Community-based Chronic Disease Management Research Articles

Impact of a community-based medication delivery program for antihypertensive medications on adherence and blood pressure reduction

Abstract Background Elevated blood pressure (BP) is the leading risk of death globally, and its burden continues to rise, disproportionately so in low- and middle-income countries. Non-adherence to antihypertensive medications is a major cause of uncontrolled hypertension, leading to cardiovascular morbidity and mortality. Ensuring consistent medication access and possession is crucial in addressing non-adherence. Community-based medication delivery is a strategy that can lead to improvement in medication possession, medication adherence, and subsequently BP reduction. Purpose Our program in western Kenya piloted a community medication delivery program for hypertensive patients, aiming to remove structural barriers to medication possession and ensuring consistent access to antihypertensive medications. Here, we reviewed secondary clinical data to evaluate the impact of this program on BP reduction and medication adherence. Methods We conducted a retrospective analysis using clinical records of hypertensive patients who participated in the medication delivery program. Between September 2019 and March 2020, patients who received care from our community-based chronic disease management program also received anti-hypertensive medications delivered to them at their doorstep. We compared differences in self-reported medication adherence and BP reduction between patients who got medication deliveries versus those who did not. Mixed effect models, controlling for baseline measurements, age, gender, and health insurance status were used to analyze outcomes of interest. Results A total of 124 patient records (80.6% female) were reviewed. Baseline systolic blood pressure (SBP) was 155.7 mmHg and baseline self-reported adherence per the Voils DOSE-Nonadherence measure was 2.7, with 1 being perfect adherence and 5 representing poor adherence. 48.4% of patients received at least 1 successful medication delivery. Patients who did not receive any medication deliveries had an SBP increase of 1.5 mmHg relative to baseline, whereas patients who received 1 medication delivery had an SBP reduction of 8 mmHg and patients who received 2 or more medication deliveries had an SBP reduction of 15.2 mmHg (Figure 1). Similarly, change in self-reported medication adherence was poorer in patients who received no medication deliveries (+0.1) versus those who received one medication delivery (−0.5) or 2 or more deliveries (−0.7). Mixed-effect model estimates demonstrated that relative to patients who did not receive any medication deliveries, mean SBP reduction was significantly greater among individuals who did receive medication deliveries (Table 1). Conclusions A community medication delivery program in western Kenya led to improved medication adherence and systolic blood pressure reduction. This is a promising strategy to improve hypertension outcomes for patients with uncontrolled hypertension by removing structural barriers to medication possession. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Purdue University Gloria Franke Pharmacy Practice Advancement Grant Change in blood pressure and adherenceMixed-effect model estimates

Effectiveness and Efficiency of Non-drug Therapy Among Community-Dwelling Adults With Hypertension in China: A Protocol for Network Meta-Analysis and Cost-Effectiveness Analysis.

Introduction: The Chinese government has established a nationwide community-based chronic disease management program since 2009 with hypertension a vital part of it. Though drugs have been proven effective with hypertensive patients, they bring economic burden as well, especially for those who with elevated blood pressure and are potentially eligible for national programs. When the effectiveness of pharmacotherapy-only interventions remains uncertain on these patients, non-pharmacological interventions have demonstrated non-inferior effectiveness and may have economic advantages. To date, there rarely are evidences on the effectiveness and cost-effectiveness of non-pharmacological treatment in comparison with pharmacological interventions for patients with varying severity of blood pressure. This study aims to propose a study for a network meta-analysis and cost-effectiveness analysis to explore what kind of intervention is potentially effective and cost-effective to four specific patient groups, stage I-III hypertensive patients and patients with elevated blood pressure, and to provide recommendations for hypertensive management to Chinese decision makers.Methods: We will systematically search databases (MEDLINE, PubMed, Cochrane Library, etc.,) for randomized controlled trials and observational studies with qualified study design in recent decade that assess the effectiveness of non-pharmacological, pharmacological, or combined intervention aimed at adult populations who are diagnosed with the above four types of hypertension in China. The effectiveness outcomes will include changes in SBP/DBP, rate of comorbidities, mortality, and health related quality of life. We will use network meta-analysis to compare and rank effectiveness of different interventions. Subgroup analyses and meta-regression analyses will be performed to analyze and explain heterogeneity. The economic outcome will include cost-effectiveness based on simulation results from Markov models. Under study perspective of Chinese health system, life-time direct cost will be included.Discussion: This study aims to compare and rank the effectiveness and cost-effectiveness of pharmacological, non-pharmacological and combined interventions for stage I–III hypertensive patients and those who with elevated blood pressure. Compared to existing studies, this comprehensive synthesis of relevant evidences will influence future practice with better efficiency and generalizability for community-based hypertensive management programs in China. The study might also be valuable for other low- and middle-income countries to find their own solutions.PROSPERO registration number: CRD42020151518

Engagement of primary care practice in Australia: learnings from a diabetes care project.

Effective community-based chronic disease management requires general practice engagement and ongoing improvement in care models. This article outlines a case study on contributing factors to insufficient participant recruitment through general practice for an evidence-based diabetes care pilot project. Key stakeholder semi-structured interviews and focus groups were undertaken at cessation of the pilot project. Participants (15 GPs, five practice nurses, eight diabetes educators) were healthcare providers engaged in patient recruitment. Through descriptive analysis, common themes were identified. Four major themes were identified: (1) low perceived need for intervention; (2) communication of intervention problematic; (3) translation of research into practice not occurring; and (4) the service providing the intervention was not widely viewed as a partner in chronic disease care. Engaging GPs in new initiatives is challenging, and measures facilitating uptake of new innovations are required. Any new intervention needs to: be developed with GPs to meet their needs; have considerable lead-in time to develop rapport with GPs and raise awareness; and ideally, have dedicated support staff within practices to reduce the demand on already-overburdened practice staff. Feasible and effective mechanisms need to be developed to facilitate uptake of new innovations in the general practice setting.

Accrued Cost Savings of a Free Clinic Using Quality-Adjusted Life Years Saved and Return on Investment.

Savings garnered through the provision of preventive services is a form of profit for health systems. Free clinics have been using this logic to demonstrate their cost-savings. The Community-Based Chronic Disease Management (CCDM) clinic treats hypertension using nurse-led teams, clinical protocols, and community-based settings. We calculated CCDM's cost-effectiveness from 2007 to 2013 using 2 metrics: Quality-adjusted life years (QALYs) saved and return on investment (ROI). QALYs were calculated using the Clinical Preventive Burden (CPB) score for hypertension care. ROI was calculated by tallying the savings from prevented heart attacks, strokes, and emergency department visits against the total operating costs. Using conservative assumptions for cost estimates, hypertension care resulted in a value of QALYs saved of $711,000 to $2,133,000 and an ROI ratio range of 0.35 to 1.20. Our study shows that when using conservative assumptions to calculate cost-savings, our free clinic did not save money. Cost-savings did occur, but the amount was modest, was less than that of cost-inputs, and was not likely captured by any single health entity. Although free clinics remain a vital health care access point for many Americans, it has yet to be demonstrated that they generate a net savings.

Reaching Urban Poor Hypertensive Patients: A Novel Model of Chronic Disease Care Versus a Traditional Fee-for-Service Approach.

There is a significant disparity in hypertensive treatment rates between those with and without health insurance. If left untreated, hypertension leads to significant morbidity and mortality. The uninsured face numerous barriers to access chronic disease care. We developed the Community-based Chronic Disease Management (CCDM) clinics specifically for the uninsured with hypertension utilizing nurse-led teams, community-based locations, and evidence-based clinical protocols. All services, including laboratory and medications, are provided on-site and free of charge. In order to ascertain if the CCDM model of care was as effective as traditional models of care in achieving blood pressure goals, we compared CCDM clinics' hypertensive care outcomes with 2 traditional fee-for-service physician-led clinics. All the clinics are located near one another in poor urban neighborhoods of Milwaukee, Wisconsin. Patients seen at the CCDM clinics and at 1 of the 2 traditional clinics showed a statistically significant improvement in reaching blood pressure goal at 6 months ( P < .001 and P < .05, respectively). Logistic regression analysis found no difference in attaining blood pressure goal at 6 months for either of the 2 fee-for-service clinics when compared with the CCDM clinics. The CCDM model of care is at least as effective in controlling hypertension as more traditional fee-for-service models caring for the same population. The CCDM model of care to treat hypertension may offer another approach for engaging the urban poor in chronic disease care.

Stratified patient appointment scheduling for mobile community-based chronic disease management programs

ABSTRACTDisease management programs have emerged as a cost-effective approach to treat chronic diseases. Appointment adherence is critical to the success of such programs; missed appointments are costly, resulting in reduced resource utilization and worsening of patients’ health states. The time of an appointment is one of the factors that impacts adherence. We investigate the benefits, in terms of improved adherence, of incorporating patients’ time-of-day preferences during appointment schedule creation and, thus, ultimately, on population health outcomes. Through an extensive computational study, we demonstrate, more generally, the usefulness of patient stratification in appointment scheduling in the environment that motivates our research, a mobile asthma management program. We find that capturing patient characteristics in appointment scheduling, especially their time preferences, leads to substantial improvements in community health outcomes. We also identify settings in which simple, easy-to-use policies can produce schedules that are comparable in quality to those obtained with an optimization-based approach.

Alberta Healthy Living Program–A Model for Successful Integration of Chronic Disease Management Services

The most common presentation of chronic disease is multimorbidity. Disease management strategies are similar across most chronic diseases. Given the prevalence of multimorbidity and the commonality in approaches, fragmented single disease management must be replaced with integrated care of the whole person. The Alberta Healthy Living Program, a community-based chronic disease management program, supports adults with, or at risk for, chronic disease to improve their health and well being. Participants gain confidence and skills in how to manage their chronic disease(s) by learning to understand their health condition, make healthy eating choices, exercise safely and cope emotionally. The program includes 3 service pillars: disease-specific and general health patient education, disease-spanning supervised exercise and Better Choices, Better Health(TM) self-management workshops. Services are delivered in the community by an interprofessional team and can be tailored to target specific diverse and vulnerable populations, such as Aboriginal, ethno-cultural and francophone groups and those experiencing homelessness. Programs may be offered as a partnership between Alberta Health Services, primary care and community organizations. Common standards reduce provincial variation in care, yet maintain sufficient flexibility to meet local and diverse needs and achieve equity in care. The model has been implemented successfully in 108 communities across Alberta. This approach is associated with reduced acute care utilization and improved clinical indicators, and achieves efficiencies through an integrated, disease-spanning patient-centred approach.

Pilot Study of a New Model for Managing Hypertension in an Uninsured Population

For millions of uninsured Americans who have hypertension, quality medical care is too expensive to access with any regularity. The Community-based Chronic Disease Management (CCDM) Clinic was created to deliver clinical care for medically uninsured patients in a setting of low resources and high need. CCDM's model melds nurse-led teams with the chronic disease model and uses evidence-based clinical decision protocols. This new model of care differs from traditional models. CCDM conducted a nonrandomized prospective trial of the effectiveness of this new model of care. The intervention included free education, medications, and laboratory investigations. For hypertensives treated for 6 months and 1 year, national benchmark goals were reached for 45% (50/110, P < .00005) and 56% (43/77, P < .00005) of patients, respectively, compared with 18% and 22% being at goal at initial presentation. The CCDM model may have implications for health service delivery in insured populations as well. Further study is warranted.

Diabetes risk evaluation and microalbuminuria (DREAM) studies: ten years of participatory research with a First Nation’s home and community model for type 2 diabetes care in Northern Saskatchewan

OBJECTIVES: To review the DREAM studies and the role of participatory research using a Home and Community Care model in treating First Nations diabetes.STUDY DESIGN: Population survey, pilot and prospective randomized trial.METHODS: Review documented history of these studies since inception. Collation of all data from the DREAM studies from 1998 to the present, including interviews with all providers and many of the participants.RESULTS: The DREAM studies were a participatory process providing a needs assessment and became the foundation for this First Nation’s Home and Community Care team involvement in providing community-based chronic-disease management. The findings motivated the community to find a process that would lead to needed changes. This participatory research enabled a culturally tailored algorithm of evidence-based management of hypertension and disease management strategies for people with diabetes. These studies demonstrated that in this community the Home and Community Care team could work together with primary care physicians and specialists to prevent the complications of diabetes.CONCLUSIONS: The DREAM studies demonstrated in the first controlled trial that with participatory research a systems change is possible; a chronic-disease management model utilizing a trained multidisciplinary Home and Community Care team and informed patients can lead to lower blood pressure in a Canadian First Nations population with diabetes.