The effectiveness and efficiency of health promotion in specialty clinic care

Caregiver Out-of-Pocket Costs for Octogenarian Intensive Care Unit Patients in Canada

ABSTRACTMedical issues facing the aging population are of growing concern with consequences for patients and their caregivers. This study determined the indirect and out-of-pocket costs incurred by the caregivers of elderly patients in Canadian Intensive Care Units (ICUs). Primary family caregivers were surveyed capturing out-of-pocket costs, hours of work, and hours of leisure forgone in providing patient care while the patient was in the ICU. Total costs of care per month were reported across caregiver sex, age, and geographic region. Average out-of-pocket costs were $791 (2016 Canadian dollars) in the first month of ICU care. The mean total cost to family caregivers per patient was $162 per day. Male primary caregivers had higher mean out-of-pocket costs than female caregivers. Subsidization programs covering expenses such as travel, meals, accommodation, and parking are needed to support family caregivers of elderly ICU patients who are incurring considerable out-of-pocket costs.

Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis

Background

A critical part of future service delivery will involve improving the degree to which people become engaged in ‘self-management’. Providing better support for self-management has the potential to make a significant contribution to NHS efficiency, as well as providing benefits in patient health and quality of care.

Objective

To determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions.

Data sources

Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, EconLit (the American Economic Association’s electronic bibliography), EMBASE, Health Economics Evaluations Database, MEDLINE (the US National Library of Medicine’s database), MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database (NHS EED) and PsycINFO (the behavioural science and mental health database), as well as the reference lists of published reviews of self-management support.

Methods

We included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. Main outcome measures were quantitative measures of service utilisation (including hospital use) and quality of life (QoL). We presented the results for each condition group using a permutation plot, plotting the effect of interventions on utilisation and outcomes simultaneously and placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. We also conducted conventional meta-analyses of outcomes.

Results

We found 184 studies that met the inclusion criteria and provided data for analysis. The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management. Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as we found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias.

Limitations

Self-management support is a complex area in which to undertake literature searches. Our analyses were limited by poor reporting of outcomes in the included studies, especially concerning health-care utilisation and costs.

Conclusions

Very few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support.

Study registration

This study is registered as PROSPERO CRD42012002694.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A randomized controlled trial to assess effectiveness of a spiritually-based intervention to help chronically ill adults

OBJECTIVE

Creative, cost-effective ways are needed to help older adults deal effectively with chronic diseases. Spiritual beliefs and practices are often used to deal with health problems. We evaluated whether a minimal intervention, consisting of a video and workbook encouraging use of patient spiritual coping, would be inoffensive and improve perceived health status.

METHODS

A randomized clinical trial of 100 older, chronically ill adults were assigned to a Spiritual (SPIRIT) or Educational (EDUC--standard cardiac risk reduction) intervention. Individuals in each group were shown a 28-minute video and given a workbook to complete over 4 weeks. Selected psychosocial and health outcome measures were administered at baseline and 6 weeks later.

RESULTS

Participants were mostly female (62%), with a mean age of 65.8 +/- 9.6 years and had an average of three chronic illnesses. More than 90% were Christian. At baseline, frequent daily spiritual experiences (DSE) were associated with being African American (p < .05) and increased pain (p < .01) and co-morbidities (p < or = .01). Energy increased significantly (p < .05) in the SPIRIT group and decreased in the EDUC group. Improvements in pain, mood, health perceptions, illness intrusiveness, and self-efficacy were not statistically significant.

CONCLUSIONS

A minimal intervention encouraging spiritual coping was inoffensive to patients, associated with increased energy, and required no additional clinician time.

A primary care cardiovascular risk reduction clinic in Canada was more effective and no more expensive than usual on-demand primary care--a randomised controlled trial

The objective of this randomised controlled trial was to compare the effects and expense of three approaches to care (1) proactive cardiovascular risk reduction (CaRR) clinic; (2) nurse telephone calls; or (3) usual care for people with cardiovascular risk factors in a Primary Care, Health Service Organisation (HSO) in Ontario, Canada. Subjects included consenting patients with an identified cardiovascular disease (CVD) risk factor identified from the HSO computerised patient information system in 2004. Patients were excluded if they were mentally incompetent, <18 years of age, in a nursing home, or not English speaking. Of 1570 eligible subjects, 523 (33.3%) verbally declined, 145 (9.2%) could not be contacted, and 249 (15.9%) were not needed. The final sample size was 653 (41.6%), 634 completed the follow-up (97%). The Cardiovascular Risk Score, Health and Social Service Utilisation, Montgomery-Asberg Depression Rating, Billings and Moos Indices of Coping, Personal Resource and Self-Efficacy Questionnaires were measured at baseline and 1-year follow-up by clinical examination and telephone interview. Cardiovascular risk scores were reduced in all treatment groups after 1 year. The proportions of subjects showing reduction in risk score greater than or equal to 10% was greatest in the CaRR group (69.2%) compared with Nurse Phone intervention (57.8%) and Usual Care (59.0%) (M-Hchi(2) = 4.33, df = 1, P = 0.037, CaRR-Usual Care). Self-efficacy scores showed the greatest improvements in the CaRR clinic. This effect was achieved with no significant difference in total person per annum costs for direct and indirect health and social service utilisation between all three groups. A CaRR clinic is more effective in reducing CVD risk after 1 year compared with nurse phone intervention and usual care with no additional expense found.

Seniors at risk: the association between the six-month use of publicly funded home support services and quality of life and use of health services for older people

This study examines the baseline characteristics and changes in health status and cost of use of health services associated with use of publicly funded home support services. The analysis includes 122 people 75 years of age or more who were eligible for home support services. Over a 6-month period, one third of the sample used home support services for more than 1 hr/week; these seniors had higher rates of depression and cognitive impairment, lower levels of physical and emotional functioning, and less effective coping styles than those who used fewer services. Cognitive impairment explained 17 per cent of the variation in use of home support services. At 6 months, use of home support services for more than 1 hr/week by seniors with higher levels of need was associated with lower cost of use of health services and lower levels of improvement in health status. These findings suggest the need for further research to identify efficacious ways of providing home support services to this population to enhance their health status using available resources.

Systemic lupus erythematosus in a multiethnic cohort: LUMINA XXXV. Predictive factors of high disease activity over time

AIM

To ascertain the predictive factors of high levels of disease activity in systemic lupus erythematosus (SLE).

PATIENTS AND METHODS

Patients with SLE (American College of Radiology criteria), aged >or=16 years, with disease duration <or=5 years and of Hispanic (Texas and Puerto Rico), African American and Caucasian ethnicities, were included. The outcome was high disease activity at any time (Systemic Lupus Activity Measure-Revised >10). A basic multivariable model (including age, sex, ethnicity, health insurance, social support, abnormal illness-related behaviours, helplessness and prior disease activity) was first examined. Additional models were built by including other variables.

RESULTS

554 patients (100 Hispanics from Texas, 94 Hispanics from Puerto Rico, 199 African Americans, 161 Caucasians) and 2366 visits were analysed; 47% of the patients and 29% of the visits met the definition of high disease activity (more common among African Americans (72.0%) and Hispanics from Texas (71.3%) than among Caucasians (43.9%) and Hispanics from Puerto Rico (31.9%)). Variables found to predict high levels of disease activity were Hispanic (from Texas) and African American ethnicities, lack of health insurance, helplessness, abnormal illness-related behaviours and poor social support; age was negatively associated with high levels of disease activity. African admixture and anti-double-stranded DNA antibodies also predicted high levels of disease activity, as did prior disease activity. None of the human leucocyte antigen variables were retained in the models.

CONCLUSIONS

Socioeconomic-demographic (age, ethnicity, health insurance), behavioural and psychological variables are important mediators of high levels of disease activity in SLE during its course. Interventions aimed at modifiable factors may improve the outcomes of SLE.

Prevalence, correlates, and costs of patients with poor adjustment to mixed cancers

Approximately 2% to 3% of the Canadian society has experienced cancer. Literature indicates that there is poor adjustment to chronic illness. Individuals with poor adjustment to chronic illness have been found to disproportionately use more health services. The purpose of this study was to determine the prevalence, correlates, and costs associated with poor adjustment to mixed cancer. A consecutive sample (n = 171) of breast, lung, and prostate cancer patients at the Nova Scotia Regional Cancer Center were surveyed. Twenty-eight percent of the cancer group showed fair to poor adjustment to illness using the Psychological Adjustment to Illness Self-report Scale Psychological Adjustment to Illness Self-Report Scale raw score. Poor adjustment was moderately correlated with depression (r = 0.50, P < .0001) and evasive coping (r = 0.38, P < .0001) and unrelated to demographic variables. Depression explained 25% of the variance in poor adjustment to illness in regression analysis. Cancer patients with fair to poor adjustment to illness had statistically significantly higher annual healthcare expenditures (P < .002) than those with good adjustment to illness. Expenditure findings agree with previous literature on chronic illnesses. The prevalence of fair to poor adjustment in this cancer population using the Psychological Adjustment to Illness Self-Report Scale measure is similar to that reported for chronic illness to date, suggesting that only those with better adjustment consented to this study.

Characteristics of People Living With HIV Who Use Community-Based Services in Ontario, Canada: Implications for Service Providers

Community-based AIDS service organizations (CBAOs) direct services to multiple-needs people living with HIV/AIDS who are less likely to use mainstream health promotion services. As people live longer with HIV, the potential to enhance quality of life increases, yet little is known about who uses CBAOs or how this use affects other health and social services. This study of people living with AIDS in Ontario, Canada (n = 297) examined the demographic and health-related characteristics of people with AIDS who do and do not use CBAOs and their patterns of mainstream service utilization. It found that users of CBAOs were significantly less healthy, less able to sustain normal activities, and more often depressed. They reported physical disabilities significantly more often. Their quality of life was also lower along certain dimensions. They were significantly poorer and more reliant on government income supports. They consumed significantly more nonhospital health and social services and had significantly higher out-of-pocket costs. These results suggest CBAOs are being accessed appropriately by those most vulnerable. In an effort to strengthen CBAO capacity to recognize and address depression and physical health problems prevalent among their clients, links to other mainstream health promotion and social services is recommended.

Intensive telephone follow-up to a hospital-based disease management model for patients with diabetes mellitus

The objective of this study was to evaluate the value of an intensive telephone follow-up as an additional component of a diabetes disease management program already shown to be effective in improving glycemic control, adherence with American Diabetes Association (ADA) standards of care, and health-related quality of life (HRQOL). The study involved a randomized controlled trial. The intervention group received a series of 12 weekly phone calls reinforcing base education and self-management skills. Five hundred and seven consenting patients, age 18 years or older, with type 1 or type 2 diabetes mellitus referred to the hospital- based disease management program who had telephones and were able to complete surveys in English or Spanish were enrolled. Outcomes were evaluated at 3 and 12 months follow- up. Adherence to ADA standards of care, specifically annual eye exams, physician foot exams, foot self-exams, and pneumonia vaccination were significantly better with the added telephone intervention, but there were no differences between the groups on glycemic control, HRQOL, or patient satisfaction. The effectiveness of the disease management program was replicated with sustained improvement in glycemic control, HRQOL, and adherence to ADA standards. The additional telephone intervention further improved adherence to ADA guidelines for self-care and medical care but did not affect glycemic control or HRQOL.

A randomized clinical trial of a psychoeducational intervention to improve outcomes in systemic lupus erythematosus

OBJECTIVE

In a cross-sectional study, we previously identified 2 potentially modifiable risk factors for adverse outcomes in systemic lupus erythematosus (SLE): self-efficacy and social support. The goal of this study was to evaluate in a randomized controlled trial a theory-based intervention to improve patient self-efficacy and partner support to manage SLE.

METHODS

Patients with SLE ages 18 years and older who met the American College of Rheumatology criteria and were able to identify a partner (spouse or family member) were recruited from 2 academic medical centers and randomized into an experimental group or a control group. Patients in the experimental group and their partners received an intervention designed to enhance self-efficacy, couples communication about lupus, social support, and problem solving, in the form of a 1-hour session with a nurse educator followed by monthly telephone counseling for 6 months. Patients in the control group and their partners received an attention placebo, including a 45-minute video presentation about lupus, and monthly telephone calls. Measures of physical and mental health status, disease activity, and psychosocial factors were collected at baseline, 6 months, and 12 months. The effect of the intervention on physical and mental health and disease activity at 6 and at 12 months was modeled with linear regression and adjusted for baseline health status, disease activity, sociodemographic factors, treatment change, and psychosocial factors.

RESULTS

One hundred twenty-two patients (plus their partners) were enrolled and randomized as follows: 64 to the experimental intervention and 58 to the attention control group. The participants were predominantly white, approximately half were college educated, and the groups were balanced for sociodemographic factors. At 6 months, significantly higher scores for couples communication (P = 0.01) and problem-focused coping (P = 0.03) were seen in the experimental group compared with the control group. At 12 months (6 months after the intervention ended), social support was higher (4.4 versus 4.1; P = 0.03), self-efficacy was higher (7.2 versus 6.2; P = 0.02), couples communication was higher (3.5 versus 3.1; P = 0.03), and fatigue was lower (5.1 versus 6.3; P = 0.02) in the experimental group compared with the control group. Global mental health status at 12 months, as measured by the Short Form 36 survey, was 69 points in the experimental group compared with 58 points in the control group (P = 0.04). In multivariate models, adjusting for baseline covariates, scores for couple communication (P = 0.01) were significantly higher at 6 months, and scores for self-efficacy (P = 0.004) and global mental health status (P = 0.03) were significantly higher at 12 months in the experimental group compared with the control group, and the mean score for global physical function was higher by 7 points, which was a clinically meaningful change (P = 0.2). The mean score for fatigue was also significantly lower in the experimental group than in the control group (P = 0.05). SLE disease activity was unchanged by this intervention.

CONCLUSION

This randomized, controlled trial of a theory-based educational intervention in SLE demonstrated significantly higher scores for couple communication, self-efficacy, and mental health status, and lower fatigue scores in the experimental group compared with the control group. Because couple communication and self-efficacy appear to be modifiable risk factors, they may also be potential targets in more disadvantaged populations.

Problem-solving counseling for caregivers of the cognitively impaired: effective for whom?

BACKGROUND

Individualized problem-solving counseling for caregivers of cognitively impaired relatives is thought to help caregivers cope with the stress and burden of caregiving. Few studies have shown the effectiveness of counseling for these caregivers.

OBJECTIVES

To determine the effectiveness of individualized problem-solving counseling by nurses for caregivers and the expenditures of health care utilization.

METHOD

Caregivers (n = 77) of the cognitively impaired living at home were randomized to receive nurse counseling or not. Psychosocial adjustment to their relative's illness, psychological distress, burden, coping skills, and expenditures were measured after 6 months and 1 year.

RESULTS

Although on average, all caregivers receiving nurse counseling indicated no improvement in psychosocial adjustment to their relative's illness, psychological distress, or caregiver burden, they found counseling very helpful and it was effective for a subgroup of caregivers. Those with poor logical analysis coping skills at baseline had decreased psychological distress (F(1,53) = 9.7, p = .003) and improved psychosocial adjustment (F(1,53) = 4.7, p = .035) after 1 year. Caregivers in control and counseling groups whose relatives entered a nursing home improved their psychosocial adjustment 23% on average whereas those continuing to live in the community decreased by 8%. Almost half as many relatives entered nursing homes in the counseling group (n = 9 vs. n = 5) but these compared to control group relatives had greater annualized per person expenditures for health and social services (Cdn$23,437 vs. Cdn$15,151).

CONCLUSIONS

Caregivers found nurse counseling most helpful. Those indicating infrequent use of logical analysis coping skills showed benefits.

Primary, secondary, and tertiary prevention capabilities of selected HMOs: findings of an employer survey

PURPOSE

To survey Health Maintenance Organizations (HMOs) of a major employer regarding the extent of their health promotion and disease prevention capabilities.

DESIGN

A one-time cross-sectional survey.

SETTING

The setting involved in this study was managed care organizations.

SUBJECTS

The subjects were 22 HMOs located in the western part of the United States.

MEASURES

The study involved completion of a survey grid on a fairly comprehensive range of primary, secondary, and tertiary prevention activities.

RESULTS

Twenty-two HMOs were surveyed and 20 responded, providing a response rate of 90.9%. Analysis of distribution of responses and simple means were used. If a "perfect score" included addressing all 52 prevention targets across all 13 intervention modalities (minus inappropriate combinations) and that represented a score of 100%, the highest scoring HMO indicated that it provided or addressed 36.8% of all possible modalities and prevention target combinations. The composite average score for all three areas of prevention for all responding HMOs was slightly less than 13%. Additionally, five of the HMO respondents provided approximately 59% of all the prevention activity reported in the survey. Nonrepresentativeness of the HMOs in the sample represents the most significant study limitation.

CONCLUSIONS

Results suggest that prevention capabilities among the HMOs surveyed are unevenly distributed and somewhat concentrated.

Age, adjustment, and costs: a study of chronic illnesses

Much concern has been expressed about increasing health costs associated with an aging population. In relation to chronic conditions, this study demonstrates that cost seems to be a function of adjustment to the chronic condition rather than of age in and of itself. We know from previous work that people with poor psychosocial adjustment cost considerably more than do people who are either moderately or well adjusted and this study shows that older, poorly adjusted persons are no more costly than their younger counterparts.

More effective and less expensive: lessons from five studies examining community approaches to care

Does the nature of community health services used by chronically ill clients and their caregivers have an impact on utilization of services, expenditure and well-being outcomes? A series of five studies, (four historic cohort and one randomized trial) examined clients suffering from a variety of chronic conditions in a number of community settings in different regions of Southern Ontario. Study sample composition and size varied. Each study was designed to quantify the well-being outcomes, and expenditure associated with different community approaches is covered under a nation-wide system of health insurance plans. As a collective, these studies represent increasing methodological rigor. Multiple-perspective client well-being outcome measures were used. Caregiver burden was also analyzed. A common approach to quantification and evaluation of expenditure for service consumption was applied across all five studies. The nature of community health services (proactive versus reactive approaches to care) was found to have direct and measurable impact on total expenditure for health service utilization and client well-being outcomes. A recurring pattern of lower expenditure for community health service utilization and equal or better client outcomes was associated with well-integrated proactive services when compared with individual fragmented, reactive approaches to care. The main lesson emerging from examining the five studies on approaches to community care is that it is as, or more, effective and less expensive to offer complete proactive health care services to chronically ill people in the early stages of their illness than to provide services on demand in a piecemeal manner.