A Longitudinal Study of Interactions Between Health Professionals and People With Newly Diagnosed Diabetes.

PURPOSE: We undertook a study to observe in detail the primary care interactions and communications of patients with newly diagnosed diabetes over time. In addition, we sought to identify key points in the process where miscommunication might occur. METHODS: All health interactions of 32 patients with newly diagnosed type 2 diabetes were recorded and tracked as they moved through the New Zealand health care system for a period of approximately 6 months. Data included video recordings of patient interactions with the health professionals involved in their care (eg, general practitioners, nurses, dietitians). We analyzed data with ethnography and interaction analysis. RESULTS: Challenges to effective communication in diabetes care were identified. Although clinicians showed high levels of technical knowledge and general communication skill, initial consultations were often driven by biomedical explanations out of context from patient experience. There was a perception of time pressure, but considerable time was spent with patients by health professionals repeating information that may not be relevant to patient need. Health professionals had little knowledge of what disciplines other than their own do and how their contributions to patient care may differ. CONCLUSIONS: Despite current high skill levels of primary care professionals, opportunities exist to increase the effectiveness of communication and consultation in diabetes care. The various health professionals involved in patient care should agree on the length and focus of each consultation.

Supported Discharge Teams for older people in hospital acute care: a randomised controlled trial.

Background: Supported Discharge Teams aim to help with the transition from hospital to home, whilst reducing hospital length-of-stay. Despite their obvious attraction, the evidence remains mixed, ranging from strong support for disease-specific interventions to less favourable results for generic services. Objective: To determine whether older people referred to a Supported Discharge Team have: (i) reduced length-of-stay in hospital; (ii) reduced risk of hospital readmission; and (iii) reduced healthcare costs. Methods: Randomised controlled trial with follow-up to 6 months; 103 older women and 80 men (n = 183) (mean age 79), in hospital, were randomised to receive either Supported Discharge Team or usual care. Home-based rehabilitation was delivered by trained Health Care Assistants up to four times a day, 7 days a week, under the guidance of registered nurses, allied health and geriatricians for up to 6 weeks. Results: Participants randomised to the Supported Discharge Team spent less time in hospital during the index admission (mean 15.7 days) in comparison to usual care (mean 21.6 days) (mean difference 5.9: 95% CI 0.6, 11.3 days: P = 0.03) and spent less time in hospital in the 6 months following discharge home. Supported discharge group costs were calculated at mean NZ$10,836 (SD NZ$12,087) compared to NZ$16,943 (SD NZ$22,303) in usual care. Conclusion: A Supported Discharge Team can provide an effective means of discharging older people home early from hospital and can make a cost-effective contribution to managing increasing demand for hospital beds.

Development and use of a research productivity assessment tool for clinicians in low-resource settings in the Pacific Islands: a Delphi study.

BACKGROUND: Research performance assessments have proliferated, but research indicators for use amongst clinicians in poorly resourced countries have been ill-defined. The aims of the present paper were to determine a set of indicators as determined by clinician participants from the Pacific Islands and a panel of research experts for use in the performance assessment of clinicians. METHODS: Two focus group discussions, one for nurses and one for doctors, were used to obtain the views of 28 Pacific Island clinicians of the BRRACAP Study about what the research indicators should be. A modified Delphi survey was used to obtain a consensus amongst 19 research experts, with Pacific Island research experience, as to what the indicators should be and then to rank these in terms of importance. A survey of the participants obtained data on the research tasks/actions performed 20 months after the initial research workshop. A resultant tool comprising of 21 indicators was used to assess the performance of 18 Pacific participants. RESULTS: The Pacific Island clinicians determined that research was important and that performance should be measured. They identified research indicators that could be used in their settings and ranked their importance using a points system. The panel of experts identified implementation of research findings, collaborations and actual change in practice as more important, with bibliometric measurements low down in the scale. Although only 64% of the 28 BRRACAP Study participants returned the questionnaire, 39% of those performed more than half of the 21 indicators used. Of the 18 Pacific clinicians assessed, 7 (39%) performed 10 or more tasks. CONCLUSIONS: A research performance assessment tool was developed using process and output indicators identified by Pacific clinicians and a panel of research experts. The tool, which placed emphasis on process and outputs that were not bibliometric based, proved useful in assessing the performance of Pacific clinicians working in a low-resource setting.

Impact of using the International Association of Diabetes and Pregnancy Study Groups criteria in South Auckland: prevalence, interventions and outcomes.

INTRODUCTION: Adopting the modified International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for diagnosing gestational diabetes mellitus (GDM) will increase the prevalence of GDM resulting in increased resource utilisation and an unknown effect on clinical outcomes. AIMS: To determine the prevalence of GDM by the modified IADPSG criteria and compare characteristics and pregnancy outcomes between women with GDM by IADPSG-additional, those with GDM by the New Zealand Society for the Study of Diabetes (NZSSD) criteria and those with a normal oral glucose tolerance test (OGTT). METHODS: All women who delivered at Counties Manukau District Health Board (CMDHB) for a 12-month period from July 2012 to June 2013 had demographic, pregnancy and laboratory data obtained from hospital databases and clinical records. RESULTS: Of the 6376 (85%) of eligible women screened for GDM, 381 (6%) had GDM by NZSSD criteria and an additional 238 (4%) by the modified IADPSG-additional criteria, a relative increase of 62%. Women with GDM by NZSSD criteria had similar characteristics compared to women with GDM by IADPSG-additional. The outcomes between the two groups were also similar with the exception of a higher induction of labour (IOL) rate in women with GDM by NZSSD and a higher mean birthweight in the GDM by IADPSG-additional. CONCLUSION: Adopting the modified IADPSG criteria will result in a 62% increase in the number of GDM cases with a significant impact on workload and resources. Currently, there is insufficient evidence to support the introduction of the IADPSG criteria for our service.

Under the same roof: co-location of practitioners within primary care is associated with specialized chronic care management.

BACKGROUND: International and national bodies promote interdisciplinary care in the management of people with chronic conditions. We examine one facilitative factor in this team-based approach - the co-location of non-physician disciplines within the primary care practice. METHODS: We used survey data from 330 General Practices in Ontario, Canada and New Zealand, as a part of a multinational study using The Quality and Costs of Primary Care in Europe (QUALICOPC) surveys. Logistic and linear multivariable regression models were employed to examine the association between the number of disciplines working within the practice, and the capacity of the practice to offer specialized and preventive care for patients with chronic conditions. RESULTS: We found that as the number of non-physicians increased, so did the availability of special sessions/clinics for patients with diabetes (odds ratio 1.43, 1.25-1.65), hypertension (1.20, 1.03-1.39), and the elderly (1.22, 1.05-1.42). Co-location was also associated with the provision of disease management programs for chronic obstructive pulmonary disease, diabetes, and asthma; the equipment available in the centre; and the extent of nursing services. CONCLUSIONS: The care of people with chronic disease is the 'challenge of the century'. Co-location of practitioners may improve access to services and equipment that aid chronic disease management.

Building reproductive health research and audit capacity and activity in the Pacific Islands (BRRACAP) study: methods, rationale and baseline results.

BACKGROUND: Clinical research and audit in reproductive health is essential to improve reproductive health outcomes and to address the Millennium Development Goals 4 and 5. Research training, mentoring and a supportive participatory research environment have been shown to increase research activity and capacity in low to middle income countries (LMIC). This paper details the methods, rationale and baseline findings of a research program aimed at increasing clinical research activity and audit in the six Pacific Islands of Fiji, Samoa, Tonga, Vanuatu, Cook Islands and the Solomon Islands. METHOD: Twenty-eight clinician participants were selected by the five Ministries of Health and the Fiji National University to undergo a research capacity building program which includes a research workshop and mentoring support to perform research and audit as teams in their country. Data on the participants' characteristics, knowledge and experiences were collected from structured interviews, questionnaires, focus groups, and an online survey. The interviews and the two focus groups were audio-recorded and all replies were analysed in a thematic framework. RESULTS: The 28 participants included 9 nurses/midwives, 17 medical doctors of whom 8 were specialists in reproductive health and 2 other health workers. Most (24, 86%) were required to perform research as part of their employment and yet 17 (61%) were not confident in writing a research proposal, 13 (46%) could not use an electronic spreadsheet and the same number had not analysed quantitative data. The limited environmental enablers contributed to poor capacity with only 11 (46%) having access to a library, 10 (42%) receiving management support and 6 (25%) having access to an experienced researcher. Barriers to research that affected more than 70% of the participants were time constraints, poor coordination, no funding and a lack of skills. CONCLUSION: Building a research capacity program appropriate for the diversity of Pacific clinicians required research evidence and collaborative effort of key stakeholders in the Pacific Islands and the region. The participants had limited research knowledge, skills and experience and would require individualized training and continuous intensive mentorship to realize their potential as clinician researchers for their services in the Pacific.

Antibiotics for the common cold and acute purulent rhinitis.

BACKGROUND: It has long been believed that antibiotics have no role in the treatment of common colds yet they are often prescribed in the belief that they may prevent secondary bacterial infections. OBJECTIVES: To determine the efficacy of antibiotics compared with placebo for reducing general and specific nasopharyngeal symptoms of acute upper respiratory tract infections (URTIs) (common colds).To determine if antibiotics have any influence on the outcomes for acute purulent rhinitis and acute clear rhinitis lasting less than 10 days before the intervention.To determine whether there are significant adverse outcomes associated with antibiotic therapy for participants with a clinical diagnosis of acute URTI or acute purulent rhinitis. SEARCH METHODS: For this 2013 update we searched CENTRAL 2013, Issue 1, MEDLINE (March 2005 to February week 2, 2013), EMBASE (January 2010 to February 2013), CINAHL (2005 to February 2013), LILACS (2005 to February 2013) and Biosis Previews (2005 to February 2013). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any antibiotic therapy against placebo in people with symptoms of acute upper respiratory tract infection for less than seven days, or acute purulent rhinitis less than 10 days in duration. DATA COLLECTION AND ANALYSIS: Both review authors independently assessed trial quality and extracted data. MAIN RESULTS: This updated review included 11 studies. Six studies contributed to one or more analyses related to the common cold, with up to 1047 participants. Five studies contributed to one or more analyses relating to purulent rhinitis, with up to 791 participants. One study contributed only to data on adverse events and one met the inclusion criteria but reported only summary statistics without providing any numerical data that could be included in the meta-analyses. Interpretation of the combined data is limited because some studies included only children, or only adults, or only males; a wide range of antibiotics were used and outcomes were measured in different ways. There was a moderate risk of bias because of unreported methods details or because an unknown number of participants were likely to have chest or sinus infections.Participants receiving antibiotics for the common cold did no better in terms of lack of cure or persistence of symptoms than those on placebo (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.59 to 1.51, (random-effects)), based on a pooled analysis of six trials with a total of 1047 participants. The RR of adverse effects in the antibiotic group was 1.8, 95% CI 1.01 to 3.21, (random-effects). Adult participants had a significantly greater risk of adverse effects with antibiotics than with placebo (RR 2.62, 95% CI 1.32 to 5.18) (random-effects) while there was no greater risk in children (RR 0.91, 95% CI 0.51 to 1.63).The pooled RR for persisting acute purulent rhinitis with antibiotics compared to placebo was 0.73 (95% CI 0.47 to 1.13) (random-effects), based on four studies with 723 participants. There was an increase in adverse effects in the studies of antibiotics for acute purulent rhinitis (RR 1.46, 95% CI 1.10 to 1.94). AUTHORS' CONCLUSIONS: There is no evidence of benefit from antibiotics for the common cold or for persisting acute purulent rhinitis in children or adults. There is evidence that antibiotics cause significant adverse effects in adults when given for the common cold and in all ages when given for acute purulent rhinitis. Routine use of antibiotics for these conditions is not recommended.

Pacific Island publications in the reproductive health literature 2000-2011: with New Zealand as a reference.

BACKGROUND: There is a keen interest to develop research systems and increase research output in the 14 Pacific Island Forum Countries (PIFC) to support development of policies and practice based on locally relevant research evidence. AIMS: To assess the quantity and characteristics of reproductive health research output by each country (14 PIFC) from 2000 to 2011 using New Zealand's reproductive research outputs as the reference. METHODS: A systematic search of the literature using a broad definition of reproductive health. RESULTS: There were 174 papers published in the PIFC from 2000 to 2011 compared with 628 papers published in New Zealand (NZ). Most (57%) of the PIFC papers were from Papua New Guinea (PNG), although Samoa had the most papers by population (10/100,000). Five of the countries did not have a single publication. The majority of papers from both the PIFC and NZ were observational studies (72 vs 36%). Authors from Australia were responsible for 34% of PIFC publications followed by 25% from PNG. Sixty-three per cent of papers by PIFC sole and first authors were published in local journals, whereas 86% of non-PIFC authors published in international journals. CONCLUSION: There is a need for reproductive research in PIFC. PNG had the most publications on the back of a well-funded dedicated research institute and a significant collaboration with Australian researchers. The large number of papers in PIFC countries without PIFC authors raises the question about the need to require non-PIFC researchers to enter into genuine research partnerships in order to build research capacity in the PIFC.

Nurse-patient communication in primary care diabetes management: an exploratory study.

BACKGROUND: Diabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management. METHODS: Thirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis.In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared. RESULTS: This study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses' clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations. CONCLUSIONS: Conscientious nursing work was evident but at times misdirected in terms of optimal use of time. The misalignment of patient expectations and clinical protocols highlights a common dilemma in clinical practice and raises questions about the best ways to balance the needs of individuals with the needs of a health system. Video- recording can be a powerful tool for reflection and peer review.

Prescribing history to identify candidates for chronic condition medication adherence promotion.

Poor adherence to long-term prescription medication is a frequent problem that undermines pharmacological control of important risk factors such as hypertension. A medication possession ratio (MPR) can be calculated from Practice Management System (PMS) data to provide a convenient indicator of adherence. We investigate how well prior MPR predicts later MPR, taking MPR<80% as indicative of 'non-adherence,' to assess the potential value of MPR calculation on PMS data for targeting adherence promotion activities by general practices. We examine PMS data for two New Zealand metropolitan general practices, one with a predominantly Pacific caseload, across 2008 and 2009. We find prevalence of non-adherence in 2009 to be 51.63% (95% confidence interval [CI] 47.9-55.3) for patients at the Pacific practice and 28.09% (95% CI 25.0-31.1) at the other practice for patients who are demonstrably active with the practice in 2009. The positive predictive value (PPV) of 2008 non-adherence for 2009 non-adherence is 71.80% (95% CI, 66.5-77.1) and negative predictive value (NPV) 61.52% (95% CI 56.9-66.1) for the Pacific practice; PPV is 61.38% (95% CI 54.6-68.2) and NPV is 82.19% (95% CI 79.2-85.2) for the other practice. The results indicate good potential for decision support tools to target adherence promotion.

The inequity of access to health: a case study of patients with gout in one general practice.

AIM: Gout is a health equity issue for Maori and Pacific peoples because disparities in quality of care exist. This study aims to describe domains of access that may contribute to the optimisation of gout care and, therefore, address health inequity. METHODS: The practice management system at one general practice in Auckland was used to identify enrolled patients with gout, using disease codes and medication lists. Barriers to access for the cohort were investigated using staff knowledge and the practice management system. The general practice is uniquely situated within an urban marae (traditional meeting house) complex serving a predominantly Maori community. This enables a focus on domains of access other than cultural safety. RESULTS: Of 3,095 people enrolled at the practice, 268 were identified as having gout. Of these, 94% had at least one other long-term health condition. The majority of people with gout enrolled at the practice have employment roles incongruent with the clinic's opening hours. CONCLUSIONS: Social circumstances, such as employment and availability of transport, should be actively discussed with all patients and recorded in the practice management system. Reorientation of health services, including hours of access, is evidentially required to ensure optimal management of gout and possibly other health conditions.

Compounding inequity: a qualitative study of gout management in an urban marae clinic in Auckland.

INTRODUCTION Gout remains a health equity issue; Maori and Pacific peoples are disproportionately afflicted, with increased burden and loss of quality of life, yet are less likely to receive appropriate management, which mainly occurs in primary care. AIM This study aims to understand the perspectives of the mainly Maori and Pacific clinicians and staff at an urban marae practice about barriers and challenges to delivering effective care to a Maori and Pacific community with high burden of gout. METHODS Semi-structured interviews were conducted with 10 staff members delivering health care to a mostly Indigenous community. Interviews sought to ascertain staff views of enablers and barriers to optimal gout management and analyse them thematically. RESULTS Three themes were identified: community disadvantage; demands unique to Indigenous providers; and challenges and opportunities for optimising gout management. High prevalence and heavy impact of gout on wellbeing in the community was intertwined with socioeconomic disadvantage, precariousness of employment and entrenched inaccurate (yet pliable) patient views on gout, to the detriment of focused, effective care. Structural and funding demands on providers inhibited staff focus on the clear community need. Providers saw the culturally safe and competent approach necessary for improvement as requiring community empowerment with appropriate clinical tools and adequate resourcing. DISCUSSION Despite provider intent to deliver culturally appropriate and safe care and equitable health outcomes for patients suffering from gout, general practice initiatives without aligned resourcing or incentives are inhibited when inequity is pervasive. Simply asking Maori providers to do more for the same amount of resource may not be effective.

Post-Acute Care for Older People Following Injury: A Randomized Controlled Trial.

OBJECTIVES: The study sought to determine whether older people, on discharge from hospital and on referral to a supported discharge team (SDT), will have: (1) reduced length of stay in hospital; (2) reduced risk of hospital readmission; and (3) reduced healthcare costs. DESIGN/INTERVENTION: Randomized controlled trial with follow-up at 4 and 12 months of post-acute home-based rehabilitation team (SDT). Programs were delivered by trained healthcare assistants, up to 4 times a day, 7 days a week, under the guidance of registered nurses, allied health, and geriatricians for up to 6 weeks. PARTICIPANTS/SETTING: A total of 303 older women and 100 older men (mean age 81) in hospital because of injury, were randomized to either SDT (n = 201) or usual care (n = 202). The intervention was operated from Waikato hospital, a regional hospital in New Zealand. METHODS: Days spent in hospital in the year following randomization and healthcare costs were collected from hospital datasets, and functional status assessed using the interRAI Contact Assessment was gathered by health professional research associates. RESULTS: Participants randomized to the SDT spent less time in hospital in the period immediately prior to discharge (mean 20.9 days) in comparison to usual care (mean 26.6 days) and spent less time in hospital in the 12 months following discharge home. Healthcare costs were lower in the SDT group in the 12 months following randomization. CONCLUSIONS/IMPLICATIONS: SDT can provide an important role in reducing hospital length of stay and readmissions of older people following an injury. Almost a million older people (65+ years of age) a year in the US are hospitalized as a consequence of falls-related injuries, most often fractured hip. Hospitals are not always the best location to provide care for older people. SDTs can help with the transition from hospital to home, while reducing hospital length-of-stay.

Patient error: a preliminary taxonomy.

PURPOSE: Current research on errors in health care focuses almost exclusively on system and clinician error. It tends to exclude how patients may create errors that influence their health. We aimed to identify the types of errors that patients can contribute and help manage, especially in primary care. METHODS: Eleven nominal group interviews of patients and primary health care professionals were held in Auckland, New Zealand, during late 2007. Group members reported and helped to classify types of potential error by patients. We synthesized the ideas that emerged from the nominal groups into a taxonomy of patient error. RESULTS: Our taxonomy is a 3-level system encompassing 70 potential types of patient error. The first level classifies 8 categories of error into 2 main groups: action errors and mental errors. The action errors, which result in part or whole from patient behavior, are attendance errors, assertion errors, and adherence errors. The mental errors, which are errors in patient thought processes, comprise memory errors, mindfulness errors, misjudgments, and-more distally-knowledge deficits and attitudes not conducive to health. CONCLUSION: The taxonomy is an early attempt to understand and recognize how patients may err and what clinicians should aim to influence so they can help patients act safely. This approach begins to balance perspectives on error but requires further research. There is a need to move beyond seeing patient, clinician, and system errors as separate categories of error. An important next step may be research that attempts to understand how patients, clinicians, and systems interact to cocreate and reduce errors.

Antidepressants versus placebo for depression in primary care.

BACKGROUND: Concern has been expressed about the relevance of secondary care studies to primary care patients specifically about the effectiveness of antidepressant medication. There is a need to review the evidence of only those studies that have been conducted comparing antidepressant efficacy with placebo in primary care-based samples. OBJECTIVES: To determine the efficacy and tolerability of antidepressants in patients (under the age of 65 years) with depression in primary care. SEARCH STRATEGY: All searches were conducted in September 2007.The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) Controlled Trials Register was searched, together with a supplementary search of MEDLINE, PsycINFO, EMBASE, LILACS, CINAHL and PSYNDEX. Abstracts of all possible studies for inclusion were assessed independently by two reviewers. Further trials were sought through searching the reference lists of studies initially identified and by scrutinising other relevant review papers. Selected authors and experts were also contacted. SELECTION CRITERIA: Studies were selected if they were randomised controlled trials of tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) versus placebo in adults. Older patients (over 65 years) were excluded. Patients had to be recruited from a primary care setting. For continuous outcomes the Hamilton Depression scale of the Montgomery Asberg Scale was requred. DATA COLLECTION AND ANALYSIS: Data were extracted using data extraction forms by two reviewers independently, with disagreements resolved by discussion. A similar process was used for the validity assessment. Pooling of results was done using Review Manager 5. The primary outcome was depression reduction, based on a dichotomous measure of clinical response, using relative risk (RR), and on a continuous measure of depression symptoms, using the mean difference (MD), with 95% confidence intervals (CI). MAIN RESULTS: There were fourteen studies (16 comparisons) with extractable data included in the review, of which ten studies examined TCAs, two examined SSRIs and two included both classes, all compared with placebo. The number of participants in the intervention groups was 1364 and in the placebo groups 919. Nearly all studies were of short duration, typically 6-8 weeks. Pooled estimates of efficacy data showed an RR of 1.24, 95% CI 1.11-1.38 in favour of TCAs against placebo. For SSRIs this was 1.28, 95% CI 1.15 to 1.43.. The numbers needed to treat (NNT) for TCAs ranged from 7 to 16 {median NNT 9} patient expected event rate ranged from 63% to 26% respectively) and for SSRIs from 7 to 8 {median NNT 7} (patient expected event rate ranged from 48% to 42% respectively) . The numbers needed to harm (NNH for withdrawal due to side effects) ranged from 4 to 30 for TCAs (excluding three studies with no harmful events leading to withdrawal) and 20 to 90 for SSRIs. AUTHORS' CONCLUSIONS: Both TCAs and SSRIs are effective for depression treated in primary care.

Mapping for Conceptual Clarity: Exploring Implementation of Integrated Community-Based Primary Health Care from a Whole Systems Perspective.

INTRODUCTION: Studying implementation of integrated models of community-based primary health care requires a "whole systems" multidisciplinary approach to capture micro, meso and macro factors. However, there is, as yet, no clear operationalization of a "whole systems" approach to guide multidisciplinary research programs. Theoretical frameworks and approaches from diverse academic traditions specify different aspects of the health system in more depth. Enabling analysis across the system, when data and ideas are captured using different taxonomies, requires that we map terms and constructs across the models. THEORY AND METHODS: This paper uses concept mapping techniques to compare and contrast the theoretical frameworks and approaches used in the iCOACH project including: Ham's Ten Characteristics of the High-Performing Chronic Care System (capturing patient/carer and provider perspectives), the Organizational Context and Capabilities for Integrating Care framework (capturing the organizational perspective), and the Health Policy Monitor framework (capturing the policy system perspective). The aim of the paper is to link concepts across different theoretical framework to guide the iCOACH study. RESULTS: A concept map was developed that identifies 8 overarching concepts across the heuristic models. A preliminary analysis of one of these overarching concepts, care coordination, demonstrates how different perspectives will assign different meanings, values, and drivers of seemingly similar ideas. For patients and carers care coordination is about having a responsive team of health care providers. Building relationships in teams that exist within and across different organizations is essential for providers to achieve care coordination, where managers and policy makers see care coordination as being more about creating linkages and addressing systems gaps. DISCUSSION AND CONCLUSION: This work represents a first step towards development of a fully formed conceptual framework that includes key domains, concepts, and mechanisms of implementing integrated community-based primary health care.

Using information communication technology in models of integrated community-based primary health care: learning from the iCOACH case studies.

BACKGROUND: Information communication technology (ICT) is a critical enabler of integrated models of community-based primary health care; however, little is known about how existing technologies have been used to support new models of integrated care. To address this gap, we draw on data from an international study of integrated models, exploring how ICT is used to support activities of integrated care and the organizational and environmental barriers and enablers to its adoption. METHODS: We take an embedded comparative multiple-case study approach using data from a study of implementation of nine models of integrated community-based primary health care, the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study. Six cases from Canada, three each in Ontario and Quebec, and three in New Zealand, were studied. As part of the case studies, interviews were conducted with managers and front-line health care providers from February 2015 to March 2017. A qualitative descriptive approach was used to code data from 137 interviews and generate word tables to guide analysis. RESULTS: Despite different models and contexts, we found strikingly similar accounts of the types of activities supported through ICT systems in each of the cases. ICT systems were used most frequently to support activities like care coordination by inter-professional teams through information sharing. However, providers were limited in their ability to efficiently share patient data due to data access issues across organizational and professional boundaries and due to system functionality limitations, such as a lack of interoperability. CONCLUSIONS: Even in innovative models of care, managers and providers in our cases mainly use technology to enable traditional ways of working. Technology limitations prevent more innovative uses of technology that could support disruption necessary to improve care delivery. We argue the barriers to more innovative use of technology are linked to three factors: (1) information access barriers, (2) limited functionality of available technology, and (3) organizational and provider inertia.

HbA1c in relation to incident diabetes and diabetes-related complications in non-diabetic adults at baseline.

AIMS: We compared the utility of glycated hemoglobin (HbA1c) and oral glucose tolerance (oGTT) in non-diabetic patients for identifying incident diabetes; all-cause mortality; cardiovascular disease (CVD) mortality; CVD, coronary heart disease (CHD), and ischemic stroke events; and diabetes microvascular complications. METHODS: Data from a New Zealand community setting were prospectively linked to hospitalization, mortality, pharmaceutical and laboratory test results data. After applying exclusion criteria (prior laboratory diagnosis or history of drug treatment for diabetes or hospitalization for diabetes or CVD event), there were 31,148 adults who had an HbA1c and 2-h 75g oGTT. HbA1c was measured by ion-exchange high-performance liquid chromatography, and glucose using a commercial enzymatic method. We compared glycemic measures and outcomes using multivariable Cox proportional hazards regression. RESULTS: The median follow-up time was 4years (range 0 to 13). The mean age was 57·6years and 53·0% were male. After adjusting for other glycemic measures (fasting glucose, 2-h glucose and/or HbA1c where relevant) in addition to age, sex, ethnicity and smoking habit, the hazard ratios for incident diabetes and diabetes complications of retinopathy and nephropathy were highest for 2-h glucose levels, followed by HbA1c and lastly by fasting glucose. However, all-cause mortality and CHD were significantly associated with HbA1c concentrations only, and ischemic stroke and CVD events with 2-h glucose only. Circulatory complications showed a stronger association with HbA1c. CONCLUSION: Apart from neuropathy, HbA1c showed stronger associations with outcomes compared to fasting glucose and provides a convenient alternative to an oGTT.