Self-management In Primary Care Research Articles

Understanding the processes underpinning IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) in primary care: study protocol for a process evaluation within a cluster randomised controlled implementation trial

BackgroundProviding supported self-management for people with asthma can reduce the burden on patients, health services and wider society. Implementation, however, remains poor in routine clinical practice. IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) is a UK-wide cluster randomised implementation trial that aims to test the impact of a whole-systems implementation strategy, embedding supported asthma self-management in primary care compared with usual care. To maximise opportunities for sustainable implementation beyond the trial, it is necessary to understand how and why the IMP2ART trial achieved its clinical and implementation outcomes.MethodsA mixed-methods process evaluation nested within the IMP2ART trial will be undertaken to understand how supported self-management was implemented (or not) by primary care practices, to aid interpretation of trial findings and to inform scaling up and sustainability. Data and analysis strategies have been informed by mid-range and programme-level theory. Quantitative data will be collected across all practices to describe practice context, IMP2ART delivery (including fidelity and adaption) and practice response. Case studies undertaken in three to six sites, supplemented by additional interviews with practice staff and stakeholders, will be undertaken to gain an in-depth understanding of the interaction of practice context, delivery, and response. Synthesis, informed by theory, will combine analyses of both qualitative and quantitative data. Finally, implications for the scale up of asthma self-management implementation strategies to other practices in the UK will be explored through workshops with stakeholders.DiscussionThis mixed-methods, theoretically informed, process evaluation seeks to provide insights into the delivery and response to a whole-systems approach to the implementation of supported self-management in asthma care in primary care. It is underway at a time of significant change in primary care in the UK. The methods have, therefore, been developed to be adaptable to this changing context and to capture the impact of these changes on the delivery and response to research and implementation processes.

A randomized controlled trial to evaluate an internet intervention (SupportBack 2) for supported self-management in primary care

A randomized controlled trial to evaluate an internet intervention (SupportBack 2) for supported self-management in primary care

IMP2ART: development of a multi-level programme theory integrating the COM-B model and the iPARIHS framework, to enhance implementation of supported self-management of asthma in primary care

BackgroundSupported asthma self-management, incorporating an asthma action plan and annual clinical review, has been recommended by UK/global guidelines for over three decades. However, implementation remains poor, as only around a third of individuals receive basic asthma care, according to the UKs leading respiratory charity Asthma and Lung UK. A systematic review of implementation studies recommended that a whole systems approach targeting patients, healthcare professional education, and organisations is needed to improve implementation of supported asthma self-management in primary care. The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) is a national Hybrid-II implementation cluster randomised controlled trial that aims to evaluate such an approach. This paper describes the development of the implementation strategy for IMP2ART with particular focus on the integration of multiple level theories.MethodsThe Medical Research Council design and evaluation of complex interventions framework and the Person-Based Approach to intervention development were used as guidance for stages of strategy development. Specifically, we (i) set up a multidisciplinary team (including practicing and academic clinicians, health psychologists, public health and patient colleagues), (ii) reviewed and integrated evidence and theory, (iii) developed guiding principles, (iv) developed prototype materials, and (v) conducted a pre-pilot study before final refinement.ResultsThe implementation strategy included resources for patients, team-based and individual healthcare professional education, practice audit and feedback, and an asthma review template, as well as a facilitator role accessible to primary care practices for 12 months. The synthesis of the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) and Capability, Opportunity, Motivation and Behaviour (COM-B) frameworks led to an evolved framework bringing together important implementation and behaviour change elements which will be used as a basis for the study process evaluation.ConclusionsA description of rigorous implementation strategy development for the IMP2ART study is provided along with newly theorised integration of implementation and behaviour change science which may be of benefit to others targeting implementation in primary care.Trial registrationISRCTN15448074. Registered on 2nd December 2019.

IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) in primary care: study protocol for a cluster randomised controlled implementation trial

BackgroundAsthma is a common long-term condition and major public health problem. Supported self-management for asthma that includes a written personalised asthma action plan, supported by regular professional review, reduces unscheduled consultations and improves asthma outcomes and quality of life. However, despite unequivocal inter/national guideline recommendations, supported self-management is poorly implemented in practice. The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) implementation strategy has been developed to address this challenge. The aim of this implementation trial is to determine whether facilitated delivery of the IMP2ART strategy increases the provision of asthma action plans and reduces unscheduled care in the context of routine UK primary care.MethodsIMP2ART is a parallel group, cluster randomised controlled hybrid II implementation trial. One hundred forty-four general practices will be randomly assigned to either the IMP2ART implementation strategy or control group. Following a facilitation workshop, implementation group practices will receive organisational resources to help them prioritise supported self-management (including audit and feedback; an IMP2ART asthma review template), training for professionals and resources to support patients to self-manage their asthma. The control group will continue with usual asthma care. The primary clinical outcome is the between-group difference in unscheduled care in the second year after randomisation (i.e. between 12 and 24 months post-randomisation) assessed from routine data. Additionally, a primary implementation outcome of asthma action plan ownership at 12 months will be assessed by questionnaire to a random sub-group of people with asthma. Secondary outcomes include the number of asthma reviews conducted, prescribing outcomes (reliever medication and oral steroids), asthma symptom control, patients’ confidence in self-management and professional support and resource use. A health economic analysis will assess cost-effectiveness, and a mixed methods process evaluation will explore implementation, fidelity and adaptation.DiscussionThe evidence for supported asthma self-management is overwhelming. This study will add to the literature regarding strategies that can effectively implement supported self-management in primary care to reduce unscheduled consultations and improve asthma outcomes and quality of life.Trial registrationISRCTN15448074. Registered on 2 December 2019.

Encouragement of patients’ self-management in primary care for the prevention of cardiovascular diseases (DECADE): protocol for a cluster randomised controlled trial

IntroductionCardiovascular diseases are the most common cause of death in Germany and among the most frequent reasons for encounters in primary care. Most patients with cardiovascular risks (CVRs) have difficulties...

Development of a patient-centred electronic review template to support self-management in primary care: a mixed-methods study.

Electronic templates are frequently used in long-term condition (LTC) reviews (for example, asthma) to act as reminders and improve documentation; however, they can restrict patient-centred care and opportunities for patients to discuss concerns and self-management. The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) programme aimed to develop a patient-centred asthma review template that encourages supported self-management. This was a mixed-methods study, which integrated qualitative and systematic review data, primary care Professional Advisory Group feedback, and qualitative data from clinician interviews. Aligned with the Medical Research Council complex intervention framework, a template was developed in the following three phases: (1) development phase, which consisted of a qualitative exploration with clinicians and patients, a systematic review, and prototype template development; (2) feasibility pilot phase, which involved feedback from clinicians (n = 7); and (3) pre-piloting phase, which consisted of delivering the template within the IMP2ART implementation strategy (incorporating the template with patient and professional resources) and eliciting clinician feedback (n = 6). Template development was guided by the preliminary qualitative work and the systematic review. A prototype template was developed with an opening question to establish patient agendas, and a closing prompt to confirm agendas have been addressed and an asthma action plan provided. The feasibility pilot identified refinements needed, including focusing the opening question on asthma. Pre-piloting ensured integration with the IMP2ART strategy. Following the multi-stage development process, the implementation strategy, including the asthma review template, is now being tested in a cluster randomised controlled trial.

Digital interventions for hypertension and asthma to support patient self-management in primary care: the DIPSS research programme including two RCTs

Digital interventions for hypertension and asthma to support patient self-management in primary care: the DIPSS research programme including two RCTs

How do nurses support chronically ill clients\u2019 participation and self-management in primary care? A cross-country qualitative study

BackgroundIn the context of the advancement of person-centered care models, the promotion of the participation of patients with chronic illness and complex care needs in the management of their care (self-management) is increasingly seen as a responsibility of primary care nurses. It is emphasized that nurses should consider the psychosocial dimensions of chronic illness and the client’s lifeworld. Little is known about how nurses shape this task in practice.MethodsThe aim of this analysis is to examine how primary care nurses understand and shape the participation of patients with chronic illness and complex care needs regarding the promotion of self-management. Guided interviews were conducted with nurses practicing in primary care and key informants in Germany, Spain, and Brazil with a subsequent cross-case evaluation. Interpretive and practice patterns were identified based on Grounded Theory.ResultsTwo interpretive and practice patterns were identified: (1) Giving clients orientation in dealing with chronic diseases and (2) supporting the integration of illness in clients’ everyday lives. Nurses in the first pattern consider it their most important task to provide guidance toward health-promoting behavior and disease-related decision-making by giving patients comprehensive information. Interview partners emphasize client autonomy, but rarely consider the limitations chronic disease imposes on patients’ everyday lives. Alternatively, nurses in the second pattern regard clients as cooperation partners. They seek to familiarize themselves with their clients’ social environments and habits to give recommendations for dealing with the disease that are as close to the client’s lifeworld as possible. Nurses’ recommendations seek to enable patients and their families to lead a largely ‘normal life’ despite chronic illness. While interview partners in Brazil or Spain point predominantly to clients’ socio-economic disadvantages as a challenge to promoting client participation in primary health care, interview partners in Germany maintain that clients’ high disease burden represents the chief barrier to self-management.ConclusionsNurses in practice should be sensitive to client’s lifeworlds, as well as to challenges that arise as they attempt to strengthen clients’ participation in care and self-management. Regular communication between clients, nurses, and further professionals should constitute a fundamental feature of person-centered primary care models.

A national program to support self-management for patients with a chronic condition in primary care: A social return on investment analysis

BackgroundChronic care patients can play an important role in the self-management of their disease; however, large-scale implementation of self-management has been challenging. To aid and stimulate self-management in primary care, a Dutch cooperation supported healthcare providers in primary care, through collective healthcare groups, who wanted to implement and execute a self-management program. The program aimed to increase the quality of life (QoL) in people with a chronic condition and simultaneously reduce healthcare costs. ObjectiveThe aim of this study was to assess the public value of the self-management program that was available for approximately 375.000 chronically ill patients. MethodsA Social Return on Investment analysis was carried out. The analysis is based on the principles of a cost-benefit analysis, and attributes monetary value to the social return of the self-management program in primary care. ResultsThe analysis of the self-management program showed that each euro invested translated to a social return of 4.90 euros per patient per year (measured over 5 years). This result was mainly caused by an increase in QoL and a decrease in healthcare costs. Importantly, the results show that costs and benefits were inequitably distributed across the relevant stakeholders. DiscussionThe results show that self-management support programs in primary care can provide a social return on investment. There is a clear need for lasting support for healthcare providers, both material and non-material, to enable successful implementation of self-management programs in practice.

Knowledge mobilisation: an ethnographic study of the influence of practitioner mindlines on atopic eczema self-management in primary care in the UK

ObjectiveTo explore how atopic eczema specific mindlines are developed by primary care practitioners.DesignEthnographic study.SettingOne large, urban general practice in central England.ParticipantsIn observation, all practitioners and support staff in the practice...

Knowledge mobilisation: an exploratory qualitative interview study to confirm and envision modification of lay and practitioner eczema mindlines to improve consultation experiences and self-management in primary care in the UK

ObjectivesTo investigate whether initial eczema mindlines, ‘collectively reinforced, internalised, tacit guidelines’, are an accurate representation of the experiences of lay people and practitioners in primary care and to explore how...

Diabetes distress and self-management in primary care in Singapore: explorations through illness perception

Background: Singapore was recently ranked the second highest in the percentage of diabetic individuals among developed countries’ populations. This study explored possible associations among type 2 diabetes mellitus (T2DM) patients’ perception of having this condition (illness perception), diabetes-related distress, and diabetes self-management with a view to understanding potentially useful emphases in health education and counselling for these patients in primary health care.Methods: A cross-sectional sample of 75 adults diagnosed with T2DM at five primary care clinics under National Healthcare Group Polyclinics completed three research questionnaires in English and Mandarin which assessed the participants’ perception of their own diabetic condition, experience of diabetes distress, and self-management behaviour.Results: Illness perception has specific dimensions (identity, consequence, and emotional representation) that correlated with specific aspects of diabetes distress (emotional burden, interpersonal distress, regimen distress, and overall diabetes distress). Further, overall diabetes distress correlated negatively with dietary control, physical activity, and overall self-management.Conclusions: Patients with TSDM may benefit most from health education and guidance that aim to reduce both their perception of diabetes’ impact on their lives and emotional reactivity in managing their diabetic condition.

Using cognitive behavioural therapy techniques in COPD

It is estimated that by 2020 chronic obstructive pulmonary disease is likely to become the fourth leading cause of death. People living with this condition may experience symptoms that can be managed with cognitive behavioural therapy, says Karen Heslop-Marshall Chronic obstructive pulmonary disease (COPD) is a term oftened used to describe two lung conditions in particular: chronic bronchitis and/or emphysema. Patients with COPD often experience symptoms of breathlessness, anxiety, panic and depression, and practice nurses are ideally placed to address these symptoms. This article looks at the use of cognitive behavioural therapy (CBT) techniques in symptom management, describes methods to assess the psychological impact of breathlessness, and outlines common techniques evaluated in a COPD CBT study by Heslop-Marshall et al (2018) . Research found that respiratory nurses were able to learn and deliver CBT techniques to patients with COPD and improved their symptoms of anxiety, depression, quality of life and reduced their use of healthcare resources. Self-management in primary care can be improved with CBT skills and practice nurses could improve self-management by incorporating CBT techniques.

Knowledge mobilisation: an ethnographic study of the influence of lay mindlines on eczema self-management in primary care in the UK

ObjectiveTo investigate the way in which mindlines, ‘collectively reinforced, internalised tacit guidelines’, are constructed among lay people with eczema in primary care.DesignEthnographic study.SettingObservation in one general practice in the UK...

Assessing treatment fidelity and contamination in a cluster randomised controlled trial of motivational interviewing and cognitive behavioural therapy skills in type 2 diabetes

BackgroundCompetencies in psychological techniques delivered by primary care nurses to support diabetes self-management were compared between the intervention and control arms of a cluster randomised controlled trial as part of a process evaluation. The trial was pragmatic and designed to assess effectiveness. This article addresses the question of whether the care that was delivered in the intervention and control trial arms represented high fidelity treatment and attention control, respectively.MethodsTwenty-three primary care nurses were either trained in motivational interviewing (MI) and cognitive behavioural therapy (CBT) skills or delivered attention control. Nurses’ skills in these treatments were evaluated soon after training (treatment arm) and treatment fidelity was assessed after treatment delivery for sessions midway through regimen (both arms) using the Motivational Interviewing Treatment Integrity (MITI) domains and Behaviour Change Counselling Index (BECCI) based on consultations with 151 participants (45% of those who entered the study). The MITI Global Spirit subscale measured demonstration of MI principles: evocation, collaboration, autonomy/support.ResultsAfter training, median MITI MI-Adherence was 86.2% (IQR 76.9–100%) and mean MITI Empathy was 4.09 (SD 1.04). During delivery of treatment, in the intervention arm mean MITI Spirit was 4.03 (SD 1.05), mean Empathy was 4.23 (SD 0.89), and median Percentage Complex Reflections was 53.8% (IQR 40.0–71.4%). In the attention control arm mean Empathy was 3.40 (SD 0.98) and median Percentage Complex Reflections was 55.6% (IQR 41.9–71.4%).ConclusionsAfter MI and CBT skills training, detailed assessment showed that nurses had basic competencies in some psychological techniques. There appeared to be some delivery of elements of psychological treatment by nurses in the control arm. This model of training and delivery of MI and CBT skills integrated into routine nursing care to support diabetes self-management in primary care was not associated with high competency levels in all skills.Trial registrationISRCTN75776892; date registered: 19/05/2010.

Evaluation of a patient-centered after visit summary in primary care

ObjectiveTo test the impact of a redesigned, patient-centered after visit summary (AVS) on patients’ and clinicians’ ratings of and experience with the document. MethodsWe conducted a difference-in-differences (DiD) evaluation of the impact of the redesigned AVS before and after its introduction in an academic primary care practice compared to a concurrent control practice. Outcomes included ratings of the features of the AVS. ResultsThe intervention site had 118 and 98 patients in the pre- and post-intervention periods and the control site had 99 and 105, respectively. In adjusted DiD analysis, introduction of the patient-centered AVS in the intervention site increased patient reports that the AVS was an effective reminder for taking medications (p = .004) and of receipt of the AVS from clinicians (p = .002). However, they were more likely to perceive it as too long (p = .04). There were no significant changes in overall rating of the AVS by clinicians or their likelihood of providing it to patients. ConclusionsA patient-centered AVS increased the number of patients receiving it and reporting that it would help them remember to take their medications. Practice implicationsImprovements in the patient-centeredness of the AVS may improve its usefulness as a document to support self-management in primary care.

Self-management support in routine primary care by nurses.

To examine how and to what extent self-management support, including behaviour change support, is provided by primary care nurses in routine consultations with chronically ill patients. Observational study design. Routine consultations of primary care nurses in the Netherlands with chronically ill patients were audio-taped and analysed. The analysis identified health topics addressed according to health care standards, self-management topics addressed using a validated set of topics, and behaviour change techniques (BCTs) using the Behaviour Change Techniques Taxonomy v1. Seventy-eight routine consultations of 17 primary care nurses with chronically ill patients were included in the analysis. Nurses addressed both health topics and self-management topics in brief, fragmented, and often inconsistent manners. Dietary intake and physical activity were the most frequently addressed topics. Nurses applied 21 BCTs to target behaviour change, but the use of these techniques was mainly inconsistent and implicit. The most consistently used BCTs were review behaviour goal(s) (56.4%) and feedback on behaviour (51.3%). Nurses addressed both health topics and self-management topics in their routine consultations. The duration, frequency, and number of addressed topics differed throughout the consultations. Nurses tended to prioritize the monitoring and optimization of patients' medical treatment and provided limited self-management support. Nurses seldom deepened their focus on behaviour change and infrequently used effective techniques to support this change. Adoption of self-management in primary care, including behaviour change, might be enhanced if nurses consistently and explicitly use effective BCTs in their consultations. Statement of contribution What is already known on this subject? Primary care nurses play a pivotal role in self-management support for patients with a chronic condition. Adequate self-management support requires nurses to activate patients and enhance behaviour change. Little is known regarding to what extent nurses provide self-management support in routine primary care. What does this study add? Self-management support is brief, fragmented, and inconsistently provided by nurses. Nurses tend to prioritize medical treatment optimization and seldom focus on behavioural change. Nurses' use of effective behaviour change techniques is low and should be enhanced.

Oral anticoagulation with vitamin K inhibitors and determinants of successful self-management in primary care.

BackgroundSelf-management may be an option to monitor oral anticoagulant therapy in health systems, but before recommending it, we need to assess patients’ ability to take on this task. The purpose of the study was to describe patients’ ability to self-manage and associated factors.MethodsThis was a 3-year prospective quasi-experimental study with a control group. Overall, 333 patients on anticoagulant therapy from seven primary care health centres of the Basque Health Service were included in the intervention group and followed up for 6 months after the intervention, assessing their ability to self-test and self-manage. The intervention consisted of a patient training programme, providing detailed information on their condition and its treatment, and practical training in how to use a portable blood coagulation monitor and adjust their anticoagulant dose. Comparisons were made with a control group (333 patients receiving OAT under usual care from the same seven health centres).Outcome variables were ability to self-manage, quality of the outcome (in terms of time in therapeutic range), and quality of life in the intervention group, and general patient characteristics (age and sex), clinical variables (reason for OAT, INR range), and quality of the outcome (in terms of percentage of INR measurements in range and complications) in both groups.ResultsOverall, 26.13 % of patients invited to participate in the intervention agreed. Of these, 99 % successfully learned to self-manage their OAT. Just 4.2 % did not complete the follow-up, in all cases for reasons unrelated to self-management, and 4.5 % required additional learning support. Outcomes were better than under usual care in terms of percentage of INR measurements in range (12 %), rate of complications (4 %) and quality of life (9.2 %).LimitationsPatients were only followed-up period for 6 months and the study was conducted in a single health organization. Though patients eligible to participate were selected randomly, they were not randomly allocated to the groups. This is a potential source of selection bias. Data needed to calculate in-range time were not collected from controls; rather the results for the self-management group were compared with external data from other studies.ConclusionsAlmost all participants achieved competency in self-management, with no differences by age, sex, concurrent illnesses, polypharmacy or educational level. The greatest barrier to self-management was the attitude of patients themselves and those around them. Self-management in primary care is a good alternative to usual care, patients having longer times in therapeutic range and fewer complications, and improving their quality of life. Remote management is a good support tool.Trial registrationClinicalTrials.gov Identifier: NCT01878539.

What does it take to set goals for self-management in primary care? A qualitative study: Table 1.

Background.There is an increasing number of patients with a chronic illness demanding primary care services. This demands for effective self-management support, including collaborative goal setting. Despite the fact that primary care professionals seem to have difficulties implementing goal setting, little information is available about the factors influencing the complexity of this process in primary care.Objective.The aim of this study was to contribute to an understanding of the complexity of self-management goal setting in primary care by exploring experts’ and primary care professionals’ experiences with self-management goal setting and viewpoints regarding influencing factors.Methods.A descriptive qualitative research methodology was adopted. Two focus groups and three individual interviews were conducted (total participants n = 17). Thematic content analysis was used to analyse the data.Results.The findings were categorized into four main themes with subordinated subthemes. The themes focus around the complexity of setting non-medical goals and around professionals’ skills and attitudes to negotiate and decide about goals with patients. Furthermore, patients’ skills and attitudes for goal setting and the integration of goal setting in the time available were formulated as themes.Conclusions.Setting self-management goals in primary care, especially in family medicine, might require a shift from a medical perspective to a biopsychosocial perspective, with an increasing role set aside for the professional to coach the patient in expressing his self-management goals and to take responsibility for these goals.

Effectiveness of personalised support for self-management in primary care: a cluster randomised controlled trial.

Self-management support is an important component of the clinical management of many chronic conditions. The validated Self-Management Screening questionnaire (SeMaS) assesses individual characteristics that influence a patient's ability to self-manage. To assess the effect of providing personalised self-management support in clinical practice on patients' activation and health-related behaviours. A cluster randomised controlled trial was conducted in 15 primary care group practices in the south of the Netherlands. After attending a dedicated self-management support training session, practice nurses in the intervention arm discussed the results of SeMaS with the patient at baseline, and tailored the self-management support. Participants completed a 13-item Patient Activation Measure (PAM-13) and validated lifestyle questionnaires at baseline and after 6 months. Data, including individual care plans, referrals to self-management interventions, self-monitoring, and healthcare use, were extracted from patients' medical records. Multilevel multiple regression was used to assess the effect on outcomes. The PAM-13 score did not differ significantly between the control (n = 348) and intervention (n = 296) arms at 6 months. In the intervention arm, 29.4% of the patients performed self-monitoring, versus 15.2% in the control arm (effect size r = 0.9, P = 0.01). In the per protocol analysis (control n = 348; intervention n = 136), the effect of the intervention was significant on the number of individual care plans (effect size r = 1.3, P = 0.04) and on self-monitoring (effect size r = 1.0, P = 0.01). This study showed that discussing SeMaS and offering tailored support did not affect patient activation or lifestyle, but did stimulate patients to self-monitor and use individual care plans.