Does mental illness history affect primary care chronic disease management in older adults? A population-based propensity score-matched study

Maintenance pharmacotherapy of mild and moderate COPD: What is the Evidence?

Introduction

A renaissance in primary health care

Management of chronic obstructive pulmonary disease: Moving beyond the asthma algorithm

Background: Chronic obstructive pulmonary disease (COPD) is a progressive disease of the respiratory system characterized by airflow limitation that is not completely reversible and is associated with systemic effects especially of the cardiovascular system. COPD is frequently complicated by acute exacerbations that contribute to physical impairment and increased health care use. As COPD is a chronic lung disease with significant systemic manifestations, it is important to have chronic disease management programs specifically targeting individuals with COPD designed to improve their overall quality of life, reduce the burden of disease and decrease the impact of COPD on daily life. Chronic disease management encompasses a multidisciplinary approach designed to enhance the quality and cost-effectiveness of health care for chronic conditions and has been defined as “an approach to patient care that emphasizes coordinated, comprehensive care along the continuum of disease and across health care delivery systems”. The purpose of this present study is to evaluate the effectiveness of a chronic obstructive pulmonary disease management program implemented at the University of Louisville in 2011. Methods: We conducted a retrospective observational cohort study of COPD subjects using clinical data from medical records and cost data from a claims dataset. Respiratory health was assessed by pulmonary function testing, St. George Respiratory questionnaire, COPD Assessment Test (CAT), 6 minute walk test (6MWT), Modified Medical Research Council (mMRC) dyspnea scale, and BODE index. General measures include Duke Profile for assessing overall health and Patient Health Questionnaire (PHQ-9) for assessing depression. At baseline, chi-square test for categorical variable and t-test for continuous variable was used to check for any difference between the two groups. To check for any longitudinal significant change in quality of life measures like SGRQ, CAT score, mMRC scale, BODE index, six minute walk distance and PFT measures from baseline paired t-test was performed. For each subject, the baseline probability of participation in the disease management program was calculated by the propensity score method using logistic regression analysis. Multiple linear regression analysis was performed to assess the rate of deterioration of various clinical parameters like FEV1 and FVC between two groups. Cost analysis was done by comparing the cost related to COPD among subjects in DMP group versus those under usual care. These costs includes total COPD cost, and also sub-categories of cost like office visit cost, in-patient hospitalization (IPH) cost, out-patient hospitalization (OPH) cost, pharmacy cost, cost related to home care and laboratory cost. Results: A total of 52 subjects were enrolled in the disease management program between February 1st 2011 and December 31st 2013: 37 in 2011, 11 in 2012 and 4 in 2013. The usual care group consists of 662 subjects diagnosed with COPD. There is a significant difference in average age of subjects…

Systematic review of the effects of chronic disease management on quality-of-life in people with chronic obstructive pulmonary disease

Background: In Canada, there is consensus about the need for integrated, team-based care in primary care settings to help manage chronic conditions such as chronic obstructive pulmonary disease (COPD). Currently, there is limited understanding on how to support the continued growth and spread of such models; this is coupled with the fact that there is limited empirical evidence to support this process within chronic disease management. There is a need to understand how to support the implementation and spread of integrated, team-based chronic disease management programs in primary care settings, a process that we call progressive implementation.
 Methods: We studied the supporting and mitigating factors required to successfully implement and spread an integrated, team-based program for COPD management in primary care. We conducted a collective case study using an integrated knowledge translation approach involving key informants and our patient partner throughout the entire research process. Data collection included interviews, living documents, and a focus group. Our study explored an integrated, team-based model of care for COPD known as Best Care COPD (BCC). The BCC program has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants in our research included healthcare providers involved in the delivery of the BCC program.
 Results: We identified mechanisms influencing the spread of BCC and categorized them as foundational (evidence-based program, readiness to implement and a peer-led implementation team), transformative (adaptive process, provider empowerment and embedded evaluation), and enabling mechanisms (provider training, administrative support, role clarity, and patient outcomes) across three different implementation phases. We developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management within primary care settings.
 Conclusions: This study explores the implementation and spread of an integrated team-based COPD management program in primary care settings. Despite using COPD management program in Ontario, Canada as an exemplar, we believe the findings can be applied in other chronic disease contexts in primary care settings around the world. We provide a framework to support progressive implementation of integrated team-based care for chronic diseases with the potential to support patients and providers by understanding how to facilitate the continued growth of appropriate models of care. 
 Next Steps: The rapidly increasing prevalence of chronic diseases emphasizes the need to understand how to spread and sustain appropriate models of care to better support patients and providers. The next phase of this study will seek to understand how to support the sustainability of integrated, team-based chronic disease management programs in a primary care setting.
 Information on Financial Support: This study has received financial support from the Asthma Research Group Inc. and Canadian Institutes of Health Research.

South Africa is facing a complex burden of disease arising from a combination of rapidly growing chronic infectious illness (driven by HIV/AIDS) and non-communicable diseases (NCDs). The extent of this burden has few global parallels and demands an extraordinary response (1). A recent publication of a multi-centre prospective cross-sectional survey of consultations in primary care in four provinces of South Africa: Western Cape, Limpopo, Northern Cape and North West indicated that Hypertension, HIV/AIDS, Type 2 Diabetes and Tuberculosis (TB) were the most common conditions in terms of chronic care visits (2) The unprecedented roll out of antiretroviral treatment (ART) has transformed HIV / AIDS into a chronic disease, as people with HIV are living longer andageing, and are developing non-HIVrelated chronic conditions similar to the rest of the population. Some NCDs are related to HIV infection itself and to the side effects of some of the medicines used to treat HIV infection (3). Providing affordable and effective care to the often large and increasing numbers of people is already an immense challenge but as the burden of chronic diseases both (communicable and NCDs) increases, this will become an even bigger problem requiring a different and innovative approach. Whilst chronic disease management of NCDS and mental health within primary care is and has been provided in primary care for many years, in many instances the health system has put greater emphasis on the relief of acute symptoms to the detriment of prevention and optimal care of chronic conditions. Moreover chronic disease services are primarily run as disease specific entities and hence programmes treat specific diseases rather than the whole person. Where an individual has more than one condition they often need to attend on different days of the week and be seen by a different practitioner with consequences not only for patient care but costs to patient in terms of time and transport. The successful management of chronic diseases requires coordination of services for individuals over an extended time period and across disciplines and is dependent on a strong health system and innovative, robustly supported service delivery models that promote patient empowerment (4). Leveraging on the innovations of the HIV program and utilising South Africa’s recently adopted policy for re-engineering primary health care an integrated chronic disease management (ICDM) World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116681– http://www.ijic.org/ model, based on the WHO health system building blocks was proposed as a vehicle to improve the management of chronic conditions. The aim of the ICDM is to achieve optimal clinical outcomes for patients with chronic communicable and non-communicable diseases in order to respond to the growing burden in an efficient and cost effective manner (5). The ICDM is designed using a Public Health approach to empower the individual to take responsibility for their own health whilst simultaneously intervening at a community/population and health service level. The model was developed through a combination of initial theoretical and academic considerations over a two year period. The ICDM consists of four inter-related phases that are dependent on overarching strong stewardship and ownership at all levels of the health system l The four inter-related phases include: • Facility re-organisation to improve service efficiency. • Clinical supportive management to improve quality of clinical care. • “Assisted “self-support and management of patients through the ward based outreach teams (WBOT) to empower individuals to take responsibility for managing their own conditions and increasing awareness of chronic diseases at the population level • Strengthening of support systems and structures outside the facility to ensure a fully functional and responsive health system. Achieving an integrated chronic care disease management model requires a new way of thinking and acting. It is imperative that this model is piloted at a limited number of sites to assess the feasibility and sustainability whilst simultaneously evaluating the outcomes of chronic patients managed within the model. The lessons gained from the pilot sites can be used to further develop the model and scale up the implementation to saturate all districts in the country.

BackgroundThe increasing number of patients with chronic diseases represents a challenge for health care systems. The Chronic Care Model suggests a multi-component remodelling of chronic disease services to improve patient outcomes. To meet the complex and ongoing needs of patients, chronic disease prevention and management (CDPM) has been advocated as a key feature of primary care producing better outcomes, greater effectiveness and improved access to services compared to other sectors. The objective of this study is to evaluate the adaptation and implementation of an intervention involving the integration of chronic disease prevention and management (CDPM) services into primary health care.Methods/DesignThe implementation of the intervention will be evaluated using descriptive qualitative methods to collect data from various stakeholders (decision-makers, primary care professionals, CDPM professionals and patients) before, during and after the implementation. The evaluation of the effects will be based on a combination of experimental designs: a randomized trial using a delayed intervention arm (n = 326), a before-and-after design with repeated measures (n = 163), and a quasi-experimental design using a comparative cohort (n = 326). This evaluation will utilize self-report questionnaires measuring self-efficacy, empowerment, comorbidity, health behaviour, functional health status, quality of life, psychological well-being, patient characteristics and co-interventions. The study will take place in eight primary care practices of the Saguenay region of Quebec (Canada). To be included, patients will have to be referred by their primary care provider and present at least one of the following conditions (or their risk factors): diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, asthma. Patients presenting serious cognitive problems will be excluded.DiscussionIn the short-term, improved patient self-efficacy and empowerment are expected. In the mid-term, we expect to observe an improvement in health behaviour, functional health status, quality of life and psychological well-being. At the organizational level, the project should lead to coordinated service delivery, improved patient follow-up mechanisms and enhanced interprofessional collaboration. Integration of CDPM services at the point of care in primary care practices is a promising innovation in care delivery that needs to be thoroughly evaluated.Trial registrationClinicalTrials.gov Identifier: NCT01319656

A conceptual framework for the revision of the ICD‐10 classification of mental and behavioural disorders

PurposeTo compare patients with and without a history of mental illness on process and outcome measures in relation to prehospital and emergency surgical care for patients with perforated ulcer.MethodsA nationwide registry-based cohort study of patients undergoing emergency surgery for perforated ulcer. We used data from the Danish Prehospital Database 2016–2017 and the Danish Emergency Surgery Registry 2004–2018 combined with data from other Danish databases. Patients were categorized according to severity of mental health history.ResultsWe identified 4.767 patients undergoing emergency surgery for perforated ulcer. Among patients calling the EMS with no history of mental illness, 51% were identified with abdominal pain when calling the EMS compared to 31% and 25% among patients with a history of moderate and major mental illness, respectively. Median time from hospital arrival to surgery was 6.0 h (IQR: 3.6;10.7). Adjusting for age, sex and comorbidity, patients with a history of major mental illness underwent surgery 46 min (95% CI: 4;88) later compared to patients with no history of mental illness. Median number of days-alive-and-out-of-hospital at 90-day follow-up was 67 days (IQR: 0;83). Adjusting for age, sex and comorbidity, patients with a history of major mental illness had 9 days (95% CI: 4;14) less alive and out-of-hospital at 90-day follow-up.ConclusionOne-third of the population had a history of mental illness or vulnerability. Patients with a history of major mental illness were less likely to be identified with abdominal pain if calling the EMS prior to arrival. They had longer delays from hospital arrival to surgery and higher mortality.

A Note on the Partnership Between Psychiatry and Primary Care

Prevention and treatment of chronic respiratory diseases in China

Background Chronic obstructive pulmonary disease is one of the world’s leading causes of morbidity and mortality, with many low- and middle-income countries still experiencing an increase. Effective management requires a strong primary healthcare system, to prevent, diagnose in a timely way, and manage prevalent disease for a long period of time through to end of life, but this is inadequate in many middle-income countries. The Breathe Well programme was a multinational collaboration between the University of Birmingham, United Kingdom, and partner institutions in four middle-income countries: Brazil, China, Georgia and North Macedonia. This review, conducted at the start of the programme, aimed to set the context for our research programme and future research, health care and policy needs by describing these four national health systems, risk factors, current burden and management of chronic obstructive pulmonary disease patients. Design and methods A descriptive review based on publicly available data identified from MEDLINE, national and international websites, supplemented by local expert opinion. For each of the included middle-income countries, we present and discuss the ability of the healthcare systems to effectively diagnose and manage chronic obstructive pulmonary disease, the barriers and limitations, including history of the healthcare system, organisation and governance, financing and medicines. The health and health care of chronic obstructive pulmonary disease patients are further illustrated by a hypothetical patient case developed with local clinical experts. Results While the sizes and features of the populations differ, the number of doctors tends to be low across most countries, the number of smokers high, the out-of-pocket expenses also high and the provision of diagnosis and management for chronic obstructive pulmonary disease in primary care suboptimal. Primary prevention including smoking cessation is insufficient across the participating countries. Cost and availability of care and medications are common barriers to effective chronic obstructive pulmonary disease management. Limitations This study is not a comprehensive systematic review. It provides a useful broad description of the subject, but we did not seek to produce detailed accounts. Discussion While there is vast diversity in settings and context, some challenges appeared to be shared: a lack of human and material resources in the primary care systems with an apparent power imbalance between primary and secondary care, pushing care burden to secondary care and potentially worsening geographic and economic health inequities. High cost (relative to average earnings) and low accessibility of long-term medications lead to high out-of-pocket expenditure, affecting quality and equity. There is generally suboptimal primary prevention with high smoking rates and high levels of air pollution. Improvement of prevention, diagnosis and management of chronic obstructive pulmonary disease via stronger primary care could help reduce health inequalities. Future work This study provided useful context for prioritising research questions within the Breathe Well programme and beyond. Research recommendations included assessment of resource-effective methods for primary prevention, screening and community-led management of chronic obstructive pulmonary disease cases, as well as mapping the educational needs of primary care staff which were then prioritised by local stakeholders including patients, clinicians, healthcare managers and policy-makers. It will be essential to update information on local context at regular intervals to ensure currency of research plans. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Global Health Research programme as award number 16/137/95.

The current focus on psychological well‐being and the treatment of people experiencing common mental disorder in primary care is of interest to health professionals and economists alike (Centre for Economic Performance Mental Health Policy Group, 2006). This brings with it an important opportunity to consider how services for people living with long term medical conditions may benefit from developments in widening access to psychological therapies. The National Service Framework for Longterm Conditions (DoH, 2005a) aims to improve the quality of life for people living with chronic medical conditions. Further to this, NICE Guidelines for the Management of Chronic Obstructive Pulmonary Disease (COPD) (NICE, 2004a) specifically focuses attention on quality of life issues for COPD sufferers and the influence of co‐morbid mental disorder on the ability of individuals to optimise selfmanagement of their condition. By examining issues relating to co‐morbidity of common mental disorders within the long‐term condition of COPD this paper concerns itself with how the agenda for widening access to psychological therapies delivered through a stepped model of care and the introduction of new mental health workforce roles such as community matrons, case managers and primary care graduate mental health workers (PCGMHWs) provides an opportunity for primary care services to integrate mental health care into chronic disease management for COPD, which in turn may provide a model for the development of services for other long‐term medical conditions.