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Young RA, Martin CM, Sturmberg JP, Hall S, Bazemore A, Kakadiaris IA, Lin S. What Complexity Science Predicts About the Potential of Artificial Intelligence/Machine Learning to Improve Primary Care. J Am Board Fam Med 2024; 37:332-345. [PMID: 38740483 DOI: 10.3122/jabfm.2023.230219r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 05/16/2024] Open
Abstract
Primary care physicians are likely both excited and apprehensive at the prospects for artificial intelligence (AI) and machine learning (ML). Complexity science may provide insight into which AI/ML applications will most likely affect primary care in the future. AI/ML has successfully diagnosed some diseases from digital images, helped with administrative tasks such as writing notes in the electronic record by converting voice to text, and organized information from multiple sources within a health care system. AI/ML has less successfully recommended treatments for patients with complicated single diseases such as cancer; or improved diagnosing, patient shared decision making, and treating patients with multiple comorbidities and social determinant challenges. AI/ML has magnified disparities in health equity, and almost nothing is known of the effect of AI/ML on primary care physician-patient relationships. An intervention in Victoria, Australia showed promise where an AI/ML tool was used only as an adjunct to complex medical decision making. Putting these findings in a complex adaptive system framework, AI/ML tools will likely work when its tasks are limited in scope, have clean data that are mostly linear and deterministic, and fit well into existing workflows. AI/ML has rarely improved comprehensive care, especially in primary care settings, where data have a significant number of errors and inconsistencies. Primary care should be intimately involved in AI/ML development, and its tools carefully tested before implementation; and unlike electronic health records, not just assumed that AI/ML tools will improve primary care work life, quality, safety, and person-centered clinical decision making.
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Affiliation(s)
- Richard A Young
- From the Director of Research and Associate Program Director, JPS Hospital Family Medicine Residency Program, Fort Worth, TX (RAY); Department of Medicine, Nursing and Allied Health, Monash University, Melbourne, Victoria, Australia (CMM); School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan New South Wales, Australia (JPS); Australian National University College of Health and Medicine, Canberra, Australia (SH); American Board of Family Medicine, Lexington, KY (AB); University of Houston (IAK); Stanford University School of Medicine Stanford, CA (SL)
| | - Carmel M Martin
- From the Director of Research and Associate Program Director, JPS Hospital Family Medicine Residency Program, Fort Worth, TX (RAY); Department of Medicine, Nursing and Allied Health, Monash University, Melbourne, Victoria, Australia (CMM); School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan New South Wales, Australia (JPS); Australian National University College of Health and Medicine, Canberra, Australia (SH); American Board of Family Medicine, Lexington, KY (AB); University of Houston (IAK); Stanford University School of Medicine Stanford, CA (SL)
| | - Joachim P Sturmberg
- From the Director of Research and Associate Program Director, JPS Hospital Family Medicine Residency Program, Fort Worth, TX (RAY); Department of Medicine, Nursing and Allied Health, Monash University, Melbourne, Victoria, Australia (CMM); School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan New South Wales, Australia (JPS); Australian National University College of Health and Medicine, Canberra, Australia (SH); American Board of Family Medicine, Lexington, KY (AB); University of Houston (IAK); Stanford University School of Medicine Stanford, CA (SL)
| | - Sally Hall
- From the Director of Research and Associate Program Director, JPS Hospital Family Medicine Residency Program, Fort Worth, TX (RAY); Department of Medicine, Nursing and Allied Health, Monash University, Melbourne, Victoria, Australia (CMM); School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan New South Wales, Australia (JPS); Australian National University College of Health and Medicine, Canberra, Australia (SH); American Board of Family Medicine, Lexington, KY (AB); University of Houston (IAK); Stanford University School of Medicine Stanford, CA (SL)
| | - Andrew Bazemore
- From the Director of Research and Associate Program Director, JPS Hospital Family Medicine Residency Program, Fort Worth, TX (RAY); Department of Medicine, Nursing and Allied Health, Monash University, Melbourne, Victoria, Australia (CMM); School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan New South Wales, Australia (JPS); Australian National University College of Health and Medicine, Canberra, Australia (SH); American Board of Family Medicine, Lexington, KY (AB); University of Houston (IAK); Stanford University School of Medicine Stanford, CA (SL)
| | - Ioannis A Kakadiaris
- From the Director of Research and Associate Program Director, JPS Hospital Family Medicine Residency Program, Fort Worth, TX (RAY); Department of Medicine, Nursing and Allied Health, Monash University, Melbourne, Victoria, Australia (CMM); School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan New South Wales, Australia (JPS); Australian National University College of Health and Medicine, Canberra, Australia (SH); American Board of Family Medicine, Lexington, KY (AB); University of Houston (IAK); Stanford University School of Medicine Stanford, CA (SL)
| | - Steven Lin
- From the Director of Research and Associate Program Director, JPS Hospital Family Medicine Residency Program, Fort Worth, TX (RAY); Department of Medicine, Nursing and Allied Health, Monash University, Melbourne, Victoria, Australia (CMM); School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan New South Wales, Australia (JPS); Australian National University College of Health and Medicine, Canberra, Australia (SH); American Board of Family Medicine, Lexington, KY (AB); University of Houston (IAK); Stanford University School of Medicine Stanford, CA (SL)
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Sturmberg JP, Martin CM. From theory to practice: The pragmatic value of applying systems thinking and complexity sciences in healthcare. J Eval Clin Pract 2024; 30:149-152. [PMID: 38462994 DOI: 10.1111/jep.13979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Joachim P Sturmberg
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont, US
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health Monash University, Clayton, Victoria, Australia
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Martin CM. Horses for courses. Commentary on Turcotte et al. (2021). The shiny new object: Deconstructing the patient-oriented paradigm in health sciences. EJPCH 9 (2) xx-xx. J Eval Clin Pract 2023. [PMID: 37272214 DOI: 10.1111/jep.13829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 06/06/2023]
Affiliation(s)
- Carmel M Martin
- Department of Medicine, Nursing and Allied Health, Monash Health, Monash University, Clayton, Australia
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Sturmberg JP, Martin CM. Complexity sciences: Applied philosophy to solve real-world wicked problems. J Eval Clin Pract 2022; 28:1169-1172. [PMID: 36345738 DOI: 10.1111/jep.13781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Joachim P Sturmberg
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia.,International Society for Systems and Complexity Sciences for Health, Newcastle, New South Wales, Australia
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health, Monash Health, Melbourne, Victoria, Australia
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Abstract
Universal health care (UHC) is primarily a financing concern, whereas primary health care (PHC) is primarily concerned with providing the right care at the right time to achieve the best possible health outcomes for individuals and communities. A recent call for contributions by the WHO emphasized that UHC can only be achieved through PHC, and that to achieve this goal will require the strengthening of the three pillars of PHC - (a) enabling primary care and public health to integrate health services, (b) empowering people and communities to create healthy living conditions, and (c) integrating multisectoral policy decisions to ensure UHC that achieves the goal of "health for all." "Pillars" - as a static metaphor - sends the wrong signal to the research and policy-making community. It, in fact, contradicts the WHO's own view, namely that there is "the need to strengthen comprehensive primary health care systems based on local priorities, needs and contexts … [that are] co-developed by people who are engaged in their own health." What we really need to develop PHC as the basis to achieve the goal of UHC is a dynamic agency to drive a "system-as-a-whole framework" that simultaneously takes into account finance, individual, and local needs. Health systems are socially constructed organizational systems that are "functionally layered" in a hierarchical fashion - governments and/or funders at the top-level not only promote the goals of the system (policies) but also constrain the system (rules, regulations, resources) in its ability to deliver. Hence, there is a need to focus on two key system features - political leadership and dynamic bottom-up agency that maintains everyone's focus on the goal to be achieved, and a limitation of system constraints so that communities can shape best adapted primary care services that truly meet the needs of their individuals, families, and community.
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Affiliation(s)
- Joachimh P Sturmberg
- School of Medicine and Public Health Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health Monash Health Clayton, Clayton, Australia
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Sturmberg JP, Martin CM. How to cope with uncertainty? Start by looking for patterns and emergent knowledge. J Eval Clin Pract 2021; 27:1168-1171. [PMID: 34216085 DOI: 10.1111/jep.13596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 06/22/2021] [Indexed: 01/14/2023]
Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont, USA
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health Monash Health Clayton, Clayton, Australia
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Young RA, Nelson MJ, Castellon RE, Martin CM. Improving quality in a complex primary care system-An example of refugee care and literature review. J Eval Clin Pract 2021; 27:1018-1026. [PMID: 32596835 DOI: 10.1111/jep.13430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 12/11/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Applying traditional industrial quality improvement (QI) methodologies to primary care is often inappropriate because primary care and its relationship to the healthcare macrosystem has many features of a complex adaptive system (CAS) that is particularly responsive to bottom-up rather than top-down management approaches. We report on a demonstration case study of improvements made in the Family Health Center (FHC) of the JPS Health Network in a refugee patient population that illustrate features of QI in a CAS framework as opposed to a traditional QI approach. METHODS We report on changes in health system utilization by new refugee patients of the FHC from 2016 to 2017. We review the literature and summarize relevant theoretical understandings of quality management in complex adaptive systems as it applies to this case example. RESULTS Applying CAS principles in the FHC, utilization of the Emergency Department and Urgent Care Center by newly arrived refugee patients before their first clinic visit was reduced by more than half (total visits decreased from 31%-14% of the refugee patients). Our review of the literature demonstrates that traditional algorithmic top-down QI processes are most often unsuccessful in improving even a few single-disease metrics, and increases clinician burnout and penalizes clinicians who care for vulnerable patients. Improvement in a CAS occurs when front-line clinicians identify care gaps and are given the flexibility to learn and self-organize to enable new care processes to emerge, which are created from bottom-up leadership that utilize existing interdependencies and interact with the top levels of the organization through intelligent top-down causation. We give examples of early adapters who are better applying the principles of CAS change to their QI efforts. CONCLUSIONS Meaningful improvement in primary care is more likely achieved when the impetus to implement change shifts from top-down to bottom-up.
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Affiliation(s)
- Richard A Young
- JPS Hospital Family Medicine Residency Program, Fort Worth, Texas, USA
| | - Mark J Nelson
- JPS Hospital Family Medicine Residency Program, Fort Worth, Texas, USA
| | | | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health, Monash University/Monash Health, Clayton, Victoria, Australia
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Sturmberg JP, Martin CM. Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed. Med J Aust 2021; 215:189-189.e1. [PMID: 34291471 DOI: 10.5694/mja2.51193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Joachim P Sturmberg
- University of Newcastle, Newcastle, NSW.,International Society for Systems and Complexity Sciences for Health, Waitsfield, VT, USA
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Sturmberg JP, Martin CM. COVID-19 - how a pandemic reveals that everything is connected to everything else. J Eval Clin Pract 2020; 26:1361-1367. [PMID: 32633056 PMCID: PMC7362160 DOI: 10.1111/jep.13419] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 01/10/2023]
Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.,International Society for Systems and Complexity Sciences for Health, Waitsfield, VT, USA
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health Monash University, Clayton, Victoria, Australia
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O'Connor M, O'Donovan B, Waller J, Ó Céilleachair A, Gallagher P, Martin CM, O'Leary J, Sharp L. Communicating about HPV in the context of head and neck cancer: A systematic review of quantitative studies. Patient Educ Couns 2020; 103:462-472. [PMID: 31558324 DOI: 10.1016/j.pec.2019.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/31/2019] [Accepted: 09/14/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Rising incidence of HPV-positive head and neck cancers (HPV-HNC) means HPV infection is increasingly relevant to patient-provider consultations. We performed a systematic review to examine, in the context of patient-provider HNC consultations: discussions about HPV, attitudes towards discussing HPV and information needs. METHODS We searched Embase, PsychINFO, and CINAHL + for studies to August 2018. Eligible studies included: HNC healthcare professionals (HCPs) and/or HNC patients investigated HNC patient-provider communication about HPV. RESULTS Ten studies were identified: six including HCPs and four including HNC patients. HCPs varied in confidence in HPV discussions, which was related to their HPV knowledge. Both HCPs and patients acknowledged the need for reliable HPV information. Factors which facilitated HPV discussions included accessible HPV information for patients and HCPs and good HPV knowledge among HCPs. Barriers included the perception, among HCPs, that HPV was a challenging topic to discuss with patients. CONCLUSIONS Information deficits, communication challenges and barriers to discussing HPV were identified in HNC patient-provider consultations. PRACTICE IMPLICATIONS Appropriate HPV information is needed for HCPs and patients. Professional development initiatives which increase HCPs' HPV knowledge and build their communication skills would be valuable.
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Affiliation(s)
- M O'Connor
- National Cancer Registry Ireland, Kinsale Road, Cork, Ireland
| | - B O'Donovan
- Department of Histopathology, University of Dublin, Trinity College, Ireland; Department of Pathology, Coombe Women and Infants University Hospital Ireland, Ireland.
| | - J Waller
- Cancer Prevention Group, King's College London, London, UK
| | | | - P Gallagher
- School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
| | - C M Martin
- Department of Histopathology, University of Dublin, Trinity College, Ireland; Department of Pathology, Coombe Women and Infants University Hospital Ireland, Ireland
| | - J O'Leary
- Department of Histopathology, University of Dublin, Trinity College, Ireland; Department of Pathology, Coombe Women and Infants University Hospital Ireland, Ireland
| | - L Sharp
- Institute of Health & Society, Newcastle University, UK
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Sturmberg JP, Picard M, Aron DC, Bennett JM, Bircher J, deHaven MJ, Gijzel SMW, Heng HH, Marcum JA, Martin CM, Miles A, Peterson CL, Rohleder N, Walker C, Olde Rikkert MGM, Melis RJF. Health and Disease-Emergent States Resulting From Adaptive Social and Biological Network Interactions. Front Med (Lausanne) 2019; 6:59. [PMID: 30984762 PMCID: PMC6447670 DOI: 10.3389/fmed.2019.00059] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 03/06/2019] [Indexed: 12/25/2022] Open
Abstract
Health is an adaptive state unique to each person. This subjective state must be distinguished from the objective state of disease. The experience of health and illness (or poor health) can occur both in the absence and presence of objective disease. Given that the subjective experience of health, as well as the finding of objective disease in the community, follow a Pareto distribution, the following questions arise: What are the processes that allow the emergence of four observable states-(1) subjective health in the absence of objective disease, (2) subjective health in the presence of objective disease, (3) illness in the absence of objective disease, and (4) illness in the presence of objective disease? If we consider each individual as a unique biological system, these four health states must emerge from physiological network structures and personal behaviors. The underlying physiological mechanisms primarily arise from the dynamics of external environmental and internal patho/physiological stimuli, which activate regulatory systems including the hypothalamic-pituitary-adrenal axis and autonomic nervous system. Together with other systems, they enable feedback interactions between all of the person's system domains and impact on his system's entropy. These interactions affect individual behaviors, emotional, and cognitive responses, as well as molecular, cellular, and organ system level functions. This paper explores the hypothesis that health is an emergent state that arises from hierarchical network interactions between a person's external environment and internal physiology. As a result, the concept of health synthesizes available qualitative and quantitative evidence of interdependencies and constraints that indicate its top-down and bottom-up causative mechanisms. Thus, to provide effective care, we must use strategies that combine person-centeredness with the scientific approaches that address the molecular network physiology, which together underpin health and disease. Moreover, we propose that good health can also be promoted by strengthening resilience and self-efficacy at the personal and social level, and via cohesion at the population level. Understanding health as a state that is both individualized and that emerges from multi-scale interdependencies between microlevel physiological mechanisms of health and disease and macrolevel societal domains may provide the basis for a new public discourse for health service and health system redesign.
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Affiliation(s)
- Joachim P. Sturmberg
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Martin Picard
- Division of Behavioral Medicine, Department of Psychiatry and Neurology, The H. Houston Merritt Center, Columbia Translational Neuroscience Initiative, Columbia Aging Center, Columbia University Medical Center, Columbia University, New York, NY, United States
| | - David C. Aron
- School of Medicine, Weatherhead School of Management, Louis Stokes Cleveland VA Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Jeanette M. Bennett
- Department of Psychological Science, University of North Carolina at Charlotte, Charlotte, NC, United States
| | - Johannes Bircher
- Hepatology, Department for Biomedical Research, University of Bern, Bern, Switzerland
| | - Mark J. deHaven
- Health and Human Services, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, NC, United States
| | - Sanne M. W. Gijzel
- Department Geriatric Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Henry H. Heng
- Department of Pathology, Center for Molecular Medicine and Genetics, School of Medicine, Wayne State University, Detroit, MI, United States
| | - James A. Marcum
- Philosophy and Medical Humanities, Baylor University, Waco, TX, United States
| | - Carmel M. Martin
- Department of Medicine, Nursing and Allied Health, Monash Health, Melbourne, VIC, Australia
| | - Andrew Miles
- European Society for Person Centered Healthcare, London, United Kingdom
| | - Chris L. Peterson
- School of Humanities and Social Sciences, La Trobe University, Bundoora, VIC, Australia
| | - Nicolas Rohleder
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | | | - René J. F. Melis
- Department Geriatric Medicine, Radboud University Medical Center, Nijmegen, Netherlands
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Martin CM, Sturmberg JP, Stockman K, Hinkley N, Campbell D. Anticipatory Care in Potentially Preventable Hospitalizations: Making Data Sense of Complex Health Journeys. Front Public Health 2019; 6:376. [PMID: 30746358 PMCID: PMC6360156 DOI: 10.3389/fpubh.2018.00376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 12/13/2018] [Indexed: 11/28/2022] Open
Abstract
Purpose: Potentially preventable hospitalizations (PPH) are minimized when adults (usually with multiple morbidities ± frailty) benefit from alternatives to emergency hospital use. A complex systems and anticipatory journey approach to PPH, the Patient Journey Record System (PaJR) is proposed. Application: PaJR is a web-based service supporting ≥weekly telephone calls by trained lay Care Guides (CG) to individuals at risk of PPH. The Victorian HealthLinks Chronic Care algorithm provides case finding from hospital big data. Prediction algorithms on call data helps optimize emergency hospital use through adaptive and anticipatory care. MonashWatch deployment incorporating PaJR is conducted by Monash Health in its Dandenong urban catchment area, Victoria, Australia. Theory: A Complex Adaptive Systems (CAS) framework underpins PaJR, and recognizes unique individual journeys, their dependence on historical and biopsychosocial influences, and difficult to predict tipping points. Rosen's modeling relationship and anticipation theory additionally informed the CAS framework with data sense-making and care delivery. PaJR uses perceptions of current and future health (interoception) through ongoing conversations to anticipate possible tipping points. This allows for possible timely intervention in trajectories in the biopsychosocial dimensions of patients as “particulars” in their unique trajectories. Evaluation: Monash Watch is actively monitoring 272 of 376 intervention patients, with 195 controls over 22 months (ongoing). Trajectories of poor health (SRH) and anticipation of worse/uncertain health (AH), and CG concerns statistically shifted at a tipping point, 3 days before admission in the subset who experienced ≥1 acute admission. The −3 day point was generally consistent across age and gender. Three randomly selected case studies demonstrate the processes of anticipatory and reactive care. PaJR-supported services achieved higher than pre-set targets—consistent reduction in acute bed days (20–25%) vs. target 10% and high levels of patient satisfaction. Discussion: Anticipatory care is an emerging trajectory data analytic approach that uses human sense-making as its core metric demonstrates improvements in processes and outcomes. Multiple sources can provide big data to inform trajectory care, however simple tailored data collections may prove effective if they embrace human interoception and anticipation. Admission risk may be addressed with a simple data collections including SRH, AH, and CG perceptions, where practical. Conclusion: Anticipatory care, as operationalized through PaJR approaches applied in MonashWatch, demonstrates processes and outcomes that successfully ameliorate PPH.
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Sturmberg JP, O'Halloran DM, McDonnell G, Martin CM. General practice work and workforce: Interdependencies between demand, supply and quality. Aust J Gen Pract 2018; 47:507-513. [DOI: 10.31128/ajgp-03-18-4515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Takigawa MT, Derval ND, Frontera AF, Vlachos KV, Kitamura TK, Chenit GC, Duchateau JD, Martin CM, Klotz NK, Pambrun TP, Denis AD, Sacher FS, Hocini MH, Haissaguerre MH, Jais PJ. 689Prediction of termination/conversion and subsequent second circuit of atrial tachycardia. Europace 2018. [DOI: 10.1093/europace/euy015.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - N D Derval
- Hospital Haut Leveque, Bordeaux-Pessac, France
| | | | - K V Vlachos
- Hospital Haut Leveque, Bordeaux-Pessac, France
| | | | - G C Chenit
- Hospital Haut Leveque, Bordeaux-Pessac, France
| | | | - C M Martin
- Hospital Haut Leveque, Bordeaux-Pessac, France
| | - N K Klotz
- Hospital Haut Leveque, Bordeaux-Pessac, France
| | - T P Pambrun
- Hospital Haut Leveque, Bordeaux-Pessac, France
| | - A D Denis
- Hospital Haut Leveque, Bordeaux-Pessac, France
| | - F S Sacher
- Hospital Haut Leveque, Bordeaux-Pessac, France
| | - M H Hocini
- Hospital Haut Leveque, Bordeaux-Pessac, France
| | | | - P J Jais
- Hospital Haut Leveque, Bordeaux-Pessac, France
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O'Connor M, O'Brien K, Waller J, Gallagher P, D'Arcy T, Flannelly G, Martin CM, McRae J, Prendiville W, Ruttle C, White C, Pilkington L, O'Leary JJ, Sharp L. Physical after-effects of colposcopy and related procedures, and their inter-relationship with psychological distress: a longitudinal survey. BJOG 2017; 124:1402-1410. [PMID: 28374937 DOI: 10.1111/1471-0528.14671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress. DESIGN Longitudinal survey. SETTING Two hospital-based colposcopy clinics. POPULATION Women with abnormal cytology who underwent colposcopy (±related procedures). METHODS Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables. MAIN OUTCOME MEASURES Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress. RESULTS Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10-8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up. CONCLUSIONS The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress. TWEETABLE ABSTRACT Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.
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Affiliation(s)
- M O'Connor
- National Cancer Registry Ireland, Cork, Ireland
| | - K O'Brien
- National Cancer Registry Ireland, Cork, Ireland
| | - J Waller
- Department of Behavioural Science and Health, University College London, London, UK
| | - P Gallagher
- School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
| | - T D'Arcy
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - G Flannelly
- National Maternity Hospital, Dublin 2, Ireland
| | - C M Martin
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - J McRae
- National Cancer Registry Ireland, Cork, Ireland
| | - W Prendiville
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - C Ruttle
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - C White
- Trinity College Dublin, Dublin 2, Ireland
| | - L Pilkington
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - J J O'Leary
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - L Sharp
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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17
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Sturmberg JP, Martin CM, Katerndahl DA. It is complicated! - misunderstanding the complexities of 'complex'. J Eval Clin Pract 2017; 23:426-429. [PMID: 27307382 DOI: 10.1111/jep.12579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 05/15/2016] [Indexed: 11/28/2022]
Abstract
Terminology matters - as Lakoff emphasised, words and phrases evoke powerful images and frames of understanding. It is for that reason that we need to discern and use appropriately the term complex/complexity in the health science/professional/policy domain. Complex is the fashionable term used when in reality one means 'complicated', 'difficult to understand' or 'multiple simultaneous actions'. However, this is not what complex means. The Latin term means 'entwined/interwoven' - a structural characteristic describing systems. Complexity arises from the interactions between structurally connected entities - a functional characteristic of a system. The basis of scientific rigor is a clear understanding of a discipline's epistemology. Complexity refers to the emergence of outcomes from the interactions of a system's constituent components (and thus has nothing in common with the colloquial meaning of complicatedness).
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Affiliation(s)
- Joachim P Sturmberg
- Department of General Practice, The University of Newcastle, Wamberal, NSW, Australia
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health, Monash Health, Clayton, VIC, Australia
| | - David A Katerndahl
- Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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18
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Sturmberg JP, Bennett JM, Martin CM, Picard M. 'Multimorbidity' as the manifestation of network disturbances. J Eval Clin Pract 2017; 23:199-208. [PMID: 27421249 DOI: 10.1111/jep.12587] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 01/02/2023]
Abstract
We argue that 'multimorbidity' is the manifestation of interconnected physiological network processes within an individual in his or her socio-cultural environment. Networks include genomic, metabolomic, proteomic, neuroendocrine, immune and mitochondrial bioenergetic elements, as well as social, environmental and health care networks. Stress systems and other physiological mechanisms create feedback loops that integrate and regulate internal networks within the individual. Minor (e.g. daily hassles) and major (e.g. trauma) stressful life experiences perturb internal and social networks resulting in physiological instability with changes ranging from improved resilience to unhealthy adaptation and 'clinical disease'. Understanding 'multimorbidity' as a complex adaptive systems response to biobehavioural and socio-environmental networks is essential. Thus, designing integrative care delivery approaches that more adequately address the underlying disease processes as the manifestation of a state of physiological dysregulation is essential. This framework can shape care delivery approaches to meet the individual's care needs in the context of his or her underlying illness experience. It recognizes 'multimorbidity' and its symptoms as the end product of complex physiological processes, namely, stress activation and mitochondrial energetics, and suggests new opportunities for treatment and prevention. The future of 'multimorbidity' management might become much more discerning by combining the balancing of physiological dysregulation with targeted personalized biotechnology interventions such as small molecule therapeutics targeting specific cellular components of the stress response, with community-embedded interventions that involve addressing psycho-socio-cultural impediments that would aim to strengthen personal/social resilience and enhance social capital.
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Affiliation(s)
- Joachim P Sturmberg
- Department of General Practice, Newcastle - Australia, The University of Newcastle, Wamberal, NSW, Australia
| | - Jeanette M Bennett
- Department of Psychology, The University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health, Monash Health, Clayton - Australia
| | - Martin Picard
- Division of Behavioral Medicine, Department of Psychiatry, Department of Neurology and CTNI, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA
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19
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Burry LD, Hutton B, Guenette M, Williamson D, Mehta S, Egerod I, Kanji S, Adhikari NK, Moher D, Martin CM, Rose L. Comparison of pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a protocol for a systematic review incorporating network meta-analyses. Syst Rev 2016; 5:153. [PMID: 27609018 PMCID: PMC5016934 DOI: 10.1186/s13643-016-0327-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/24/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Delirium is characterized by acute changes in mental status including inattention, disorganized thinking, and altered level of consciousness, and is highly prevalent in critically ill adults. Delirium has adverse consequences for both patients and the healthcare system; however, at this time, no effective treatment exists. The identification of effective prevention strategies is therefore a clinical and research imperative. An important limitation of previous reviews of delirium prevention is that interventions were considered in isolation and only direct evidence was used. Our systematic review will synthesize all existing data using network meta-analysis, a powerful statistical approach that enables synthesis of both direct and indirect evidence. METHODS We will search Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science from 1980 to March 2016. We will search the PROSPERO registry for protocols and the Cochrane Library for published systematic reviews. We will examine reference lists of pertinent reviews and search grey literature and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We will include randomized and quasi-randomized trials of critically ill adults evaluating any pharmacological, non-pharmacological, or multi-component intervention for delirium prevention, administered in or prior to (i.e., peri-operatively) transfer to the ICU. Two authors will independently screen search results and extract data from eligible studies. Risk of bias assessments will be completed on all included studies. To inform our network meta-analysis, we will first conduct conventional pair-wise meta-analyses for primary and secondary outcomes using random-effects models. We will generate our network meta-analysis using a Bayesian framework, assuming a common heterogeneity parameter across all comparisons, and accounting for correlations in multi-arm studies. We will perform analyses using WinBUGS software. DISCUSSION This systematic review will address the existing knowledge gap regarding best practices for delirium prevention in critically ill adults by synthesizing evidence from trials of pharmacological, non-pharmacological, and multi-component interventions administered in or prior to transfer to the ICU. Use of network meta-analysis will clarify which delirium prevention strategies are most effective in improving clinical outcomes while causing least harm. The network meta-analysis is a novel approach and will provide knowledge users and decision makers with comparisons of multiple interventions of delirium prevention strategies. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016036313.
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Affiliation(s)
- L D Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Department of Pharmacy, Mount Sinai Hospital, 600 University Ave, Rm 18-377, Toronto, ON, M5G1X5, Canada
| | - B Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Rd, Room L1288, Ottawa, ON, K1H8L6, Canada. .,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - M Guenette
- Department of Pharmacy, Mount Sinai Hospital, 600 University Ave, Rm 18-377, Toronto, ON, M5G1X5, Canada
| | - D Williamson
- Faculté de pharmacie, Université de Montréal, Montreal, QC, Canada.,Département de pharmacie, hôpital du Sacré-Coeur, Montreal, QC, Canada
| | - S Mehta
- Department of Medicine, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Critical Care, Mount Sinai Hospital, Toronto, ON, Canada
| | - I Egerod
- University of Copenhagen, Rigshospitalet, Neurointensive Intensive Care, Blegdamsvej 9, DK-2100, Copenhagen O, Denmark
| | - S Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Rd, Room L1288, Ottawa, ON, K1H8L6, Canada.,Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada
| | - N K Adhikari
- Department of Medicine, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Evaluative Clinical Sciences, Trauma, Emergency & Critical Care Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - D Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Rd, Room L1288, Ottawa, ON, K1H8L6, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - C M Martin
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - L Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Evaluative Clinical Sciences, Trauma, Emergency & Critical Care Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Provincial Centre of Weaning Excellence, Toronto East General Hospital, Toronto, ON, Canada
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20
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White C, Bakhiet S, Bates M, Keegan H, Pilkington L, Ruttle C, Sharp L, O' Toole S, Fitzpatrick M, Flannelly G, O' Leary JJ, Martin CM. Triage of LSIL/ASC-US with p16/Ki-67 dual staining and human papillomavirus testing: a 2-year prospective study. Cytopathology 2016; 27:269-76. [PMID: 26932360 DOI: 10.1111/cyt.12317] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate human papillomavirus (HPV) DNA testing and p16/Ki-67 staining for detecting cervical intraepithelial grade 2 or worse (CIN2+) and CIN3 in women referred to colposcopy with minor abnormal cervical cytology low-grade squamous intraepithelial lesions (LSIL) and atypical squamous cells of undermined significance (ASC-US). The clinical performance of both tests was evaluated as stand-alone tests and combined, for detection CIN2+ and CIN3 over 2 years. METHODS ThinPrep(®) liquid-based cytology (LBC) specimens were collected from 1349 women with repeat LSIL or ASC-US. HPV DNA was performed using Hybrid Capture. Where adequate material remained (n = 471), p16/Ki-67 overexpression was assessed. Clinical performance for detection of histologically diagnosed CIN2+ and CIN3 was calculated. RESULTS Approximately 62.2% of the population were positive for HPV DNA, and 30.4% were positive for p16/Ki-67. p16/Ki-67 showed no significant difference in positivity between LSIL and ASC-US referrals (34.3% versus 28.6%; P = 0.189). Women under 30 years had a higher rate of p16/Ki-67 compared to those over 30 years (36.0% versus 26.6%; P = 0.029). Overall HPV DNA testing produced a high sensitivity for detection of CIN3 of 95.8% compared to 79.2% for p16/Ki-67. In contrast, p16/Ki-67 expression offered a higher specificity, 75.2% versus 40.4% for detection of CIN3. Combining p16/Ki-67 with HPV DNA improved the accuracy in distinguishing between CIN3 and <CIN3. The absolute risk of CIN3 increased from 15.6% in women who were HPV DNA positive to 27% in women positive for HPV DNA and p16/Ki-67. Those negative for HPV DNA and p16/Ki-67 had a low risk of 1.2% of CIN3. CONCLUSION The addition of p16/Ki-67 to HPV DNA testing leads to a more accurate stratification of CIN in women presenting with minor cytological abnormalities.
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Affiliation(s)
- C White
- Department of Histopathology, Trinity College Dublin, Dublin, Ireland.,Department of Pathology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - S Bakhiet
- Department of Pathology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - M Bates
- Department of Histopathology, Trinity College Dublin, Dublin, Ireland.,Department of Pathology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - H Keegan
- Department of Histopathology, Trinity College Dublin, Dublin, Ireland.,Department of Pathology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - L Pilkington
- Department of Pathology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - C Ruttle
- Department of Pathology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - L Sharp
- National Cancer Registry Ireland, Cork, Ireland
| | - S O' Toole
- Department of Pathology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - M Fitzpatrick
- Department of Obstetrics and Gynaecology, National Maternity Hospital, Dublin, Ireland
| | - G Flannelly
- Department of Obstetrics and Gynaecology, National Maternity Hospital, Dublin, Ireland
| | - J J O' Leary
- Department of Histopathology, Trinity College Dublin, Dublin, Ireland.,Department of Pathology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - C M Martin
- Department of Histopathology, Trinity College Dublin, Dublin, Ireland.,Department of Pathology, Coombe Women and Infants University Hospital, Dublin, Ireland
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21
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Abstract
RATIONALE, AIMS AND OBJECTIVES The focus on the diagnosis is a pivotal aspect of medical practice since antiquity. Diagnostic taxonomy helped to categorize ailments to improve medical care, and in its social sense resulted in validation of the sick role for some, but marginalization or stigmatization for others. In the medical industrial complex, diagnostic taxonomy structured health care financing, management and practitioner remuneration. However, with increasing demands from multiple agencies, there are increasing unintended and unwarranted consequences of our current taxonomies and diagnostic processes resulting from the conglomeration of underpinning concepts, theories, information and motivations. RESULTS We argue that the increasing focus on the diagnosis resulted in excessive compartmentalization - 'partialism' - of medical practice, diminishing medical care and being naively simplistic in light of the emerging understanding of the interconnected nature of the diseasome. The human is a complex organic system of interconnecting dynamics and feedback loops responding to internal and external forces including genetic, epigenetic and environmental attractors, rather than the sum of multiple discrete organs which can develop isolated diseases or multiple morbidities. Solutions to these unintended consequences of many contemporary health system processes involve revisiting the nature of diagnostic taxonomies and the processes of their construction. A dynamic taxonomic framework would shift to more relevant attractors at personal, clinical and health system levels recognizing the non-linear nature of health and disease. Human health at an individual, group and population level is the ability to adapt to internal and external stressors with resilience throughout the life course, yet diagnostic taxonomies are increasingly constructed around fixed anchors. CONCLUSIONS Understanding diagnosis as dissecting, pigeonholing or bean counting (learning by dividing) is no longer useful, the challenge for the future is to understand the big picture (learning by connecting). Diagnostic categorization needs to embrace a meta-learning approach open to human variability.
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Affiliation(s)
| | - Carmel M Martin
- Department of Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland
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22
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O'Connor M, Gallagher P, Waller J, Martin CM, O'Leary JJ, Sharp L. Adverse psychological outcomes following colposcopy and related procedures: a systematic review. BJOG 2016; 123:24-38. [PMID: 26099164 DOI: 10.1111/1471-0528.13462] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although colposcopy is the leading follow-up option for women with abnormal cervical cytology, little is known about its psychological consequences. OBJECTIVES We performed a systematic review to examine: (1) what, if any, are the adverse psychological outcomes following colposcopy and related procedures; (2) what are the predictors of adverse psychological outcomes post-colposcopy; and (3) what happens to these outcomes over time. SEARCH STRATEGY Five electronic databases (PubMed, PsychINFO, CINAHL, Web of Science, Scopus) were searched for studies published in English between January 1986 and February 2014. SELECTION CRITERIA Eligible studies assessed psychological wellbeing at one or more time-points post-colposcopy. DATA COLLECTION AND ANALYSIS Two reviewers independently screened titles and abstracts. Full texts of potentially eligible papers were reviewed. Data were abstracted from, and a quality appraisal performed of, eligible papers. MAIN RESULTS Twenty-three papers reporting 16 studies were eligible. Colposcopy and related procedures can lead to adverse psychological outcomes, particularly anxiety. Ten studies investigated predictors of adverse psychological outcomes; management type and treatment had no impact on this. Seven studies investigated temporal trends in psychological outcomes post-colposcopy; findings were mixed, especially in relation to anxiety and distress. Studies were methodologically heterogeneous. CONCLUSIONS Follow-up investigations and procedures for abnormal cervical cytology can cause adverse psychological outcomes among women. However, little is known about the predictors of these outcomes or how long they persist. There is a need for a more standardised approach to the examination of the psychological impact of colposcopy, especially longer-term outcomes. TWEETABLE ABSTRACT Follow-up investigations for abnormal cervical cytology can cause adverse psychological outcome among women.
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Affiliation(s)
- M O'Connor
- National Cancer Registry Ireland, Cork, Ireland
| | - P Gallagher
- School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
| | - J Waller
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, London, UK
| | - C M Martin
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - J J O'Leary
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - L Sharp
- Institute of Health &/ Society, Newcastle University, Newcastle, UK
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Campaniello MA, Harrington AM, Martin CM, Ashley Blackshaw L, Brierley SM, Hughes PA. Activation of colo-rectal high-threshold afferent nerves by Interleukin-2 is tetrodotoxin-sensitive and upregulated in a mouse model of chronic visceral hypersensitivity. Neurogastroenterol Motil 2016; 28:54-63. [PMID: 26468044 DOI: 10.1111/nmo.12696] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 09/02/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic visceral pain is a defining feature of irritable bowel syndrome (IBS). IBS patients often show alterations in innate and adaptive immune function which may contribute to symptoms. Immune mediators are known to modulate the activity of viscero-sensory afferent nerves, but the focus has been on the innate immune system. Interleukin-2 (IL-2) is primarily associated with adaptive immune responses but its effects on colo-rectal afferent function in health or disease are unknown. METHODS Myeloperoxidase (MPO) activity determined the extent of inflammation in health, acute trinitrobenzene-sulfonic acid (TNBS) colitis, and in our post-TNBS colitis model of chronic visceral hypersensitivity (CVH). The functional effects of IL-2 on high-threshold colo-rectal afferents and the expression of IL-2R and NaV 1.7 mRNA in colo-rectal dorsal root ganglia (DRG) neurons were compared between healthy and CVH mice. KEY RESULTS MPO activity was increased during acute colitis, but subsided to levels comparable to health in CVH mice. IL-2 caused direct excitation of colo-rectal afferents that was blocked by tetrodotoxin. IL-2 did not affect afferent mechanosensitivity in health or CVH. However, an increased proportion of afferents responded directly to IL-2 in CVH mice compared with controls (73% vs 33%; p < 0.05), and the abundance of IL-2R and NaV 1.7 mRNA was increased 3.5- and 2-fold (p < 0.001 for both) in colo-rectal DRG neurons. CONCLUSIONS & INFERENCES IL-2, an immune mediator from the adaptive arm of the immune response, affects colo-rectal afferent function, indicating these effects are not restricted to innate immune mediators. Colo-rectal afferent sensitivity to IL-2 is increased long after healing from inflammation.
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Affiliation(s)
- M A Campaniello
- Centre for Nutritional and Gastrointestinal Diseases, Department of Medicine, University of Adelaide and South Australian Health Medical Health Research Institute, Adelaide, SA, Australia
| | - A M Harrington
- Centre for Nutritional and Gastrointestinal Diseases, Department of Medicine, University of Adelaide and South Australian Health Medical Health Research Institute, Adelaide, SA, Australia
| | - C M Martin
- Centre for Nutritional and Gastrointestinal Diseases, Department of Medicine, University of Adelaide and South Australian Health Medical Health Research Institute, Adelaide, SA, Australia
| | - L Ashley Blackshaw
- Neurogastroenterology Group, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - S M Brierley
- Centre for Nutritional and Gastrointestinal Diseases, Department of Medicine, University of Adelaide and South Australian Health Medical Health Research Institute, Adelaide, SA, Australia
| | - P A Hughes
- Centre for Nutritional and Gastrointestinal Diseases, Department of Medicine, University of Adelaide and South Australian Health Medical Health Research Institute, Adelaide, SA, Australia
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Martin CM, Félix-Bortolotti M. Person-centred health care: a critical assessment of current and emerging research approaches. J Eval Clin Pract 2014; 20:1056-64. [PMID: 25492282 DOI: 10.1111/jep.12283] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2014] [Indexed: 12/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Person-centred health care is prominent in international health care reforms. A shift to understanding and improving personal care at the point of delivery has generated debates about the nature of the person-centred research agenda. This paper purviews research paradigms that influence current person-centred research approaches and traditions that influence knowledge foundations in the field. It presents a synthesis of the emergent approaches and methodologies and highlights gaps between static academic research and the increasing accessibility of evaluation, informatics and big data from health information systems. FINDINGS Paradigms in health services research range from theoretical to atheoretical, including positivist, interpretive, postmodern and pragmatic. Interpretivist (subjective) and positivist (objectivist) paradigms have been historically polarized. Yet, integrative and pragmatic approaches have emerged. Nevertheless, there is a tendency to reductionism, and to reduce personal experiences to metrics in the positivist paradigm. Integrating personalized information into clinical systems is increasingly driven by the pervasive health information technology, which raises many issues about the asymmetry and uncertainty in the flow of information to support personal health journeys. The flux and uncertainty of knowledge between and within paradigmatic or pragmatic approaches highlights the uncertainty and the 'unorder and disorder' in what is known and what it means. Transdisciplinary, complex adaptive systems theory with multi-ontology sense making provides an overarching framework for making sense of the complex dynamics in research progress. CONCLUSION A major challenge to current research paradigms is focus on the individualizing of care and enhancing experiences of persons in health settings. There is an urgent need for person-centred research to address this complex process. A transdisciplinary and complex systems approach provides a sense-making framework.
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Affiliation(s)
- Carmel M Martin
- Public Health and Primary Care, Trinity College Dublin, Dublin, Co Dublin, Ireland
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Anantha RV, Mazzuca DM, Xu SX, Porcelli SA, Fraser DD, Martin CM, Welch I, Mele T, Haeryfar SMM, McCormick JK. T helper type 2-polarized invariant natural killer T cells reduce disease severity in acute intra-abdominal sepsis. Clin Exp Immunol 2014; 178:292-309. [PMID: 24965554 DOI: 10.1111/cei.12404] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2014] [Indexed: 01/09/2023] Open
Abstract
Sepsis is characterized by a severe systemic inflammatory response to infection that is associated with high morbidity and mortality despite optimal care. Invariant natural killer T (iNK T) cells are potent regulatory lymphocytes that can produce pro- and/or anti-inflammatory cytokines, thus shaping the course and nature of immune responses; however, little is known about their role in sepsis. We demonstrate here that patients with sepsis/severe sepsis have significantly elevated proportions of iNK T cells in their peripheral blood (as a percentage of their circulating T cells) compared to non-septic patients. We therefore investigated the role of iNK T cells in a mouse model of intra-abdominal sepsis (IAS). Our data show that iNK T cells are pathogenic in IAS, and that T helper type 2 (Th2) polarization of iNK T cells using the synthetic glycolipid OCH significantly reduces mortality from IAS. This reduction in mortality is associated with the systemic elevation of the anti-inflammatory cytokine interleukin (IL)-13 and reduction of several proinflammatory cytokines within the spleen, notably interleukin (IL)-17. Finally, we show that treatment of sepsis with OCH in mice is accompanied by significantly reduced apoptosis of splenic T and B lymphocytes and macrophages, but not natural killer cells. We propose that modulation of iNK T cell responses towards a Th2 phenotype may be an effective therapeutic strategy in early sepsis.
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Affiliation(s)
- R V Anantha
- Division of General Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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O'Connor M, Costello L, Murphy J, Prendiville W, Martin CM, O'Leary JJ, Sharp L. 'I don't care whether it's HPV or ABC, I just want to know if I have cancer.' Factors influencing women's emotional responses to undergoing human papillomavirus testing in routine management in cervical screening: a qualitative study. BJOG 2014; 121:1421-9. [PMID: 24690225 DOI: 10.1111/1471-0528.12741] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore emotional responses, and predictors of negative reactions, among women undergoing human papillomavirus (HPV) tests in routine clinical practice. DESIGN Exploratory qualitative interview study. SETTING A large busy colposcopy clinic in a Dublin hospital. SAMPLE Twenty-seven women who had had an HPV DNA test in the previous 6 months following one or more low-grade cytology tests or treatment for cervical intraepithelial neoplasia (CIN). METHODS In-depth semi-structured interviews were conducted. Interview transcripts were analysed using a thematic approach (Framework Analysis). MAIN OUTCOME MEASURES Women's emotional responses and predictors of negative emotional reactions. RESULTS For most women, having a test for high-risk HPV types generated little negative or positive emotional impact. Adverse emotional responses related to HPV infection rather than testing. Factors that influenced whether women experienced negative emotional responses were: concerns over abnormal cytology or diagnosis of CIN; HPV knowledge; awareness of HPV being sexually transmitted; awareness of HPV prevalence; and HPV information needs. Women's concerns about abnormal cytology/CIN dominated all other issues. CONCLUSIONS These qualitative data suggest that in the context of follow up of abnormal cytology or treatment for CIN, the emotional impact of HPV testing may be modest: women's primary concerns at this time relate to abnormal cytology/CIN.
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Affiliation(s)
- M O'Connor
- National Cancer Registry Ireland, Cork Airport Business Park, Cork, Ireland
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Sturmberg JP, Martin CM, Katerndahl DA. Systems and complexity thinking in the general practice literature: an integrative, historical narrative review. Ann Fam Med 2014; 12:66-74. [PMID: 24445105 PMCID: PMC3896540 DOI: 10.1370/afm.1593] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Over the past 7 decades, theories in the systems and complexity sciences have had a major influence on academic thinking and research. We assessed the impact of complexity science on general practice/family medicine. METHODS We performed a historical integrative review using the following systematic search strategy: medical subject heading [humans] combined in turn with the terms complex adaptive systems, nonlinear dynamics, systems biology, and systems theory, limited to general practice/family medicine and published before December 2010. A total of 16,242 articles were retrieved, of which 49 were published in general practice/family medicine journals. Hand searches and snowballing retrieved another 35. After a full-text review, we included 56 articles dealing specifically with systems sciences and general/family practice. RESULTS General practice/family medicine engaged with the emerging systems and complexity theories in 4 stages. Before 1995, articles tended to explore common phenomenologic general practice/family medicine experiences. Between 1995 and 2000, articles described the complex adaptive nature of this discipline. Those published between 2000 and 2005 focused on describing the system dynamics of medical practice. After 2005, articles increasingly applied the breadth of complex science theories to health care, health care reform, and the future of medicine. CONCLUSIONS This historical review describes the development of general practice/family medicine in relation to complex adaptive systems theories, and shows how systems sciences more accurately reflect the discipline's philosophy and identity. Analysis suggests that general practice/family medicine first embraced systems theories through conscious reorganization of its boundaries and scope, before applying empirical tools. Future research should concentrate on applying nonlinear dynamics and empirical modeling to patient care, and to organizing and developing local practices, engaging in community development, and influencing health care reform.
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Affiliation(s)
- Joachim P Sturmberg
- Department of General Practice, Newcastle University, Newcastle, New South Wales, Australia
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Martin CM. Health systems innovation: addressing the dynamics of multilayered 'complex bundles' of knowledge. J Eval Clin Pract 2013; 19:1085-6. [PMID: 24128263 DOI: 10.1111/jep.12089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Carmel M Martin
- Department of Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland; Northern Ontario School of Medicine, Sudbury, Canada
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Reeve J, Blakeman T, Freeman GK, Green LA, James PA, Lucassen P, Martin CM, Sturmberg JP, van Weel C. Generalist solutions to complex problems: generating practice-based evidence--the example of managing multi-morbidity. BMC Fam Pract 2013; 14:112. [PMID: 23919296 PMCID: PMC3750615 DOI: 10.1186/1471-2296-14-112] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 08/02/2013] [Indexed: 11/14/2022]
Abstract
Background A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare? Discussion Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem. We need practice-based evidence to fill this gap. By recognising generalist practice as a ‘complex intervention’ (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem. Summary Answers to the complex problem of multi-morbidity won’t come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.
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Affiliation(s)
- Joanne Reeve
- University of Liverpool, B122 Waterhouse Buildings, 1-5 Brownlow St, Liverpool L693GL, UK.
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Martin CM, Vogel C, Grady D, Zarabzadeh A, Hederman L, Kellett J, Smith K, O' Shea B. Implementation of complex adaptive chronic care: the Patient Journey Record system (PaJR). J Eval Clin Pract 2012; 18:1226-34. [PMID: 22816797 DOI: 10.1111/j.1365-2753.2012.01880.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Patient Journey Record system (PaJR) is an application of a complex adaptive chronic care model in which early detection of adverse changes in patient biopsychosocial trajectories prompts tailored care, constitute the cornerstone of the model. AIMS To evaluate the PaJR system's impact on care and the experiences of older people with chronic illness, who were at risk of repeat admissions over 12 months. DESIGN Community-based cohort study - random assignment into intervention and usual care group, with process and outcome evaluation. STUDY POPULATION Adult and older patients with multiple morbidity, one or more chronic diseases with one or more overnight hospitalizations, and seven or more general practice visits in the past 6 months. COMPLEX INTERVENTION: PaJR lay care guides/advocates call patients and their caregivers. The care guides summarize their semi-structured conversations about health concerns and well-being. Predictive modelling and rules-based algorithms trigger alerts in relation to online call summaries. Alerts are acted upon according to agreed guidelines. ANALYSIS Descriptive and comparative statistics. OUTCOMES Impact on unplanned emergency ambulatory care sensitive admissions (ACSC) with an overnight stay; sensitivity of alerts and predictions; rates of care guides-supported activities. FINDINGS Five part-time lay care guides and a care manager monitored 153 intervention patients for 500 person months with 5050 phone calls. The 153 patients in the intervention group were comparable to the 61 controls. The intervention group reported in 50% of calls that their health limited their social activities; and one-third of calls reported immediate health concerns. Predictive analytics were highly sensitive to risk of hospitalization. ACSC admissions were reduced by 50% compared to controls across the sites. DISCUSSION The initial implementation of a complex patient-centred adaptive chronic care model using lay care guides, supported by machine learning, appeared sensitive to risk of hospitalization and capable of stabilizing illness journeys in older patients with multi-morbidity. CONCLUSION Actions based on alerts produced in this study appeared to significantly reduce hospitalizations. This paves the way for further testing of the model.
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Affiliation(s)
- Carmel M Martin
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada.
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Abstract
It is the 'moral compass', however subtle, that underpins leadership. Leadership, meaning showing the way, demands as much conviction as gentile diplomacy in the discourse with supporters and detractors. In particular, leadership defends the goal by safeguarding its principles from its detractors. The authors writing in the Forum on Complexity in Medicine and Healthcare since its inception are leaders in an intellectual transition to complex systems thinking in medicine and health.
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Abstract
BACKGROUND Everyone wants a sustainable well-functioning health system. However, this notion has different meaning to policy makers and funders compared to clinicians and patients. The former perceive public policy and economic constraints, the latter clinical or patient-centred strategies as the means to achieving a desired outcome. DESIGN Theoretical development and critical analysis of a complex health system model. RESULTS AND CONCLUSIONS We introduce the concept of the health care vortex as a metaphor by which to understand the complex adaptive nature of health systems, and the degree to which their behaviour is predetermined by their 'shared values' or attractors. We contrast the likely functions and outcomes of a health system with a people-centred attractor and one with a financial attractor. This analysis suggests a shift in the system's attractor is fundamental to progress health reform thinking.
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Abstract
RATIONALE Complex adaptive chronic care (CACC) is a framework based upon complex adaptive systems' theory developed to address different stages in the patient journey in chronic illness. Simple, complicated, complex and chaotic phases are proposed as diagnostic types. AIMS To categorize phases of the patient journey and evaluate their utility as diagnostic typologies. METHODS A qualitative case study of two cohorts, identified as being at risk of avoidable hospitalization: 12 patients monitored to establish typologies, followed by 46 patients to validate the typologies. Patients were recruited from a general practitioner out-of-hours service. Self-rated health, medical and psychological health, social support, environmental concerns, medication adherence and health service use were monitored with phone calls made 3-5 times per week for an average of 4 weeks. Analysis techniques included frequency distributions, coding and categorization of patients' longitudinal data using a CACC framework. FINDINGS Twelve and 46 patients, mean age 69 years, were monitored for average of 28 days in cohorts 1 and 2 respectively. Cohorts 1 and 2 patient journeys were categorized as being: stable complex 66.66% vs. 67.4%, unstable complex 25% vs. 26.08% and unstable complex chaotic 8.3% vs. 6.52% respectively. An average of 0.48, 0.75 and 2 interventions per person were provided in the stable, unstable and chaotic journeys. Instability was related to complex interactions between illness, social support, environment, as well as medication and medical care issues. CONCLUSION Longitudinal patient journeys encompass different phases with characteristic dynamics and are likely to require different interventions and strategies - thus being 'adaptive' to the changing complex dynamics of the patient's illness and care needs. CACC journey types provide a clinical tool for health professionals to focus time and care interventions in response to patterns of instability in multiple domains in chronic illness care.
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Affiliation(s)
- Carmel M Martin
- National Digital Research Centre, Department of Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland.
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Abstract
Health systems are increasingly recognised to be complex adaptive systems (CASs), functionally characterised by their continuing and dynamic adaptation in response to core system drivers, or attractors. The core driver for our health system (and for the health reform strategies intended to achieve it) should clearly be the improvement of people's health - the personal experience of health, regardless of organic abnormalities; we contend that a patient-centred health system requires flexible localised decision making and resource use. The prevailing trend is to use disease protocols, financial management strategies and centralised control of siloed programs to manage our health system. This strategy is suggested to be fatally flawed, as: people's health and health experience as core system drivers are inevitably pre-empted by centralised and standardised strategies; the context specificity of personal experience and the capacity of local systems are overlooked; and in line with CAS patterns and characteristics, these strategies will lead to "unintended" consequences on all parts of the system. In Australia, there is still the time and opportunity for health system redesign that truly places people and their health at the core of the system.
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Affiliation(s)
- Joachim P Sturmberg
- Department of General Practice, Monash University, Melbourne, VIC, Australia.
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Abstract
Making sense of complex adaptive clinical practice and health systems is a pressing challenge as health services continue to struggle to adapt to changing internal and external constraints. In this Forum, we begin with Dervin's Sense-Making theories and research in communications. This provides a conceptual and theoretical context for this editions research on comparative complexity of family medicine consultations in the USA, models for adaptive leadership in clinical care and social networking to make sense of health promotion challenges for young people. Finally, a Sense-Making schema is proposed.
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Sturmberg JP, Martin CM. The dynamics of health care reform--learning from a complex adaptive systems theoretical perspective. Nonlinear Dynamics Psychol Life Sci 2010; 14:525-540. [PMID: 20887693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Health services demonstrate key features of complex adaptive systems (CAS), they are dynamic and unfold in unpredictable ways, and unfolding events are often unique. To better understand the complex adaptive nature of health systems around a core attractor we propose the metaphor of the health care vortex. We also suggest that in an ideal health care system the core attractor would be personal health attainment. Health care reforms around the world offer an opportunity to analyse health system change from a complex adaptive perspective. At large health care reforms have been pursued disregarding the complex adaptive nature of the health system. The paper details some recent reforms and outlines how to understand their strategies and outcomes, and what could be learnt for future efforts, utilising CAS principles. Current health systems show the inherent properties of a CAS driven by a core attractor of disease and cost containment. We content that more meaningful health systems reform requires the delicate task of shifting the core attractor from disease and cost containment towards health attainment.
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Abstract
BACKGROUND Metaphors are central to the human understanding of complex issues; through the immediate associations they evoke and frame problems and suggest solutions. Our suggestion of Music in the Park as a metaphor for health systems reform brings to the forefront the environmentally diverse but bounded spaces of health services that offer a variety of attractors within their confines, while pushing into the background organizational and economic concerns. REFLECTIONS Parks, like health services, are embedded in their local landscape, serving their communities, but most importantly parks are public spaces, publically funded, ideally offering universal access and equity and to be shared by all who want to go there. Music, like health, is tangible, technical and scientific, yet ultimately experiential and based on meaning. While it encompasses a wide range of styles and approaches, music making requires as its most important skill active listening which brings with it to be 'in the moment', to take personal risks and to draw energy and inspiration from the participants. Hence 'audiences' are equally active participants because music only has meaning if it internally resonates with the listener and only can exist in what is a co-constructed experience. CONCLUSIONS Music in the Park is a metaphor for primary health care systems based on shared values of experts and unique local communities. Health professionals are players in this arena, who develop and practise the full range of their skills in response to individual and community needs and preferences. Their leadership works through inspiration and empowerment, making patients 'co-producers' of their own health and 'co-shapers' of their health services.
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Abstract
RATIONALE The outputs from vastly expanding health research and knowledge industry with a broadening range of approaches to the synthesis of knowledge provide an impetus to develop complex science and theory-informed knowledge management in health care. Aims To stimulate debate in order to assist health care decision makers to move beyond framing certainty and evidence in purely reductionist terms. OBJECTIVES To locate health, health care and health knowledge systems research using a complex adaptive systems theory framework. Methods An conceptual analysis of pervading methodologies and ways of knowing in health systems research to elucidate a framework in order to inform health care decision making. FINDINGS A living Tree of (Research) Knowledge is proposed, with theoretic and operational frameworks. Branches of the tree are linked to differing evolutionary and developmental processes in order to assist researchers in the ongoing self-organizing of taxonomies, multiple methods and types of knowledge, recognizing the 'lived', developing and adaptive nature of our understandings. CONCLUSIONS It is challenging to determine whither the directions 'knowledge' creation and management should take in complex health systems, beyond a total reliance on reductionism. Yet quality will wither, if knowledge does not pertain to real world contexts.
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Affiliation(s)
- Carmel M Martin
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada.
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Abstract
CONTEXT Four maternity/obstetrical care organizations, representing women, midwives, obstetricians and family doctors conducted interdisciplinary policy research under auspices of four key stakeholder groups. These projects teams and key stakeholders subsequently collaborated to develop consensus on strategies for improved maternity services in Ontario. OBJECTIVES The objective of this study is to evaluate a 2-day research synthesis and consensus building conference to answer policy questions in relation to new models of interdisciplinary maternity care organizations in different settings in Ontario. METHODS The evaluation consisted of a scan of individual project activities and findings as were presented to an invited audience of key stakeholders at the consensus conference. This involved: participant observation with key informant consultation; a survey of attendees; pattern processing and sense making of project materials, consensus statements derived at the conference in the light of participant observation and survey material as pertaining to a complex system. The development of a systems framework for maternity care policy in Ontario was based on secondary analysis of the material. FINDINGS Conference participants were united on the importance of investment in maternity care for Ontario and the impending workforce crisis if adaptation of the workforce did not take place. The conference participants proposed reforming the current system that was seen as too rigid and inflexible in relation to the constraints of legislation, provider scope of practice and remuneration issues. However, not one model of interdisciplinary maternity/obstetrical care was endorsed. Consistency and coherence of models (rather than central standardization) through self-organization based on local needs was strongly endorsed. An understanding of primary maternity care models as subsystems of networked providers in complex health organizations and a wider social system emerged. The patterns identified were incorporated into a complexity framework to assist sense making to inform policy. DISCUSSION Coherence around core values, holism and synthesis with responsiveness to local needs and key stakeholders were themes that emerged consistent with complex adaptive systems principles. Respecting historical provider relationships and local history provided a background for change recognizing that systems evolve in part from where they have been. The building of functioning relationships was central through education and improved communication with ongoing feedback loops (positive and negative). Information systems and a flexible improved central and local organization of maternity services was endorsed. Education and improved communication through ongoing feedback loops (positive and negative) were central to building functioning relationships. Also, coordinated central organization with a flexible and adaptive local organization of maternity services was endorsed by participants. CONCLUSIONS This evaluation used an approach comprising scoping, pattern processing and sense making. While the projects produced considerable typical research evidence, the key policy questions could not be addressed by this alone, and a process of synthesis and consensus building with stakeholder engagement was applied. An adaptive system with local needs driving a relationship based network of interdisciplinary groupings or teams with both bottom up and central leadership. A complexity framework enhanced sense making for the system approaches and understandings that emerged.
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Abstract
Contemporary views hold that health and disease can be defined as objective states and thus should determine the design and delivery of health services. Yet health concepts are elusive and contestable. Health is neither an individual construction, a reflection of societal expectations, nor only the absence of pathologies. Based on philosophical and sociological theory, empirical evidence, and clinical experience, we argue that health has simultaneously objective and subjective features that converge into a dynamic complex-adaptive health model. Health (or its dysfunction, illness) is a dynamic state representing complex patterns of adaptation to body, mind, social, and environmental challenges, resulting in bodily homeostasis and personal internal coherence. The "balance of health" model-emergent, self-organizing, dynamic, and adaptive-underpins the very essence of medicine. This model should be the foundation for health systems design and also should inform therapeutic approaches, policy decision-making, and the development of emerging health service models. A complex adaptive health system focused on achieving the best possible "personal" health outcomes must provide the broad policy frameworks and resources required to implement people-centered health care. People-centered health systems are emergent in nature, resulting in locally different but mutually compatible solutions across the whole health system.
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Affiliation(s)
- Joachim P Sturmberg
- Department of General Practice, Monash University, Australia, and Newcastle University, Australia.
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Hughes PA, Brierley SM, Martin CM, Brookes SJH, Linden DR, Blackshaw LA. Post-inflammatory colonic afferent sensitisation: different subtypes, different pathways and different time courses. Gut 2009; 58:1333-41. [PMID: 19324867 DOI: 10.1136/gut.2008.170811] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Intestinal infection evokes hypersensitivity in a subgroup of patients with irritable bowel syndrome (IBS) long after healing of the initial injury. Trinitrobenzene sulfonic acid (TNBS)-induced colitis in rodents likewise results in delayed maintained hypersensitivity, regarded as a model of some aspects of IBS. The colon and rectum have a complex sensory innervation, comprising five classes of mechanosensitive afferents in the splanchnic and pelvic nerves. Their plasticity may hold the key to underlying mechanisms in IBS. Our aim was therefore to determine the contribution of each afferent class in each pathway towards post-inflammatory visceral hypersensitivity. DESIGN TNBS was administered rectally and mice were studied after 7 (acute) or 28 (recovery) days. In vitro preparations of mouse colorectum with attached pelvic or splanchnic nerves were used to examine the mechanosensitivity of individual colonic afferents. RESULTS Mild inflammation of the colon was evident acutely which was absent at the recovery stage. TNBS treatment did not alter proportions of the five afferent classes between treatment groups. In pelvic afferents little or no difference in response to mechanical stimuli was apparent in any class between control and acute mice. However, major increases in mechanosensitivity were recorded from serosal afferents in mice after recovery, while responses from other subtypes were unchanged. Both serosal and mesenteric splanchnic afferents were hypersensitive at both acute and recovery stages. CONCLUSIONS Colonic afferents with high mechanosensory thresholds contribute to inflammatory hypersensitivity, but not those with low thresholds. Pelvic afferents become involved mainly following recovery from inflammation, whereas splanchnic afferents are implicated during both inflammation and recovery.
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Affiliation(s)
- P A Hughes
- Nerve-Gut Research Laboratory, Hanson Institute, Frome Road, Adelaide SA 5000, Australia
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Biswas R, Joshi A, Joshi R, Kaufman T, Peterson C, Sturmberg JP, Maitra A, Martin CM. Revitalizing primary health care and family medicine/primary care in India--disruptive innovation? J Eval Clin Pract 2009; 15:873-80. [PMID: 19811603 DOI: 10.1111/j.1365-2753.2009.01271.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT India has rudimentary and fragmented primary health care (PHC) and family medicine systems, yet it also has the policy expectation that PHC should meet the needs of extremely large populations with slums and difficult to reach groups, rapid social and epidemiological transition from developing to developed nation profiles. Historically, the system has lacked impetus to achieve PHC. OBJECTIVE To provide an overview of PHC approaches and the current state of PHC and family medicine in India in order to assess the opportunities for their revitalization. METHODS A narrative review of the published and grey literature on PHC, family medicine, Web2.0 and health informatics key papers and policy documents, pertinent to India. OUTCOMES A conceptual framework and recommendations for policy makers and practitioner audiences. FINDINGS PHC is constructed through systems of local providers who address individual, family and local community basic health needs with strong community participation. Successful PHC is a pre-eminent strategy for India to address the determinants of health and the almost chaotic of massive social transition in its institutions and health care sector. There is a lack of an articulated comprehensive framework for the publicly stated goals of improving health and implementing PHC. Also, there exists a very limited education and organization of a medical and PHC workforce who are trained and resourced to address individual, family and local community health and who have become increasingly specialized. However, emerging technology, Health2.0 and user generated health care informatics, which are largely conducted through mobile phones, are co-evolving patient-driven health systems, and potentially enhance PHC and family medicine workforce development. CONCLUSIONS In order to improve health outcomes in an equitable manner in India, there is a pressing need for a framework for implementing PHC. The co-emergence of information technologies accessible to the mass population and user-driven health care provide a potential catalyst or innovation for this transition.
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Affiliation(s)
- Rakesh Biswas
- Department of Medicine, People's College of Medical Sciences, Bhopal, India.
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Sturmberg JP, O'Halloran DE, Jackson C, Mitchell CD, Martin CM. "Barking up the right tree": challenges for health care reform. Med J Aust 2009; 191:64-6. [PMID: 19619084 DOI: 10.5694/j.1326-5377.2009.tb02691.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 05/20/2009] [Indexed: 11/17/2022]
Abstract
Current approaches to health care reform are largely based on the metaphor of imminent flood waves threatening to inundate the health care system. This metaphor reflects the system's preoccupation with disease and disease management in a hospital-centric environment. We suggest that the debate needs to be reframed around health, or more precisely the patient's health experience. Most patients are healthy most of the time, and even those with identifiable morbidities generally regard themselves as being in good health. The majority of people receive most of their care in the community from primary care professionals. An integrated, effective and efficient primary health care system supports continuity of care through a primary care provider and fosters clinical leadership that is supported by other primary health care professionals and medical specialists. Each primary care setting will have its own model that best provides flexible and responsive services to meet its patients' needs and expectations.
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Abstract
PURPOSE The purpose of this paper is to argue the importance of contemporary analysis of the modern social construction of chronicity--encapsulating the world views of the chronically ill, and the medical and health system constructions of chronic disease, through the nature of care for chronic conditions. It is argued that chronic diseases are themselves, socially constructed, despite widely accepted disease classification systems. Thus, there is a need to examine how different ideas have permeated our clinical and health system developments and their social context and vice versa. METHODS We examine historical ideas, theory and evidence about the tensions in social construction of chronic illness by those afflicted and the responses of society, the medical and health professions and increasingly the public and private institutions that shape health care. This is with the background of major differences in the two cultures that create knowledge: those based upon argument and intellectual logic--hermeneutic, and those based upon 'objectivist' empirical science, often called heuristic. Evidence-based medicine (EBM) is the flagship of disease management, increasingly narrative-based medicine and other similar genres are becoming the pragmatic face of social constructions, yet sit in juxtaposition without synthesis. A third culture has emerged of scientific intellectuals who straddle these cultures and in health care their public face is 'mixed methods'. FINDINGS Recent cases of modern ideas about improving chronic care were reviewed. We found that despite developments of social theory, the world view of the chronically ill exerts small influence in health system redesign, apparently dominated by chronic disease models. Confusion remains within health system reforms as to the social construction of chronicity--chronic disease, chronic condition or chronic illness and chronic care transformations. The role of Primary Care remains ambiguous straddling disease and illness. Radical redesign of health systems is taking place without an understanding and discourse about the nature of their construction. Ad hoc eclectism with unquestioning adoption of the dominant EBM paradigm is driving a new health culture based on disease-based performance incentives, which is intrusive beyond the medical model and pays little attention to narratives of illness and even less to the whole social reconstruction of illness and wellness. CONCLUSIONS Health care systems cannot afford to avoid, and should actively embrace the critiques of social theory and analyses in the transformations of health systems to improve chronic care. Creative tensions between empirical and intellectual critique, and a synthetic middle ground are likely to lead to more realistic and innovative approaches spanning the nature of chronicity and the transformation of Primary Care.
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Affiliation(s)
- Carmel M Martin
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada.
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Affiliation(s)
- Joachim P Sturmberg
- Monash University, Melbourne, and The Newcastle University, Newcastle, Australia.
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Affiliation(s)
- Carmel M Martin
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada.
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Hughes PA, Brierley SM, Martin CM, Liebregts T, Persson J, Adam B, Holtmann G, Blackshaw LA. TRPV1-expressing sensory fibres and IBS: links with immune function. Gut 2009; 58:465-6. [PMID: 19211857 DOI: 10.1136/gut.2008.161760] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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