Chronic Disease Management Strategies Research Articles

Burden and determinants of multimorbidity among women in reproductive age group: a cross-sectional study based in India

Background: India's government is currently running several programs with a sole focus on women's health during their child-bearing years. However, none of these programs incorporate the management of chronic health conditions during the reproductive span. This issue is an emerging public health concern; therefore, the present study aims to identify the patterns and correlates of multimorbidity among women in reproductive age groups in India. Methods: The study utilizes nationally-representative cross-sectional data from the Demographic and Health Survey on 661,811 women in the reproductive age group of 15-49 years. The study uses information on seven chronic morbidities, namely asthma, cancers, heart disease, diabetes, tuberculosis, hypertension, and thyroid disorder. Descriptive, bivariate, and multivariable techniques were utilized to accomplish the study objective. Results: The findings show that 17.4 and 3.5 per 100 women of reproductive age suffered from any one morbidity and multimorbidity, respectively. Hypertension, diabetes, and thyroid disorders were commonly occurring morbidities. The prevalence of having any one morbidity or multimorbidity increased with age. Variables like religion, wealth, parity, menopause, consumption of tobacco and alcohol, body mass index, and type of diet were found to be significantly related to the burden of multimorbidity. The prevalence of multimorbidity was found to be higher for women who belong to the Southern, Eastern, and North-Eastern regions of India. Conclusions: Findings suggest the importance of multimorbidity in the context of women of reproductive age. Inclusion of chronic disease management strategies with maternal and child health services needs to be taken into consideration by the program and policymakers. The annexation of social marketing approaches at the primary level of healthcare would assist policy-makers in educating women about the importance of leading a healthy lifestyle. Practicing dietary diversity can help in maintaining optimal estrogen levels, which would further help in decreasing multimorbidity rates among women in India.

Burden and determinants of multimorbidity among women in reproductive age group: a cross-sectional study based in India

Background: India's government is currently running several programs with a sole focus on women's health during their child-bearing years. However, none of these programs incorporate the management of chronic health conditions during the reproductive span. This issue is an emerging public health concern; therefore, the present study aims to identify the patterns and correlates of multimorbidity among women in reproductive age groups in India. Methods: The study utilizes nationally-representative cross-sectional data from the Demographic and Health Survey on 661,811 women in the reproductive age group of 15-49 years. The study uses information on seven chronic morbidities, namely asthma, cancers, heart disease, diabetes, tuberculosis, hypertension, and thyroid disorder. Descriptive, bivariate, and multivariable techniques were utilized to accomplish the study objective. Results: The findings show that 17.4 and 3.5 per 100 women of reproductive age suffered from any one morbidity and multimorbidity, respectively. Hypertension, diabetes, and thyroid disorders were commonly occurring morbidities. The prevalence of having any one morbidity or multimorbidity increased with age. Variables like religion, wealth, parity, menopause, consumption of tobacco and alcohol, body mass index, and type of diet were found to be significantly related to the burden of multimorbidity. The prevalence of multimorbidity was found to be higher for women who belong to the Southern, Eastern, and North-Eastern regions of India. Conclusions: Findings suggest the importance of multimorbidity in the context of women of reproductive age. Inclusion of chronic disease management strategies with maternal and child health services needs to be taken into consideration by the program and policymakers. The annexation of social marketing approaches at the primary level of healthcare would assist policy-makers in educating women about the importance of leading a healthy lifestyle. Practicing dietary diversity can help in maintaining optimal estrogen levels, which would further help in decreasing multimorbidity rates among women in India.

Adults with diabetes mellitus in Newfoundland and Labrador: a population-based, cross-sectional analysis.

Although the province of Newfoundland and Labrador has the highest rates of chronic disease in Canada, the current state of many chronic diseases in the province, including diabetes mellitus, has not been well explored. We profiled the demographic characteristics associated with, and the management of, diabetes in Newfoundland and Labrador, including any rural-urban differences. We performed a population-based, cross-sectional analysis using data from the provincial Chronic Disease Registry for fiscal year 2015/16. Patients in the study sample were 20 years of age or older, with documented identifiers for age, sex and geographic location. We examined demographic characteristics, results of screening and diabetes clinical tests (glycated hemoglobin [HbA1c], low-density lipoprotein [LDL] cholesterol and urine albumin-to-creatinine ratio) and hospitalization rates. We described and compared demographic, clinical and hospitalization variables across urban and rural residents of the province. The study sample consisted of 66 325 individuals with diabetes in Newfoundland and Labrador (mean age 64.1 yr; 56.3% rural residents). Larger proportions of rural than urban residents with diabetes were aged 65 to 79 years (41.2% v. 37.5%), were female (50.2% v. 48.7%) and were identified as having the disease by laboratory tests only (19.6% v. 13.1%). Rural residents had worse clinical test outcomes than their urban counterparts, specifically with respect to HbA1c (mean and standard deviation [SD], 7.41% [SD 1.49] v. 7.26% [SD 1.50]) and LDL cholesterol (mean 2.46 [SD 0.95] v. mean 2.36 [SD 0.94] mmol/L). A total of 13.7% of individuals were admitted to hospital during the cohort year, with slightly more rural residents admitted for renal disease (standardized difference 0.021, 95% confidence interval 0.005 to 0.036). For many individuals with diabetes in Newfoundland and Labrador, recommended targets for diabetes management are not being met, and residents in rural areas have poorer clinical outcomes. To inform the development and implementation of targeted provincial strategies for chronic disease management, further research is needed to determine how outcomes relate to the availability of primary health care services.

Hospital-based chronic disease care model: protocol for an effectiveness and implementation evaluation

IntroductionNovel and efficient healthcare approaches are needed to better serve increasingly older chronic disease patients. Many effective integrated chronic disease management strategies have emerged from the primary care sector. However,...

Comparative analysis of quality of life of HIV positive support group and non-support group members in a tertiary hospital in Anambra State, Nigeria

Background: Peer support as a component of chronic disease management strategy is fast gaining prominence especially in resource poor settings. It is apt to X-ray the effects if any, of support group memberships on the quality of life (QoL) of HIV positive clients in our clime. This study aims to determine and compare the QoL of HIV positive support group and non-support group members in a tertiary hospital in Anambra state, Nigeria.Methods: This was an institution based comparative study of 482 HIV positive clients selected using a two-stage sampling. Data were collected by interview using WHOQOLHIV-Bref and semi-structured questionnaire, while data were analysed with statistical package for social sciences version 22.0. Chi square, Pearson chi square and t-test were applied as appropriate to determine statistically significant associations between variables. Level of statistical significance was set at p value of <0.05.Results: Differences between the two comparison groups include: duration of HAART treatment (p=0.003), in the physical domain (p=0.043), psychological domain (p≤0.001), and the level of independence domain (p≤0.001). More of support group members had good QoL in the physical domain (p=0.04,), psychological domain (p=0.001), level of independence domain (p≤0.001) and reported satisfaction with their perceived health status (p=0.000). Clients who were members of support group and those that reported high level of satisfaction with their perceived health status in most domains had higher QoL scores.Conclusions: We recommend continued counselling and health education on the effect of participation in support group and positive perception cum positive living on QoL.

Research priorities for rehabilitation and aging with HIV: a framework from the Canada-International HIV and Rehabilitation Research Collaborative (CIHRRC)

BackgroundPeople living with HIV are living longer, and can experience physical, mental and social health challenges associated with aging and multimorbidity. Rehabilitation is well positioned to address disability and maximize healthy aging. An international collaborative network, called the Canada-International HIV and Rehabilitation Research Collaborative (CIHRRC), works to guide this emerging field. In this article, we report findings from CIHRRC’s aim to identify emerging research priorities in HIV, aging and rehabilitation from the perspectives of people living with HIV, clinicians, researchers, representatives from community organizations and policy stakeholders.MethodsWe conducted a multi-stakeholder multi-method international consultation with people living with HIV, researchers, clinicians and representatives of community-based organizations to identify research priorities in HIV, aging and rehabilitation. Stakeholders identified research priorities during a one-day International Forum comprised of presentations and facilitated discussion. We collated and analyzed data using content analytical techniques, resulting in a framework of research priorities.ResultsSixty-nine stakeholders from countries including Canada (n = 62; 90%), the United Kingdom (n = 5; 7%), United States (n = 1; 1%) and Australia (n = 1; 1%) attended the International Forum on HIV, Aging and Rehabilitation Research. Stakeholders represented community-based organizations (n = 20; 29%), academic institutions (n = 18; 26%), community or institutional healthcare organizations (n = 11; 16%), research or knowledge production organizations (n = 10; 14%), and organizations representing government or industry (n = 10; 14%). The Framework of Research Priorities in HIV, Aging and Rehabilitation includes seven research priorities: (1) nature, extent and impact of disability, concurrent health conditions and chronic inflammation with HIV; (2) prevalence, severity and impact of frailty; (3) community and social participation aging with HIV; (4) strategies for chronic disease management and healthy aging with HIV; (5) facilitators and barriers to access and engagement in, rehabilitation; (6) effectiveness of rehabilitation interventions for healthy aging with HIV; and (7) advancing development and use of patient reported outcome measures in HIV and aging. The Framework highlights methodological considerations to approach the priorities and the importance of knowledge translation and exchange to apply research knowledge into practice, programs and policy.ConclusionsThese priorities offer a foundation for collaboration among international and multidisciplinary teams to advance the field of HIV, aging and rehabilitation in order to promote healthy aging with HIV.

Burden and Determinants of Multimorbidity Among Women in Reproductive Age-Group: A Cross-Sectional Study Based in India

Background: Government of India is currently running several programs with a sole focus on women’s health during their child-bearing years. However, none of these programs incorporate management of chronic health conditions during the reproductive span (15-49 years). This issue is an emerging public health concern, and therefore, the present study aims to identify the patterns and correlates of multi-morbidity among women in their reproductive age-groups (15-49 years) in India. Methods: The study utilizes a nationally-representative cross-sectional data from the Demographic and Health Survey on 661,811 women in their reproductive age group of 15-49 years in India during 2015-16. The study uses the information of seven chronic morbidities, namely asthma, cancers, heart disease, diabetes, tuberculosis, hypertension, and thyroid disorder. Descriptive, bi-variate, and multivariate techniques were utilized to accomplish the study objective. Results: The findings show that 17.4 and 3.5 per 100 women in the reproductive age-group suffered from any one morbidity and multi-morbidity, respectively. Hypertension, diabetes, and thyroid disorders were commonly occurring chronic morbidities among women. The prevalence of having any one morbidity or multi-morbidity increased with age. Variables like religion, region, wealth, parity, menopause, consumption of tobacco and alcohol, Body Mass Index, and type of diet were found to be significantly related to the burden of multi-morbidity. The prevalence of multi-morbidity was found to be higher for the women who belong to the Southern, Eastern, and North-eastern region of India. Conclusions: Findings suggests the importance of multi-morbidity in the context of women in the reproductive age-group. Inclusion of chronic disease management strategies with Maternal and Child Health (MCH) services needs to be taken into consideration by the program and policy-makers. The annexation of social marketing approaches at the primary level of healthcare would assist the policy- makers in educating the women about the importance of leading a healthy lifestyle. Practicing dietary diversity can help in maintaining optimal estrogen level, which would further help in plummeting multi-morbidity rates among women in India.

The EMPOWER-SUSTAIN e-Health Intervention to improve patient activation and self-management behaviours among individuals with Metabolic Syndrome in primary care: study protocol for a pilot randomised controlled trial

BackgroundEpidemiological studies conducted in various parts of the world have clearly demonstrated that metabolic syndrome (MetS) is an increasing global health problem, not only in Western societies but also in Asian populations. Web-based and mobile phone-based self-management applications have been proven to be effective in improving self-management behaviour of patients with MetS components (i.e., diabetes or hypertension). However, evidence is lacking in terms of their effectiveness specifically for patients with MetS. The aim of this pilot study is to evaluate the feasibility and potential effectiveness of the EMPOWER-SUSTAIN Self-Management e-Health Intervention in improving activation and self-management behaviours among patients with MetS. This paper presents the study protocol.MethodsA pilot randomised controlled trial will be conducted in a university primary care clinic. A total of 232 patients aged 18–60 years with MetS will be recruited; 116 will be randomised to receive the EMPOWER-SUSTAIN intervention for 6 months, and another 116 patients will continue with usual care. The EMPOWER-SUSTAIN intervention is a multifaceted chronic disease management strategy based on the Chronic Care Model and persuasive technology theory. It consists of training primary care physicians, nurses and patients to use the EMPOWER-SUSTAIN web-based self-management mobile app, strengthening the patient–physician relationship and reinforcing the use of relevant clinical practice guidelines to guide management and prescribing. The primary outcome is the mean change in patient activation score using the Patient Activation Measure short form Malay version (PAM-13-M) questionnaire. The secondary outcomes include the changes in waist circumference, body mass index, blood pressure, patient physical activity level, eating behaviour, perception of chronic illness care, satisfaction with patient–physician interaction, and perceived absolute 10-year cardiovascular disease risk. Feasibility of implementing the intervention will be evaluated. This includes acceptability of the intervention, estimating the likely rate of participant recruitment and retention, appropriateness of the outcome measures, calculation of sample size, and the intervention’s potential effectiveness.ConclusionTo our knowledge, this is the first study in Malaysia that aims to determine the feasibility of a multifaceted e-health intervention, as well as to indicate more useful aspects of this intervention for further exploration in a larger trial.Trial registrationClinicalTrials.gov, NCT04120779. Registered on 9 October 2019, protocol version 1.

Couple-based collaborative management model of type 2 diabetes mellitus for community-dwelling older adults in China: protocol for a hybrid type 1 randomized controlled trial

BackgroundChina’s limited health care resources cannot meet the needs of chronic disease treatment and management of its rapid growing ageing population. The improvement and maintenance of patient’s self-management is essential to disease management. Given disease management mainly occurs in the context of family, this study proposes to validate a Couple-based Collaborative Management Model of chronic diseases that integrates health professionals and family supporters; such as to empower the couples with disease management knowledge and skills, and to improve the couples’ health and quality of life.MethodsThe proposed study will validate a couple-based collaborative management model of Type 2 Diabetes Mellitus (T2DM) in a community-based multicenter, two-arm, randomized controlled trial of block design in Guangzhou, China. Specifically, 194 T2DM patients aged ≥55 and their partners recruited from community health care centers will be randomized at the patient level for each center at a 1:1 ratio into the couple-based intervention arm and the individual-based control arm. For the intervention arm, both the patients and their spouses will receive four-weekly structured group education & training sessions and 2 months of weekly tailored behavior change boosters; while these interventions will be only provided to the patients in the control group. Behavior change incentives will be targeted at the couples or only at the patient respectively. Treatment effects on patients’ hemoglobin, spouses’ quality of life, alongside couples’ behavior outcomes will be compared between arms. Study implementation will be evaluated considering its Reach, Effectiveness, Adoption, Implementation and Maintenance following the RE-AIM framework.DiscussionThis study will generate a model of effective collaboration between community health professionals and patients’ family, which will shield light on chronic disease management strategy for the increasing ageing population.Trial registrationChinese Clinical Trial Registry, ChiCTR1900027137, Registered 1st Nov. 2019

COPD and the gut-lung axis: the therapeutic potential of fibre.

Current management strategies for chronic obstructive pulmonary disease (COPD) incorporate a step-wise, multidisciplinary approach to effectively manage patient symptoms and prevent disease progression. However, there has been limited advancement in therapies to address the underlying cause of COPD pathogenesis. Recent research has established the link between the lungs and the gut-the gut-lung axis -and the gut microbiome is a major component. The gut microbiome is likely perturbed in COPD, contributing to chronic inflammation. Diet is a readily modifiable factor and the diet of COPD patients is often deficient in nutrients such as fibre. The metabolism of dietary fibre by gut microbiomes produces anti-inflammatory short chain fatty acid (SCFAs), which could protect against inflammation in the lungs. By addressing the 'fibre gap' in the diet of COPD patients, this targeted dietary intervention may reduce inflammation, both systemically and in the airways, and value-add to the paradigm shift in respiratory medicine, from reactive to personalised and participatory medicine.

Social support and management strategies for chronic disease in patients with systemic lupus erythematosus

To investigate the social support level and its influencial factors in patients with systemic lupus erythematosus (SLE), and to develop the management strategies for chronic disease. Methods: Patients with SLE were investigated by Social Support Rating Scale (SSRS), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), 36-Item Short-Form Health Survey (SF-36) and Visual Analogue Scale (VAS) of fatigue. The demographic and clinical data of SLE patients were recorded. SLE disease activity and damage severity were assessed by SLE Disease Activity Index (SLEDAI) and SLE Damage Index (SDI), respectively. Influencial factors for social support were analyzed. Results: A total of 246 patients were included. Social support scores for these patients were 40.76±7.93 and the scores showed no significant difference with the national norm (P>0.05). Patients who were younger than 18, single, unemployed or damaged by disease showed lower level of social support (P<0.05). Compared with the high social support group, patients in the low social support group experienced more severe depression or anxiety, and scored lower on mental component summary scale (vitality, social functioning, emotional role and mental health perception) and physical role of SF-36 (P<0.05). Conclusion: Social support levels for patients with SLE are closely related to the quality of life, and influenced by age, marital status, professional condition, and disease damage. Health education for patients and their families should be strengthened in chronic disease management to enhance social support and finally, improve their quality of life.

Is Nonadherence to Cancer Screening a Marker for Higher 15-Year Noncancer Mortality?

Nonadherence to cancer screening guidelines is associated with general nonadherence to chronic disease management and preventive strategies.

Disease Burdens and Risk Factors for Diabetes, Hypertension, and Hyperlipidemia among Refugees in Buffalo, New York, 2004-2014.

Limited is known about prevalence and risk factors for diabetes, hypertension, and hyperlipidemia among refugees. At a refugee clinic in Buffalo, N.Y. (2004-2014), 1,570 adults were studied using multivariate logistic regression. Prevalences of diabetes, hypertension, and hyperlipidemia were 7.8%, 24.1%, and 27.1%, respectively. Among refugees, 49.2% of diabetes and 46.7% of hypertension were uncontrolled. Obesity (odds ratio [OR]=2.49; 95% confidence interval [CI]=1.61-3.85) and length of stay (OR=1.25; 95%CI=1.16-1.35) were risk factors for diabetes. Eastern European origin (OR=4.09; 95%CI=2.00-8.38), obesity (OR=2.62; 95%CI=1.92-3.58), length of follow-up (OR=1.06; 95%CI=1.00-1.12), gender (OR=0.59; 95%CI=0.44-0.78) and tobacco use (OR=1.54; 95%CI=1.00-2.38) were associated with hypertension. Age (OR=1.02; 95%CI=1.01-1.04) was associated with hyperlipidemia. Refugees had comparable burden of non-communicable diseases, but a greaterleast once during the study period proportion of refugees than of the U.S. population had uncontrolled conditions. Duration of follow-up, obesity, tobacco use, gender, age, and region of origin were risk factors for diagnosis. Culturally-tailored chronic disease management strategies are needed.

Implementation of the\xa0Chronic Disease Care System and its association with health care costs and continuity of care in Korean adults with type 2 diabetes mellitus

BackgroundThe Chronic Disease Care System (CDCS) has been implemented in Korea to encourage treatment continuity in chronic disease patients. This study investigated the effect of the introduction of the CDCS on health care costs and continuity of care in individuals with type 2 diabetes mellitus (T2DM).MethodsThe National Health Insurance data from August, 2010 to March, 2012 (pre-policy) and from May, 2012 to December, 2013 (post-policy) were used. Introduction of the CDCS was defined as the intervention. The intervention group consisted of T2DM patients participating in the program and the control group patients not participating in the program. The Difference-in-Differences (DID) method was used to estimate the differences in total health care costs for outpatient services and continuity of care between the intervention and the control group before and after the intervention period.ResultsImplementation of the CDCS was associated with decreased health care costs (β = − 46,877 Korean Won, P < 0.0001) and improved continuity of care (β = 0.0536, P < 0.0001) in the intervention group with adjustment for covariates.ConclusionFindings confirm an association between the adoption of the CDCS and reduced health care costs and improved continuity of care. The results reveal the potential benefits of reinforcing effective chronic disease management strategies in reducing health care costs and improving treatment continuity.

Marketing Self-management Education: Lessons on Messaging and Framing.

Objective Self-management education (SME) refers to educational interventions that help individuals with chronic diseases maintain or improve their quality of life. To help increase SME participation, the US Centers for Disease Control and Prevention conducted audience research to assess feasibility of a campaign to market SME as a chronic disease management strategy and increase future receptivity to specific SME programs. Methods Twenty focus groups were conducted in 3 rounds across 8 cities with men and women ages 45-75 with a variety of, or multiple, chronic conditions. Data were analyzed to identify cross-cutting themes and assess differences by sex, race/ethnicity, and location. Results Findings revealed that although people with chronic disease are not aware of SME, it is feasible to deliver motivating messages about SME, and content need not be condition- or intervention-specific. Concepts viewed most positively by focus groups incorporated positive tone, empowering language, specific references to health, relatable images, and a website for more information. Conclusion This qualitative work suggests SME marketing strategies will be most effective by providing background information, framing messages positively, using clear relatable language, and making it easy for potential participants to find a program.

Canadian Alliance for Healthy Hearts and Minds: First Nations Cohort Study Rationale and Design.

This is the first national indigenous cohort study in which a common, in-depth protocol with a common set of objectives has been adopted by several indigenous communities across Canada. The overarching objective of the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort is to investigate how the community-level environment is associated with individual health behaviors and the presence and progression of chronic disease risk factors and chronic diseases such as cardiovascular disease (CVD) and cancer. CAHHM aims to recruit approximately 2,000 First Nations indigenous individuals from up to nine communities across Canada and have participants complete questionnaires, blood collection, physical measurements, cognitive assessments, and magnetic resonance imaging (MRI). Through individual- and community-level data collection, we will develop an understanding of the specific role of the socioenvironmental, biological, and contextual factors have on the development of chronic disease risk factors and chronic diseases. Information collected in the indigenous cohort will be used to assist communities to develop local management strategies for chronic disease, and can be used collectively to understand the contextual, environmental, socioeconomic, and biological determinants of differences in health status in harmony with First Nations beliefs and reality.

Implementation of an evaluation system for chronic care models in Spain

Background: The Spanish public healthcare system is composed of 17 regional health services managed by the Autonomous Regions. The Autonomous Regions have full management autonomy at structural, organizational and budgetary levels in health and social policies. In the last decade, it became clear that it was needed to rethink the way of responding to the needs of people with one or more chronic conditions, especiallywith older, multimorbid, polymedicated patients and in situations of greater complexity or vulnerability. In 2010, the IEMAC-ARCHO instrument was designed with the purpose of evaluating and re-orienting chronic disease management strategies in various regions. Objective: To describe the evaluation of the chronic care models in the Regional Health Services of Spain during the period 2011-2016. Method: Review of the frequency of use of the IEMAC-ARCHO tool in the different regional health services at the macro, meso and micro levels for the evaluation of plans, programs and strategies of integrated chronic care. IEMAC-ARCHO is the only validated tool that is being used in Spain for evaluation purposes of approaches to chronicity. With 75 items the tool is based on the Chronic Care Model (CCM) and provides a score in all 6 dimensions of the CCM. There are specific versions for diabetes and musculoskeletal conditions. The use of this tool allows to draw the degree of evaluation (and in some way of its deployment) of the strategies or plans of integrated care for chronicity. Results: In the period 2011 to 2016, the IEMAC-ARCHO tool was used in 157 evaluations (14 at the macro level, 78 at the meso level and 65 at the micro level). At the macro level, it has been used by 14/17 (82,3%) of regional health services. At the meso level, 45/78 (57,7%) correspond to evaluations in the Basque Health Service and 8/78 (10,2%) to Andalusia. At the micro level, 28/65 (38,2%) evaluations were performed in Catalonia. The dominant profile of meso-level centers that used IEMAC-ARCHO corresponded to Integrated Care Organizations (ICOs) (42.3%). The highest scored dimension was “The reorganization of Delivery Model” (45 points in average) and the lowest “Community Health” (30 points in average). 14,1% of organizations have evaluated twice or more showing highest improvements in “The reorganization of Delivery Model”, “Self-management Support” and “Information Systems”. Conclusions: The mapping of the self-assessments carried out with IEMAC-ARCHO gives us an overview of the development of new models in relation to chronicity in Spain, which largely corresponds with the development of chronicity plans. The main users of the tool are the vertically integrated organizations, since to a large extent the development of these new organizational forms is linked to new approaches of integrated care for chronicity and to new approaches of population health management. In the Spanish context where evaluation of policies is usually scarce, IEMAC-ARCHO has proven to be a useful tool for systematic evaluation of plans and strategies related to chronicity.

Chronic disease management interventions for people with chronic kidney disease in primary care: a systematic review and meta-analysis.

Primary care providers manage the majority of patients with chronic kidney disease (CKD), although the most effective chronic disease management (CDM) strategies for these patients are unknown. We assessed the efficacy of CDM interventions used by primary care providers managing patients with CKD. The Medline, Embase and Cochrane Central databases were systematically searched (inception to November 2014) for randomized controlled trials (RCTs) assessing education-based and computer-assisted CDM interventions targeting primary care providers managing patients with CKD in the community. The efficacy of CDM interventions was assessed using quality indicators [use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), proteinuria measurement and achievement of blood pressure (BP) targets] and clinical outcomes (change in BP and glomerular filtration rate). Two independent reviewers evaluated studies for inclusion, quality and extracted data. Random effects models were used to estimate pooled odds ratios (ORs) and weighted mean differences for outcomes of interest. Five studies (188 clinics; 494 physicians; 42 852 patients with CKD) were included. Two studies compared computer-assisted intervention strategies with usual care, two studies compared education-based intervention strategies with computer-assisted intervention strategies and one study compared both these intervention strategies with usual care. Compared with usual care, computer-assisted CDM interventions did not increase the likelihood of ACEI/ARB use among patients with CKD {pooled OR 1.00 [95% confidence interval (CI) 0.83-1.21]; I2 = 0.0%}. Similarly, education-related CDM interventions did not increase the likelihood of ACEI/ARB use compared with computer-assisted CDM interventions [pooled OR 1.12 (95% CI 0.77-1.64); I2 = 0.0%]. Inconsistencies in reporting methods limited further pooling of data. To date, there have been very few randomized trials testing CDM interventions targeting primary care providers with the goal of improving care of people with CKD. Those conducted to date have shown minimal impact, suggesting that other strategies, or multifaceted interventions, may be required to enhance care for patients with CKD in the community.

A qualitative study of satisfaction with the Community-based Primary Care Project among primary care patients and its efficacy

This study aimed to characterize patients experiences as service recipients, and to examine their satisfaction with the Community-based Primary Care Project and its efficacy. To achieve these aims, qualitative data were collected from 13 patients through a semi-structured in-depth interview. Four trained researchers extracted each theme separately and discussed them, at which point they were subjected to thematic analysis. Patient satisfaction was found to be associated with the doctor-patient relationship, comprehensive chronic disease care, face-to-face education, standardized education material, and computer-based education modules. Education allowed patients to strengthen their knowledge and establish their motivations, which brought about behavioral change and improved health conditions. In addition to these effects, patients also reported improved perceptions of the quality of primary care based on experiences with clinical team coordination. The findings of this study emphasize that community-based primary care services should be considered to be an effective chronic disease management strategy.

Transforming Chronic Illness Management through Integrated Care: A Systematic Review of What Works Best and Why

Introduction: Evidence from the international literature is that the prevention and management of chronic diseases through integrated care should be primary care GP led supported by primary care specialists and secondary care specialist services. Primary care led services towards integrated care marks a transformational shift away from hospital centric services, which has traditionally dominated healthcare in many countries. The shift towards integrated primary care led services is now a strategic priority at Government level across European countries and elsewhere in effort to tackle the growing burden of chronic disease (Nolte & Knai). The emphasis on integrated care is to avoid fragmentation of services between primary and secondary care and to ensure the delivery of “the right service, at the right time, in the right place by the right team”. The aims of this paper is to systematically present the evidence on: (i) what works best towards an integrated approach to chronic illness management between primary and secondary specialist services; (ii) the effectiveness of best models of integrated care programmes; and (iii) how best to implement an integrated care programme into a national healthcare service (such as Ireland) drawing on international best practices. Methods: This desk based research was guided by the principles of conducting systematic reviews (Higgins & Green 2011; Centre for Systematic Reviews & Dissemination 2008). Inclusion criteria for papers were by population (adults) with chronic disease (respiratory, diabetes, musculoskeletal, cardiovascular); focus on integration (across healthcare boundaries); publication type (meta-review, meta-analysis, meta-synthesis, RCT, or evaluation study); all limited to a publication within 10 year period from 2005. Databases searched were MEDLINE, CINAHL, Cochrane Library and Grey Literature. From a total of 6,466 records screened 24 studies in 33 papers were included for review. For the quality appraisal process, studies were stratified and grouped according to study type. For RCTs, internal validity was assessed using the Cochrane Collaboration’s Tool for Assessing Risk of Bias, and external validity was assessed using the criteria adapted from Foy et al. (2010). For the quality appraisal of synthesis papers, the AMSTAR (Assessment of Multiple Systematic Reviews) was used. Results: This findings indicate that a primary care GP led approach to integrated care for chronic illness management works best. The critical components of integrated care were found to be (i) nurse/led specialist care in primary care with a link into secondary care with a role in scheduled patient care, self-management support, risk stratification, speciality support for primary care teams, and care co-ordination across services (ii) ) shared or centralised information systems between primary and secondary care services e.g. medical records, tracking and recall systems, disease registers; (iii) shared clinical decision support tools such as clinical guidelines. These components were found to be effective in promoting positive outcomes at clinical, process and service healthcare levels. Transforming chronic illness management through an integrated care programme into a national health service was found to need a phased and bottom up approach, starting with pilot sites and working towards larger scale implementation and evaluation. Discussion: The evidence from this review supports recommendations for primary care services and clinical care delivery. There needs to be a shift from ‘individual patient’ care to a population based philosophy and approach to chronic disease management with an added emphasis on primary prevention for health and wellbeing. Identification of high-risk population groups using risk stratification techniques followed with implementation of targeted interventions are needed. There needs to be an increase in the number of specialist nurses working across clusters of primary care practices in countries such as Ireland where hospital centric healthcare system dominates. Lessons can be learned from other countries currently operationalizing strategies for chronic disease management through integrated care approaches (Nolte & Knai 2015). Conclusion: A well-designed integrated approach to chronic disease prevention and management can lead to positive clinical, process and service utilization outcomes. The review is limited by inclusion of studies of mixed quality and reliance of papers only. Primary authors or leads on integrated care in various countries were not contacted for additional insights. However, the pattern of evidence was consistent across the range of studies offering some practical solutions at clinical, professional, organisational and systems level for implementing an integrated approach to chronic illness management. The evidence provides a basis for further research such as the development of a pilot phase study for implementing one or more of the critical components of integrated care with a longer term goal for up scaling this research to wider implementation and evaluation.