Chronic Conditions In Primary Care Research Articles

Screening for Unhealthy Alcohol Use Among Patients With Multiple Chronic Conditions in Primary Care

IntroductionUnhealthy alcohol use (UAU) increases risk for and exacerbation of chronic health conditions. As such, screening, prevention, and management of UAU is especially critical to improving health outcomes for patients with multiple physical or mental chronic health conditions (MCC). It is unclear to what extent multiple chronic condition (MCC) status is a barrier to screening for UAU in the primary care setting. We hypothesized that patients with MCC would be at lower odds of being screened for UAU compared with patients with no MCC. MethodsWe performed a secondary analysis of electronic health record data for patients from 67 primary care practices in Virginia (2020-2023). Using the Center for Medicare and Medicaid Services’ chronic disease framework, we classified patients by MCC status: no MCC, physical MCC (P-MCC), mental health MCC (MH-MCC), and physical & mental health MCC (P&MH-MCC). We used multiple logistic regressions with an added practice-level random effect to analyze the relationship between MCC status and odds of receiving an alcohol-related assessment, of being screened for UAU with a U.S. Preventive Services Task Force (USPSTF)-recommended instrument, and of screening positive for UAU within the past 2 years. ResultsWithin a final cohort of n= 11,789, a total of 6796 patients (58%) had MCC (29% P-MCC, 4% MH-MCC, and 25% P&MH-MCC). In all, 69% of patients were screened for UAU, while 16% were screened with a USPSTF-recommended instrument and 7% screened positive for UAU. Relative to those with no MCC, patients with P&MH-MCC had 0.9 times lower odds of receiving any screening for UAU [95% CI: (0.8, 1.0), p = 0.0240], while patients with only P-MCC or only MH-MCC had similar odds. There was no difference in odds of being screened with a USPSTF-recommended instrument based on MCC status. Patients with MH-MCC and P&MH-MCC had 1.8 and 1.5 times greater odds, respectively, of screening positive for UAU [95% CI: (1.3, 2.7), p= 0.0014) and 95% CI: (1.2, 1.8), p=0.0003)]. ConclusionAlthough patients with chronic mental health conditions were more likely to screen positive for UAU than patients without MCC, Virginia primary care patients with P&MH MCC were less likely to receive an alcohol-related assessment during the past 2 years. Given the overall modest rate of screening with a USPSTF-recommended instrument, further efforts are needed to create the conditions for high quality alcohol-related preventive service delivery in primary care, particularly for patients with high complexity and/or mental health conditions.

Common barriers and enablers to the use of non-drug interventions for managing common chronic conditions in primary care: an overview of reviews

BackgroundNon-drug interventions are recommended for chronic condition prevention and management yet are underused in clinical practice. Understanding barriers and enablers to using non-drug interventions may help implement non-drug interventions in primary care. We aimed to conduct an overview of reviews to identify and summarise common barriers and enablers for using non-drug interventions for common chronic conditions in primary care.MethodsWe included qualitative and quantitative reviews that used systematic process or methods to examine barriers and enablers to using non-drug interventions for chronic condition prevention and management in primary care settings. We searched 5 electronic databases (PubMed, Cochrane Database of Systematic Reviews, EMBASE, PsycInfo and CINAHL) from inception to September 2022. Two authors independently screened reviews. One author extracted and deductively coded data to Consolidated Framework of Implementation Research (CFIR) (and where relevant, Theoretical Domains Framework [TDF]). A second author validated 10% of extracted data and coding. Data was synthesised thematically using CFIR and TDF. One author assessed the methodological quality of included reviews using a modified AMSTAR 2 tool, with 10% validated by a second author. We assessed overlap between primary studies in included reviews.ResultsFrom 5324 records, we included 25 reviews, with data predominately from patients. Overall, 130 subthemes (71 barrier and 59 enabler) were identified across 4 CFIR domains (Innovation, Outer Setting, Inner Setting, and Individuals), and all TDF domains. Common barrier and enabler subthemes were identified for CFIR constructs of Innovation Adaptability, Innovation Cost, Innovation Relative Advantage, Local Attitudes, External Pressure, Local Conditions, Relational Connections, Available Resources, and Access to Knowledge and Information. For TDF domains, important barrier and enabler subthemes were identified for Knowledge, Skills, Environmental Context and Resources, Beliefs about Consequences, Reinforcement, and Emotion.ConclusionsWe synthesised reviews to provide new insight into common barriers and enablers for using non-drug interventions to prevent and manage chronic conditions in primary care. The factors identified can inform the development of generalisable implementation interventions to enhance uptake of multiple non-drug interventions simultaneously.Trial RegistrationThis study was registered in PROSPERO (CRD42022357583).

Patients' experiences of and roles in interprofessional collaborative practice in primary care: a constructivist grounded theory study.

This constructivist grounded theory study aimed to (1) explore patients' experiences of and roles in interprofessional collaborative practice for chronic conditions in primary care and (2) consider the relevance and alignment of an existing theoretical framework on patients' roles and based on the experiences of patient advocates. High-quality management of chronic conditions requires an interprofessional collaborative practice model of care considering an individual's mental, physical, and social health situation. Patients' experiences of this model in the primary care setting are relatively unknown. A constructivist grounded theory approach was taken. Interview data were collected from primary care patients with chronic conditions across Australia in August 2020 - February 2022. Interviews were recorded, transcribed verbatim, and thematically analysed by (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation, and (5) theme and sub-theme development. Themes and sub-themes were mapped against an existing theoretical framework to expand and confirm the results from a previous study with a similar research aim. Twenty adults with chronic conditions spanning physical disability, diabetes, heart disease, cancer, autoimmune, and mental health conditions participated. Two themes were developed: (1) Adapting to Change with two sub-themes describing how patients adapt to interprofessional team care and (2) Shifting across the spectrum of roles, with five sub-themes outlining the roles patients enact while receiving care. The findings suggest that patients' roles are highly variable and fluid in interprofessional collaborative practice, and further work is recommended to develop a resource to support greater patient engagement in interprofessional collaborative practice.

Patient-reported measures for integrated care assessment: interprofessional collaboration, self-care and outcomes.

Chronicity is spreading and rapidly becoming a urgent issue also for the complexity of care. 32.2 million of NCD deaths (80%) are due to chronic diseases (1). Every country has been developing strategies to guarantee assistance to chronic patients while ensuring the sustainability of the system. Interprofessional collaboration is among the features to improve the assistance for chronic patients and to reach coordination, appropriateness, and continuity along the care pathways (2,3). Data collection on this topic is still scarce, especially from the point of view of patients themselves. Patient Reported Outcome and Experience Measures (PROMs and PREMs) collected in an integrated way can help in understanding the relationship of experience and outcome along the patient care pathway, thus providing a complete vision of the quality and integration of care from the patient perspective (4).
 This work aims at reporting some preliminary results about the impact of interprofessional collaboration on the health outcomes and self-care capacity of chronic heart failure (CHF) patients. 
 Data from the Observatory on PROMs and PREMs of the Tuscany Region in Italy will be used to explore the hypothesis that interprofessional collaboration can lead to better self-care and outcome scores as reported by patients. The selected sample replied to four questionnaires: one at discharge by the hospital, a first follow-up after 30 days; a second follow-up after 7 months; a final follow-up after 12 months (5). Average scores and deltas for the KCCQ-12 and the SCHFI scales will be used to detect potential differences between patients’ self-care, health status and quality of care according to the reported level of integration between the general practitioner and the specialist.
 132 responses were valid to be analysed. At baseline, 23% of patients declared that their GP and their specialist were in contact to take care of the care pathway, 15% declared they did not know. Differences between scores are not significant for the KCCQ-12 on health status and quality of life. A weak difference emerged for the Self-care Maintenance about daily lifestyle adherence. 
 Further research should be conducted on this topic to understand if these results are linked to a scarce knowledge of patients with respect to the joint work of GPs and specialists or if the interprofessional collaboration is not sufficient to guarantee an improvement of outcomes, at least for CHF patients. Indeed, the same analyses could be repeated on other two chronic populations (e.g. diabetic and IBD patients) which are providing their data that will be available next year.
 
 1.2018. “NCD Countdown 2030: Worldwide Trends in NCD Mortality and Progress towards Sustainable Development Goal Target 3.4.” Lancet 
 2.Pascucci2021. “Impact of Interprofessional Collaboration on Chronic Disease Management.” Health Policy 
 3.Davidson2022. “What Do Patients Experience? Interprofessional Collaborative Practice for Chronic Conditions in Primary Care” BMC Primary Care
 4.Pennucci“Can the Jointly Collection of PROMs and PREMs Improve Integrated Care?” IJIC
 5.Pennucci“Piloting a Web-Based Systematic Collection and Reporting of PROMs/PREMs in Chronic Heart Failure.” BMJ Open

Blood pressure control and treatment burden from comorbidities

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): the National Research Foundation of Korea grants funded by the Korea government (MEST) Background Achieving the optimal target blood pressure is important for patients with hypertension to prevent cardiovascular complications. Adhering to recommended therapeutic regimens is crucial to control the blood pressure. However, patients with non-cardiovascular comorbid conditions along with hypertension may experience difficulty performing adequate self-care of hypertension and achieving the optimal target blood pressure because they need to simultaneously manage hypertension and comorbidities. Treatment burden refers to workloads to manage chronic conditions and their impact. Thus, it is possible that the burden of treatment associated with managing multiple conditions adversely affects blood pressure control. Purpose To examine whether treatment burden was associated with achieving the optimal target blood pressure in patients with hypertension and non-cardiovascular comorbidities. Methods Patients with hypertension and non-cardiovascular comorbidities were recruited and asked to complete the questionnaires via online survey. Treatment burden was measured with the Multimorbidity Treatment Burden Questionnaire. Comorbid conditions that were diagnosed and/or treated were measured with the list developed to document self-reported chronic conditions in primary care. Patients were asked to report their blood pressure readings that were measured most recently within three months. Based on their blood pressure readings, patients were classified into two groups: controlled group with the blood pressure readings of < 140/90 mmHg and uncontrolled group with the blood pressure readings of 140/90 mmHg or above. To determine whether treatment burden was associated with blood pressure group assignment, multivariable logistic regression was used after adjusting for covariates (i.e., age, gender, education levels, employment status, periods since hypertension diagnosis, the number of non-cardiovascular comorbidities, and self-care maintenance of hypertension). Results A total of 280 patients with hypertension and non-cardiovascular comorbidities (52 years old, 33.2% female) were included in this study. Patients had an average of 3 comorbidities (SD 1.3). Of 280 patients, 153 (54.6%) had the blood pressure readings of <140/90 mmHg (i.e., controlled group). The multivariate logistic regression model shows that patients with greater levels of treatment burden were less likely to be in the controlled group after adjusting for covariates (adjusted odds ratio: 0.98, 95% confidence interval: 0.971-0.997). Conclusion We found that treatment burden was negatively associated with achieving the optimal target blood pressure in patients with hypertension and non-cardiovascular comorbidities. It is important for clinicians to assess patients’ burden of treatment associated with managing hypertension and comorbidities when discussing blood pressure management.

Determinants of post-COVID-19 symptoms among adults aged 55 or above with chronic conditions in primary care: data from a prospective cohort in Hong Kong.

Primary care patients, especially those with an older age, are one of the most vulnerable populations for post-COVID-19 symptoms. Identifying predictors of post-COVID symptoms can help identify high-risk individuals for preventive care. Out of 977 primary care patients aged 55 years or above with comorbid physical and psychosocial conditions in a prospective cohort in Hong Kong, 207 patients infected in the previous 5-24 weeks were included. The three most common post-COVID-19 symptoms (breathlessness, fatigue, cognitive difficulty), which lasted beyond the 4-week acute infection period, were assessed using items from the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS), together with other self-reported symptoms. Multivariable analyses were conducted to identify predictors of post-acute and long COVID-19 symptoms (5-24 weeks after infection). The 207 participants had a mean age of 70.8 ± 5.7 years, 76.3% were female, and 78.7% had ≥2 chronic conditions. In total, 81.2% reported at least one post-COVID symptom (mean: 1.9 ± 1.3); 60.9, 56.5 and 30.0% reported fatigue, cognitive difficulty, and breathlessness respectively; 46.1% reported at least one other new symptom (such as other respiratory-related symptoms (14.0%), insomnia or poor sleep quality (14.0%), and ear/nose/throat symptoms (e.g., sore throat) (10.1%), etc.). Depression predicted post-COVID-19 fatigue. The female sex predicted cognitive difficulty. Receiving fewer vaccine doses (2 doses vs. 3 doses) was associated with breathlessness. Anxiety predicted a higher overall symptom severity level of the three common symptoms. Depression, the female sex, and fewer vaccine doses predicted post-COVID symptoms. Promoting vaccination and providing intervention to those at high-risk for post-COVID symptoms are warranted.

Superando las barreras en el abordaje del paciente crónico

At least one in three adults has multiple chronic conditions. The assistance of patients with chronic conditions is mandatory. This is one of the main tasks of the primary care physicians. The approach in these patients is challenging, as there are many barriers at different levels (sanitary system, healthcare professionals and patients). In addition, COVID-19 pandemic has worsened this situation even more. Therefore, it is necessary to take actions that try to improve this state. For this purpose, with the aim to find solutions/recommendations that may be helpful to attain a better diagnosis, treatment and follow-up of patients with chronic diseases, a group of experts of SEMERGEN have tried to identify the problems in the attention to these patients, searching for potential solutions and areas of improvement. The present document has specifically focused on four prevalent chronic conditions in primary care: dyslipidemia, arterial hypertension, chronic venous disease and depression.

Patient advocates' views of patient roles in interprofessional collaborative practice in primary care: A constructivist grounded theory study.

Interprofessional collaborative practice has been shown to be an appropriate model of care for chronic disease management in primary care. However, how patients play a role in this model is relatively unknown. The aim of this constructivist grounded theory focus group study was to explore the perceptions of patient advocates regarding the role of patients in interprofessional collaborative practice for chronic conditions in primary care. Primary data were collected from patient advocates, from public and private Australian organisations and who represent patients with chronic disease in primary care, through focus groups in July-August 2020. Videoconference focus groups were recorded, transcribed verbatim and inductively, thematically analysed using the five-step approach by Charmaz: (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation and (5) theme and sub-theme development. Three focus groups comprising 17 patient advocates with diverse cultural and professional backgrounds participated. Two themes and five sub-themes relating to interprofessional collaborative practice teams were constructed from the data. In theme 1, patients 'shifted across the spectrum of roles' from 'relinquishing control to the team', 'joining the team' to 'disengaging from the team'. The second theme was the need for 'juggling roles' by 'integrating patient role with life roles', and 'learning about the patient role'. The diversity and variability of patient roles as described by patient advocates highlight the challenges of working with people with chronic conditions. The diverse patient roles described by advocates are an important finding that may better inform communication between patients and health professionals when managing chronic conditions. From the health professional perspective, identification of the role of a patient may be challenging. Therefore, future research should explore the development of a tool to assist both patients and health professionals to identify patient roles as they move across the spectrum, with the support of policy makers. This tool should aim to identify and promote patient engagement in interprofessional collaborative practice in primary care settings.

Measuring Health Literacy in Primary Healthcare: Adaptation and Validation of a French-Language Version of the Brief Health Literacy Screening among Patients with Chronic Conditions Seen in Primary Care.

Background: The Brief Health Literacy Screening (BHLS) is a short self-report instrument developed to identify patients with inadequate health literacy. This study aimed to translate the BHLS into French Canadian (BHLS-FCv) and to evaluate its psychometric properties among patients with chronic conditions in primary care. Methods: The BHLS was translated into French using the Hawkins and Osborne’s method. Content validity was evaluated through cognitive interviews. A validation study of the BHLS-FCv was conducted in two primary care clinics in the province of Quebec (Canada) among adult patients with chronic conditions. Psychometric properties evaluated included: internal consistency (Cronbach’s alpha); test–retest reliability (intraclass correlation coefficient); and concurrent validity (Spearman’s correlations with the Health Literacy Questionnaire (HLQ)). Results: 178 participants completed the questionnaire at baseline and 47 completed the questionnaire two weeks later over the telephone. The average score was 13.3. Cronbach’s alpha for internal consistency was 0.77. The intraclass correlation coefficient for test–retest reliability was 0.69 (95% confidence interval: 0.45–0.83). Concurrent validity with Spearman’s correlation coefficient with three subscales of HLQ ranged from 0.28 to 0.58. Conclusions: The BHLS-FCv demonstrated acceptable psychometric properties and could be used in a population with chronic conditions in primary care.

Assessment of functioning in Dutch primary care: Development study of a consultation tool for patients with chronic conditions and multimorbidity.

BackgroundIn primary care, a shift from a disease‐oriented approach for patients with multimorbidity towards a more person‐centred approach is needed.AimTo transform a self‐report questionnaire for patients with chronic conditions in primary care, the Primary Care Functioning Scale (PCFS), into an understandable, visually attractive and feasible consultation tool for patients and health care providers. The consultation tool consists of a web‐based version of the PCFS, which is filled in by the patient and is processed to a feedback report that summarizes and visualizes the main findings. The feedback report can be discussed with the patient to facilitate a more person‐centred conversation for patients with chronic conditions and multimorbidity in general practice.Design and SettingIn this qualitative study, we developed the consultation tool by using design thinking in a participatory developmental process.MethodsIn the first phase, we constructed five different feedback report templates to summarize and display the results of a completed PCFS questionnaire in a series of two expert meetings with patients and general practitioners (GPs). In the second phase, we performed an exploratory qualitative interview study involving dyads of patients with chronic conditions and their practice nurses. In an iterative process, we explored their experiences with the consultation tool.ResultsPatients, as well as GPs, preferred a clear manner of presenting the results of the questionnaire in a feedback report. In 18 interviews with patients and practice nurses during three different interview rounds, we adjusted the feedback report and consultation tool based on the input from patients and practice nurses. After the final interview round, patients and practice nurses consented that the consultation tool was useful for having a more in‐depth consultation about functioning and patients' preferences when integrated into the regularly scheduled consultations.ConclusionWe were able to develop an understandable and feasible consultation tool that is applicable in already existing chronic disease management programmes in general practice in the Netherlands.Patient or Public ContributionTo increase the understandability and feasibility of the consultation tool, we collaborated with end‐users and actively involved patients, GPs and practice nurses in a participatory development process.

What do patients experience? Interprofessional collaborative practice for chronic conditions in primary care: an integrative review

BackgroundImproving the patient experience is one of the quadruple aims of healthcare. Therefore, understanding patient experiences and perceptions of healthcare interactions is paramount to quality improvement. This integrative review aimed to explore how patients with chronic conditions experience Interprofessional Collaborative Practice in primary care.MethodsAn integrative review was conducted to comprehensively synthesize primary studies that used qualitative, quantitative, and mixed methods. Databases searched were Medline, Embase, CINAHL and Web of Science on June 1st, 2021. Eligible studies were empirical full-text studies in primary care that reported experiences or perceptions of Interprofessional Collaborative Practice by adult patients with a chronic condition, in any language published in any year. Quality appraisal was conducted on included studies using the Mixed Method Appraisal Tool. Data on patients’ experiences and perceptions of Interprofessional Collaborative Practice in primary care were extracted, and findings were thematically analyzed through a meta-synthesis.ResultsForty-eight (n = 48) studies met the inclusion criteria with a total of n = 3803 participants. Study quality of individual studies was limited by study design, incomplete reporting, and the potential for positive publication bias. Three themes and their sub-themes were developed inductively: (1) Interacting with Healthcare Teams, subthemes: widening the network, connecting with professionals, looking beyond the condition, and overcoming chronic condition collectively; (2) Valuing Convenient Healthcare, subthemes: sharing space and time, care planning creates structure, coordinating care, valuing the general practitioner role, and affording healthcare; (3) Engaging Self-care, subthemes: engaging passively is circumstantial, and, engaging actively and leading care.ConclusionsPatients overwhelmingly had positive experiences of Interprofessional Collaborative Practice, signaling it is appropriate for chronic condition management in primary care. The patient role in managing their chronic condition was closely linked to their experience. Future studies should investigate how the patient role impacts the experience of patients, carers, and health professionals in this context.Systematic review registrationPROSPERO: CRD42020156536.

Organisational models in primary health care to manage chronic conditions: A scoping review.

Chronic diseases are increasing incessantly, and more efforts are needed in order to develop effective organisational models in primary health care, which may address the challenges posed by the consequent multimorbidity. The aim of this study was to assess and map methods, interventions and outcomes investigated over the last decade regarding the effectiveness of chronic care organisational models in primary care settings. We conducted a scoping review including systematic reviews, clinical trials, and observational studies, published from 2010 to 2020, that evaluated the effectiveness of organisational models for chronic conditions in primary care settings, including home care, community, and general practice. We included 67 international studies out of the 6,540 retrieved studies. The prevalent study design was the observational design (25 studies, 37.3%), and 62 studies (92.5%) were conducted on the adult population. Four main models emerged, called complex integrated care models. These included models grounded on the Chronic Care Model framework and similar, case or care management, and models centred on involvement of pharmacists or community health workers. Across the organisational models, self-management support and multidisciplinary teams were the most common components. Clinical outcomes have been investigated the most, while caregiver outcomes have been detected in the minority of cases. Almost one-third of the included studies reported only significant effects in the outcomes. No sufficient data were available to determine the most effective models of care. However, more complex models seem to lead to better outcomes. In conclusion, in the development of more comprehensive organisational models to manage chronic conditions in primary health care, more efforts are needed on the paediatric population, on the inclusion of caregiver outcomes in the effectiveness evaluation of organisational models and on the involvement of social community resources. As regarding the studies investigating organisational models, more detailed descriptions should be provided with regard to interventions, and the training, roles and responsibilities of health and lay figures in delivering care.

Barriers and facilitators to the implementation of a care program based on the Chronic Care Model for patients with chronic conditions in primary care A systematic review

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Patterns of patients with multiple chronic conditions in primary care: A cross-sectional study.

ObjectiveOur aim was to identify the patterns of multimorbidity among a group of patients who visited primary care in Singapore.MethodsA cross-sectional study of electronic medical records was conducted on 437,849 individuals aged 0–99 years who visited National Healthcare Group Polyclinics from 1 Jul 2015 to 30 Jun 2016 for the management of chronic conditions. Patients’ health conditions were coded with the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), and patient records were extracted for analysis. Patients’ diagnosis codes were grouped by exploratory factor analysis (EFA), and patterns of multimorbidity were then identified by latent class analysis (LCA).ResultsEFA identified 19 groups of chronic conditions. Patients with at least three chronic conditions were further separated into eight classes based on demographics and probabilities of various diagnoses. We found that older patients had higher probabilities of comorbid hypertension, kidney disease and ischaemic heart disease (IHD), while younger patients had a higher probability of comorbid obesity. Female patients had higher probabilities of comorbid arthritis and anaemia, while male patients had higher probabilities of comorbid kidney diseases and IHD. Indian patients presented with a higher probability of comorbid diabetes than Chinese and Malay patients.ConclusionsThis study demonstrated that patients with multimorbidity in primary care could be classified into eight patterns. This knowledge could be useful for more precise management of these patients in the multiethnic Asian population of Singapore. Programmes for early intervention for at-risk groups can be developed based on the findings.

Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Development of a Tool by Adapted Delphi Procedure.

BackgroundLong-term care for patients with chronic diseases poses a huge challenge in primary care. There are deficits in care, especially regarding monitoring and creating structured follow-ups. Appropriate electronic medical records (EMR) could support this, but so far, no generic evidence-based template exists.ObjectiveThe aim of this study is to develop an evidence-based standardized, generic template that improves the monitoring of patients with chronic conditions in primary care by means of an EMR.MethodsWe used an adapted Delphi procedure to evaluate a structured set of evidence-based monitoring indicators for 5 highly prevalent chronic diseases (ie, diabetes mellitus type 2, asthma, arterial hypertension, chronic heart failure, and osteoarthritis). We assessed the indicators’ utility in practice and summarized them into a user-friendly layout.ResultsThis multistep procedure resulted in a monitoring tool consisting of condensed sets of indicators, which were divided into sublayers to maximize ergonomics. A cockpit serves as an overview of fixed goals and a set of procedures to facilitate disease management. An additional tab contains information on nondisease-specific indicators such as allergies and vital signs.ConclusionsOur generic template systematically integrates the existing scientific evidence for the standardized long-term monitoring of chronic conditions. It contains a user-friendly and clinically sensible layout. This template can improve the care for patients with chronic diseases when using EMRs in primary care.

Service utilization and chronic condition outcomes among primary care patients with substance use disorders and co-occurring chronic conditions

BackgroundPatients with a substance use disorder (SUD) often present with co-occurring chronic conditions in primary care. Despite the high co-occurrence of chronic medical conditions and SUD, little is known about whether chronic condition outcomes or related service utilization in primary care varies between patients with versus without documented SUDs. This study examined whether having a SUD influenced the use of primary care services and common chronic condition outcomes for patients with diabetes, hypertension, and obesity. MethodsA longitudinal cohort observational study examined electronic health record data from 21 primary care clinics in Washington and Idaho to examine differences in service utilization and clinical outcomes for diabetes, hypertension, and obesity in patients with and without a documented SUD diagnosis. Differences between patients with and without documented SUD diagnoses were compared over a three-year window for clinical outcome measures, including hemoglobin A1c, systolic and diastolic blood pressure, and body mass index, as well as service outcome measures, including number of encounters with primary care and co-located behavioral health providers, and orders for prescription opioids. Adult patients (N = 10,175) diagnosed with diabetes, hypertension, or obesity before the end of 2014, and who had ≥2 visits across a three-year window including at least one visit in 2014 (baseline) and at least one visit occurring 12 months or longer after the 2014 visit (follow-up) were examined. ResultsPatients with SUD diagnoses and co-occurring chronic conditions were seen by providers more frequently than patients without SUD diagnoses (p's < 0.05), and patients with SUD diagnoses were more likely to be prescribed opioid medications. Chronic condition outcomes were no different for patients with versus without SUD diagnoses. DiscussionDespite the higher visit rates to providers in primary care, a majority of patients with SUD diagnoses and chronic medical conditions in primary care did not get seen by co-located behavioral health providers, who can potentially provide and support evidence informed care for both SUD and chronic conditions. Patients with chronic medical conditions also were more likely to get prescribed opioids if they had an SUD diagnosis. Care pathway innovations for SUDs that include greater utilization of evidence-informed co-treatment of SUDs and chronic conditions within primary care settings may be necessary for improving care overall for patients with comorbid SUDs and chronic conditions.

Adherence to treatment and related factors among patients with chronic conditions in primary care: a cross-sectional study

BackgroundAdherence to treatment, a public health issue, is of particular importance in chronic disease therapies. Primary care practices offer ideal venues for the effective care and management of these conditions. The aim of this study is to assess adherence to treatment and related-factors among patients with chronic conditions in primary care settings.MethodsA cross-sectional study was conducted among 299 adult patients with ≥1 chronic condition(s) and prescribed medication in primary healthcare centers of Spain. The Morisky-Green-Levine questionnaire was used to assess medication adherence via face-to-face interviews. Crude and adjusted multivariable logistic regression models were used to analyze factors associated with adherence using the Multidimensional Model proposed by the World Health Organization — social and economic, healthcare team and system-related, condition-related, therapy-related, and patient-related factors.ResultsThe proportion of adherent patients to treatment was 55.5%. Older age (adjusted odds ratio 1.31 per 10-year increment, 95% CI 1.01–1.70), lower number of pharmacies used for medication refills (0.65, 95% CI 0.47–0.90), having received complete treatment information (3.89, 95% CI 2.09–7.21), having adequate knowledge about medication regimen (4.17, 95% CI 2.23–7.80), and self-perception of a good quality of life (2.17, 95% CI 1.18–4.02) were independent factors associated with adherence.ConclusionsAdherence to treatment for chronic conditions remained low in primary care. Optimal achievement of appropriate levels of adherence through tailored multifaceted interventions will require attention to the multidimensional factors found in this study, particularly those related to patients’ education and their information needs.

How prescribers can use technology to improve patient care

Health information technologies (HITs) have become increasingly used in the NHS and offer prescribers the opportunity to prescribe in a more consistent and reliable way. There is a growing use of electronic prescribing systems, especially in primary care. This will likely reduce prescription errors, but evidence is unclear if it will improve patient outcomes. Clinical decision support systems can reduce variability and alert clinicians when prescriptions could cause patients harm; however, automation bias can create new errors to prescribers who over-rely on the system. HITs can better communication by improving discharge letters, facilitating telehealth appointments and supporting those working in remote settings. Mobile apps offer a way to engage patients in their own care and allow remote monitoring of chronic conditions in primary care, and acute conditions in emergency care settings. There are challenges in realising these benefits, with inconsistent infrastructure and a 10-year delay in realising predicted efficiency savings.

Effectiveness of an mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care: The mWellcare Cluster-Randomized Controlled Trial.

The burden of noncommunicable diseases and their risk factors has rapidly increased worldwide, including in India. Innovative management strategies with electronic decision support and task sharing have been assessed for hypertension, diabetes mellitus, and depression individually, but an integrated package for multiple chronic condition management in primary care has not been evaluated. In a prospective, multicenter, open-label, cluster-randomized controlled trial involving 40 community health centers, using hypertension and diabetes mellitus as entry points, we evaluated the effectiveness of mWellcare, an mHealth system consisting of electronic health record storage and an electronic decision support for the integrated management of 5 chronic conditions (hypertension, diabetes mellitus, current tobacco and alcohol use, and depression) versus enhanced usual care among patients with hypertension and diabetes mellitus in India. At trial end (12-month follow-up), using intention-to-treat analysis, we examined the mean difference between arms in change in systolic blood pressure and glycated hemoglobin as primary outcomes and fasting blood glucose, total cholesterol, predicted 10-year risk of cardiovascular disease, depression score, and proportions reporting tobacco and alcohol use as secondary outcomes. Mixed-effects regression models were used to account for clustering and other confounding variables. Among 3698 enrolled participants across 40 clusters (mean age, 55.1 years; SD, 11 years; 55.2% men), 3324 completed the trial. There was no evidence of difference between the 2 arms for systolic blood pressure (Δ=-0.98; 95% CI, -4.64 to 2.67) and glycated hemoglobin (Δ=0.11; 95% CI, -0.24 to 0.45) even after adjustment of several key variables (adjusted differences for systolic blood pressure: - 0.31 [95% CI, -3.91 to 3.29]; for glycated hemoglobin: 0.08 [95% CI, -0.27 to 0.44]). The mean within-group changes in systolic blood pressure in mWellcare and enhanced usual care were -13.65 mm Hg versus -12.66 mm Hg, respectively, and for glycated hemoglobin were -0.48% and -0.58%, respectively. Similarly, there were no differences in the changes between the 2 groups for tobacco and alcohol use or other secondary outcomes. We did not find an incremental benefit of mWellcare over enhanced usual care in the management of the chronic conditions studied. URL: https://www. gov. Unique identifier: NCT02480062.

The development of an ICF-based questionnaire for patients with chronic conditions in primary care

ObjectivesWe developed a self-reported questionnaire for patients in primary care with chronic conditions aged 50 years or older. The questionnaire supports a more person-centered approach by adopting a biopsychosocial focus on functional status instead of a focus on disease. Study Design and SettingBased on the International Classification of Functioning, Disability and Health (ICF), an ICF Primary Care set for patients with chronic conditions was constructed in three phases. In the first phase, we identified relevant ICF categories for the ICF Primary Care set by using existing ICF sets for chronic health conditions. The ICF Primary Care set was completed by a multidisciplinary expert panel and consisted of 52 ICF categories covering ICF's body functions, activities, participation, environmental factors, and personal factors. In the last phase, we constructed a draft version of the questionnaire by converting the ICF categories from the ICF Primary Care set into questions and corresponding scales. To improve the draft version of the questionnaire, we conducted cognitive interviews with patients with chronic conditions in an iterative process, focusing on the problems patients experienced in answering the items of the questionnaire. Interview analysis was used for assessing the content and construct validity of the questionnaire. ResultsThirty cognitive interviews with patients were conducted in five different interview rounds. In these interviews, we identified 124 problems in the responding process of answering the questionnaire, mostly concerning difficulties with the comprehension of the constructs of the questions. The number of problems reduced from an average of 11 problems per interview in the first round to an average of two problems in the last round. ConclusionConclusion: The final version of the questionnaire demonstrated high content and construct validity (i.e., patients are well capable of describing their functional status in terms of ICF) and is applicable in primary care in the Netherlands.