Chronic Care Improvement Research Articles

Digital Health Interventions for Quality Improvements in Chronic Kidney Disease Primary Care: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Chronic kidney disease (CKD) is a significant public health issue globally. The importance of its timely identification and early intervention is paramount. However, a systematic approach for early CKD management in the primary care setting is currently lacking, receiving less attention compared to upstream risk factors such as diabetes and hypertension. This oversight may lead to a failure in meeting quality-of-care indicators. Digital health interventions (DHIs), which leverage digital tools to enhance healthcare delivery, have shown effectiveness in managing chronic diseases and improving the quality, safety, and efficiency of primary care. Our research aimed to evaluate the effectiveness of DHIs in the care process, focusing on their reach, uptake, and feasibility. In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov for randomized controlled trials (RCTs) assessing DHIs' effectiveness in CKD patient care among adults in primary care settings. The search, conducted on 30 June 2023, included studies published in English from 1 January 2009. Screening was conducted using Covidence, adhering to Cochrane's guidelines for data extraction. We primarily evaluated changes in care processes (testing, documentation, medication use, etc.) and the use of renin-angiotensin-aldosterone system inhibitors (RAASi), referrals, among others. Multilevel meta-analysis was employed to address within-study clustering, and meta-regression analyzed the impact of study characteristics on heterogeneity in effect sizes. Clinical endpoints were recorded where available. Bias risk was assessed using the Cochrane Risk of Bias 2 tool. Data on reach, uptake, and feasibility were narratively summarized. The study is registered with PROSPERO (CRD42023449098). From 679 records, 12 RCTs were included in the narrative synthesis, and 6 studies (encompassing 7 trials) in the meta-analysis. The trials indicated a -0.85% change (95%CI, -5.82% to 4.11%) in the proportion of patients receiving desired care. This result showed considerable heterogeneity (I2 = 91.9%). One study characteristic (co-intervention, education) correlated with larger effects. Although including co-intervention in multivariable meta-regression was significant, it did not diminish heterogeneity. The reported reach varied and was not high, while the uptake was relatively high. Most studies did not explicitly address feasibility, though some statements implied its evaluation. The current literature on the impact of DHIs in community-based CKD care is limited. The studies suggest a non-significant effect of DHIs on enhancing CKD management in community settings, marked by significant heterogeneity. Future research should focus on rigorous, methodologically sound implementations to better assess the effectiveness of DHIs in the primary care management of CKD.

The Stockholm CREAtinine Measurements (SCREAM) project: Fostering improvements in chronic kidney disease care.

SCREAM (Stockholm CREAtinine Measurements project) was initiated in 2010 in collaboration with the healthcare provider of Stockholm County healthcare to quantify potential medication errors, estimate the burden of chronic kidney disease (CKD) and to illustrate the value of incorporating measures of kidney function into the medical decision process. Because most patients are unaware of their CKD and diagnoses are seldom issued, SCREAM took advantage of the commonness of serum/plasma creatinine testing, which can be used to estimate the glomerular filtration rate (eGFR) and classify the stage of CKD severity. SCREAM is periodically updated, and at present contains healthcare information of all residents in Stockholm region during 2006-2019 (about 3 million people), enriched with a broad range of laboratory measurements for those in whom creatinine or albuminuria has been measured (about 1.8 million people). This health information was linked with national administrative and quality registries via the unique personal identification number of each Swedish citizen, conforming the richest characterization in Sweden of the population's journey through health and disease. This review discusses the context of its creation, strengths and weakness, key findings and plans for the future. We summarize our findings related to the burden of CKD in Sweden, its adverse health risks (such as risk of infections, cancer or dementia) and how underlying kidney function alters the risk-benefit ratio of common medications. Results have had clinical impact and demonstrate the importance of population-based research in the spectrum of clinical research to improve health.

Improving Management of Non-communicable Chronic Diseases in Primary Healthcare Centres in The Saudi Health Care System

Evaluation of patient perceptions of quality and adequacy of care is a critical component of continuous improvement in chronic disease care. The purpose of this study was to ascertain how patients with non-communicable diseases (NCDs) assess their routine care in primary care centres in Saudi Arabia and to identify areas for improvement. This cross-sectional study used the PACIC questionnaire to assess the quality of care received by these patients in primary care centres in Saudi Arabia. Data collection took place between May 2019 and July 2019. The questionnaire was self-completed anonymously by 315 patients with NCD attending primary health care centres in Riyadh, Saudi Arabia. The results showed that the average overall PACIC score was 2.97 (SD = 0.65), the mean scores for the subscales ranged from 2.76 (SD = 0.78) for the subscale of goal settings/tailoring to 3.17 (SD = 0.78) for delivery system design/decision support. PACIC scores varied significantly with age, occupation, monthly income, type and duration of chronic illness and educational attainment. In conclusion, patients with NCDs prioritised improvements in organised care that; is comprehensive, focussed on their needs, helps them identify clear goals for their treatments and become more involved in their condition(s) management.

Tools, Time, Training, and Team-Military Primary Care Providers' Perspectives on Improving Chronic Pain Assessment and Management.

Primary care providers are on the front lines of chronic pain management, with many reporting frustration, low confidence, and dissatisfaction in handling the complex issues associated with chronic pain care. Given the importance of their role and reported inadequacies and dissatisfaction in managing this challenging population, it is important to understand the perspectives of primary care providers when considering approaches to chronic pain management. This qualitative descriptive study aimed to comprehensively summarize the provider challenges and suggestions to improve chronic pain care in military primary care settings. Semi-structured interviews with 12 military primary care providers were conducted in a single U.S. Army medical center. All interviews were audio-recorded and lasted between 30 and 60 minutes. Interview transcripts were analyzed using ATLAS 9.0 software. Narratives were analyzed using a general inductive approach to content analysis. The Framework Method was used to organize the codes and emergent categories. All study procedures were approved by the Institutional Review Board of the University of Washington. Four categories captured providers' challenges and suggestions for improving chronic pain care: (1) tools for comprehensive pain assessment and patient education, (2) time available for each chronic pain appointment, (3) provider training and education, and (4) team-based approach to chronic pain management. Providers suggested use of the Pain Assessment Screening Tool and Outcomes Registry, more time per visit, incorporation of chronic pain care in health sciences curriculum, consistent provider training across the board, insurance coverage for complementary and integrative therapies, patient education, and improved access to interdisciplinary chronic pain care. Lack of standardized multifaceted tools, time constraints on chronic pain appointments, inadequate provider education, and limited access to complementary and integrative health therapies are significant provider challenges. Insurance coverage for complementary and integrative health therapies needs to be expanded. The Stepped Care Model of Pain Management is a positive and definite stride toward addressing many of these challenges. Future studies should examine the extent of improvement in guidelines-concordant chronic pain care, patient outcomes, and provider satisfaction following the implementation of the Stepped Care Model of Pain Management in military health settings.

Clinical Characteristics, Preventive Care and Attitude to Telemedicine among Patients with Diabetic Retinopathy: A Cross-Sectional Study.

Diabetic retinopathy (DR) is the most frequent and one of the most severe complications of both types of diabetes. Despite the development of versatile diabetes management programs in most developed countries, many patients remain at increased risk for developing this life-limiting and life-threatening condition. This cross-sectional analysis objective was to examine and compare the prevalence of diabetic retinopathy and comorbidities, as well as the clinical characteristics, prevention patterns, and attitude to telemedicine in patients with diabetes. We found that, when compared to the non-DR group, patients with DR significantly more often utilize clinical preventive services and counseling; however, there is still a significant gap in the receipt of preventative care. Moreover, in the DR subgroup, inadequate diabetic control and the presence of various signs and symptoms of diseases were observed. Although less than a fifth of all patients use mobile applications to monitor their health status, the patients indicate their willingness to use telemedical technology, particularly if it is recommended by the physician and provided without additional costs. The evolution of telemedicine offers a possibility of inexpensive, continuous monitoring of the disease that could improve treatment outcomes. Our observations emphasize DR’s perception as a complex disease in which education and continuous monitoring, particularly with telemedicine methods, are critical for further improvement in chronic care.

Quality improvement in chronic care by self-audit, benchmarking and networking in general practices in South Tyrol, Italy: results from an interventional study.

Systematic strategies promoting quality of care in general practice are yet under-represented in several European countries. This interventional study assessed whether a combined intervention (self-audit, benchmarking, quality circles) improved quality of care in Salzburg, Austria and South Tyrol, Italy. The present publication reports the Italian results. We developed quality indicators for general practice in a consensus process based on pre-existing quality programmes. The indicators addressed diagnosis and treatment regarding eight common chronic conditions. A quality score comprising 91 indicators was calculated (0-5 points per indicator depending on fulfilment, maximum 455 points). We collected anonymous data from the electronic health records of the participating physicians in 2012, 2013 and 2014. Wilcoxon signed-rank tests were used for pre-post analysis. Thirty-six GPs participated in the study. The median quality score increased significantly from 177.0 points at baseline to 272.0 points at the second follow-up (P = 0.000). Improvements concerned process and intermediate outcome indicators particularly between baseline and the first follow-up. Performance was relatively low at baseline and improved considerably, mainly in the first study period. The intervention investigated in this study can serve as a model for future quality programmes. A customized electronic health record for the implementation of this intervention as well as standardized and consistent documentation by GPs is a prerequisite. Use of a limited set of quality indicators (QIs) and regular QI modification is probably advisable to increase the benefits. Long-term prospective studies should investigate the impact of QI-based interventions on end-result outcomes.

How healthcare systems shape a purchaser’s strategies and actions when managing chronic care

Healthcare purchasing organisations in both insurance-based and tax-based healthcare systems struggle to improve chronic care. A key challenge for purchasers is to deal with the chain of multiple providers involved in caring for patients with complex needs. To date, most research has focused on differences between healthcare systems in terms of regulation, tools and the freedom that healthcare purchasers have. However, this does not explain how such different healthcare system characteristics lead to different purchasing strategies and actions. A better understanding of this link between system characteristics and purchaser behaviour would assist policymakers seeking to improve healthcare purchasing. This multiple case study conducted in England, Sweden and the Netherlands examines the link between the different healthcare systems’ characteristics and the purchasers’ strategies and actions when managing chronic care chains. Purchasers’ strategies and actions varied in terms of the purchaser’s engagement, strategic lens and influencing style. Our findings suggest that differences in purchaser competition, purchaser governance and patient choice in healthcare systems are key factors in explaining a purchaser’s strategies and actions when pursuing improvements in chronic care. This study contributes to knowledge on what shapes the purchaser’s role, and shows how policymakers in both insurance- and tax-based regimes can improve healthcare purchasing.

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial

BackgroundAcross sub-Saharan Africa, evidence-based clinical guidelines to screen and manage hypertension exist; however, country level application is low due to lack of service readiness, uneven health worker motivation, weak accountability of health worker performance, and poor integration of hypertension screening and management with chronic care services. The systems analysis and improvement approach (SAIA) is an evidence-based implementation strategy that combines systems engineering tools into a five-step, facility-level package to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). As hypertension screening and management are integrated into chronic care services in sub-Saharan Africa, an opportunity exists to test whether SAIA interventions shown to be effective in improving efficiency and coverage of HIV services can be effective when applied to the non-communicable disease services that leverage the same platform. We hypothesize that SAIA-hypertension (SAIA-HTN) will be effective as an adaptable, scalable model for broad implementation.MethodsWe will deploy a hybrid type III cluster randomized trial to evaluate the impact of SAIA-HTN on hypertension management in eight intervention and eight control facilities in central Mozambique. Effectiveness outcomes include hypertension cascade flow measures (screening, diagnosis, management, control), as well as hypertension and HIV clinical outcomes among people living with HIV. Cost-effectiveness will be estimated as the incremental costs per additional patient passing through the hypertension cascade steps and the cost per additional disability-adjusted life year averted, from the payer perspective (Ministry of Health). SAIA-HTN implementation fidelity will be measured, and the Consolidated Framework for Implementation Research will guide qualitative evaluation of the implementation process in high- and low-performing facilities to identify determinants of intervention success and failure, and define core and adaptable components of the SAIA-HTN intervention. The Organizational Readiness for Implementing Change scale will measure facility-level readiness for adopting SAIA-HTN.DiscussionSAIA packages user-friendly systems engineering tools to guide decision-making by front-line health workers to identify low-cost, contextually appropriate chronic care improvement strategies. By integrating SAIA into routine hypertension screening and management structures, this pragmatic trial is designed to test a model for national scale-up.Trial registrationClinicalTrials.gov NCT04088656 (registered 09/13/2019; https://clinicaltrials.gov/ct2/show/NCT04088656).

Learning from implementation setbacks: Identifying and responding to contextual challenges.

IntroductionWe address organizational learning about implementation context during setbacks to primary care redesign in an ambulatory system. The redesign expanded care teams and added a medical assistant assigned administrative and coordination tasks. The redesign was expected to improve care efficiency, prevention, and continuity. In response to setbacks, redesign and system leaders used understanding of context to plan system‐wide changes, as well as program adjustments. Doing so enhanced the redesign's prospects and contributed to system learning.MethodsWe conducted a 33‐month, mixed‐methods study. Qualitative data included quarterly calls with the redesign leaders and 63 activity log entries. There were three site visits; 73 interviews with practice leaders, providers, and medical assistants. Data analysis used categories from an implementation research framework; these were refined and then expanded inductively using log reports, debriefings with change leaders, and documents. Quantitative analysis used system operational data on chronic care, prevention, efficiency, productivity, and patient access.ResultsRedesigned teams were not implemented as widely or rapidly as anticipated and did not deliver hoped‐for gains in operational metrics. Interviews reported that team redesign was leading to improvements in chronic care and prevention and eased provider burden. Besides making small adjustments to cope with setbacks, redesign and system leaders engaged in more thorough organizational learning. They examined contextual challenges underlying setbacks and posing risks to the delivery system as a whole. Their responses to challenges helped strengthen the redesign's prospects, improved the delivery system's position in its labor market, and helped the system prepare to meet emerging requirements for value‐based care and population health.ConclusionsThis case points to benefits for both health care researchers and change practitioners of paying closer attention to how context affects implementation of organizational change, and to opportunities and conditions for learning from setbacks during change.

The Patient Assessment of Chronic Illness Care produces measurements along a single dimension: results from a Mokken analysis

BackgroundAs the worldwide prevalence of chronic illness increases so too does the demand for novel treatments to improve chronic illness care. Quantifying improvement in chronic illness care from the patient perspective relies on the use of validated patient-reported outcome measures. In this analysis we examine the psychometric and scaling properties of the Patient Assessment of Chronic Illness Care (PACIC) questionnaire for use in the United Kingdom by applying scale data to the non-parametric Mokken double monotonicity model.MethodsData from 1849 patients with long-term conditions in the UK who completed the 20-item PACIC were analysed using Mokken analysis. A three-stage analysis examined the questionnaire’s scalability, monotonicity and item ordering. An automated item selection procedure was used to assess the factor structure of the scale. Analysis was conducted in an ‘evaluation’ dataset (n = 956) and results were confirmed using an independent ‘validation’ (n = 890) dataset.ResultsAutomated item selection procedures suggested that the 20 items represented a single underlying trait representing “patient assessment of chronic illness care”: this contrasts with the multiple domains originally proposed. Six items violated invariant item ordering and were removed. The final 13-item scale had no further issues in either the evaluation or validation samples, including excellent scalability (Ho = .50) and reliability (Rho = .88).ConclusionsFollowing some modification, the 13-items of the PACIC were successfully fitted to the non-parametric Mokken model. These items have psychometrically robust and produce a single ordinal summary score. This score will be useful for clinicians or researchers to assess the quality of chronic illness care from the patient's perspective.

Getting right to the point: identifying Australian outpatients' priorities and preferences for patient-centred quality improvement in chronic disease care.

To identify specific actions for patient-centred quality improvement in chronic disease outpatient settings, this study identified patients' general and specific preferences among a comprehensive suite of initiatives for change. A cross-sectional survey was conducted in three hospital-based clinics specializing in oncology, neurology and cardiology care located in New South Wales, Australia. Adult English-speaking outpatients completed the touch-screen Consumer Preferences Survey in waiting rooms or treatment areas. Participants selected up to 23 general initiatives that would improve their experience. Using adaptive branching, participants could select an additional 110 detailed initiatives and complete a relative prioritization exercise. A total of 541 individuals completed the survey (71.1% consent, 73.1% completion). Commonly selected general initiatives, presented in order of decreasing priority (along with sample proportion), included: improved parking (60.3%), up-to-date information provision (15.0%), ease of clinic contact (12.9%), access to information at home (12.8%), convenient appointment scheduling (14.2%), reduced wait-times (19.8%) and information on medical emergencies (11.1%). To address these general initiatives, 40 detailed initiatives were selected by respondents. Initiatives targeting service accessibility and information provision, such as parking and up-to-date information on patient prognoses and progress, were commonly selected and perceived to be of relatively greater priority. Specific preferences included the need for clinics to provide patient-designated parking in close proximity to the clinic, information on treatment progress and test results (potentially in the form of designated brief appointments or via telehealth) and comprehensive and trustworthy lists of information sources to access at home.

A First Step on the Journey to High-Quality Chronic Illness Care.

The Atlantic Healthcare Collaboration (AHC) conducted a quality improvement initiative to improve chronic disease prevention and management for the four Atlantic provinces and their regional health authorities. Leaders and front-line teams carried out a range of projects, each suited to the needs of that region. This initiative helped build the case for improvement, increased the motivation to change, exposed participants to proven ideas for improvement and supported participating organizations in developing the capacity and culture to test, implement and spread improvements. The AHC also created a politically safe learning community with the potential to support and sustain the work of chronic care improvement over time. In carrying this initiative forward, the greatest challenge will be the magnitude of work to be done.

Readiness to tackle chronicity in Spanish health care organisations: a two-year experience with the Instrumento de Evaluación de Modelos de Atención ante la Cronicidad/Assessment of Readiness for Chronicity in Health Care Organisations instrument.

The Instrumento de Evaluación de Modelos de Atención ante la Cronicidad/Assessment of Readiness for Chronicity in Health Care Organisations instrument was developed to implement the conceptual framework of the Chronic Care Model in the Spanish national health system. It has been used to assess readiness to tackle chronicity in health care organisations. In this study, we use self-assessments at macro-, meso- and micro-management levels to (a) describe the two-year experience with the Instrumento de Evaluación de Modelos de Atención ante la Cronicidad/Assessment of Readiness for Chronicity in Health Care Organisations tool in Spain and (b) assess the validity and reliability of this instrument. The results from 55 organisational self-assessments were included and described. In addition to that, the internal consistency, reliability and construct validity of Instrumento de Evaluación de Modelos de Atención ante la Cronicidad/Assessment of Readiness for Chronicity in Health Care Organisations were examined using Cronbach's alpha, the Spearman-Brown coefficient and factorial analysis. The obtained scores reflect opportunities for improvement in all dimensions of the instrument. Cronbach's alpha ranged between 0.90 and 0.95 and the Spearman-Brown coefficient ranged between 0.77 and 0.94. All 27 components converged in a second-order factorial solution that explained 53.8% of the total variance, with factorial saturations for the components of between 0.57 and 0.94. Instrumento de Evaluación de Modelos de Atención ante la Cronicidad/Assessment of Readiness for Chronicity in Health Care Organisations is an instrument that allows health care organisations to perform self-assessments regarding their readiness to tackle chronicity and to identify areas for improvement in chronic care.

Hemoglobinopathy Education in Canadian Hematology Training Programs: How Much Are Residents Learning?

The number of hemoglobinopathy patients in North America continues to increase, due to high rates of immigration from countries with high prevalence and improved survival. Recent research has led to evidence-based improvements in acute and chronic care of patients with sickle cell disease and thalassemia. Studies have noted gaps in clinicians’ knowledge about management of hemoglobinopathies, with the result that common presentations, such as sickle vaso-occlusive episodes, are often mismanaged. Hematologists completing training in North America require the knowledge and expertise to manage these medically complex patients.To ascertain the extent of hemoglobinopathy teaching and exposure in Canadian Adult and Pediatric Hematology Training Programs, and to assess the perceived importance of hemoglobinopathy knowledge, we administered an online survey to all Training Program Directors (TPDs), and to all residents who were currently enrolled or who had completed training in the previous year. Surveys were available in English and French.The response rate for TPDs was 92% (22/24). Ninety five percent of PDs felt that hemoglobinopathy learning is “important” or “very important” for hematology trainees in their region. Four programs have a mandatory hemoglobinopathy rotation, 14 programs have mandatory hemoglobinopathy clinic participation, and 17 programs have mandatory hemoglobinopathy lab exposure. Laboratory time ranges widely, from “0-2 hours” to “greater than 20 hours”. All programs covered laboratory aspects of hemoglobinopathy, outpatient care of sickle cell disease and inpatient care of sickle cell disease, and all but one program covered outpatient care of thalassemias. In 1/2 to 2/3 of adult training programs, these topics were covered at only a basic level. All pediatric programs covered outpatient and inpatient care of sickle cell disease “in-depth”, with 90% and 40% of programs covering outpatient thalassemia care and laboratory diagnostics “in-depth”, respectively. All 22 programs had academic half-days with teaching devoted to hemoglobinopathy. Seventy-seven percent of programs had faculty member(s) with an interest in hemoglobinopathy.The response rate for residents was 45% (70/156). The majority of respondents were senior residents, with 88% currently in post-graduate year five, or above. Among residents in adult hematology programs, 61% had completed a rotation or elective with a focus on hemoglobinopathy versus 25% in the pediatric programs. Total numbers of hemoglobinopathy patients seen ranged from “0” to “more than 50”, and laboratory exposure varied from “none” to “in-depth”. Most residents with clinical hemoglobinopathy experience had seen patients with both sickle cell disease and thalassemia major or intermedia. Of residents who responded, 83% felt that hemoglobinopathy knowledge was “important” or “very important” to their future practice.All TPDs and 90% of residents felt that online hemoglobinopathy learning modules could be beneficial for resident learning.There appears to be wide variability in depth and breadth of clinical and laboratory hemoglobinopathy learning in Hematology training programs across Canada. TPDs and residents place high importance on hemoglobinopathy learning, but some centres have small patient numbers, or lack faculty with interest in hemoglobinoapthies. Online learning modules could provide added learning opportunities for residents. DisclosuresNo relevant conflicts of interest to declare.

Pain Management Experiences and the Acceptability of Cognitive Behavioral Strategies Among American Indians and Alaska Natives.

The purpose of this project was to explore the chronic pain experience and establish cultural appropriateness of cognitive behavioral pain management (CBPM) techniques in American Indians and Alaska Natives (AI/ANs). A semistructured interview guide was used with three focus groups of AI/AN patients in the U.S. Southwest and Pacific Northwest regions to explore pain and CBPM in AI/ANs. The participants provided rich qualitative data regarding chronic pain and willingness to use CBPM. Themes included empty promises and health care insufficiencies, individuality, pain management strategies, and suggestions for health care providers. Results suggest that there is room for improvement in chronic pain care among AI/ANs and that CBPM would likely be a viable and culturally appropriate approach for chronic pain management. This research provides evidence that CBPM is culturally acceptable and in alignment with existing traditional AI/AN strategies for coping and healing.

Medicare Part D Enrollees' Use of Out‐of‐Plan Discounted Generic Drugs, Revisited

Medicare Part D Enrollees' Use of Out‐of‐Plan Discounted Generic Drugs, Revisited

The German version of the Assessment of Chronic Illness Care: instrument translation and cultural adaptation

In Switzerland, there is a dearth of information on the extent to which patients with chronic illnesses receive care congruent with the Chronic Care Model (CCM). To drive quality improvement programmes, it is necessary to have practical assessment tools in the country's own language to evaluate the delivery of CCM activities. German translation and adaptation of the original Assessment of Chronic Illness Care (ACIC). We followed a sequential forward and backward translation approach. In a multidisciplinary committee review the original English version and the translations were compared, instructions and formats modified and cross-cultural equivalences verified. The second version was pre-tested and multidisciplinary group discussion led to the final version which aimed to create a comprehensive culturally adapted translation capturing the original idea of the items rather than a direct one to one translation. Difficulties encountered during the translation process consisted in the difference of health care settings and health care organization in Switzerland and USA.The adapted German version was delivered to a managed care organization in the city of Zurich to test the initial use for diabetes care. The average ACIC subscale scores were: organization of the health care delivery system: mean (m) = 7.31 (SD = 0.79), community linkages: m = 3.78 (SD = 1.09), self-management support: m = 4.88 (SD = 1.21), decision support: m = 4.79 (SD = 1.16), delivery system design: m = 5.56 (SD = 1.28) and clinical information systems: m = 4.50 (SD = 2.69). Overall, the ACIC subscale scores were comparable with the scores of the original testing. After cultural adaptations the German version of the ACIC is applicable as a tool to guide quality improvement in chronic illness care in German speaking countries in Europe.

Developing Targeted Health Service Interventions Using the PRECEDE-PROCEED Model: Two Australian Case Studies.

Aims and Objectives. This paper provides an overview of the applicability of the PRECEDE-PROCEED Model to the development of targeted nursing led chronic illness interventions. Background. Changing health care practice is a complex and dynamic process that requires consideration of social, political, economic, and organisational factors. An understanding of the characteristics of the target population, health professionals, and organizations plus identification of the determinants for change are also required. Synthesizing this data to guide the development of an effective intervention is a challenging process. The PRECEDE-PROCEED Model has been used in global health care settings to guide the identification, planning, implementation, and evaluation of various health improvement initiatives. Design. Using a reflective case study approach, this paper examines the applicability of the PRECEDE-PROCEED Model to the development of targeted chronic care improvement interventions for two distinct Australian populations: a rapidly expanding and aging rural population with unmet palliative care needs and a disadvantaged urban community at higher risk of cardiovascular disease. Results. The PRECEDE-PROCEED Model approach demonstrated utility across diverse health settings in a systematic planning process. In environments characterized by increasing health care needs, limited resources, and growing community expectations, adopting planning tools such as PRECEDE-PROCEED Model at a local level can facilitate the development of the most effective interventions. Relevance to Clinical Practice. The PRECEDE-PROCEED Model is a strong theoretical model that guides the development of realistic nursing led interventions with the best chance of being successful in existing health care environments.

A comparison of chronic illness care quality in US and UK family medicine practices prior to pay-for-performance initiatives

The Quality and Outcomes Framework (QOF) has contributed to modest improvements in chronic illness care in the UK. US policymakers have proposed similar pay-for-performance (P4P) approaches to improve care. Since previous studies have not compared chronic illness care quality in US and UK primary care practices prior to the QOF, the relative preparedness of practices to respond to P4P incentives is unknown. To compare US and UK practices on P4P measures prior to program implementation. We analysed medical record data collected before QOF implementation from randomly selected patients with diabetes or coronary artery disease (CAD) in 42 UK and 55 US family medicine practices. We compared care processes and intermediate outcomes using hierarchical logistic regression. While we found gaps in chronic illness care quality across both samples, variation was lower in UK practices. UK patients were more likely to receive recommended care processes for diabetes [odds ratio (OR), 8.94; 95% confidence interval (CI), 4.26-18.74] and CAD (OR, 9.18; 95% CI, 5.22-16.17) but less likely to achieve intermediate diabetes outcome targets (OR, 0.50; 95% CI, 0.39-0.64). Following National Health Service (NHS) investment in primary care preparedness, but prior to the QOF, UK practices provided more standardized care but did not achieve better intermediate outcomes than a sample of typical US practices. US policymakers should focus on reducing variation in care documentation to ensure the effectiveness of P4P efforts while the NHS should focus on moving from process documentation to better patient outcomes.

Untangling Practice Redesign from Disease Management: How Do We Best Care for the Chronically Ill?

In the past 10 years, a wide spectrum of chronic care improvement interventions has been tried and evaluated to improve health outcomes and reduce costs for chronically ill individuals. On one end of the spectrum are disease-management interventions--often organized by commercial vendors--that work with patients but do little to engage medical practice. On the other end are quality-improvement efforts aimed at redesigning the organization and delivery of primary care and better supporting patient self-management. This qualitative review finds that carve-out disease management interventions that target only patients may be less effective than those that also work to redesign care delivery. Imprecise nomenclature and poor study design methodology limit quantitative analysis. More innovation and research are needed to understand how disease-management components can be more meaningfully embedded within practice to improve patient care.