Disease Management In Primary Care Research Articles

Chronic Disease Management in Primary Care: A Cross-Sectional Study in Türkiye

Objective: The aim of our study was to evaluate the chronic disease management of family physicians and family health workers and to examine their views on the Disease Management Platform (DMP) and the usability of this platform. 
 Material and Methods: This study is a descriptive cross-sectional type of study. The universe of the study consisted of family physicians and family health workers working in family health centers (FHC) in our country. Sociodemographic data, chronic disease management practices, questions about DMP, System Usability Scale (SUS) were asked. 
 Results: Of the participants 19.0% can make using the DMP system a part of their routine work. The percentage of those who thought that the biggest obstacle to the use of the DMP was the waste of time was 79.4%. The SUS scores of the participants who knew the number of obese, diabetic and hypertensive patients registered in their unit were also significantly higher (p

Role of cultural brokering in advancing holistic primary care for diabetes and obesity: a participatory qualitative study

ObjectivesDiabetes and obesity care for ethnocultural migrant communities is hampered by a lack of understanding of premigration and postmigration stressors and their impact on social and clinical determinants of health...

The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach

Governments are investing in primary care policies that support chronic disease management. Large scale population-based evaluations are lacking. We aim to determine the effectiveness of government-funded chronic disease management policies to improve long-term outcomes (survival, hospital presentations, and preventive medication adherence) following stroke/Transient Ischemic Attack (TIA). Using a population-based cohort we utilized the target trial methodology. Participants were identified through the Australian Stroke Clinical Registry (January 2012-December 2016) from 42 hospitals in the states of Victoria and Queensland and linked with state and national hospital, primary care, pharmaceutical, aged care, and death datasets. Registrants living in the community, not receiving palliative care and who survived to 18 months following stroke/TIA were included. The comparison was a Medicare claim for policy-supported chronic disease management, 7-18 months following stroke/TIA versus usual care. Outcomes were modelled using multi-level, mixed-effects inverse probability of treatment weighted regression. 12,368 registrants were eligible (42% female, median age 70 years, 26% TIA), 45% had a chronic disease management claim. The difference in mean outcomes for participants with a claim, compared to those without, showed a 26% lesser mortality rate (adjusted hazard ratio [aHR]: 0.74, 95% confidence interval [CI]: 0.62, 0.87) and a greater adjusted Odds Ratio [aOR] of being adherent with preventive medications: antithrombotics (aOR: 1.16, 95% CI: 1.07, 1.26); lipid-lowering (aOR: 1.23, 95% CI: 1.13, 1.33). Impacts on hospital presentations were variable. Government policies that financially support primary care physicians to provide structured chronic disease management improve survival in the long-term following stroke/TIA. National Health and Medical Research Council Australia.

OPTIMA FORMA – Towards a patient-centred multimorbidity approach for chronic disease management in primary care

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 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Experiences of German health care professionals with spiritual history taking in primary care: a mixed-methods process evaluation of the HoPES3 intervention.

Spiritual needs gain importance in old age but are often ignored in health care. Within the 'Holistic care program for elderly patients to integrate spiritual needs, social activity and self-care into disease management in primary care (HoPES3)' a complex intervention was evaluated in a cluster-randomized trial. The aim of this study was to explore the acceptability, feasibility, benefits, and harms of a spiritual history taken by general practitioners (GPs) as part of the complex intervention. In this mixed-methods study telephone interviews with 11 German GPs and 12 medical assistants (MAs) of the HoPES3 intervention group were conducted and analysed using a content-analytical approach. Furthermore, GPs were asked to complete a questionnaire after each spiritual history. One hundred and forty-one questionnaires from 14 GPs were analysed descriptively. GPs considered the spiritual history very/quite helpful for the patient in 27% (n= 38) and very/quite stressful in 2% (n = 3) of the cases. Interviews indicated that GPs found discussing spiritual history easier than anticipated. GPs and MAs saw a difficulty in that many patients associated spirituality with religion or church and reacted with surprise or rejection. Benefits for patients were seen in the opportunity to talk about non-medical topics, and increased awareness of their own resources. Benefits for GPs mainly related to information gain and an intensified patient-physician relationship. A spiritual history in general practice has the potential to reveal important information about patients' lives and to improve the patient-physician relationship. Implementation barriers identified in this study have to be considered and addressed.

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.

The impact of COVID-19 on chronic disease management in primary care: lessons for Australia from the international experience.

The impact of COVID-19 on chronic disease management in primary care: lessons for Australia from the international experience.

Challenges and Strategies for Improving COPD Primary Care Services in Quebec: Results of the Experience of the COMPAS+ Quality Improvement Collaborative.

IntroductionManagement of chronic obstructive pulmonary disease (COPD) remains a challenge in primary care and multiple barriers can limit implementation of COPD guidelines. Since 2016, a quality improvement (QI) collaborative, called COMPAS+, has been implemented across the province of Quebec (Canada) to support improvement of chronic disease management in primary care. The aim of this study was to describe the main COPD quality problems reported by participating teams and the strategies they proposed and implemented to improve COPD primary care services in Quebec.MethodsSixteen sites in four different regions of Quebec were engaged in the COMPAS+ intervention to improve primary care services delivered to people living with COPD. A total of 14 workshop reports, 31 QI action plans and 4 regional final reports underwent content analysis. Key COPD quality problems were first identified and, for each of them, root causes were classified according to the domains and constructs of the Consolidated Framework for Implementation Research. Proposed strategies were organized according to the intervention function types described in the Behavior Change Wheel.ResultsFour key COPD quality problems were identified: 1) lack of organization/coordination of COPD services, 2) lack of screening services coordination, 3) lack of interprofessional communication and collaboration and 4) lack of treatment adherence. Main root causes explaining these quality gaps were 1) lack of awareness of COPD, 2) lack of professional knowledge, 3) lack of definition of professional roles, 4) lack of resources and tools for COPD prevention, diagnosis, and follow-up, 5) lack of communication tools, 6) lack of integration of the patient-as-partner approach, and 7) lack of adaptation of patient education to their specific needs. Multiple strategies were proposed to improve healthcare professionals’ education and interprofessional collaboration and communication.ConclusionQI collaborative activities can support achieving understanding of QI challenges healthcare organizations face to improve COPD services.

Primary care disease management for venous leg ulceration\u2014study protocol for the Ulcus Cruris Care [UCC] randomized controlled trial (DRKS00026126)

BackgroundVenous leg ulcers (VLU) have a prevalence of 1–2% in developed countries, and affected patients are severely and long-term impaired in daily activities, work, and social participation. Evidence-based outpatient treatment based on compression therapy is frequently not implemented. The “Ulcus Cruris Care” project was established to develop a disease management concept to improve outpatient treatment for patients with VLU in German primary care. For this purpose, a multifaceted intervention was conceived consisting of an online training for general practitioners and medical assistants, standardized treatment recommendations, e-learning and print-based information for patients, and a software support for case management. The main aims of the Ulcus Cruris Care intervention are to promote standardized treatment according to current scientific knowledge, to facilitate case management for VLU patients exerted by medical assistants, and to support patient education and participation in the treatment process. The UCC trial was designed to evaluate the effectiveness of the Ulcus Cruris Care intervention.MethodsThe UCC trial is a prospective cluster-randomized controlled multicenter trial. Fifty GP practices are intended to be recruited and randomized 1:1 to intervention or control arm. Patients with venous leg ulcers will be recruited by participating GP practices, to include a total of 63 patients in each arm. The primary outcome is time to ulcer healing. Secondary outcomes comprise number and sizes of ulcers, recurrence, pain intensity according to the visual analog scale, health-related quality of life according to EQ-5D-5L, depressiveness according to Patient Health Questionnaire (PHQ-9), patient satisfaction according to the Patient Assessment of Chronic Illness Care (PACIC-5A) query, and adherence to VLU treatment. The outcome analysis of the UCC trial is accompanied by a health economic analysis and a process evaluation.DiscussionThe UCC trial will evaluate whether the Ulcus Cruris Care intervention may lead to faster wound healing, higher health-related quality of life, and lower use of medical resources. If the intervention turns out to have a positive impact on assessed outcomes, comprehensive implementation in primary care may be considered.Trial registrationThe trial protocol (version 1 as of July 19, 2021) has been registered in the German Clinical Trials Register on August 30, 2021 (DRKS00026126).

Evaluation of a Spiritual History with Elderly Multi-Morbid Patients in General Practice-A Mixed-Methods Study within the Project HoPES3.

Background: The “Holistic Care Program for Elderly Patients to Integrate Spiritual Needs, Social Activity and Self-Care into Disease Management in Primary Care” (HoPES3) examines the implementation of a spiritual history (SH) as part of a multifaceted intervention in German general practices. While the effectiveness of the interventions was evaluated in a cluster-randomized trial, this article investigates the patients’ views concerning the acceptability of the SH and its effects. Methods: A mixed-methods study was conducted in which 133 patients of the intervention group filled in a standardized questionnaire after the intervention. Later, 29 of these patients took part in qualitative semi-standardized interviews. Results: According to the survey, 63% (n = 77) of patients found the SH helpful. In the interviews, however, many indicated that they either kept the conversation brief or declined the offer to talk about spirituality. Contents of longer conversations referred to difficult life events, personal sources of strength, and experiences with religious institutions. Many patients who had a longer conversation about spirituality reported that their relationship with their general practitioner (GP) had improved. Almost all patients recommended integrating a personal conversation of this kind into primary care. Conclusions: The SH seems to be a possible ‘door opener’ for a trusting doctor-patient relationship, which can then be built upon.

Online clinical pathway for chronic kidney disease management in primary care: a retrospective cohort study

BackgroundClinical pathways aim to improve patient care. We sought to determine whether an online chronic kidney disease (CKD) clinical pathway was associated with improvements in CKD management.MethodsWe conducted a retrospective pre/post population-based cohort study using linked health data from Alberta, Canada. We included adults 18 years or older with mean estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2. The primary outcome was measurement of an outpatient urine albumin creatinine ratio (ACR) in a 28-day period, among people without a test in the prior year. Secondary outcomes included use of guideline-recommended drug therapies (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statins).ResultsThe study period spanned October 2010 to March 2017. There were 84 independent 28-day periods (53 pre, 31 post pathway implementation) including 345,058 adults. The population was predominantly female (56%) with median age 77 years; most had category 3A CKD (67%) and hypertension (82%). In adjusted segmented regression models, the increase in the rate of change of ACR testing was greatest in Calgary zone (adjusted OR 1.19 per year, 95% CI 1.16–1.21), where dissemination of the pathway was strongest; this increase was more pronounced in those without diabetes (adjusted OR 1.25 per year, 95% CI 1.21–1.29). Small improvements in guideline-concordant medication use were also observed.ConclusionsFollowing implementation of an online CKD clinical pathway, improvements in ACR testing were evident in regions where the pathway was most actively used, particularly among individuals without diabetes.

Training General Practitioners and Medical Assistants Within the Framework of HoPES3, a Holistic Care Program for Elderly Patients to Integrate Spiritual Needs, Social Activity, and Self-Care into Disease Management in Primary Care.

BackgroundThis study presents a concept for training general practitioners (GPs) in taking a spiritual history. In the same workshop, medical assistants (MAs) were trained in counselling elderly, chronically ill patients on social activities and home remedies. After the training, GPs and MAs will apply the acquired skills in their practices within the scope of the HoPES3 intervention study, which aims at raising patients’ self-efficacy.MethodsSixteen GPs and 18 MAs were trained in a 5-hour workshop and completed an evaluation questionnaire.ResultsAll participants reported great satisfaction. In particular, 85% of GPs (n=11) affirmed increased capacity to address patients’ spiritual needs. About 88% (n=15) of MAs were satisfied with the training, yet expressed difficulties in integrating theoretical knowledge into daily professional routine.DiscussionWhile the evaluation of the workshop is promising, the results of the randomized-controlled trial evaluating the effectiveness of the complete HoPES3 intervention have to be awaited.ConclusionTo our knowledge, this is the first interdisciplinary, holistic care training in primary care in Germany. It fosters GPs’ and MAs’ competency in providing a proactive support in spirituality, social activities, and home remedies to their patients. If the concept proves to be effective, it could be integrated into existing care models and curriculums and provide clear guidance on how to consider elderly patients’ spiritual needs and strengthen their self-efficacy in primary care settings.

Frequency of Renal Monitoring - Creatinine and Cystatin C (FORM-2C): an observational cohort study of patients with reduced eGFR in primary care.

BackgroundMonitoring is the mainstay of chronic kidney disease management in primary care; however, there is little evidence about the best way to do this.AimTo compare the effectiveness of estimated glomerular filtration rate (eGFR) derived from serum creatinine and serum cystatin C to predict renal function decline among those with a recent eGFR of 30–89 ml/min/1.73 m2.Design and settingObservational cohort study in UK primary care.MethodSerum creatinine and serum cystatin C were both measured at seven study visits over 2 years in 750 patients aged ≥18 years with an eGFR of 30–89 ml/min/1.73 m2 within the previous year. The primary outcome was change in eGFR derived from serum creatinine or serum cystatin C between 6 and 24 months.ResultsAverage change in eGFR was 0.51 ml/min/1.73 m2/year when estimated by serum creatinine and −2.35 ml/min/1.73 m2/year when estimated by serum cystatin C. The c-statistic for predicting renal decline using serum creatininederived eGFR was 0.495 (95% confidence interval [CI] = 0.471 to 0.519). The equivalent c-statistic using serum cystatin C-derived eGFR was 0.497 (95% CI = 0.468 to 0.525). Similar results were obtained when restricting analyses to those aged ≥75 or <75 years, or with eGFR ≥60 ml/min/1.73 m2. In those with eGFR <60 ml/min/1.73 m2, serum cystatin C-derived eGFR was more predictive than serum creatinine-derived eGFR for future decline in kidney function.ConclusionIn the primary analysis neither eGFR estimated from serum creatinine nor from serum cystatin C predicted future change in kidney function, partly due to small changes during 2 years. In some secondary analyses there was a suggestion that serum cystatin C was a more useful biomarker to estimate eGFR, especially in those with a baseline eGFR <60 ml/min/1.73 m2.

The impact of a mental health service on chronic disease management in primary care.

The impact of a mental health service on chronic disease management in primary care.

Virtual Group Visits: Hope for Improving Chronic Disease Management in Primary Care During and After the COVID-19 Pandemic.

As health care systems respond to the COVID-19 pandemic, new virtual care approaches are emerging for health promotion and chronic disease management. Virtual group visits (VGVs) supporting a healthy lifestyle, adapted from the well-established shared medical appointment (SMA) model, hold promise as a primary care delivery tool for preventing and managing chronic disease. In order to establish VGVs as standard of care, evidence for clinical effectiveness, financial sustainability, and access for vulnerable populations is needed. In the future, VGVs could improve the quality and reach of chronic disease prevention and management strategies.

Develop and validate family nurse practitioner transition program in Taiwan by using modified Delphi method

BackgroundPrevious studies have shown that family nurse practitioners (FNPs) provide an important contribution to health promotion and disease management in primary care. Nevertheless, the position of FNP does not exist in Taiwan. In Taiwan, the leading cause of most disability and death is diabetes, for which an FNP has great potential to fulfill healthcare needs. Therefore, establishing how to cultivate competent FNPs is an important issue. It is feasible to train current acute care nurse practitioners (NPs) to become FNPs through enrollment in a transition program. ObjectivesThe purpose of this study is to develop an FNP transition program, including the necessary competencies and curriculum. DesignA modified Delphi method (use of an expert panel) is used to validate the preliminary curriculum of an FNP transition program. SettingsThe Delph method conducted through email and physical meetings. ParticipantsFour expert panel groups involve in this project with different group has its own mission. Totally, there were 14 experts completed the transition program. MethodsA modified Delphi method was used to validate the competencies and curriculum. Descriptive data analysis was used to evaluate the target consensus of 80%. ResultsThis study provided the first FNP transition program design in Taiwan, based on the global literature and a local gap analysis. ConclusionsNursing faculty, healthcare delivery system administration leaders, and policymakers can use the curriculum to train current NPs to become competent FNPs to provide optimal quality of care in the community.

Occupational Therapy in Primary Care -- Barriers, Pivots, and Outcomes: A pilot study

Purpose: Habits, roles, and routines are important behaviors that affect lifestyle and can lead to the development of chronic disease such as diabetes mellitus. Primary care physicians (PCPs) have limited time, suggesting an interprofessional team approach would be beneficial in helping patients modify behaviors for the prevention and treatment of chronic disease. Occupational therapists (OTs) specialize in addressing health behaviors, and literature supports including OTs on the primary care team to improve the self-management techniques of patients with chronic disease. This study was guided by Lifestyle Redesign®, an evidence-based program that addresses the health behaviors of patients with diabetes in primary care. We aimed to improve health outcomes by combining an OT-led lifestyle modification program with patient-centered treatment recommendations from an external interprofessional team. We hypothesized that the health outcomes of patients with diabetes in primary care would improve after participating in an OT-led interprofessional lifestyle modification program, and that reimbursement for services would be obtainable. Method: Two PCPs in community practice initially agreed to involve an OT on their primary care team. Due to reimbursement concerns, the PCPs later preferred to refer patients to receive the OT-led intervention at an offsite clinic, rather than onsite at the primary care practice. Health outcomes were measured pre- and post-intervention using industry standard assessments and biometrics. Descriptive and non-parametric statistics were used to evaluate change. Results: Thirty-one patients with diabetes were referred, and three (9.7%) participated in the offsite lifestyle modification program. While statistical significance was not achieved (p≥0.10), trends toward individual improvement were noted for occupational performance and satisfaction and empowerment, and reimbursement was received from the third-party payers. Conclusions: Patient participation in this study was consistent with participation rates for offsite behavioral health referrals. An offsite OT-led interprofessional lifestyle modification program demonstrated potential for meaningful change and services were reimbursed. These findings support practice redesign efforts to include OTs as part of an integrated primary care model. Offering onsite services will increase patient accessibility to care and improve referral completion rates, thus providing OTs the opportunity to further demonstrate the efficacy of delivering chronic disease management in primary care.

우리나라 일차의료 만성질환 관리 이용자의 경험 분석: 포커스 그룹 인터뷰에 기초하여

Objectives: This study aimed to explore the experience of patients of chronic disease management pilot project in primary care and to derive policy implications. Methods: Six focus group interviews were held with 36 patients enrolled in the pilot project. All interviews were recorded and transcribed as they were spoken, and a qualitative thematic analysis method was employed for the research questions. Results: Three themes were derived: experience in chronic disease management, experience in primary health care, and expectations for chronic disease management in primary care. Participants with chronic diseases were regularly taking medication, but efforts to manage their lifestyle were strenuous. They selected primary care due to trust in disease management, active communication with doctors, friendliness and convenience. Awareness raising, systematic services, diversification and capacity building, and quality improvement are needed to strengthen chronic disease management in primary care. Conclusion: It was meaningful to analyze the need for patient-specific and comprehensive service management for successful chronic disease management. There is a need to conduct continuous research on service quality, cooperative workforce development, and payment system to improve the quality of primary healthcare in Korea.

A digital health intervention for cardiovascular disease management in primary care (CONNECT) randomized controlled trial

Digital health applications (apps) have the potential to improve health behaviors and outcomes. We aimed to examine the effectiveness of a consumer web-based app linked to primary care electronic health records (EHRs). CONNECT was a multicenter randomized controlled trial involving patients with or at risk of cardiovascular disease (CVD) recruited from primary care (Clinical Trial registration ACTRN12613000715774). Intervention participants received an interactive app which was pre-populated and refreshed with EHR risk factor data, diagnoses and, medications. Interactive risk calculators, motivational messages and lifestyle goal tracking were also included. Control group received usual health care. Primary outcome was adherence to guideline-recommended medications (≥80% of days covered for blood pressure (BP) and statin medications). Secondary outcomes included attainment of risk factor targets and eHealth literacy. In total, 934 patients were recruited; mean age 67.6 (±8.1) years. At 12 months, the proportion with >80% days covered with recommended medicines was low overall and there was no difference between the groups (32.8% vs. 29.9%; relative risk [RR] 1.07 [95% CI, 0.88–1.20] p = 0.49). There was borderline improvement in the proportion meeting BP and LDL targets in intervention vs. control (17.1% vs. 12.1% RR 1.40 [95% CI, 0.97–2.03] p = 0.07). The intervention was associated with increased attainment of physical activity targets (87.0% intervention vs. 79.7% control, p = 0.02) and e-health literacy scores (72.6% intervention vs. 64.0% control, p = 0.02). In conclusion, a consumer app integrated with primary health care EHRs was not effective in increasing medication adherence. Borderline improvements in risk factors and modest behavior changes were observed.

User-Centered Design for Promoting Patient Engagement in Chronic Diseases Management: The Development of CONCERTO.

Multimorbidity increases care needs among people with chronic diseases. In order to support communication between patients, their informal caregivers and their healthcare teams, we developed CONCERTO+, a patient portal for chronic disease management in primary care. A user-centered design comprising 3 iterations with patients and informal caregivers was performed. Clinicians were also invited to provide feedback on the feasibility of the solution. Several improvements were brought to CONCERTO+, and it is now ready to be implemented in real-life setting.