Care For Chronic Conditions Research Articles

Implementing Measurement-Based Care (MBC) for Mental Health in a Paediatric Hospital Setting

Introduction: Measurement-Based Care (MBC) is the routine, systematic use of validated measures (e.g., patient-reported outcome measures [PROMs]) before or during clinical encounters to inform treatment decision-making. A large body of evidence, including randomized controlled trials, suggest that MBC outperforms usual care in response to treatment, remission rates, time to response and remission for individuals with depression, anxiety and other mental health conditions. MBC is a standard of care for most chronic conditions (e.g., diabetes, hypertension, asthma), however, it is underutilized in pediatric mental healthcare, despite well documented benefits and feasibility. As part of the hospital’s broader mandate to better integrate physical and mental healthcare, the MBC implementation team set out to develop an MBC system for evaluation of mental health concerns across the hospital with the goal to facilitate monitoring and response of mental health metrics at the patient, provider, organizational, and system levels.
 Methods: An environmental scan was conducted to understand the priority areas for health systems’ improvement. Stakeholders engaged in the process were physician leaders, clinical operational directors, clinical staff, Youth and Family Advisory Panel members across hospital departments. The environmental scan and follow-up focus groups (n=57) highlighted the need to prioritize implementation of standardized mental assessment tools hospital-wide for patients at each health system encounter as part of a vision to deliver holistic, integrated care and improve quality of patient care. Early identification of mental health needs of patients across the hospital and the importance of establishing standardized metrics for common mental health conditions were additional key priorities. Hospital surveys highlighted anxiety and depression as the top mental health concerns across the hospital. An extensive review was conducted to identify validated tools available and to understand implementation best practices.
 Learnings: Learnings from our review pointed to some key factors for successful implementation. These included the need for tools that are brief and easy to use, are validated and sensitive to change, are user friendly and visually appealing for the pediatric population and are integrated into the electronic health record with appropriate decision support tools to enable real time review. The need for extensive patient and provider education about the value of MBC and its implementation was also a key learning.
 
 Work in progress & next steps: Work is underway to map out clinical workflows, including ensuring a timely response to results, addressing implementation challenges such as virtual vs. in-person tool completion, and managing accessibility of sensitive data to the patient or their proxy in the electronic health record. Workflows will take an integrated, holistic care approach, whereby, a patient’s care team will action appropriate interventions based on a standardized algorithm that engages an interdisciplinary care team. Voxe, an external, patient-friendly platform to administer the two chosen assessment tools will be trialed. Discussions are underway with Information Management and Technology teams to integrate Voxe and clinical workflows in the hospital’s electronic health record. Evaluation of implementation of MBC in clinical settings will consider both process and outcome measures such as uptake, timely receipt of services, and clinical response.

Improving care for chronic conditions may take longer than expected: Evaluation of the Health Links chronic care flexible funding model of care

Introduction: Current models of care and funding systems in Australia for managing chronic disease are largely designed to be responsive to single episodes of acute care. The Victorian Department of Health developed a flexible funding model which aimed to improve care for patients at high risk of unplanned hospital admissions, many of whom had chronic and complex conditions. The initiative investigated whether the model could remove several barriers that inhibit integrated models of care and promote innovation to produce better outcomes for patients. Four hospital and health services participated in the trial with three acting as control hospitals. Each of the participating hospitals undertook their own unique intervention, ranging from redesigns of existing services to advanced coaching models using tele-care guides.
 Methods: We undertook an analysis of HealthLinks enrolled intervention patient outcomes compared to a usual care patient cohort. In addition, we compared outcomes from participating individual health services compared to control health services. Outcomes measured were inpatient length of stay, number of inpatient admissions and 30-day readmissions, and emergency department (ED) length of stay and number of ED presentations.
 Administrative datasets of enrolled patients were converted into monthly panels where outcomes were summed to a count per patient per month for the period 12-months prior to the trial start date for participating health services and the 1st of July 2016 for control health services and for 24 months after. 
 Results: A total of 2,400 Healthlinks enrolees received an intervention model of care during the two year trial out of 49,000 enrolees.
 Compared to patients from control hospitals there were significantly fewer ED presentations per month (-0.1) and shorter ED lengths of stay (-40 mins), but more admissions per month( 0.03) and longer inpatient lengths of stay (0.2 days) for patients at intervention hospitals. A similar pattern was observed for individual hospital compared to controls.
 Patterns of hospital use varied by health service for intervention patients compared with usual care patients. Compared with usual care patients there were significant increases in ED length of stay at all hospitals; significantly fewer 30-day readmissions per month (–0.004 ) at Hospital C; significantly more hospital admissions per month at hospitals B (0.2) and C (0.1) ; and significantly shorter inpatient lengths of stay for hospital b (-2 days) but longer for hospital D (0.5 days) compared with usual care patients. 
 Discussion: Most outcomes measured in this evaluation showed little effect for those patients directly involved in an intervention apart from hospital and ED length of stay measures for one health service. Patients from flexibly funded health services seemed to have reduced ED presentations and length of stay in the ED; however, it is unclear whether this is because of flexible funding or differences in outcome trajectories before flexible funding commenced. There is an emerging view that the effects on patient outcomes from chronic disease models of care may be more apparent in the longer term, suggesting health policy takes a similar view when trialling new initiatives.
 
 
 
 
 
 
 

"Integration as organising principle to strengthen quality of chronic care: Scoping Review results (First part of work commissioned by the World Health Organization on specifications of quality of care for chronic conditions)"

Introduction & Who Is It For? There is a need to strengthen quality of chronic care to benefit people with chronic conditions (PwCC). Cascades of care for chronic conditions consistently show marked decline from “overall prevalence” to “good control”[1,2]. Qualitative studies demonstrate that user-related barriers redound on care quality, e.g. accessibility (geographically inaccessible, service non-availability), (non-)affordability, and affective concerns (not person-centered)[3,4]. Hence, many do not complete the “journey”: those screened do not return for confirmatory diagnosis, those diagnosed do not return for treatment; and those on treatment are not adherent. The WHO recognizes this and has proposed putting forth financing mechanisms to strengthen chronic care quality. However, there is currently no existing sound conceptualization of good quality chronic care.
 Involvement & Methodology: For a comprehensive overview of dimensions of chronic care quality, a multi-disciplinary team (PwCC, general practitioner, public health/health system/policy researcher, anthropologist, sociologist, health economist) conducted scoping review. We reviewed 48 scientific articles studying implementation of (new/established) models and/or dimensions of chronic care quality. We purposively retrieved 26 grey literature. 
 Results: We retained the Institute of Medicine’s quality aims/dimensions: effectiveness; efficiency; safety; equitability; accessibility, affordability, timeliness; and person-centredness[5]; and added continuity of care. We considered the health system determinants groups: leadership and governance; financing; resources; and service delivery[6]. 
 Learnings: Analysis indicates that acting on determinants would achieve chronic care quality dimensions. Applying integration principles[7] can organize actions. Akin to population-based integrated care models, we envision an integrated health service delivery model for PwCC, including those at risk. This model offers community-based and facility-based chronic care services responsive to population and individual needs, encompassing health promotion, and primary, secondary, tertiary prevention; addressing risks, social determinants; involving different sectors, disciplines; and with virtual integration[8] of care levels/organisations. This way, multi-sectoral strategies and chronic care services at different levels delivered by various healthcare providers are integrated to include population actions, incorporate mechanisms connecting PwCC with various resources, and assure seamless access to all care levels, including informal caregiver- and self-management. Thus, covering all steps of the “journey”. 
 At the same time, functional integration[9] would organize actions on: 
 -Leadership and governance (policies,engagement). PwCC engagement is crucial to co-formulate policies and co-design and co-implement interventions with greater likelihood for success. Multi-sectoral engagement is relevant for co-designing/co-implementing interventions on risks and determinants of chronic conditions.
 -Financing (generation/sharing, [re-]allocation), and 
 -Resources (generation/sharing/augmentation, re-distribution). 
 These integrative approaches can increase efficiency, effectiveness and person-centredness; ensure continuity; feasibly make services equitably accessible; and motivate people to complete the “journey” to prevent/control risks, augment adherence, and achieve good control.
 We previously demonstrated integration of integrated primary diabetes care with other ongoing health care activities in a lower-middle-income country, which improved diabetes care quality[10,11]. 
 Successful integration of “integrated chronic care services” to improve chronic care quality is therefore plausible. Chronic care quality dimensions can then be measured through specific indicators (structures, processes, outcomes) and corresponding financing mechanism(s) put in place. 
 Next Step: The chronic care quality indicators will be finalised through Delphi surveys with various stakeholders from the different WHO regions.

THE BOSTON HOSPITAL-IN-HOME PROGRAM—A LOCAL PERSPECTIVE

Abstract The Hospital-in-Home (HIH) model provides patient centered care, may reduce complications and costs. VA Boston Healthcare System (VABHS) planned its HIH program in 2018 and enrolled its first patient in May 2019. HIH provided care to 45 patients in 2019 which grew to 185 in 2022. The team is comprised of 2 clinicians (a hospitalist physician and a physician assistant), a nurse manager, 5 registered nurses (RN), a social worker and a pharmacist. The program practices complementary HIH (admissions from inpatient care) and substitutive care (all other admissions). At this time, majority of the recruitment comes from the inpatient services, followed by heart failure and primary care clinics. The program catchment area is about 25 miles from the West Roxbury campus of VABHS. A hybrid visit approach is taken for clinician visits - initially, the veteran is seen in person or by video by the clinician on admission to the program. Subsequent visits are done with RN assessments in the home and the clinician conducting the visit by telephone or video. In FY 2021, conditions of patients treated by HIH include congestive heart failure (50%), chronic obstructive pulmonary disease (14%), wound care (6%), diabetes (2%) and other conditions (20%). In FY 2022, the average daily census was 15.9 veterans and average visits per day 4.8. The HIH program outcomes include reduction of bed days of acute care in the hospital and reduction in the use of unnecessary medications through deprescribing which may translate to cost avoidance for the medical center.

Reproductive decision making in women with medical comorbidities: a qualitative study

BackgroundA growing number of reproductive-age women in the U.S. have chronic medical conditions, increasing their risk of perinatal morbidity and mortality. Still, they experience unintended pregnancies at similar rates to low-risk mothers. We have limited understanding of how these individuals consider decisions about pregnancy and contraceptive use. The purpose of this study was to understand factors that influence reproductive decision-making among pregnant women with chronic medical conditions.MethodsWe conducted 28 semi-structured interviews with pregnant women with pre-existing medical conditions admitted to a tertiary maternal hospital to examine factors influencing reproductive decision making. Maternal demographic characteristics, medical history, and pregnancy outcome data were obtained through participant surveys and abstraction from electronic health records. Interview transcripts were coded and analyzed using Dedoose® with both deductive and inductive content analysis.ResultsOut of 33 eligible participants, 30 consented to participate and 28 completed interviews. The majority of participants identified as black, Christian, made less than $23,000 yearly, and had a variety of preexisting medical conditions. Overarching themes included: 1) Perceived risks-benefits of pregnancy, 2) Perceived risks-benefits of birth control, 3) Determinants of contraceptive utilization, and 4) Perceived reproductive self-agency. Contraception was viewed as acceptable, but with concerning physical and psychological side effects. Although some considered pregnancy as a health threat, more experienced pregnancy as positive and empowering. Few planned their pregnancies.ConclusionsPreexisting health conditions did not significantly influence reproductive decision-making. Barriers to birth control use were generally based in patient value-systems instead of external factors. Interventions to improve uptake and use of birth control in this cohort should focus on improving care for chronic health conditions and influencing patient knowledge and attitudes toward contraception.

Patterns of health care interactions of individuals with alcohol use disorder: A latent class analysis

IntroductionGiven the high rates at which individuals with alcohol use disorder (AUD) utilize health care for co-existing conditions, health systems are promising venues for interventions that will facilitate access to AUD treatment. However, how individuals with AUD interact with such systems and, thus, how systems should intervene is unclear. In this study, we seek to identify patterns in how individuals diagnosed with AUD within an academic health system interacted with the system prior to diagnosis. MethodsWe use electronic health records from a single academic health system in a major US metropolitan area to create a deidentified retrospective cohort including all individuals age 18+ diagnosed with AUD 2010–2019 (n = 26,899). Latent class analysis (LCA) identified subgroups defined by aspects of previous system interaction and health status, including having an in-system primary care provider, previous utilization of primary and specialty care, diagnosis setting, payer, and presence of other chronic conditions. We then assessed subgroup differences in demographics and associations with in-system AUD treatment receipt in the year following diagnosis, adjusting for demographics. ResultsThe population was on average 38.6 years old (standard deviation = 15.4) and predominantly male (66.1 %), White (64.5 %), and not of Hispanic/Latino ethnicity (87.8 %). Only 4.7 % received in-system treatment following diagnosis. We deemed the four-class model the optimal LCA model. This model identified subgroups that can be described as 1) average utilization (20.7 % of population), 2) low utilization (54.5 %), 3) high health burden and low utilization (14.2 %), and 4) high health burden and high utilization (10.6 %). Predicted membership in the high health burden and high utilization subgroup and low utilization subgroup were associated with higher and lower odds of treatment receipt, respectively, compared with predicted membership in the average utilization subgroup (odds ratio (OR) for high/high subgroup = 1.21, 95 % confidence interval (CI) = 1.01, 1.27; OR for low subgroup = 0.29 95 % CI = 0.24, 0.34). ConclusionIndividuals diagnosed with AUD within a health system interact with that system in markedly different ways and are unlikely to benefit uniformly from system-based interventions to facilitate treatment. Group-tailored interventions are more likely to have impact and provide returns on investments for systems.

Developing quality measures fornon-pharmacological prevention andrehabilitation inprimary health care forchronic conditions: a consensus study.

Poor health-related behaviours are root causes of a large number of chronic conditions; however, this study is the first to develop guideline-based quality measures targeting health-related behaviours through generic non-pharmacological secondary prevention and rehabilitation in municipal primary health care for persons with chronic conditions. From January 2020 to September 2021, a consensus study was conducted in accordance with the current scientific recommendations for developing guideline-based quality measures. A clinical expert panel (n = 11) was established and included a patient representative, health care professionals, researchers, and key specialists. The process for developing quality measures was led by methodologists and encompassed a modified Research and Development/University of California at Los Angeles (RAND/UCLA) study to evaluate consensus in the expert panel. The consensus recommendations were directed to a steering group including the Danish Ministry of Health, the Danish Regions, and the Local Government Denmark. The expert panel rated 102 clinical practice recommendations. Consensus was demonstrated on 13 quality measures assessing whether the patients are offered participation in and adhere to: self-management, smoking cessation, physical exercise training, nutritional efforts, and preventive consultation on excessive alcohol consumption; whether the patients participate in a closing meeting, whether they are offered follow-up, and whether reasons for dropout are documented. The identified quality measures constitute a framework for assessing the quality of non-pharmacological prevention and rehabilitation in municipal primary health care for persons with chronic conditions. The next steps focus on field testing of the quality measures to refine measure criteria and assess implementation. A close link between clinical practice, the evidence and practice recommendations, the data infrastructure, economic considerations, and national priorities was a key to the consensus process.

Preferences of Patients with Congenital Thrombotic Thrombocytopenic Purpura and Other Chronic Conditions for in-Home Prophylactic Infusions

Background Congenital thrombotic thrombocytopenic purpura (cTTP) is an ultra-rare, life-threatening, thrombotic microangiopathy caused by an inherited deficiency of the von Willebrand factor (VWF)-cleaving enzyme ADAMTS13. Current treatment approaches include replacement therapy with intravenous (IV) infusions of either fresh frozen plasma, solvent/detergent-treated plasma, or factor VIII/VWF concentrates administered in a hospital/clinical setting. There is recent interest in novel treatments for cTTP and other chronic conditions where patients may be able to receive treatment at home with limited risk and a manageable safety profile compared to outpatient treatment. Understanding patient preferences regarding treatment at home vs an outpatient setting could help to inform approaches to patient care for both cTTP and other chronic conditions. Aims The primary objective was to assess stated preferences of patients with either cTTP or another chronic condition requiring treatment with regular IV infusions (listed in Table 1) toward prophylactic infusions administered at home vs in an outpatient setting. Secondary objectives were to estimate the utility and disutility of 7 attributes (listed in Table 2) associated with patient preferences and to assess whether clinical, sociodemographic, or other factors influence patient preferences. Methods This cross-sectional cohort study utilized an online discrete choice experiment survey, in which patients were presented with pairwise choice sets consisting of 7 attributes and their associated levels (listed in Table 2). In the survey, each patient was asked to choose their preferred alternative in a choice set (repeated 16 times) using different combinations of varying attribute levels for all 7 attributes, using an orthogonal experimental design. The survey also included a time trade-off exercise to enable the attribute levels to be adjusted for quality adjusted life years. The survey was conducted in France, Germany, Spain, the UK, and the US. Patients ≥18 years old with either cTTP or another chronic condition (listed in Table 1) who were receiving prophylactic IV infusions for ≥3 months, in either an outpatient setting or a hybrid outpatient and at-home setting, were eligible for inclusion. Treatment frequency ranged from once a week to once every 3 weeks. Data were analyzed using multinomial logit regression models. Results In total, 307 complete patient responses (France, n=18; Germany, n=95; Spain, n=96; UK, n=7; US, n=91) were included in the analyses. Median (range) age was 44.0 (20.0-78.0) years and 25 patients (8.1%) had cTTP ( Table 1). Overall, 137 patients (44.6%) reported an overall preference for receiving infusions at home, 85 patients (27.7%) reported a preference for receiving treatment in a hospital/clinic, and 85 patients (27.7%) reported a preference for receiving treatment via a hybrid outpatient and at-home setting. The majority of patients would prefer either a doctor or a nurse to administer their treatment at home (n=125, 40.7%). Patients placed significantly greater value on certain treatment-setting attributes ( Table 2); being comfortable with the treatment environment was considered the most important attribute. For the ‘convenience and impact on daily life’ attribute, selection of ‘flexibility in scheduling infusions’ was influenced by age (estimate: 0.019, 95% CI: 0.007; 0.032), and whether the patient had been diagnosed >5 years ago vs <1 year ago (estimate: 0.744, 95% CI: 0.255; 1.269). A high proportion of patients (60.9%) were willing to trade 12 months of their lives to receive treatment at home. Also, 59.0% and 56.4% of patients, respectively, were willing to trade 12 months to ensure that complications did not necessitate treatment in a hospital setting and that travelling to a hospital/clinic was not required to receive prophylaxis. Conclusions The majority of patients with cTTP or another chronic condition requiring treatment with regular IV infusions stated that they would prefer to receive treatment at home with support from healthcare providers. A high proportion of patients were also willing to trade 12 months of their lives to receive treatment at home; a limitation of the time trade-off exercise was that the maximum time that could be traded was 12 months. These findings provide insights into the importance of the treatment setting preferences of patients receiving prophylactic infusions.

The Role of Social Isolation on Mediating Depression and Anxiety among Primary Family Caregivers of Older Adults: A Two-Wave Mediation Analysis

BackgroundPrimary family caregivers of older people with chronic care conditions are highly vulnerable to social isolation and psychological strains such as depression and anxiety due to their demanding responsibilities. This study examines how social isolation mediates the relationship between caregiving stress and mental health symptoms of primary family caregivers.MethodsThe analytic sample included 881 primary caregivers of older adults from the 2015 and 2017 National Study of Caregiving (NSOC). Social isolation was measured using a composite structure that includes objective social disconnectedness and subjective loneliness. Two-wave mediation models were estimated to examine longitudinally if social isolation mediated the relationship between caregiving stress (subjective & objective stress) and mental health symptoms (depression & anxiety) of primary caregivers.ResultsThe study findings indicate that both subjective (β = 0.32, p < 0.001) and objective stress (β = 0.21, p = 0.003) have direct effects on depression among primary caregivers. Social isolation was found to only mediate the relationship between objective stress and depression (β = 0.18, p < 0.001). In contrast, no significant direct and indirect pathway was found in the anxiety model.ConclusionsThe study demonstrates the internal mechanism where objective strains of caregiving make family caregivers socially isolated, which in turn leads to increased symptoms of depression. Future interventions and practices aimed at improving the psychological well-being of family caregivers should prioritize strategies aimed at increasing social engagement, particularly for those with heavy caregiver burdens.

Diabetes care components effectively implemented in the ASEAN health systems: an umbrella review of systematic reviews

ObjectivesAssociation of Southeast Asian Nations (ASEAN) is among the hardest hit low-income and middle-income countries by diabetes. Innovative Care for Chronic Conditions (ICCC) framework has been adopted by the WHO...

The impact of health and wellness coaching on patient-important outcomes in chronic illness care: A systematic review and meta-analysis

BackgroundHealth and Wellness Coaching (HWC) may be beneficial in chronic condition care. We sought to appraise its effectiveness on quality of life (QoL), self-efficacy (SE), depression, and anxiety. MethodsWe searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane CENTRAL for randomized trials published January 2005 - March 2023 that compared HWC to standard clinical care or another intervention without coaching. We examined QoL, SE, depression, or anxiety outcomes. Meta-analysis utilizing the random-effects model was used to estimate the pooled standardized mean difference (SMD). ResultsThirty included studies demonstrated that HWC improved QoL within 3 months (SMD 0.62 95 % CI 0.22–1.02, p = 0.002), SE within 1.5 months (SMD 0.38, 95 % CI 0.03–0.73, p = 0.03), and depression at 3, 6, and 12 months (SMD 0.67, 95 % CI 0.13–1.20, p = 0.01), (SMD 0.72, 95 % CI 0.19–1.24, p = 0.006), and (SMD 0.41, 95 % CI 0.09–0.73, p = 0.01) Certainty in the evidence for most outcomes was either very low or low primarily due to the high risk of bias, heterogeneity, and imprecision. ConclusionHWC improves QoL, SE, and depression across chronic illness populations. Future research needs to standardize intervention reporting and outcome collection. Practice ImplicationsFuture HWC studies should standardize intervention components, reporting, and outcome measures, apply relevant chronic illness theories, and aim to follow participants for greater than one year.

The association between patients' frailty status, multimorbidity, and demographic characteristics and changes in primary care for chronic conditions during the COVID-19 pandemic: a pre-post study.

The purpose of this study was to assess the impact of SARS-COV-2 (Severe acute respiratory syndrome coronavirus 2) pandemic on primary care management (frequency of monitoring activities, regular prescriptions, and test results) of older adults with common chronic conditions (diabetes, hypertension, and chronic kidney disease) and to examine whether any changes were associated with age, sex, neighbourhood income, multimorbidity, and frailty. A research database from a sub-set of McMaster University Sentinel and Information Collaboration family practices was used to identify patients ≥65 years of age with a frailty assessment and 1 or more of the conditions. Patient demographics, chronic conditions, and chronic disease management information were retrieved. Changes from 14 months pre to 14 months since the pandemic were described and associations between patient characteristics and changes in monitoring, prescriptions, and test results were analysed using regression models. The mean age of the 658 patients was 75 years. While the frequency of monitoring activities and prescriptions related to chronic conditions decreased overall, there were no clear trends across sub-groups of age, sex, frailty level, neighbourhood income, or number of conditions. The mean values of disease monitoring parameters (e.g. blood pressure) did not considerably change. The only significant regression model demonstrated that when controlling for all other variables, patients with 2 chronic conditions and those with 4 or more conditions were twice as likely to have reduced numbers of eGFR (Estimated glomerular filtration rate) measures compared to those with only 1 condition ((OR (odds ratio) = 2.40, 95% CI [1.19, 4.87]); (OR = 2.19, 95% CI [1.12, 4.25]), respectively). In the first 14 months of the pandemic, the frequency of common elements of chronic condition care did not notably change overall or among higher-risk patients.

A fingertip-type magnetic pulse detection device for unusual monitoring conditions

Wearable devices for continuous non-invasive monitoring of physiological signals are crucial for preventive care and management of chronic conditions. However, these devices are either sensitive to skin conditions or require external stimuli, such as light or electrical excitation, to penetrate the skin for pulse detection. This often results in large motion artifacts and unsuitability for certain skin conditions. Here we demonstrate a simple fingertip-type device which can detect clear pulse signals under a range of conditions, including fingers covered by opaque substances such as a plaster or nail polish, or fingers immersed in water. The structure of the device consists of a pair of magnets and a magnetic sensor. Both experimental and numerical results show that the detected pulsation signals correspond directly to the vibrations induced by blood circulation with negligible influence from modulated magnetic signature of blood. Therefore, this device could be used in conditions which are challenging for existing pulse detectors and might also have its application extended to blood pressure measurement.

Effects of the COVID-19 Pandemic on Primary Health Care for Chronic Conditions in Canada: Protocol for a Retrospective Pre-Post Study Using National Practice-Based Research Network Data.

Since the COVID-19 pandemic began, there have been concerns that interruptions to the health care system may have led to changes in primary care, especially for care of chronic conditions such as diabetes and heart failure. Such changes may have longer term implications for population health. This study aims to describe the impacts of the COVID-19 pandemic on indicators of primary care access, comprehensiveness, and appropriateness among adult patients, as well as on specific indictors of chronic conditions. Additionally, this study aims to determine whether any identified changes were associated with patient sociodemographic characteristics and multimorbidity. This is a retrospective, single-arm, pre-post study using Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data. CPCSSN is a research network supported by a primary care electronic medical record database, comprising over 1500 physicians and nearly 2 million patients. We are examining changes in care (eg, frequency of contacts, laboratory tests and investigations, referrals, medications prescribed, etc) among adults. We will also examine indicators specific to evidence-based recommendations for care in patients with diabetes and those with heart failure. We will compare rates of outcomes during key periods of the pandemic between March 13, 2020, and December 31, 2022, with equal time periods before the pandemic. Differences will be examined among specific subgroups of adults, including by decade of age, number of comorbidities, and socioeconomic status. Regression models appropriate to outcome distributions will be used to estimate changes, adjusting for potential confounders. This analysis is part of a mixed-methods study with a qualitative component investigating how patients with diabetes with or without concurrent heart failure perceived the impact of the pandemic on access to primary care and health care-related decisions. This study was approved by the Hamilton Integrated Research Ethics Board (14782-C). The start date of this study was October 5, 2022, and the prospective end date is January 31, 2024. As of May 2023, the study cohort (n=875,934) is defined, data cleaning is complete, and exploratory analyses have begun. Extended analyses using 2022 data are planned once the new data becomes available. We will disseminate results through peer-reviewed publications and academic conference, as well as creating evidence briefs, infographics, and a video for policy maker and patient audiences. This study will investigate whether the COVID-19 pandemic has resulted in changes in the provision of primary care in Canada and whether these potential changes have led to gaps in care. This study will also identify patient-level characteristics associated with changes in care patterns across the COVID-19 pandemic. Indicators specific to chronic conditions, namely diabetes and heart failure, will also be explored to determine whether there were changes in care of these conditions. ClinicalTrials.gov NCT05813652; https://clinicaltrials.gov/ct2/show/NCT05813652. RR1-10.2196/49131.

A web-based survey on self-management for patients with inflammatory bowel disease in Japan.

Self-management (SMN) is a recognized component of care for chronic conditions, yet its importance in the context of inflammatory bowel disease (IBD) is unclear. This study evaluates the status of SMN and its relationship with quality of life (QOL) in Japanese patients with IBD. A web-based survey was conducted among adult (≥20 years old) Japanese patients with ulcerative colitis (UC) or Crohn's disease (CD). Registered members of an online IBD information platform completed a 45-item survey covering demographics, diet, treatment, physical condition, stress management, financial concerns, support services, and QOL. SMN was operationally defined by dietary and lifestyle behaviours, and contingency analysis was used to test for associated factors. Individual-level contributions to SMN were identified with logistic regression. There were 372 responses to the survey (211 with UC, 161 with CD). Approximately 60% of participants practiced SMN and these patients were 4-24% more likely to report positive QOL than those who did not. SMN was more common in patients with CD than those with UC. SMN practice was also associated with IBD-related hospitalisation/surgery and consultation with others about IBD (e.g. physicians, nurses, patients). The results of this study suggest an association between the practice of SMN and positive QOL in patients with IBD in Japan.

Factors associated with continuity of care in hypertension and type 2 diabetes among forcibly displaced persons in the Bidibidi refugee settlement in Uganda: Protocol for a cross-sectional, mixed-methods study.

Non-communicable diseases in humanitarian settings are generally under-researched, particularly in Africa and have been called a neglected crisis. Little is known about factors affecting access to and (dis)continuity of care for chronic conditions, such as hypertension (HTN) and type 2 diabetes among forcibly displaced persons (FDPs) in Uganda. To investigate factors affecting access to and (dis)continuity of HTN and/or type 2 diabetes care among FDPs in the Bidibidi refugee settlement, Uganda. A sequential explanatory mixed-methods design incorporating methodological and investigator triangulation will be conducted. The study aims to employ a community-based participatory research approach to equitably engage community members, researchers, and other stakeholders in the research process, recognising and maximising their diverse contributions. In phase 1, the quantitative arm of the study, 960 FDPs with HTN and/or type 2 diabetes will be interviewed about their sociodemographic characteristics, health status, migration experiences, social capital, and awareness, treatment, and control of these diseases. Participants will be purposively recruited from phase 1 as well as village health teams, healthcare providers, and policymakers to participate in phase 2, the qualitative study, in order to gain more insight into how mobility and social factors affect (dis)continuity of care among FDPs with HTN and/or type 2 diabetes. The findings from phase 1 and phase 2 of the study will be integrated through a triangulation process to provide a more holistic and comprehensive insight into the factors affecting access to and (dis)continuity for HTN and/or type 2 diabetes care among FDPs. Understanding these factors is expected to pave the way for conceptualizing health-enabling environments and strengthening health systems for FDPs with chronic conditions. It is anticipated that the study will generate baseline evidence that might be beneficial in developing and implementing HTN and diabetes care models for FDPs in the region.

Implementing Digital Cognitive-Behavioral Therapy for Major Depressive Disorder in Routine Psychiatric Appointments: A Pilot Project in a Rural Population.

Psychotherapy is well-established as an effective treatment for major depressive disorder (MDD). However, many individuals with MDD in rural areas of the United States do not have access to psychotherapy. Self-management (SM) strategies are now the standard of care for chronic medical conditions and may be a viable alternative for individuals without access to psychotherapy. The current article describes the implementation of a 13-week pilot project to integrate digital cognitive-behavioral therapy (dCBT) SM programs into routine psychiatric advanced practice nurse (APN) telehealth appointments in the rural United States. Eight participants completed the project. The project did not meet the benchmark of 20 participants to improve access to treatment; however, one half (n = 4) of participants reported clinically significant improvement in MDD symptoms over 6 weeks. For clients without access to psychotherapy, dCBT SM programs can be effective in improving individual client outcomes when implemented by APNs in routine telehealth appointments. [Journal of Psychosocial Nursing and Mental Health Services, 61(10), 44-51.].

Review of “Prisons and Health in the Age of Mass Incarceration”

In Prisons and Health in the Age of Mass Incarceration, Jason Schnittker, Michael Massoglia, and Christopher Uggen provide a foundational and comprehensive understanding of how incarceration creates and exacerbates health disparities in the United States. This book describes how incarceration, an adverse event that is disproportionately experienced among vulnerable population groups including people of color and the poor, is a social determinant of health and wellbeing. The authors draw on more than a decade of research—much of it their own—to provide a thorough understanding of the repercussions of incarceration for people confined in carceral facilities, people reentering their families and communities after confinement, and the families and communities of currently and formerly incarcerated people. One innovative strength of this book is its focus on the paradoxical relationship between prisons and health, a paradox the authors introduce at the beginning of the book and reference throughout. The authors describe how correctional facilities are responsible for providing residents both punishment and health care (and how these two responsibilities often conflict). Medical professionals who work in prisons are responsible for upholding the conditions of confinement (such as solitary confinement, a form of segregation known to be quite damaging to mental health) and simultaneously providing care for acute and chronic physical and mental health conditions. People in prison, while enduring a loss of liberty and other rights, have a constitutional right to a particular standard of health care. It is this paradox that serves as a backdrop for understanding the relationship between incarceration and health. In highlighting this paradox, the book does a phenomenal job of describing specific aspects of health care in carceral facilities, an important descriptive point that is missing from most research on this topic. The authors describe, for example, the medical professionals who work in these facilities and the process for receiving care in these facilities. The result is a sobering assessment of the inadequate and often substandard healthcare services available to incarcerated people. The authors also describe the process (and corresponding difficulties) of receiving physical and mental health care after release from prison, which provides an even more sobering assessment of the US health care system for vulnerable groups. These accounts highlight how the health care needs of this vulnerable population are routinely ignored or overlooked.

Clinical Validity of the PROMIS Healthcare Engagement 8-Item Short Form.

Healthcare engagement is a key measurement target for value-based healthcare, but a reliable and valid patient-reported measure has not yet been widely adopted. To assess the validity of a newly developed patient-reported measure of healthcare engagement, the 8-item PROMIS Healthcare Engagement (PHE-8a). Prospective cohort study of the association between healthcare engagement and quality of care over 1 year. We fit mixed effects models of quality indicators as a function of engagement scores, adjusting for age, race/ethnicity, rural residence, and risk scores. National stratified random sample of 9552 Veterans receiving Veterans Health Administration care for chronic conditions (hypertension, diabetes) or mental health conditions (depression, post-traumatic stress disorder). Patient experience: Consumer Assessment of Health Plans and Systems communication and self-management support composites; no-show rates for primary care and mental health appointments; use of patient portal My HealtheVet; and Healthcare Effectiveness Data and Information Set electronic quality measures: HbA1c poor control, controlling high blood pressure, and hyperlipidemia therapy adherence. Higher engagement scores were associated with better healthcare quality across all outcomes, with each 5-point increase (1/2 standard deviation) in engagement scores associated with statistically significant and clinically meaningful gains in quality. Across the continuum of low to high engagement scores, we observed a concomitant reduction in primary care no-show rates of 37% and 24% for mental health clinics; an increased likelihood of My HealtheVet use of 15.4%; and a decreased likelihood of poor diabetes control of 44%. The PHE-8a is a brief, reliable, and valid patient-reported measure of healthcare engagement. These results confirm previously untested hypotheses that patient engagement can promote healthcare quality.

Interdisciplinary behavioral health provider perceptions of implementing the Collaborative Chronic Care Model: an i-PARIHS-guided qualitative study

BackgroundThe evidence-based Collaborative Chronic Care Model (CCM), developed to help structure care for chronic health conditions, comprises six elements: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. As the CCM is increasingly implemented in real-world settings, there is heightened interest in understanding specific influences upon implementation. Therefore, guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we (i) identified innovation-, recipient-, context-, and facilitation-related influences on CCM implementation and (ii) assessed the influences’ relationship to each CCM element’s implementation.MethodsUsing semi-structured interviews, we examined interdisciplinary behavioral health providers’ experiences at nine VA medical centers that implemented the CCM. We used i-PARIHS constructs as a priori codes for directed content analysis, then analyzed the data for cross-coding by CCM element and i-PARIHS construct.ResultsParticipants (31 providers) perceived the CCM innovation as enabling comprehensive care but challenging to coordinate with existing structures/procedures. As recipients, participants recounted not always having the authority to design CCM-consistent care processes. They perceived local leadership support to be indispensable to implementation success and difficult to garner when CCM implementation distracted from other organizational priorities. They found implementation facilitation helpful for keeping implementation on track. We identified key themes at the intersection of i-PARIHS constructs and core CCM elements, including (i) the CCM being an innovation that offers a formal structure to stepping down care intensity for patients to encourage their self-management, (ii) recipients accessing their multidisciplinary colleagues’ expertise for provider decision support, (iii) relationships with external services in the community (e.g., homelessness programs) being a helpful context for providing comprehensive care, and (iv) facilitators helping to redesign specific interdisciplinary team member roles.ConclusionsFuture CCM implementation would benefit from (i) facilitating strategic development of supportive maintenance plans for patients’ self-management, (ii) collocating multidisciplinary staff (on-site or virtually) to enhance provider decision support, (iii) keeping information on available community resources up to date, and (iv) making clearer the explicit CCM-consistent care processes that work roles can be designed around. This work can inform concrete tailoring of implementation efforts to focus on the more challenging CCM elements, which is crucial to better account for multiple influences that vary across diverse care settings in which the CCM is being implemented.