Statewide evaluation of measuring physician delivery of self-management support in chronic disease care

One Month into the Reinforcement of Social Distancing due to the COVID-19 Outbreak: Subjective Health, Health Behaviors, and Loneliness among People with Chronic Medical Conditions

We sought to examine how the near-lockdown measures, announced by the Israeli government in an effort to contain the COVID-19 outbreak, impacted the self-rated health (SRH), health behaviors, and loneliness of people with chronic illnesses. An online cross-sectional survey was carried out about one month (April 20-22, 2020) after the Israeli government reinforced the severe social distancing regulations, among a convenience sample of 315 participants (60% women) with chronic conditions (27% metabolic, 17% cardiovascular, 21% cancer/autoimmune, 18% orthopedic/pain, 12% mental-health). Results suggested that about half of the participants reported a decline in physical or mental SRH, and as many as two-thirds reported feeling lonely. A significant deterioration in health behaviors was reported, including a decrease in vegetable consumption (p = 0.008) and physical activity (p < 0.001), an increase in time spent on social media (p < 0.001), and a perception among about half of the participants that they were eating more than before. Ordinal regression suggested that a decline in general SRH was linked with female gender (p = 0.016), lack of higher education (p = 0.015), crowded housing conditions (p = 0.001), longer illness duration (p = 0.010), and loneliness (p = 0.008). Findings highlight the important role of loneliness in SRH during the COVID-19 lockdown period. Future studies are warranted to clarify the long-term effects of social-distancing and loneliness on people with chronic illnesses.

Clinical outcomes of an integrated primary-secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial

AIMS/HYPOTHESIS

The aim of the study was to determine if a Beacon model of integrated care utilising general practitioners (GPs) with special interests could achieve similar clinical outcomes to a hospital-based specialist diabetes outpatient clinic.

METHODS

This pragmatic non-inferiority multisite randomised controlled trial assigned individuals with complex type 2 diabetes to care delivered by a Beacon clinic or to usual care delivered by a hospital outpatient department, in a 3:1 ratio. Owing to the nature of the study, researchers were only blinded during the allocation process. Eligible participants were aged 18 or over, had been referred by their usual GP to the hospital central referral hub with type 2 diabetes and had been triaged to be seen within 30 or 90 days. The intervention consisted of diabetes management in primary care by GPs with a special interest who had been upskilled in complex diabetes under the supervision of an endocrinologist. The primary outcome was HbA_1c at 12 months post-recruitment. The non-inferiority margin was 4.4 mmol/mol (0.4%). Both per-protocol and intention-to-treat analyses are reported.

RESULTS

Between 27 November 2012 and 14 July 2015, 352 individuals were recruited and 305 comprised the intention-to-treat sample (71 in usual care group and 234 in the Beacon model group). The Beacon model was non-inferior to usual care for both the per-protocol (difference -0.38 mmol/mol [95% CI -4.72, 3.96]; -0.03% [95% CI -0.43, 0.36]) and the intention-to-treat (difference -1.28 mmol/mol [95% CI -5.96, 3.40]; -0.12% [95% CI -0.55, 0.31]) analyses. Non-inferiority was sustained in a sensitivity analysis at 12 months. There were no statistically or clinically significant differences in the secondary outcomes of BP, lipids or quality of life as measured by the 12 item short-form health survey (SF-12v2) and the diabetes-related quality of life (DQoL-Brief) survey. Safety indicators did not differ between groups. Participant satisfaction on the eight-item client satisfaction questionnaire (CSQ-8) was good in both groups, but scores were significantly higher in the Beacon model group than the usual care group (mean [SD] 28.4 [4.9] vs 25.6 [4.9], respectively, p < 0.001).

CONCLUSIONS/INTERPRETATION

In individuals with type 2 diabetes, a model of integrated care delivered in the community by GPs with a special interest can safely achieve clinical outcomes that are not inferior to those achieved with gold-standard hospital-based specialist outpatient clinics. Individuals receiving care in the community had greater satisfaction. Further studies will determine the cost of delivering this model of care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000380897 FUNDING: The study was funded by the Australian National Health and Medical Research Council (GNT1001157).

Patient Experience with Primary Care Physician and Risk for Hospitalization in Hispanics with CKD

BACKGROUND AND OBJECTIVES

In the general population, the quality of the patient experience with their primary care physician may influence health outcomes but this has not been evaluated in CKD. This is relevant for the growing Hispanic CKD population, which potentially faces challenges to the quality of the patient experience related to language or cultural factors. We evaluated the association between the patient experience with their primary care physician and outcomes in Hispanics with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This prospective observational study included 252 English- and Spanish-speaking Hispanics with entry eGFR of 20-70 ml/min per 1.73 m2, enrolled in the Hispanic Chronic Renal Insufficiency Cohort study between 2005 and 2008. Patient experience with their primary care physician was assessed by the Ambulatory Care Experiences Survey subscales: communication quality, whole-person orientation, health promotion, interpersonal treatment, and trust. Poisson and proportional hazards models were used to assess the association between the patient experience and outcomes, which included hospitalization, ESKD, and all-cause death.

RESULTS

Participants had a mean age of 56 years, 38% were women, 80% were primary Spanish speakers, and had a mean eGFR of 38 ml/min per 1.73 m2. Over 4.8 years (median) follow-up, there were 619 hospitalizations, 103 ESKD events, and 56 deaths. As compared with higher subscale scores, lower scores on four of the five subscales were associated with a higher adjusted rate ratio (RR) for all-cause hospitalization (communication quality: RR, 1.54; 95% confidence interval [95% CI], 1.25 to 1.90; health promotion: RR, 1.31; 95% CI, 1.05 to 1.62; interpersonal treatment: RR, 1.50; 95% CI, 1.22 to 1.85; and trust: RR, 1.57; 95% CI, 1.27 to 1.93). There was no significant association of subscales with incident ESKD or all-cause death.

CONCLUSIONS

Lower perceived quality of the patient experience with their primary care physician was associated with a higher risk of hospitalization.

Disparities in Diabetes Care Quality by English Language Preference in Community Health Centers

OBJECTIVE

To conduct a parallel analysis of disparities in diabetes care quality among Latino and Asian community health center (CHC) patients by English language preference.

STUDY SETTING/DATA COLLECTION

Clinical outcomes (2011) and patient survey data (2012) for Type 2 diabetes adults from 14 CHCs (n = 1,053).

STUDY DESIGN

We estimated separate regression models for Latino and Asian patients by English language preference for Clinician & Group-Consumer Assessment of Healthcare Providers and System, Patient Assessment of Chronic Illness Care, hemoglobin A1c, and self-reported hypoglycemic events. We used the Blinder-Oaxaca decomposition method to parse out observed and unobserved differences in outcomes between English versus non-English language groups.

PRINCIPAL FINDINGS

After adjusting for socioeconomic and health characteristics, disparities in patient experiences by English language preference were found only among Asian patients. Unobserved factors largely accounted for linguistic disparities for most patient experience measures. There were no significant differences in glycemic control by language for either Latino or Asian patients.

CONCLUSIONS

Given the importance of patient retention in CHCs, our findings indicate opportunities to improve CHC patients' experiences of care and to reduce disparities in patient experience by English preference for Asian diabetes patients.

How much do clinicians support patient self-management? The development of a measure to assess clinician self-management support

BACKGROUND

Primary care provider (PCP) support of patient self-management may be important mechanism to improving patient health outcomes. In this paper we develop a PCP-reported measure of clinician strategies for supporting patient self-management, and we psychometrically test and validate the measure.

METHODS

We developed survey items based upon effective self-management support strategies identified in a prior mixed methods study. We fielded a survey in the fall of 2014 with 139 Fairview Health Services PCPs, and conducted exploratory factor analysis and Cronbach's Alpha to test for scale reliability. To validate the measure, we examined the Self-Management Support (SMS) scale's relationship to survey items on self-management support, as well as clinicians' patient panel rates of smoking cessation and weight loss.

RESULTS

Nine survey items clustered reliably to create a single factor (Cronbach's Alpha=0.73). SMS scores ranged from 2.1 to 4.9. The SMS was related to each of the validation variables. PCPs who reported spending 60% percent or more of their time counseling, educating, and coaching patients had a mean SMS score of 4.0, while those who reported spending less than 30% of their time doing so had mean SMS scores 15% lower. PCPs' SMS scores exhibited significant but modest associations with their patients' smoking cessation and weight loss (among obese patients) (r=0.21 and r=0.13 respectively).

CONCLUSIONS

This study develops and tests a promising measure of PCPs' strategies to support patient self-management. It highlights variation across PCPs. Future work should examine whether increasing scores of PCPs low on the SMS improves chronic care quality outcomes.

[Conceptual self-management analysis of hypertensive individuals]

This research aimed to analyze the concept of self-management of hypertensive individuals. Theoretical and documentary study based on Walker and Avant's conceptual analysis by means of the Scientific Electronic Library Brazil and the Medical Literature Analysis and Retrieval System Online in the Coordination for Higher Education Personnel Development (CAPES, in Portuguese) and the National Library of Medicine websites. Fourteen (14) articles and one (1) thesis were selected and reviewed in Portuguese and English, in the period January 2007 to September 2012.

BACKGROUND

missing doctor's appointments, non-compliance to blood pressure control treatment to recommendations to proper diet standards and stress. Attributer blood pressure control and disease management Consequences home monitoring of blood pressure with control improvement, accomplishment of disease management, compliance and sharing of the creation process of self-management goals and caring activities by the interdiscplinary team through individualized actions. It was concluded that the self-management concept is a dynamic, active process which requires knowledge, attitude, discipline, determination, commitment self-regulation, empowerment and self-efficiency in order to manage the disease and achieve healthy living.

A new model of integrated primary-secondary care for complex diabetes in the community: study protocol for a randomised controlled trial

BACKGROUND

A new model of complex diabetes care is provided by a multidisciplinary team which incorporates general practitioner (GP) Clinical Fellows supported by an Endocrinologist and diabetes educator within a community-based general practice setting. This study evaluates the health and clinical benefits of the new model of care, assesses the acceptability of the model to patients, GPs and other health professionals, and examines the cost-effectiveness of the model.

METHODS/DESIGN

The study is an open, non-inferiority randomised controlled trial with data collected at baseline, 6 and 12 months. Participants are identified from new patients on hospital-based diabetes outpatient clinic waiting lists and new GP referrals. Eligible consenting patients are randomised to either a community practice site (intervention) or a hospital site (usual care). In the intervention model, medical care is led by a GP Clinical Fellow in partnership with an Endocrinologist. Quantitative measures include clinical indicators with HbA1c as the primary outcome; patient-reported outcomes include health-related quality of life, mental health and satisfaction with care. Qualitative methods will be used to explore the perspectives and experiences of patients and providers regarding the new model of care. An economic evaluation will also be undertaken.

DISCUSSION

This model of care seeks to improve the quality and safety of healthcare at the interface between the hospital and primary care sectors for patients with complex diabetes. The study will provide empirical evidence about the impact of the model of care on health outcomes, patient and clinician satisfaction, as well as any economic impacts.

TRIAL REGISTRATION

Clinical Trials Registry Number: ACTRN12612000380897.

Measuring chronic care delivery: patient experiences and clinical performance

OBJECTIVE

To assess the relationship between clinical care metrics and patient experiences of care among patients with chronic disease.

DESIGN

Cross-sectional survey and clinical performance data.

SETTING

Eighty-nine medical groups across California caring for patients with chronic disease.

PARTICIPANTS

Using patient surveys, we identified 51 129 patients with a chronic disease.

MAIN OUTCOME MEASURES

Using patient surveys, we produced five composite measures of patient experiences of care and self-management support (scale 0-100). Using Health Plan Employer Data and Information Set data, we analyzed care for asthma, diabetes and cardiovascular disease, producing one composite summarizing clinical processes of care and one composite summarizing outcomes of care. We calculated adjusted Spearman's correlation coefficients to assess the relationship between patient experiences of care, clinical processes and clinical outcomes.

RESULTS

Clinical performance was higher for process measures compared with outcomes measures, ranging from 91% for appropriate asthma medication use to 59% for controlling low-density lipoprotein cholesterol in the presence of diabetes. Performance on patient experiences of care measures was the highest for the quality of clinical interactions (88.5) and the lowest for delivery of self-management support (68.8). Three of the 10 patient experience-clinical performance composite correlations were statistically significant. These three correlations involved composites summarizing integration of care and quality of clinical interactions, and ranged from a low of 0.30 to a high of 0.39.

CONCLUSIONS

Chronic care delivery is variable across diseases and domains of care. Improving care integration processes and communication between health-care providers and their patients may lead to improved clinical outcomes.

Using the Teamlet Model to improve chronic care in an academic primary care practice

BACKGROUND

Team care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges.

OBJECTIVES

To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.

DESIGN

Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.

PARTICIPANTS

First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.

INTERVENTION

Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.

MEASUREMENTS

Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.

RESULTS

Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p = 0.02), with a trend towards significance for LDL at goal (p = 0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p = 0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P = 0.001).

CONCLUSIONS

The Teamlet Model may improve chronic care in academic primary care practices.