-out disease management interventions that target only patients may be less effective than those that also work to redesign care delivery. Imprecise nomenclature and poor study design methodology limit quantitative analysis. More innovation and research are needed to understand how disease-management components can be more meaningfully embedded within practice to improve patient care.
The federal government is preparing to test the concept of the “medical home” in the Medicare program. The demonstration program will operate for 3 years in rural, urban, and underserved areas in up to 8 states. John Iglehart reports.
Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
Background:
Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care.
Objectives:
To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings.
Search strategy:
We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999), Cinahl (1982-1999), and reference lists of articles.
Selection criteria:
Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability.
Data collection and analysis:
Two reviewers independently extracted data and assessed study quality.
Main results:
Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes.
Reviewer's conclusions:
Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment.
The chronic care model is a guide to higher-quality chronic illness management within primary care. The model predicts that improvement in its 6 interrelated components-self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources-can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. Case studies are provided describing how components of the chronic care model have been implemented in the primary care practices of 4 health care organizations.
This article reviews research evidence showing to what extent the chronic
care model can improve the management of chronic conditions (using diabetes
as an example) and reduce health care costs. Thirty-two of 39 studies found
that interventions based on chronic care model components improved at least
1 process or outcome measure for diabetic patients. Regarding whether chronic
care model interventions can reduce costs, 18 of 27 studies concerned with
3 examples of chronic conditions (congestive heart failure, asthma, and diabetes)
demonstrated reduced health care costs or lower use of health care services.
Even though the chronic care model has the potential to improve care and reduce
costs, several obstacles hinder its widespread adoption.
We have little systematic information about the extent to which standard processes involved in health care--a key element of quality--are delivered in the United States.
We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores.
Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9 percent), the proportion of recommended acute care provided (53.5 percent), and the proportion of recommended care provided for chronic conditions (56.1 percent). Among different medical functions, adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care (95 percent confidence interval, 73.3 to 84.2) for senile cataract to 10.5 percent of recommended care (95 percent confidence interval, 6.8 to 14.6) for alcohol dependence.
The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.
The Chronic Care Model (CCM) is a widely used conceptual model for improving chronic illness care, but there is limited evidence to support the validity of this model. Seventeen clinics in a single medical group used the CCM in a diabetes improvement initiative, and the study tested which CCM components at the clinic level were associated with improved glycohemoglobin (A1C) and low-density (LDL) outcomes for patients with diabetes.
Three leaders from each of 17 clinics completed a survey in 2002 that assessed the presence of CCM components in their clinics. Clinic scores from this survey were correlated with change in clinic-level measures of the quality of care for their diabetes patients (A1C and LDL outcomes) during the preceding year.
Delivery system design (DSD) scores were positively correlated with improvements in A1C and lipid test rates and levels at these clinics (r = 0.49-0.57, p < .05). Self-management support and clinical information systems demonstrated associations that may have substantive significance but did not reach p < 05.
These data suggest that delivery system design is associated with improved A1C and LDL outcomes for people with diabetes. Additional studies are necessary to determine the association of other CCM components with improved outcomes.
To describe the extent of adoption of diabetes care management processes in physician organizations in the U.S. and to investigate the organizational factors that affect the adoption of diabetes care management processes.
Data are derived from the National Survey of Physician Organizations and the Management of Chronic Illness, conducted in 2000-2001. A total of 1,104 of the 1,590 physician organizations identified responded to the survey. The extent of adoption of four diabetes care management processes is measured by an index consisting of the organization's use of diabetic patient registries, clinical practice guidelines, case management, and physician feedback. The ordinary least-squares model is used to determine the association of organizational characteristics with the adoption of diabetes care management processes in physician organizations. A logistic regression model is used to determine the association of organizational characteristics with the adoption of individual diabetes care management processes.
Of the 987 physician organizations studied that treat patients with diabetes, 48% either do not use any or use only one of the four diabetes care management processes. A total of 20% use two care management processes, and 32% use three or four processes. External incentives to improve quality, computerized clinical information systems, and ownership by hospitals or health maintenance organizations are strongly associated with the diabetes care management index and the adoption of individual diabetes care management processes.
Policies to encourage external incentives to improve quality and to facilitate the adoption of computerized clinical information technology may promote greater use of diabetes care management processes.
To assess the clinical quality of diabetes care and the systems of care in place in Medicare managed care organizations (MCOs) to determine which systems are associated with the quality of care.
Cross-sectional, observational study that included a retrospective review of 2001 diabetes Health Plan Employer and Data Information Set (HEDIS) measures and a mailed survey to MCOs.
One hundred and thirty-four plans received systems surveys. Data on clinical quality were obtained from HEDIS reports of diabetes measures.
Ninety plans returned the survey. Composite diabetes quality scores (CDSs) were based on averaging scores for the 6 HEDIS diabetes measures. For the upper quartile of responding plans, the average score was 77.6. The average score for the bottom quartile was 53.9 (P < .001). The mean number of systems or interventions for the upper-quartile group and the bottom-quartile group was 17.5 and 12.5 (P < .01), respectively. There were significant differences in the 2 groups in the following areas: computer-generated reminders, physician champions, practitioner quality-improvement work groups, clinical guidelines, academic detailing, self-management education, availability of laboratory results, and registry use. After adjusting for structural and geographic variables, practitioner input and use of clinical-guidelines software remained as independent predictors of CDS. Structural variables that were independent predictors were nonprofit status and increasing number of Medicare beneficiaries in the MCO.
MCO structure and greater use of systems/interventions are associated with higher-quality diabetes care. These relationships require further exploration.
There is a large gap between what physicians do for patients with chronic
diseases and what should be done.1 Most physicians
lack the time, information technology, and financial incentives to develop
organized processes to systematically improve the quality of care provided
to these patients.2 During the past decade,
2 main models have emerged to address this “quality chasm” in
outpatient care: disease management and the chronic care model. Early in 2005,
the Center for Medicare & Medicaid Services (CMS) will begin a large disease
management initiative that may profoundly impact patient care and the organization
of physician practice. But few physicians are aware of this initiative, and
in general, neither disease management, nor the chronic care model are easily
understood. Neither model appears in the index of a major collection of essays
on medical group practice published in 2004.3 This
article will describe the CMS initiative, and describe and compare the disease
management and chronic care model models and the effects they may have on
physician practice and on patient care.
To examine whether a collaborative to improve pediatric asthma care positively influenced processes and outcomes of that care.
Medical record abstractions and patient/parent interviews were used to make pre- and postintervention comparisons of patients at 9 sites that participated in the evaluation of a Breakthrough Series (BTS) collaborative for asthma care with patients at 4 matched control sites.
Thirteen primary care clinics.
Three hundred eighty-five asthmatic children who received care at an intervention clinic and 126 who received care at a control clinic (response rate = 76%).
Three 2-day educational sessions for quality improvement teams from participating sites followed by 3 "action" periods over the course of a year.
The overall process of asthma care improved significantly in the intervention group but remained unchanged in the control group (change in process score +13% vs 0%; P < .0001). Patients in the intervention group were more likely than patients in the control group to monitor their peak flows (70% vs 43%; P < .0001) and to have a written action plan (41% vs 22%; P = .001). Patients in the intervention group had better general health-related quality of life (scale score 80 vs 77; P = .05) and asthma-specific quality of life related to treatment problems (scale score 89 vs 85; P < .05).
The intervention improved some important aspects of processes of care that have previously been linked to better outcomes. Patients who received care at intervention clinics also reported higher general and asthma-specific quality of life.
To test a quality improvement intervention, a learning collaborative based on the Institute for Healthcare Improvement's Breakthrough Series methodology, specifically intended to improve care and outcomes for patients with childhood asthma.
Randomized trial in primary care practices.
Practices in greater Boston, Mass, and greater Detroit, Mich.
Forty-three practices, with 13 878 pediatric patients with asthma, randomized to intervention and contro