An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions

Advanced Practice Nurses and Their Roles in Swiss Cancer Care: A Cross-Sectional Study

OBJECTIVES

To examine the advanced practice nurse workforce in Swiss cancer care and how their roles are being implemented (eg, role structures, processes) to achieve optimal outcomes for patients and their families, care organizations, and the broader health care system.

METHODS

A cross-sectional study was conducted. The sample included master-prepared advanced practice nurses in cancer care, who completed an online questionnaire from December 2021 to January 2022. Thirty-nine items assessed structures (eg, role characteristics, utilization), processes (eg, role activities, interventions), and perceived outcomes (eg, for patients, the health care system) of advanced practice nurses in Swiss cancer care. Data from closed questions were analyzed using descriptive statistics. Data from open-ended questions were organized and summarized into categories related to domains of advanced practice nursing and its reported frequency by the advanced practice nurses.

RESULTS

The participating advanced practice nurses (n = 53), worked in half of the 26 Swiss cantons. Interventions were identified within nine categories, of which most were targeted to patients and their families (n = 7), followed by health care professionals (n = 2). Perceived positive outcomes were patient symptom management, length of hospital stay, and health care costs. Participants felt less confident in cancer care (eg, autonomous practice) and reported 15 professional development needs (eg, medical interventions, teaching).

CONCLUSIONS

This study provides a comprehensive examination of 53 advanced practice nurses, detailing the characteristics of their roles and utilization across various jurisdictions and health care settings. The results highlight the diverse dimensions of advanced practice nursing and its potential to enhance cancer services and outcomes in Switzerland. Opportunities for role development support and expansion are identified.

IMPLICATIONS FOR NURSING PRACTICE

More systematic health human resource planning is needed to expand the deployment of advanced practice nurses across jurisdictions, practice settings, and more diverse patient populations. Role development needs show the desire for specialized educational preparation in cancer care.

Urban Rural Differences on Accessing Patient- Centered Medical Home Among Children With Mental/Developmental Health Conditions/Disorders

INTRODUCTION

To address healthcare spending growth and coordinated primary care, most states in the United States have adopted patient-centered medical homes (PCMHs). To evaluate urban rural difference on accessing PCMH among US children, particularly for children with developmental disabilities (DDs) and mental health disorders (MHDs).

METHODS

This cross-sectional study used the 2016-2018 National Survey for Children's Health (NSCH). Multivariable adjusted logistic regression analyses were used to assess the association between accessing PCMHs and rurality and mental/developmental conditions/disorders.

RESULTS

Children with both DDs and MHDs were statistically significantly higher in rural areas (10.9% rural vs. 8.3% urban, p ≤ .001). Children in rural areas reported higher odds of accessing PCMHs (14%) among all U.S. children, but no differences by subgroups for children with MHDs and/or DDs. Compared with children without DDs/MHDs, the reduction in access to PCMHs varies by children's health status (41% reduction for children both DDs and MHDs, 25% reduction for children with MHDs without DDs) effects. Children with MHDs/DDs were less likely to receive family-centered care, care coordination, and referrals.

CONCLUSIONS

Quality improvements through PCMHs could focus on family-centered care, care coordination, and referrals. Patient-centered medical home performance measurement could be improved to better measure mental health integration and geographical differences.

Challenges and strategies for wide-scale artificial intelligence (AI) deployment in healthcare practices: A perspective for healthcare organizations

Healthcare organizations have realized that Artificial intelligence (AI) can provide a competitive edge through personalized patient experiences, improved patient outcomes, early diagnosis, augmented clinician capabilities, enhanced operational efficiencies, or improved medical service accessibility. However, deploying AI-driven tools in the healthcare ecosystem could be challenging. This paper categorizes AI applications in healthcare and comprehensively examines the challenges associated with deploying AI in medical practices at scale. As AI continues to make strides in healthcare, its integration presents various challenges, including production timelines, trust generation, privacy concerns, algorithmic biases, and data scarcity. The paper highlights that flawed business models and wrong workflows in healthcare practices cannot be rectified merely by deploying AI-driven tools. Healthcare organizations should re-evaluate root problems such as misaligned financial incentives (e.g., fee-for-service models), dysfunctional medical workflows (e.g., high rates of patient readmissions), poor care coordination between different providers, fragmented electronic health records systems, and inadequate patient education and engagement models in tandem with AI adoption. This study also explores the need for a cultural shift in viewing AI not as a threat but as an enabler that can enhance healthcare delivery and create new employment opportunities while emphasizing the importance of addressing underlying operational issues. The necessity of investments beyond finance is discussed, emphasizing the importance of human capital, continuous learning, and a supportive environment for AI integration. The paper also highlights the crucial role of clear regulations in building trust, ensuring safety, and guiding the ethical use of AI, calling for coherent frameworks addressing transparency, model accuracy, data quality control, liability, and ethics. Furthermore, this paper underscores the importance of advancing AI literacy within academia to prepare future healthcare professionals for an AI-driven landscape. Through careful navigation and proactive measures addressing these challenges, the healthcare community can harness AI's transformative power responsibly and effectively, revolutionizing healthcare delivery and patient care. The paper concludes with a vision and strategic suggestions for the future of healthcare with AI, emphasizing thoughtful, responsible, and innovative engagement as the pathway to realizing its full potential to unlock immense benefits for healthcare organizations, physicians, nurses, and patients while proactively mitigating risks.

Temporal Trends in Treatment and Outcomes of Endometrial Carcinoma in the United States, 2005-2020

Endometrial cancer has continued to see a rising incidence in the US over the years. The main aim of this study was to assess current trends in patients' characteristics and outcomes of treatment for endometrial carcinoma over 16 years. A dataset from the National Cancer Database (NCDB) for patients diagnosed with endometrial carcinoma from 2005 to 2020 was used in this retrospective, case series study. The main outcomes and measures of interest included tumor characteristics, hospitalization, treatments, mortality, and overall survival. Then, 569,817 patients who were diagnosed with endometrial carcinoma were included in this study. The mean (SD) age at diagnosis was 62.7 (11.6) years, but 66,184 patients (11.6%) were younger than 50 years, indicating that more patients are getting diagnosed at younger ages. Of the patients studied, 37,079 (6.3%) were Hispanic, 52,801 (9.3%) were non-Hispanic Black, 432,058 (75.8%) were non-Hispanic White, and 48,879 (8.6%) were other non-Hispanic. Patients in the 4th period from 2017 to 2020 were diagnosed more with stage IV (7.1% vs. 5.2% vs. 5.4% vs. 5.9%; p < 0.001) disease compared with those in the other three periods. More patients with severe comorbidities (Charlson Comorbidity Index score of three) were seen in period 4 compared to the first three periods (3.9% vs. ≤1.9%). Systemic chemotherapy use (14.1% vs. 17.7% vs. 20.4% vs. 21.1%; p < 0.001) and immunotherapy (0.01% vs. 0.01% vs. 0.2% vs. 1.1%; p < 0.001) significantly increased from period 1 to 4. The use of laparotomy decreased significantly from 42.1% in period 2 to 16.7% in period 4, while robotic surgery usage significantly increased from 41.5% in period 2 to 64.3% in period 4. The 30-day and 90-day mortality decreased from 0.6% in period 1 to 0.2% in period 4 and 1.4% in period 1 to 0.6% in period 4, respectively. Over the period studied, we found increased use of immunotherapy, chemotherapy, and minimally invasive surgery for the management of endometrial cancer. Overall, the time interval from cancer diagnosis to final surgery increased by about 6 days. The improvements observed in the outcomes examined can probably be associated with the treatment trends observed.

Differences in Healthcare Utilization in Children with Developmental Disabilities Following Value-Based Care Coordination Policies

GOAL

To address healthcare spending growth, coordinate care, and improve primary care utilization, a majority of states in the United States have adopted value-based care coordination programs. The objective of this study was to identify changes in national healthcare utilization for children with developmental disabilities (DDs), a high-cost and high-need population, following the broad adoption of value-based care coordination policies.

METHODS

This retrospective study included 9,109 children with DDs and used data from 2002-2018 Medical Expenditure Panel Survey. We applied an interrupted time series design approach to compare pre- and post-Affordable Care Act (ACA) care coordination policies concerning healthcare utilization outcomes, including outpatient visits, home provider days, emergency department (ED) visits, inpatient discharge, and inpatient nights of stay.

PRINCIPAL FINDINGS

We found statistically significant increases in low-cost care post-ACA, including outpatient visits (5% higher, p < .001) and home provider days (11% higher, p < .001). The study findings also showed a statistically significant increase in inpatient nights of stay post-ACA (4% higher, p = .001). There were no changes in the number of ED and inpatient visits. Overall, broad implementation of care coordination programs was associated with increased utilization of low-cost care without increases in the number of high-cost ED and inpatient visits for children with DDs. Our study also found changes in population composition among children with DDs post-ACA, including increases in Hispanic (16.9% post-ACA vs. 13.4% pre-ACA, p = .006) and non-Hispanic multiracial children (9.1% post-ACA vs. 5.5% pre-ACA, p = .001), a decrease in non-Hispanic Whites (60.2% post-ACA vs. 68.6% pre-ACA, p = .001), more public-only insurance (44.3% post-ACA vs. 35.7% pre-ACA, p = .001), fewer children with DDs from middle-income families (27.4% post-ACA vs. 32.8% pre-ACA, p < .001), and more children with DDs from poor families (28.2% post-ACA vs. 25.1% pre-ACA, p = .043).

PRACTICAL APPLICATIONS

These findings highlight the importance of continued support for broad care coordination programs for U.S. children with DDs and potentially others with complex chronic conditions. Policymakers and healthcare leaders might consider improving care transitions from inpatient to community or home settings by overcoming barriers such as payment models and the lack of home care nurses who can manage complex chronic conditions. Healthcare leaders also need to understand and consider the changing population composition when implementing care coordination-related policies. This study provides data regarding trends in hospital and home care utilization and evidence of the effectiveness of care coordination policies before the COVID-19 interruption. These findings apply to current healthcare management because COVID-19 has incentivized home care, which may have a strong potential to minimize high-cost care for people with complex chronic conditions. More research is warranted to continue monitoring care coordination changes over a longer period.

Sustainable and replicable clinical and financial outcomes in an interprofessional education and collaborative practice nexus

Our Interprofessional Education and Collaborative Practice (IPECP) Nexus previously reported significant reductions in Emergency Department (ED) visits, hospitalizations, hemoglobin A1c levels, and patient charges. This study examines sustainability of these results over two additional years and replication in two subsequent independent patient cohorts. Participants in the sustainability cohort (N = 276) met ≥1 of the following criteria: (a) ≥3 ED visits in first or second half of the year, (b) hemoglobin A1c level ≥ 9, or (c) Length of Stay, Acuity, Comorbidities, and ER (Emergency Room) Visits (LACE) score ≥ 10. Participants in two replicability cohorts (N = 255) and (N = 160) met the same criteria, but the LACE criterion was changed to ≥3 hospitalizations in baseline years. The Nexus, housed in a family medicine (FM) residency clinic, included professionals and students from multiple disciplines. IPECP skills and interventions included communication, team building, and conflict engagement skills training, daily huddles and pre-visit planning, immediate consultations, small teamlet IPECP interactions, and weekly IPECP case conferences for complex patients. Original health improvements and charge reductions were sustained for two additional years for ED visits, hospitalizations, A1c, and patient charges, and replicated in two additional patient cohorts. The IPECP Nexus interventions were associated with Quadruple Aim outcomes while training the next generation of health care professionals.

Strategies to Measure and Improve Emergency Department Performance: A Review

Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.

Transforming Healthcare: The Revolutionary Benefits of Cashless Healthcare Services

As cashless hospital services have grown in popularity, the healthcare sector has seen a tremendous transition. That means the payments are done in an electronic manner which is also known as e-pay. The article discusses the benefits of cashless healthcare services, which are transforming the healthcare sector by providing a streamlined, secure, and effective experience for patients and healthcare providers. Cashless healthcare facilities make use of cutting-edge technologies, including mobile applications, digital wallets, and secure internet platforms, to optimize the utilization of resources within the healthcare ecosystem and improve the overall patient experience. The incorporation of technology has led to revolutionary innovations that continue to redefine the way people access and experience health services. The advantages of cashless hospital services have transformed the healthcare sector by enhancing data security, facilitating transparent billing, and encouraging a patient-centered approach. Cashless services are a preferred method of payment for both consumers and organizations due to their convenience and accessibility. Patients can make payments using digital channels such as mobile payment applications, online payment gateways, or contactless payment cards, whether they are paying for medications, lab tests, or complicated surgeries. Cashless transactions drastically reduce administrative challenges for healthcare providers by eliminating the requirement for manual documentation, which facilitates quick electronic transactions and reduces processing times. As the billing and payment process becomes digitized and streamlined, doctors and medical personnel can focus more on treating and caring for patients. Additionally, much faster insurance claim processing and verification processes result in quicker pay-outs and minimize the financial burden on patients.

Evaluation of a Transitional Care Strategy Implemented in Adults With High-Risk and Multimorbidity in Chile

OBJECTIVES

Fragmentation of continuity of care impacts the health system's efficiency and increases inequity. It severely affects high-risk patients with multimorbidity, requiring coordinated care to avoid preventable complications. The Centro de Innovación en Salud ANCORA UC, together with the Servicio de Salud Metropolitano Sur Oriente, and the National Health Fund, implemented a transitional care strategy for high-risk adults with multimorbidity at 3 hospitals in the southeast of Santiago. The study aimed to evaluate the impact on length of hospital stay, consultations with primary care physicians and contacts after discharge, and also to describe the implementation process of the transition nurse activities.

METHODS

A cohort study was performed between 2017 and 2019, with 137 hospitalizations from exposed patients and 167 hospitalizations from unexposed patients. The results of the study showed a significant decrease in the length of hospital stays and an increase in consultations with physicians.

RESULTS

The results of the implementation process showed that the transition nurse followed-up in a mean of 24 hospitalizations monthly, and 91% of the discharged patients were contacted via the telephone within 7 days. The implementation process showed that the transition nurse's tasks merged with the daily clinical activities in which training on case management, transition care, and continuous support were key aspects of success.

CONCLUSION

We conclude that transitional care intervention has a strong potential in addressing fragmentation of care and is feasible to install and sustain over time in the Chilean context. Finally, this study provides a detailed description of the intervention strategy contributing to its spread and scale-up.

Bed flow priorities and the spatial and temporal dimensions of rural older adult care

Despite prior research that examines the spatial and temporal dimensions of older adult care, there is disparate research on the influence of patient flow priorities on older adult care over time and place. Drawing on a qualitative case study of rural older adult transitions in care in the Canadian context we examine how patient flow prioritization undervalues older patients' needs and the local contexts in which care is provided. Certainly, accounting for the spatial and temporal dimensions of older adult care has broader implications that will enhance future research, policy and practice. Policy makers, researchers and clinicians may then use these recommendations as a stepping stone to align the health care system with the older populations that they serve.

Nurse-led supportive Coordinated Transitional Care (CTraC) program improves care for veterans with serious illness

BACKGROUND

The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness.

METHODS

We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival.

RESULTS

The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups.

CONCLUSIONS

A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.

Acute Health Care Provision in Rural Long-Term Care Facilities: A Scoping Review of Integrated Care Models

OBJECTIVES

We aimed to map integrated care models for acute health care in rural long-term care facilities (LTCFs) for future investigation.

DESIGN

Systematic scoping review.

SETTING AND PARTICIPANTS

Residential LTCFs in rural areas worldwide.

METHODS

The common health-related online databases were systematically searched complemented by a manual search of gray literature. Following the 5-stage framework of Arksey and O'Malley, the extent of included literature was identified and findings were summarized using qualitative meta-summary.

RESULTS

A total of 35 references were included for synthesis, predominantly primary research on completed and ongoing projects reporting on integrated health care services in rural LTCFs. Incorporating previous research, we extracted 5 approaches of integrated acute-health care models: (1) Availability of Specialists, (2) Networks, (3) Quality Management (QM) and Organization, (4) Telemedicine, and (5) Telehealth.

CONCLUSIONS AND IMPLICATIONS

This research presents the result of a literature review examining integrated care models as a way to improve acute health care in LTCFs in rural areas. Integrated care models in rural settings can help face the challenging situation and fulfil the complex health care needs of LTCF residents by reducing fragmentation and thereby improve continuity and coordination of acute health care services. These results can guide policy making in creating interventions and support adequate implementation of care models by knowledge translation in health care.

Disparities in utilization of preventive health services among Asian young adults in the United States

Despite the favorable health impacts of preventive services use, young adults remain at a higher risk of not using these services compared with older adults. This study seeks to identify barriers to receiving recommended preventive services among Asian young adults compared to other racial/ethnic young adults. Using 2016-2018 National Health Interview Survey data, this study examined barriers to recommended preventive services among non-Hispanic (NH) Asian young adults aged 18-39 years compared with other racial/ethnic groups in the United States (Total = 25,430; NH Asians = 6.3%). General prevention included fasting blood sugar, cholesterol, blood pressure, and Human Immunodeficiency Virus checkups. We documented information on vaccinations for influenza, pneumonia, tetanus, hepatitis A/B, and female-specific preventive care measures. NH Asian young adults reported blood pressure checkups less often than NH Whites (72.88% vs. 79.92%, p < 0.001). NH Asian young adults were also less likely to report HIV testing than all other racial/ethnic groups (p < 0.001). After controlling for covariates, NH Whites (odds ratio [OR] = 2.00, 95% confidence interval [CI] = 1.60, 2.50), NH Blacks (OR = 1.55, 95% CI = 1.18, 2.02), and other races (OR = 2.40, 95% CI = 1.60, 3.58) were more likely to receive any preventive services than NH Asians. Among those receiving any preventive services, there were no differences between NH Asians and all other racial/ethnic groups in whether they reported receiving relatively more preventive services. Our findings demonstrate that the rates of certain recommended preventive services use were lower among NH Asian young adults. Targeted public health strategies are needed to increase the use of preventive healthcare for racial/ethnic minority young adults.

Parsley Health: Feasibility and acceptability of a large-scale holistic telehealth program for chronic disease care

Background

A holistic, personalized approach to medicine can be used to prevent and manage a variety of chronic diseases. However, effectively managing chronic diseases can be difficult due to barriers related to insufficient provider time, staffing, and lack of patient engagement. To address these challenges telehealth strategies are being increasingly adopted, yet few studies have explored how to evaluate the feasibility and implementation success of large-scale holistic telehealth models for chronic disease care. The aim of this study is to assess the feasibility and acceptability of a large-scale holistic telehealth program for the management of chronic diseases. Our study findings can inform the future development and assessment of chronic disease programs delivered through telehealth strategies.

Methods

Data was collected from participants enrolled in a Parsley Health membership from June 1, 2021 to June 1, 2022, a subscription-based holistic medicine practice designed to help people prevent or manage chronic diseases. Implementation outcome frameworks were used to understand engagement with services, participant satisfaction, and preliminary effectiveness of the program via a patient-reported symptom severity tool.

Results

Data from 10,205 participants with a range of chronic diseases were included in our analysis. Participants averaged 4.8 visits with their clinical team and reported high levels of satisfaction with their care (average NPS score of 81.35%). Preliminary evidence also showed substantial reduction in patient reported symptom severity.

Conclusion

Our findings suggest the Parsley Health program is a feasible and acceptable large-scale holistic telehealth program for chronic disease care. Successful implementation was due, in part, to services that promoted participant engagement along with tools and interfaces that were helpful and easy to use. These findings can be used to develop future holistic-focused telehealth programs for the management and prevention of chronic diseases.

Change of home visit frequency by public health nurses predicts emergency escorts for psychiatric patients living in the community: A retrospective medical record review

Background

Improper or insufficient treatment of mental health illness harms individuals, families, and society. When psychiatric treatment shifts from a hospital-based to a community-based health care system, risk management is essential to the provision of effective care.

Objective

We examine whether an upgrade in home visit frequency of psychiatric patients as identified by public health nurses can predict the subsequent need for emergency escort services for medical treatment.

Design

A 2-year retrospective medical record review.

Settings

A district of New Taipei City in Taiwan.

Participants

A total of 425 patients with a diagnosed mental health illness cared for through home visits by public health nurses from January 2018 to December 2019.

Methods

We accessed the Ministry of Health and Welfare's psychiatric care management information system to identify a set of medical records, and analyzed these records using chi-square and regression analyses.

Results

The analyses indicated that the groups experiencing the greatest need for emergency escort services were: male, 35-49 years old, with a senior high school level of education, without a disability identification card, with a schizophrenia diagnosis, and had been reported by the nurse as having progressed to a serious level. Nurses' increased frequency of home visits (an indicator that the patient's overall condition was worsening) and nurses' reports of increased severity of problems were significant predictors of the need for emergency escort services.

Conclusions

The nurses' adjustment of visit frequency based on the results of the visit assessment predicts the need for emergency escort services for mental patients. The findings support not only the professional roles and functions of public health nurses, but also the importance of strengthening psychiatric health community support services.

Medication Adherence of People Living with HIV in Japan-A Cross-Sectional Study

Long-term medical care for people living with HIV (PLHIV) is critical for treatment efficacy, and various studies have examined reasons for antiretroviral therapy (ART) non-adherence. In Japan, doctors assume patients maintain high adherence. However, little is known about real-world treatment adherence. We conducted an anonymous self-administered web-based survey asking about adherence for a total of 1030 Japanese PLHIV who were currently on ART. Adherence was determined using the eight-item Morisky Medication Adherence Scale (MMAS-8), for which scoring ranged from 0 to 8 and scores < 6 points were classified as low adherence. Data were analyzed based on patient-related factors; therapy-related factors; condition-related factors, such as a comorbidity with depression (utilizing the Patient Health Questionnaire 9, PHQ-9); and healthcare/system-related factors. Among 821 PLHIV who responded to the survey, 291 responders (35%) were identified as being in the low adherence group. A statistically significant relationship was found between the number of missed anti-HIV drug doses within the previous 2 weeks and long-term adherence, per the MMAS-8 score (p < 0.001). Risk factors for low adherence included age (younger than 21 years, p = 0.001), moderate to severe depression (p = 0.002, using the PHQ-9), and drug dependence (p = 0.043). Adherence was also influenced by a shared decision-making process, including treatment selection, doctor-patient relations, and treatment satisfaction. Adherence was mainly affected by treatment decision factors. Hence, support of care providers should be considered critical for improving adherence.

Cellular mechanisms and molecular pathways linking bitter taste receptor signalling to cardiac inflammation, oxidative stress, arrhythmia and contractile dysfunction in heart diseases

Heart diseases and related complications constitute a leading cause of death and socioeconomic threat worldwide. Despite intense efforts and research on the pathogenetic mechanisms of these diseases, the underlying cellular and molecular mechanisms are yet to be completely understood. Several lines of evidence indicate a critical role of inflammatory and oxidative stress responses in the development and progression of heart diseases. Nevertheless, the molecular machinery that drives cardiac inflammation and oxidative stress is not completely known. Recent data suggest an important role of cardiac bitter taste receptors (TAS2Rs) in the pathogenetic mechanism of heart diseases. Independent groups of researchers have demonstrated a central role of TAS2Rs in mediating inflammatory, oxidative stress responses, autophagy, impulse generation/propagation and contractile activities in the heart, suggesting that dysfunctional TAS2R signalling may predispose to cardiac inflammatory and oxidative stress disorders, characterised by contractile dysfunction and arrhythmia. Moreover, cardiac TAS2Rs act as gateway surveillance units that monitor and detect toxigenic or pathogenic molecules, including microbial components, and initiate responses that ultimately culminate in protection of the host against the aggression. Unfortunately, however, the molecular mechanisms that link TAS2R sensing of the cardiac milieu to inflammatory and oxidative stress responses are not clearly known. Therefore, we sought to review the possible role of TAS2R signalling in the pathophysiology of cardiac inflammation, oxidative stress, arrhythmia and contractile dysfunction in heart diseases. Potential therapeutic significance of targeting TAS2R or its downstream signalling molecules in cardiac inflammation, oxidative stress, arrhythmia and contractile dysfunction is also discussed.

Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island

As health systems attempt to contain utilization and costs, care management programs are proliferating. However, there are mixed findings on their impact. In 2018, Rhode Island initiated a care management program for dually eligible Medicare and Medicaid beneficiaries at high risk of hospitalization or institutionalization. The objective of this study is to evaluate the association between health care utilization and costs and care management for dual-eligible participants (n = 169). The authors employed an interrupted time series analysis of administrative claims data using the Rhode Island All Payer Claims Database, which includes data from all major payers in the state, for 11 quarters (January 1, 2017 until September 1, 2019). On average, participants were younger (46.2% were 19-64 years of age vs. 41.9% of non-participants), female (71% vs. 62.6% of non-participants), and had a higher comorbidity burden (more commonly had anemia, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hyperlipidemia, hypertension, ischemic heart disease, and stroke). Participation was associated with significantly fewer hospital admissions (118 fewer admissions per 1000 admissions per quarter; 95% confidence interval [CI] -11 to -22), and a reduction in Medicaid ($1841 less spent per quarter, 95% CI -2407 to -1275) and total ($2570 less spent per quarter; 95% CI -$4645 to -$495) costs. Participation was not significantly associated with a change in Emergency Department (ED) visits, preventable ED visits, Skilled Nursing Facility stays, or Medicare costs. These results suggest that targeted care management programs may provide dual-eligible beneficiaries with needed services while diverting inefficient health care utilization.

Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Chronic pain (CP) affects over 50 million Americans daily and represents a unique challenge for healthcare professionals due to its complexity. Across all health professions, only a small percentage of the curriculum is devoted to treating patients with CP. Unfortunately, much of the content is delivered passively via lecture without giving students an opportunity to practice the communication skills to effectively treat patients in the clinic. An interprofessional team of health educators identified 5 essential messages that students frequently struggle to convey to patients with CP. Those messages were based on interprofessional and profession-specific competencies to treat patients with CP from the International Association for the Study of Pain. The 5 messages highlighted the importance of (1) therapeutic alliance, (2) consistent interdisciplinary language, (3) patient prognosis, (4) evidence for pain medicine, surgery, and imaging, and (5) early referral to the interprofessional team. For each message, the team summarized relevant research supporting the importance of each individual message that could serve as a foundation for didactic content. The team then developed active learning educational activities that educators could use to have students practice the skills tied to each message. Each learning activity was designed to be delivered in an interprofessional manner.

Postdelivery Intervention to Prevent Type 2 Diabetes and the Cost-Effectiveness of Screening Criteria for Gestational Diabetes

PURPOSE AND OBJECTIVES

The objective of our study was to model the costs and benefits of 2 screening criteria for people with gestational diabetes. Because people with a history of gestational diabetes are at increased risk for type 2 diabetes, we modeled the effects of a postdelivery intervention based on the Diabetes Prevention Program, which is offered to all people with a history of gestational diabetes defined by either set of criteria.

INTERVENTION APPROACH

We used a probabilistic decision tree model to compare the cost-effectiveness of the International Association of Diabetes in Pregnancy Study Group's (IADPSG's) screening criteria and the Carpenter-Coustan screening criteria for gestational diabetes through delivery and a follow-up period during which people might develop type 2 diabetes after pregnancy.

EVALUATION METHODS

The model included perinatal outcomes for the infant and mother and a 10-year postdelivery period to model maternal progression to type 2 diabetes. The model assumed the health care system perspective. People with gestational diabetes received treatment for gestational diabetes during pregnancy, and we assumed that 10% would participate in a Diabetes Prevention Program-based postdelivery intervention to reduce the risk of type 2 diabetes. We estimated the cost-effectiveness of each screening strategy in quality-adjusted life-years (QALYs) in 2022 dollars.

RESULTS

At 10% participation in a Diabetes Prevention Program-based postdelivery intervention, the Carpenter-Coustan criteria were cost-effective, compared with no screening ($66,085 per QALY). The IADPSG screening criteria were slightly less cost-effective, compared with no screening ($97,878 per QALY) or Carpenter-Coustan screening criteria ($122,279 per QALY). With participation rates of 23% or higher, the IADPSG screening criteria were highly cost-effective ($48,588 per QALY), compared with Carpenter-Coustan screening criteria.

IMPLICATIONS FOR PUBLIC HEALTH

Diagnosing a larger proportion of pregnant people using the IADPSG screening criteria, compared with using Carpenter-Coustan screening criteria, is not cost-effective at low levels of participation. However, with moderate levels of participation (23%) in a Diabetes Prevention Program-based postdelivery intervention, the expanded IADPSG screening criteria are cost-effective and reach up to 4 times as many people as Carpenter-Coustan screening.

Improving the efficiency of integrated cancer screening delivery across multiple cancers: case studies from Idaho, Rhode Island, and Nebraska

BACKGROUND

Three current and former awardees of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program launched integrated cancer screening strategies to better coordinate multiple cancer screenings (e.g., breast, cervical, colorectal). By integrating the strategies, efficiencies of administration and provision of screenings can be increased and costs can be reduced. This paper shares findings from these strategies and describes their effects.

METHODS

The Idaho Department of Health and Welfare developed a Baseline Assessment Checklist for six health systems to assess the current state of policies regarding cancer screening. We analyzed the checklist and reported the percentage of checklist components completed. In Rhode Island, we collaborated with a nurse-patient navigator, who promoted cancer screening, to collect details on patient navigation activities and program costs. We then described the program and reported total costs and cost per activity. In Nebraska, we described the experience of the state in administering an integrated contracts payment model across colorectal, breast, and cervical cancer screening and reported cost per person screened. Across all awardees, we interviewed key stakeholders.

RESULTS

In Idaho, results from the checklist offered guidance on areas for enhancement before integrated cancer screening strategies, but identified challenges, including lack of capacity, limited staff availability, and staff turnover. In Rhode Island, 76.1% of 1023 patient navigation activities were for colorectal cancer screening only, with a much smaller proportion devoted to breast and cervical cancer screening. Although the patient navigator found the discussions around multiple cancer screening efficient, patients were not always willing to discuss all cancer screenings. Nebraska changed its payment system from fee-for-service to fixed cost subawards with its local health departments, which integrated cancer screening funding. Screening uptake improved for breast and cervical cancer but was mixed for colorectal cancer screening.

CONCLUSIONS

The results from the case studies show that there are barriers and facilitators to integrating approaches to increasing cancer screening among primary care facilities. However, more research could further elucidate the viability and practicality of integrated cancer screening programs.

Changing the research paradigm for digital transformation in healthcare delivery

The growing focus on healthcare transformation (i.e., new healthcare delivery models) raises interesting issues related to research design, methodology, and funding. More than 20 years have passed since the Institute of Medicine first called for the transition to digital health with a focus on system-wide change. Yet progress in healthcare delivery system change has been painfully slow. A knowledge gap exists; research has been inadequate and critical information is lacking. Despite calls by the National Academies of Science, Engineering, and Medicine for convergent, team-based transdisciplinary research with societal impact, the preponderance of healthcare research and funding continues to support more traditional siloed discipline research approaches. The lack of impact on healthcare delivery suggests that it is time to step back and consider differences between traditional science research methods and the realities of research in the domain of transformational change. The proposed new concepts in research design, methodologies, and funding are a needed step to advance the science. The Introduction looks at the growing gap in expectations for transdisciplinary convergent research and prevalent practices in research design, methodologies, and funding. The second section summarizes current expectations and drivers related to digital health transformation and the complex system problem of healthcare fragmentation. The third section then discusses strengths and weaknesses of current research and practice with the goal of identifying gaps. The fourth section introduces the emerging science of healthcare delivery and associated research methodologies with a focus on closing the gaps between research and translation at the frontlines. The final section concludes by proposing new transformational science research methodologies and offers evidence that suggests how and why they better align with the aims of digital transformation in healthcare delivery and could significantly accelerate progress in achieving them. It includes a discussion of challenges related to grant funding for non-traditional research design and methods. The findings have implications broadly beyond healthcare to any research that seeks to achieve high societal impact.

Approaches to reducing fragmented care in systemic lupus erythematosus (SLE) and other multimorbid conditions: A realist review

Introduction

Fragmented care overwhelmingly affects populations with multimorbid chronic conditions, like systemic lupus erythematosus (SLE). However, strategies to mitigate care fragmentation typically focus on singular disease frameworks with insufficient evidence regarding approaches for individuals with two or more concurrent chronic conditions (multimorbidity). This review explores the literature to identify the (C)ontextual influences, underlying (M)echanisms, and associated (O)utcomes of fragmented care prevention in SLE and other multimorbid conditions.

Methods

A realist review was applied to systematically examine literature, including the search of >1300 published articles focused on SLE and multimorbidity, continuity of care, and approaches to mitigate fragmented care. The analysis was guided by care continuity elements and organized by fragmented care concepts explicated by the MacColl Institute for Healthcare Innovations Care Coordination Model and further grouped for context–mechanism–outcome (CMO) configurations.

Results

Fourteen articles met inclusion/exclusion criteria and were included in the sample to illustrate the relationship between C-M-O for approaches focused on fragmented care prevention. Favorable outcomes in mechanisms that produced positive responses to resources relevant to fragmented care prevention included 1) opportunities for exposure and negotiation within professional teams, 2) structured health education, role clarity, and access to adherence services for patients, and 3) awareness of workflow waste and use of clinical algorithms.

Discussion

Review findings suggest using a multidimensional approach to mitigate fragmented care in SLE and other multimorbid conditions. Multidimensional approaches should focus on shared decision-making, social support, social–cultural–economic factors, patient engagement, and technological infrastructure to support the complex care needs of the multimorbid patient.

The SMILe integrated care model in allogeneic SteM cell TransplantatIon faciLitated by eHealth: a protocol for a hybrid effectiveness-implementation randomised controlled trial

Background

While effectiveness outcomes of eHealth-facilitated integrated care models (eICMs) in transplant and oncological populations are promising, implementing and sustaining them in real-world settings remain challenging. Allogeneic stem cell transplant (alloSCT) patients could benefit from an eICM to enhance health outcomes. To combat health deterioration, integrating chronic illness management, including continuous symptom and health behaviour monitoring, can shorten reaction times. We will test the 1st-year post-alloSCT effectiveness and evaluate bundled implementation strategies to support the implementation of a newly developed and adapted eICM in allogeneic stem cell transplantation facilitated by eHealth (SMILe–ICM).

SMILe-ICM has been designed by combining implementation, behavioural, and computer science methods. Adaptions were guided by FRAME and FRAME-IS. It consists of four modules: 1) monitoring & follow-up; 2) infection prevention; 3) physical activity; and 4) medication adherence, delivered via eHealth and a care coordinator (an Advanced Practice Nurse). The implementation was supported by contextually adapted implementation strategies (e.g., creating new clinical teams, informing local opinion leaders).

Methods

Using a hybrid effectiveness-implementation randomised controlled trial, we will include a consecutive sample of 80 adult alloSCT patients who were transplanted and followed by University Hospital Basel (Switzerland). Inclusion criteria are basic German proficiency; elementary computer literacy; internet access; and written informed consent. Patients will be excluded if their condition prevents the use of technology, or if they are followed up only at external centres. Patient-level (1:1) stratified randomisation into a usual care group and a SMILe-ICM group will take place 10 days pre-transplantation. To gauge the SMILe–ICM’s effectiveness primary outcome (re-hospitalisation rate), secondary outcomes (healthcare utilization costs; length of inpatient re-hospitalizations, medication adherence; treatment and self-management burden; HRQoL; Graft-versus-Host Disease rate; survival; overall survival rate) and implementation outcomes (acceptability, appropriateness, feasibility, fidelity), we will use multi-method, multi-informant assessment (via questionnaires, interviews, electronic health record data, cost capture methods).

Discussion

The SMILe–ICM has major innovative potential for reengineering alloSCT follow-up care, particularly regarding short- and medium-term outcomes. Our dual focus on implementation and effectiveness will both inform optimization of the SMILe-ICM and provide insights regarding implementation strategies and pathway, understudied in eHealth-facilitated ICMs in chronically ill populations.

Trial registration

ClinicalTrials.gov. Identifier: NCT04789863. Registered April 01, 2021.

Development and implementation of an interprofessional digital platform to increase therapeutic adherence: a mixed design (Preprint)

Background

Adherence to care plans is a major issue in health care systems. Improved adherence has several potential benefits such as ensuring treatment effectiveness and control of chronic diseases. There is currently a lack of tools to maximize treatment adherence in an integrated manner, that is, covering multiple aspects of patients’ health continuously throughout their medical care. To ensure better adherence, such tools must meet the needs of patients with chronic conditions as well as those of health care professionals. Acknowledging the health issues associated with nonadherence to treatment, an industry-research-clinical partnership aims to adapt a digital platform—facilitating patient-health care professional interactions—to improve therapeutic adherence in patients with chronic illnesses. The platform allows for exchanges between patients and health care professionals to facilitate the timing of medication use or chronic disease management and maximize patient adherence.

Objective

This study aims to (1) identify the needs of patients living with a chronic condition and their health professionals concerning their interactions regarding treatment; (2) codevelop an adaptation of an interactive patient-professional platform that meets the needs identified; and (3) then test the platform and document its effects and acceptability in a clinical setting.

Methods

The study will use a creative design thinking process based on the needs expressed by users (patients and health professionals) concerning treatment adherence for chronic diseases (eg, diabetes, asthma, high blood pressure, depression and anxiety, chronic obstructive pulmonary disease). A mixed method evaluation research design will be used to develop and evaluate the platform. Qualitative data will be used to assess user needs and acceptability of the platform, and quantitative data will provide the necessary insights to document its effects.

Results

Technological development of the platform has been completed. Recruitment for the first part of Phase 1 started in May 2022. The results of this project to codevelop an interprofessional digital platform to increase therapeutic adherence will be relevant to clinicians and managers seeking contemporary solutions that support patient adherence to treatment for chronic diseases. These results will enable optimal use of the platform and identify areas for improvement in interactive patient-health care professional apps.

Conclusions

The adoption of an interactive digital platform to facilitate effective exchanges between patients and health care professionals in primary care settings could improve adherence to treatment. The platform tested in this project takes a first step in this direction by ensuring that the technological product is developed according to the needs of patients as well as the health professionals who are likely to use it.

International Registered Report Identifier (IRRID)

DERR1-10.2196/34463

Integrating Population Health Strategies into Primary Care: Impact on Outcomes and Hospital Use for Low-Income Adults

Objective

Our objectives were two-fold: 1) To evaluate the benefits of population health strategies focused on social determinants of health and integrated into the primary care medical home (PCMH) and 2) to determine how these strategies impact diabetes and cardiovascular disease outcomes among a low-income, primarily minority community. We also investigated associations between these outcomes and emergency department (ED) and inpatient (IP) use and costs.

Design

Retrospective cohort.

Setting

Community-based PCMH: Baylor Scott & White Health and Wellness Center (BSW HWC).

Patients/Participants

All patients who attended at least two primary care visits at BSW HWC within a 12-month time span from 2011-2015.

Methods

Outcomes for patients participating in PCMH only (PCMH) as compared to PCMH plus population health services (PCMH+PoPH) were compared using electronic health record data.

Main Outcomes

Diastolic and systolic blood pressure, hemoglobin A1c, ED visits and costs, and IP hospitalizations and costs were examined.

Results

From 2011-2015, 445 patients (age=46±12 years, 63% African American, 61% female, 69.5% uninsured) were included. Adjusted regression analyses indicated PCMH+PoPH had greater improvement in diabetes outcomes (prediabetes HbA1c= -.65[SE=.32], P=.04; diabetes HbA1c= -.74 [SE=.37], P<.05) and 37% lower ED costs than the PCMH group (P=.01). Worsening chronic disease risk factors was associated with 39% higher expected ED visits (P<.01), whereas improved chronic disease risk was associated with 32% fewer ED visits (P=.04).

Conclusions

Integrating population health services into the PCMH can improve chronic disease outcomes, and impact hospital utilization and cost in un- or under-insured populations.

BRAVE: A Point of Care Adaptive Leadership Approach to Providing Patient-Centric Care in the Emergency Department

The practice of emergency medicine has reached its cross roads. Emergency physicians (EPs) are managing many more time-dependent conditions, initiating complex treatments in the emergency department (ED), handling ethical and end of life care discussions upfront, and even performing procedures which used to be done only in critical care settings, in the resuscitation room. EPs manage a wide spectrum of patients, 24 h a day, which reflects the community and society they practice in. Besides the medical and “technical” issues to handle, they have to learn how to resolve confounding elements which their patients can present with. These may include social, financial, cultural, ethical, relationship, and even employment matters. EPs cannot overlook these, in order to provide holistic care. More and more emphasis is also now given to the social determinants of health. We, from the emergency medicine fraternity, are proposing a unique “BRAVE model,” as a mnemonic to assist in the provision of point of care, adaptive leadership at the bedside in the ED. This represents another useful tool for use in the current climate of the ED, where patients have higher expectations, need more patient-centric resolution and handling of their issues, looming against the background of a more complex society and world.

Lessons learned in the development of a nurse-led family centered approach to developing a holistic comprehensive clinic and integrative holistic care plan for children with cerebral palsy

CLINICAL PROBLEM

Children with cerebral palsy (CP) typically receive care from multiple specialty providers including Developmental Pediatrics, Orthopedics, Physical Medicine, Occupational Therapy, Physical Therapy, Speech Therapy, Clinical Social Work, Clinical Nutrition, Nursing and Orthotists, which often require many individual visits to the hospital annually. The potential for conflicting plans of care is increased by this fragmented approach, which may lead to duplication of services and increased healthcare costs.

SOLUTION

To address the problem and alleviate burden for families, the Comprehensive Cerebral Palsy Program implemented a nurse-led comprehensive interdisciplinary team approach to provide optimal care coordination to patients and families, using an Integrative Holistic Care Plan (IHCP). During an annual 3-4 hour Comprehensive CP Clinic appointment, a team of specialists meets with the family, and a holistic, evidence-based plan of care is developed. The family-centered care plan includes summaries of each discipline's plan of care with individualized goals, recommendations, and evidence-based outcomes. After the visit, the plan of care is communicated with the family, primary care provider, and other community providers to ensure continuity of care.

RESULTS

Early in the program and electronic IHCP development stage, clinical, and financial outcomes were improved. In addition to significant cost savings, family satisfaction surveys showed continuous improvement in the areas of access, communication, and coordination of care.

PRACTICE IMPLICATIONS

Nurses working in interdisciplinary clinics are in a position to facilitate improved outcomes by developing and implementing a family-centered care plan that provides a comprehensive holistic approach to impacting the areas of quality, effectiveness, and efficiency of care delivery. The use of an IHCP decreases fragmentation of care and duplication of services leading to healthcare cost savings and enhanced patient satisfaction.

A Statewide EMS Viral Syndrome Pandemic Triage Protocol: 24 Hour Outcomes

Background: Early during the COVID-19 pandemic, Emergency Medical Services (EMS) systems encountered many challenges that prompted crisis-level strategies. Maryland's statewide EMS system implemented the Viral Syndrome Pandemic Triage Protocol which contained a decision tool to help identify patients potentially safe for self-care at home. Objectives: This study assessed the effects of the Maryland Viral Syndrome Pandemic Triage Protocol and the safety of referring patients for self-care at home. Methods: This is a retrospective statewide analysis of EMS patients from March 19 thru September 4, 2020, who were not transported and had documentation of the Viral Syndrome Pandemic Triage Protocol's decision support tool completed, as well as a random sample of 150 patients who were not transported and did not have documentation of the decision tool. Descriptive statistics were performed as well as a two-stage multivariable logistic regression model for the outcomes of ED presentation within 24 hours and subsequent hospitalization. Results: 301 EMS patients were documented as triaged to home using the protocol and outcomes data were available for 282 (94%). 41(14.5%) patients presented to an ED within 24 hours and 14 (5% of 282) required inpatient hospitalization. Nine (3.2%) patients were subsequently hospitalized with a diagnosis of COVID-19 illness. Of those patients for whom the decision tool was not documented, 35 (23%) had an ED visit within 24 hours and 15 (10%) were hospitalized (p = 0.075). Multivariate logistic regression model results (N = 432) suggest that those with documentation of triage protocol use had some advantage over those patients without documentation. The 95% CIs of the estimated effect of Triage/No Triage protocol documented were wide and crossed the 1.0 limit but overall, all effects Odds Ratios and Adjust Odds Ratios were consistently over 1.0 with the lowest value of 1.3 and the highest value of 2.1. Conclusion: Most patients (95%) who were triaged to self-care at home with home documented decision support tool use did not require hospitalization within 24 hours following EMS encounter and this appears to be safe. Future opportunity exists to incorporate such tools into comprehensive pandemic preparedness strategies along with appropriate follow up and quality improvement mechanisms.

Understanding the groups of care transition strategies used by U.S. hospitals: an application of factor analytic and latent class methods

Background

After activation of the Hospital Readmission Reduction Program (HRRP) in 2012, hospitals nationwide experimented broadly with the implementation of Transitional Care (TC) strategies to reduce hospital readmissions. Although numerous evidence-based TC models exist, they are often adapted to local contexts, rendering large-scale evaluation difficult. Little systematic evidence exists about prevailing implementation patterns of TC strategies among hospitals, nor which strategies in which combinations are most effective at improving patient outcomes. We aimed to identify and define combinations of TC strategies, or groups of transitional care activities, implemented among a large and diverse cohort of U.S. hospitals, with the ultimate goal of evaluating their comparative effectiveness.

Methods

We collected implementation data for 13 TC strategies through a nationwide, web-based survey of representatives from short-term acute-care and critical access hospitals (N = 370) and obtained Medicare claims data for patients discharged from participating hospitals. TC strategies were grouped separately through factor analysis and latent class analysis.

Results

We observed 348 variations in how hospitals implemented 13 TC strategies, highlighting the diversity of hospitals’ TC strategy implementation. Factor analysis resulted in five overlapping groups of TC strategies, including those characterized by 1) medication reconciliation, 2) shared decision making, 3) identifying high risk patients, 4) care plan, and 5) cross-setting information exchange. We determined that the groups suggested by factor analysis results provided a more logical grouping. Further, groups of TC strategies based on factor analysis performed better than the ones based on latent class analysis in detecting differences in 30-day readmission trends.

Conclusions

U.S. hospitals uniquely combine TC strategies in ways that require further evaluation. Factor analysis provides a logical method for grouping such strategies for comparative effectiveness analysis when the groups are dependent. Our findings provide hospitals and health systems 1) information about what groups of TC strategies are commonly being implemented by hospitals, 2) strengths associated with the factor analysis approach for classifying these groups, and ultimately, 3) information upon which comparative effectiveness trials can be designed. Our results further reveal promising targets for comparative effectiveness analyses, including groups incorporating cross-setting information exchange.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01422-7.

Adults' experience of living with multimorbidity: a qualitative systematic review protocol

OBJECTIVE

The objective of the review is to synthesize the qualitative research literature on the experiences of adults living with multimorbidity.

INTRODUCTION

Persons living with two or more chronic health conditions, known as multimorbidity, is a global health problem in countries of all income levels. Multimorbidity presents an ever-increasing resource and financial burden for health care systems and similarly challenges those living with multiple health conditions because of the complexity of their health and treatment requirements. Overall, persons with multimorbid conditions experience a high risk of mortality and a lower quality of life. Understanding the adult experience of multimorbidity is important for creating and implementing health care that meets the needs of individuals living with the burden of multiple chronic health conditions.

INCLUSION CRITERIA

The systematic review will include published peer-reviewed and unpublished English-language studies from 2000 to 2020 that provide qualitative evidence of adults' (18+ years of age) experiences of living with multimorbidity.

METHODS

CINAHL with full text, Cochrane, MEDLINE, Embase, PsycINFO, Consumer Health Database, Scopus, and ScienceDirect journals and books will be searched. Reference lists of included studies will also be cross-checked with search outcomes to identify additional studies. Sources of gray literature will also be searched for unpublished studies. The critical appraisal of selected studies and the extraction of data will be independently undertaken by two reviewers using JBI methods. The findings will be pooled using meta-aggregation to produce comprehensive synthesized findings. A ConQual Summary of Findings will also be presented.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020152038.

Patient-Centered Approaches to Transitional Care Research and Implementation: Overview and Insights From Patient-Centered Outcomes Research Institute's Transitional Care Portfolio

BACKGROUND

This Special Issue, Future Directions in Transitional Care Research, focuses on the approaches used and lessons learned by researchers conducting care transitions studies funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI's approach to transitional care research augments prior research by encouraging researchers to focus on head-to-head comparisons of interventions, the use of patient-centered outcomes, and the engagement of stakeholders throughout the research process.

OBJECTIVES

This paper introduces the themes and topics addressed by the articles that follow, which are focused on opportunities and challenges involved in conducting patient-centered clinical comparative effectiveness research in transitional care. It provides an overview of the state of the care transitions field, a description of PCORI's programmatic objectives, highlights of the patient and stakeholder engagement activities that have taken place during the course of these studies, and a brief overview of PCORI's Transitional Care Evidence to Action Network, a learning community designed to foster collaboration between investigators and their research teams and enhance the collective impact of this body of work.

CONCLUSIONS

The papers in this Special Issue articulate challenges, lessons learned, and new directions for measurement, stakeholder engagement, implementation, and methodological and design approaches that reflect the complexity of transitional care comparative effectiveness research and seek to move the field toward a more holistic understanding of transitional care that integrates social needs and lifespan development into our approaches to improving care transitions.

Coached, Coordinated, Enhanced Neonatal Transition (CCENT): protocol for a multicentre pragmatic randomised controlled trial of transition-to-home support for parents of high-risk infants

INTRODUCTION

Having an infant admitted to the neonatal intensive care unit (NICU) is associated with increased parental stress, anxiety and depression. Enhanced support for parents may decrease parental stress and improve subsequent parent and child outcomes. The Coached, Coordinated, Enhanced Neonatal Transition (CCENT) programme is a novel bundled intervention of psychosocial support delivered by a nurse navigator that includes Acceptance and Commitment Therapy-based coaching, care coordination and anticipatory education for parents of high-risk infants in the NICU through the first year at home. The primary objective is to evaluate the impact of the intervention on parent stress at 12 months.

METHODS AND ANALYSIS

This is a multicentre pragmatic randomised controlled superiority trial with 1:1 allocation to the CCENT model versus control (standard neonatal follow-up). Parents of high-risk infants (n=236) will be recruited from seven NICUs across three Canadian provinces. Intervention participants are assigned a nurse navigator who will provide the intervention for 12 months. Outcomes are measured at baseline, 6 weeks, 4, 12 and 18 months. The primary outcome measure is the total score of the Parenting Stress Index Fourth Edition Short Form at 12 months. Secondary outcomes include parental mental health, empowerment and health-related quality of life for calculation of quality-adjusted life years (QALYs). A cost-effectiveness analysis will examine the incremental cost of CCENT versus usual care per QALY gained. Qualitative interviews will explore parent and healthcare provider experiences with the intervention.

ETHICS AND DISSEMINATION

Research ethics approval was obtained from Clinical Trials Ontario, Children's Hospital of Eastern Ontario Research Ethics Board (REB), The Hospital for Sick Children REB, UBC Children's and Women's REB and McGill University Health Centre REB. Results will be shared with Canadian level III NICUs, neonatal follow-up programmes and academic forums.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03350243).

Synthesising evidence regarding hospital to home transitions supported by volunteers of third sector organisations: a scoping review protocol

INTRODUCTION

Given the risks inherent in care transitions, it is imperative that patients discharged from hospital to home receive the integrated care services necessary to ensure a successful transition. Despite efforts by the healthcare sector to develop health system solutions to improve transitions, problems persist. Research on transitional support has predominantly focused on services delivered by healthcare professionals; the evidence for services provided by lay navigators or volunteers in this context has not been synthesised. This scoping review will map the available literature on the engagement of volunteers within third sector organisations supporting adults in the transition from hospital to home.

METHODS AND ANALYSIS

Using the well-established scoping review methodology outlined by the Joanna Briggs Institute, a five-stage review is outlined: (1) determining the research question, (2) search strategy, (3) inclusion criteria, (4) data extraction and (5) analysis and presentation of the results. The search strategy will be applied to 10 databases reflecting empirical and grey literature. A two-stage screening process will be used to determine eligibility of articles. To be included in the review, articles must describe a community-based programme delivered by a third sector organisation that engages volunteers in the provisions of services that support adults transitioning from hospital to home. All articles will be independently assessed for eligibility, and data from eligible articles will be extracted and charted using a standardised form. Extracted data will be analysed using narrative and descriptive analyses.

ETHICS AND DISSEMINATION

Ethics approval is not required for this scoping review. Members of an international special interest group focused on the voluntary sector will be consulted to provide insight and feedback on study findings, help with dissemination of the results and engage in the development of future research proposals. Dissemination activities will include peer-reviewed publications and academic presentations.

Management of chronic non-communicable diseases in Ghana: a qualitative study using the chronic care model

Background

While the burden and mortality from chronic non-communicable diseases (CNCDs) have reached epidemic proportions in sub-Saharan Africa (SSA), decision-makers and individuals still consider CNCDs to be infrequent and, therefore, do not pay the needed attention to their management. We, therefore, explored the practices and challenges associated with the management of CNCDs by patients and health professionals.

Methods

This was a qualitative study among 82 CNCD patients and 30 health professionals. Face-to-face in-depth interviews were used in collecting data from the participants. Data collected were analysed using thematic analysis.

Results

Experiences of health professionals regarding CNCD management practices involved general assessments such as education of patients, and specific practices based on type and stage of CNCDs presented. Patients’ experiences mainly centred on self-management practices which comprised self-restrictions, exercise, and the use of anthropometric equipment to monitor health status at home. Inadequate logistics, work-related stress due to heavy workload, poor utility supply, and financial incapability of patients to afford the cost of managing their conditions were challenges that militated against the effective management of CNCDs.

Conclusions

A myriad of challenges inhibits the effective management of CNCDs. To accelerate progress towards meeting the Sustainable Development Goal 3 on reducing premature mortality from CNCDs, the Ghana Health Service and management of the respective hospitals should ensure improved utility supply, adequate staff motivation, and regular in-service training. A chronic care management policy should also be implemented in addition to the review of the country’s National Health Insurance Scheme (NHIS) by the Ministry of Health and the National Health Insurance Authority to cover the management of all CNCDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11170-4.

A randomized trial examining the effect of predictive analytics and tailored interventions on the cost of care

This two-arm randomized controlled trial evaluated the impact of a Stepped-Care intervention (predictive analytics combined with tailored interventions) on the healthcare costs of older adults using a Personal Emergency Response System (PERS). A total of 370 patients aged 65 and over with healthcare costs in the middle segment of the cost pyramid for the fiscal year prior to their enrollment were enrolled for the study. During a 180-day intervention period, control group (CG) received standard care, while intervention group (IG) received the Stepped-Care intervention. The IG had 31% lower annualized inpatient cost per patient compared with the CG (3.7 K, $8.1 K vs. $11.8 K, p = 0.02). Both groups had similar annualized outpatient costs per patient ($6.1 K vs. $5.8 K, p = 0.10). The annualized total cost reduction per patient in the IG vs. CG was 20% (3.5 K, $17.7 K vs. $14.2 K, p = 0.04). Predictive analytics coupled with tailored interventions has great potential to reduce healthcare costs in older adults, thereby supporting population health management in home or community settings.

Clinical laboratory services for primary healthcare centers in urban cities: a pilot ACO model of ten primary healthcare centers

Background

Primary healthcare centers (PHC) ensure that patients receive comprehensive care from promotion and prevention to treatment, rehabilitation, and palliative care in a familiar environment. It is designed to provide first-contact, continuous, comprehensive, and coordinated patient care that will help achieve equity in the specialty healthcare system. The healthcare in Saudi Arabia is undergoing transformation to Accountable Care Organizations (ACO) model. In order for the Kingdom of Saudi Arabia (KSA) to achieve its transformational goals in healthcare, the improvement of PHCs’ quality and utilization is crucial. An integral part of this service is the laboratory services.

Methods

This paper presents a pilot model for the laboratory services of PHC's in urban cities. The method was based on the FOCUS-PDCA quality improvement method focusing on the pre-analytical phase of the laboratory testing as well as the Saudi Central Board for Accreditation of Healthcare Institutes (CBAHI) gap analysis and readiness within the ten piloted primary healthcare centers.

Results

The Gap analysis, revealed in-consistency in the practice, lead to lower the quality of the service, which was seen in the low performance of the chosen key performance indicators (KPI's) (high rejection rates, lower turn-around times (TAT) for test results) and also in the competency of the staff. Following executing the interventions, and by using some of the ACO Laboratory strategies; the KPI rates were improved, and our results exceeded the targets that we have set to reach during the first year. Also introducing the electronic connectivity improved the TAT KPI and made many of the processes leaner.

Conclusions

Our results revealed that the centralization of PHC's laboratory service to an accredited reference laboratory and implementing the national accreditation standards improved the testing process and lowered the cost, for the mass majority of the routine laboratory testing. Moreover, the model shed the light on how crucial the pre-analytical phase for laboratory quality improvement process, its effect on cost reduction, and the importance of staff competency and utilization.

Web-Based Peer Support Interventions for Adults Living With Chronic Conditions: Scoping Review

Background

Globally, 1 in 3 adults live with multiple chronic conditions. Thus, effective interventions are needed to prevent and manage these chronic conditions and to reduce the associated health care costs. Teaching effective self-management practices to people with chronic diseases is one strategy to address the burden of chronic conditions. With the increasing availability of and access to the internet, the implementation of web-based peer support programs has become increasingly common.

Objective

The purpose of this scoping review is to synthesize existing literature and key characteristics of web-based peer support programs for persons with chronic conditions.

Methods

This scoping review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews guidelines. Studies were identified by searching MEDLINE, CINAHL, Embase, PsycINFO, and the Physiotherapy Evidence Database. Chronic diseases identified by the Public Health Agency of Canada were included. Our review was limited to peer support interventions delivered on the web. Peers providing support had to have the chronic condition that they were providing support for. The information abstracted included the year of publication, country of study, purpose of the study, participant population, key characteristics of the intervention, outcome measures, and results.

Results

After duplicates were removed, 12,641 articles were screened. Data abstraction was completed for 41 articles. There was a lack of participant diversity in the included studies, specifically with respect to the conditions studied. There was a lack of studies with older participants aged ≥70 years. There was inconsistency in how the interventions were described in terms of the duration and frequency of the interventions. Informational, emotional, and appraisal support were implemented in the studied interventions. Few studies used a randomized controlled trial design. A total of 4 of the 6 randomized controlled trials reported positive and significant results, including decreased emotional distress and increased health service navigation, self-efficacy, social participation, and constructive attitudes and approaches. Among the qualitative studies included in this review, there were several positive experiences related to participating in a web-based peer support intervention, including increased compassion and improved attitudes toward the individual’s chronic condition, access to information, and empowerment.

Conclusions

There is limited recent, high-level evidence on web-based peer support interventions. Where evidence exists, significant improvements in social participation, self-efficacy, and health-directed activity were demonstrated. Some studies incorporated a theoretical framework, and all forms of peer support—emotional, informational, and appraisal support—were identified in the studies included in this review. We recommend further research on web-based peer support in more diverse patient groups (eg, for older adults and chronic conditions outside of cancer, cardiovascular disease, and HIV or AIDS). Key gaps in the area of web-based peer support will serve to inform the development and implementation of future programs.

Use of social determinants of health codes in home-based primary care

BACKGROUND

The Affordable Care Act created funding for nurse practitioner education programs to transform the primary health care workforce through student awareness of how social, political, economic, and environmental factors influence individual and population health. Funding established Academic Clinical Partnerships (ACPs) that created value-based health care models, which improved patient outcomes and decreased hospital and emergency department admissions and health care costs. The ACP established a home-based primary health care (HBPC) program to deliver primary care and collect patient data.

PURPOSE

The purposes were to describe the incidence of chronic conditions for HBPC patients and determine associations between chronic conditions and presence of social determinants of health (SDoH).

METHODOLOGY

Nurse practitioner students were assigned to HBPC clinical placements. A convenience sample of 102 high-risk, homebound patients was identified. Nurse practitioners and students recorded deidentified patient data, including ICD-10-CM codes into a Health Insurance Portability and Accountability Act compliant platform. Secondary analysis of patient records assessed for SDoH through Z codes.

RESULTS

Patients had high incidences of hypertension, diabetes, pulmonary disease, heart disease, chronic pain, mood, and substance abuse disorders. Secondary analysis revealed that 92% of patients had indications for the use of Z codes, but these were not recorded.

CONCLUSIONS

Common Z codes were personal risk factors, housing/economic circumstances, care provider dependency, lifestyle, and family support.

IMPLICATIONS FOR PRACTICE

By coding for SDoH, providers and agencies can realize higher reimbursement rates in HBPC settings. Nurse practitioners can use this information to provide better treatment recommendations, more accurate diagnoses, and referrals to enhance primary care services to a patient population negatively affected by SDoH.

A Systematic Review of Primary Care and Payment Models on Emergency Department Use in Patients Classified as High Need, High Cost

INTRODUCTION

Reducing costly and harmful ED use by patients classified as high need, high cost is a priority across health care systems. The purpose of this systematic review was to evaluate the impact of various primary care and payment models on ED use and overall costs in patients classified as high need, high cost.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search was performed from January 2000 to March 2020 in 3 databases. Two reviewers independently appraised articles for quality. Studies were eligible if they evaluated models implemented in the primary care setting and in patients classified as high need, high cost in the United States. Outcomes included all-cause and preventable ED use and overall health care costs.

RESULTS

In the 21 articles included, 4 models were evaluated: care coordination (n = 8), care management (n = 7), intensive primary care (n = 4), and alternative payment models (n = 2). Statistically significant reductions in all-cause ED use were reported in 10 studies through care coordination, alternative payment models, and intensive primary care. Significant reductions in overall costs were reported in 5 studies, and 1 reported a significant increase. Care management and care coordination models had mixed effects on ED use and overall costs.

DISCUSSION

Studies that significantly reduced ED use had shared features, including frequent follow-up, multidisciplinary team-based care, enhanced access, and care coordination. Identifying primary care models that effectively enhance access to care and improve ongoing chronic disease management is imperative to reduce costly and harmful ED use in patients classified as high need, high cost.

The value proposition of efficiency discount options: The government employees medical scheme emerald value option case study

Background

The Government Employees Medical Scheme (GEMS) introduced an EDO named the Emerald Value Option (EVO) in January 2017. The option was introduced to contain the cost of care whilst simultaneously improving the quality of care by championing care coordination.

Aim

This study aimed to assess the impact of introducing an EDO such as EVO as a cost-containment strategy using contracted provider networks and coordinated care.

Setting

The study was conducted using aggregated data from GEMS. Government Employees Medical Scheme is a restricted medical scheme available to government employees in South Africa.

Methods

This is a descriptive pairwise comparison study between the Emerald benefit option (the parent option), which does not have embedded care coordination, and its derivative, EVO.

Results

Membership and claims data for 2018 were analysed. Expenditure per life per month in 2018 on the EVO amounts to R1357.01. After adjusting for the risk profile of beneficiaries on the EVO, expenditure per life per month would be expected to be R1621.73 (based on the conventional Emerald option). This translates to a savings of 16.3%. Similarly, health outcomes for EVO were more favourable than expected, actual admission rates were lower at 23.2% versus 26.2% expected.

Conclusions

The EVO benefit design has succeeded in lowering the cost of care through network provider contracting and care coordination. The EVO has saved approximately R490 million in healthcare costs in 2018. If applied across the medical schemes industry, it is estimated that EVO contracting, and care coordination principles could save R20 billion per annum.

Improving evidence-based grouping of transitional care strategies in hospital implementation using statistical tools and expert review

BACKGROUND

As health systems transition to value-based care, improving transitional care (TC) remains a priority. Hospitals implementing evidence-based TC models often adapt them to local contexts. However, limited research has evaluated which groups of TC strategies, or transitional care activities, commonly implemented by hospitals correspond with improved patient outcomes. In order to identify TC strategy groups for evaluation, we applied a data-driven approach informed by literature review and expert opinion.

METHODS

Based on a review of evidence-based TC models and the literature, focus groups with patients and family caregivers identifying what matters most to them during care transitions, and expert review, the Project ACHIEVE team identified 22 TC strategies to evaluate. Patient exposure to TC strategies was measured through a hospital survey (N = 42) and prospective survey of patients discharged from those hospitals (N = 8080). To define groups of TC strategies for evaluation, we performed a multistep process including: using ACHIEVE'S prior retrospective analysis; performing exploratory factor analysis, latent class analysis, and finite mixture model analysis on hospital and patient survey data; and confirming results through expert review. Machine learning (e.g., random forest) was performed using patient claims data to explore the predictive influence of individual strategies, strategy groups, and key covariates on 30-day hospital readmissions.

RESULTS

The methodological approach identified five groups of TC strategies that were commonly delivered as a bundle by hospitals: 1) Patient Communication and Care Management, 2) Hospital-Based Trust, Plain Language, and Coordination, 3) Home-Based Trust, Plain language, and Coordination, 4) Patient/Family Caregiver Assessment and Information Exchange Among Providers, and 5) Assessment and Teach Back. Each TC strategy group comprises three to six, non-mutually exclusive TC strategies (i.e., some strategies are in multiple TC strategy groups). Results from random forest analyses revealed that TC strategies patients reported receiving were more important in predicting readmissions than TC strategies that hospitals reported delivering, and that other key co-variates, such as patient comorbidities, were the most important variables.

CONCLUSION

Sophisticated statistical tools can help identify underlying patterns of hospitals' TC efforts. Using such tools, this study identified five groups of TC strategies that have potential to improve patient outcomes.

Prediction for the Risk of Multiple Chronic Conditions Among Working Population in the United States With Machine Learning Models

Objective: Chronic diseases have become the most prevalent and costly health conditions in the healthcare industry, deteriorating the quality of life, adversely affecting the work productivity, and costing astounding medical resources. However, few studies have been conducted on the predictive analysis of multiple chronic conditions (MCC) based on the working population. Results: Seven machine learning algorithms are used to support the decision making of healthcare practitioner on the risk of MCC. The models were developed and validated using checkup data from 451,425 working population collected by the healthcare providers. Our result shows that all proposed models achieved satisfactory performance, with the AUC values ranging from 0.826 to 0.850. Among the seven predictive models, the gradient boosting tree model outperformed other models, achieving an AUC of 0.850. Conclusions: Our risk prediction model shows great promise in automating real-time diagnosis, supporting healthcare practitioners to target high-risk individuals efficiently, and helping healthcare practitioners tailor proactive strategies to prevent the onset or delay the progression of the chronic diseases.

Integrated care effectiveness for adults with co-occurring disorders

Purpose

This study examined effectiveness of an integrated care program on emergency department visits within a longitudinal sample of patients with both primary care and behavioral health diagnoses.

Design/methodology/approach

Patients with co-occurring disorders enrolled in an integrated care clinic and were followed over time to determine whether participation in the clinic, including engagement in wellness/peer services, predicted decreases in Emergency Department (ED) use. Associations between socio-demographic characteristics of patients and ED use were also analyzed.

Findings

After 6 months, clinic patients had decreases in ED use that continued for twelve months, albeit to a lesser degree. Demographics and program services were not related to ED use; however, multiple associations existed between high ED utilizers, severe mental illness (SMI), substance use disorders (SUD) and non-retention in services.

Research limitations/implications

The study lacked a comparison group and there was no distinction between avoidable and unavoidable ED visits. A small sample size across time points led to inconclusive post hoc findings.

Originality/value

This study explored effectiveness of primary care integration into a behavioral health clinic for persons with multiple morbidities. Although initial decreases in ED visits were present, results indicate that these models may not be effective for persons with SMI or SMI/SUD who are already high ED users. This study provides support for integrated care in reducing ED use among persons with multiple morbidities and calls for further research on designing effective integrated models for persons with SMI and SUD.

Are Online Reviews of Physicians Reliable Indicators of Clinical Outcomes? A Focus on Chronic Disease Management

Are Online Reviews of Physicians Reliable Indicators of Clinical Outcomes? A Focus on Chronic Disease Management

Quality Assessment of an Integrated Care Pathway Using Telemonitoring in Patients with Chronic Heart Failure and Chronic Obstructive Pulmonary Disease: Protocol for a Quasi-Experimental Study

Background

Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) often coexist and are associated with a high morbidity and reduced quality of life (QoL). Although these diseases share similarities in symptoms and clinical course, and exacerbations of both diseases often overlap, care pathways for both conditions are usually not integrated. This results in frequent outpatient consultations and suboptimal treatment during exacerbations, leading to frequent hospital admissions. Therefore, we propose an integrated care pathway for both diseases, using telemonitoring to detect deterioration at an early stage and a single case manager for both diseases.

Objective

This study aims to investigate whether an integrated care pathway using telemonitoring in patients with combined CHF and COPD results in a higher general health-related QoL (HRQoL) as compared with the traditional care pathways. Secondary end points include disease-specific HRQoL, level of self-management, patient satisfaction, compliance to the program, and cost-effectiveness.

Methods

This is a monocenter, prospective study using a quasi-experimental interrupted time series design. Thirty patients with combined CHF and COPD are included. The study period of 2.5 years per patient is divided into a preintervention phase (6 months) and a postintervention phase (2 years) in which end points are assessed. The intervention consists of an on-demand treatment strategy based on monitoring symptoms related to CHF/COPD and vital parameters (weight, blood pressure, heart rate, oxygen saturation, temperature), which are uploaded on a digital platform. The monitoring frequency and the limit values of the measurements to detect abnormalities are determined individually. Monitoring is performed by a case manager, who has the opportunity for a daily multidisciplinary meeting with both the cardiologist and the pulmonologist. Routine appointments at the outpatient clinic are cancelled and replaced by telemonitoring-guided treatment.

Results

Following ethical approval of the study protocol, the first patient was included in May 2018. Inclusion is expected to be complete in May 2021.

Conclusions

This study is the first to evaluate the effects of a novel integrated care pathway using telemonitoring for patients with combined CHF and COPD. Unique to this study is the concept of remote on-demand disease management by a single case manager for both diseases, combined with multidisciplinary meetings. Moreover, modern telemonitoring technology is used instead of, rather than as an addition to, regular care.

Trial Registration

Netherlands Trial Register NL6741; https://www.trialregister.nl/trial/6741

International Registered Report Identifier (IRRID)

DERR1-10.2196/20571

Towards Better Health, Social, and Community-Based Services Integration for Patients with Chronic Conditions and Complex Care Needs: Stakeholders' Recommendations

The objective was to report on issues related to patients with complex care needs and recommendations identified by 160 key participants at a summit in Quebec City about better integration of primary health care services for patients with chronic diseases and complex care needs. A descriptive qualitative approach was used. While focus groups were led by a facilitator, a rapporteur noted highlights and a research team member took independent notes. All notes were analyzed by using a thematic analysis according to an inductive method. Seven issues were identified, leading to the formulation of recommendations: (1) valuing the experience of the patient; (2) early detecting of a non-homogeneous patient population; (3) defining interprofessional collaboration based on patient needs; (4) conciliating services provided by clinical settings according to a registered clientele-based logic with the population-based logic; (5) working with the community sector; (6) aligning patient-oriented research values with existing challenges to primary care integration; and (7) promoting resource allocation consistent with targeted recommendations. The summit highlighted the importance of engaging all stakeholders in improvement of integrated care for patients with complex care needs. The resulting recommendations target shared priorities towards better health, social, and community-based services integration for these patients.

A Mixed Method Investigation to Determine Priorities for Improving Information, Interaction, and Individualization of Care Among Individuals on In-center Hemodialysis: The Triple I Study

BACKGROUND

Current health systems do not effectively address all aspects of chronic care. For better self-management of disease, kidney patients have identified the need for improved health care information, interaction with health care providers, and individualization of care.

OBJECTIVE

The Triple I study examined challenges to exchange of information, interaction between patients and health care providers and individualization of care in in-center hemodialysis with the aim of identifying the top 10 challenges that individuals on in-center hemodialysis face in these 3 areas.

DESIGN

We employed a sequential mixed methods approach with 3 phases:1. A qualitative study with focus groups and interviews (Apr 2017 to Aug 2018);2. A cross-sectional national ranking survey (Jan 2019 to May 2019);3. A prioritization workshop using a modified James Lind Alliance process (June 2019).

SETTING

In-center hemodialysis units in 7 academic centers across Canada: Vancouver, Calgary, Edmonton, Winnipeg, Ottawa, Montreal, and Halifax.

PARTICIPANTS

Individuals receiving in-center hemodialysis, their caregivers, and health care providers working in in-center hemodialysis participated in each of the 3 phases.

METHODS

In Phase 1, we collected qualitative data through (1) focus groups and interviews with hemodialysis patients and their caregivers and (2) individual interviews with health care providers and decision makers. Participants identified challenges to in-center hemodialysis care and potential solutions to these challenges. In Phase 2, we administered a pan-Canadian cross-sectional ranking survey. The survey asked respondents to prioritize the challenges to in-center hemodialysis care identified in Phase 1 by ranking their top 5 topics/challenges in each of the 3 "I" categories. In Phase 3, we undertook a face-to-face priority setting workshop which followed a modified version of the James Lind Alliance priority setting workshop process. The workshop employed an iterative process incorporating small and large group sessions during which participants identified, ranked, and voted on the top challenges and innovations to hemodialysis care. Four patient partners contributed to study design, implementation, analysis, and interpretation.

RESULTS

Across the 5 participating centers, we conducted 8 focus groups and 44 interviews, in which 113 participants identified 45 distinct challenges to in-center hemodialysis care. Subsequently, completion of a national ranking survey (n = 323) of these challenges resulted in a short-list of the top 30 challenges. Finally, using small and large group sessions to develop consensus during the prioritizing workshop, 38 stakeholders used this short-list to identify the top 10 challenges to in-center hemodialysis care. These included individualization of dialysis-related education; improved information in specific topic areas (transplant status, dialysis modalities, dialysis-related complications, and other health risks); more flexibility in hemodialysis scheduling; better communication and continuity of care within the health care team; and increased availability of transportation, financial, and social support programs.

LIMITATIONS

Participants were from urban centers and were predominately English-speaking. Survey response rate of 31.5% in Phase 2 may have led to selection bias. We collected limited information on social determinants of health, which could confound our results.

CONCLUSION

Overall, the challenges we identified demonstrate that individualized care and information that improves interaction with health care providers is important to patients receiving in-center hemodialysis. In future stages of this project, we will aim to address these challenges by trialing innovative patient-centered solutions.

TRIAL REGISTRATION

Not applicable.