The revised Patient Perception of Patient-Centeredness Questionnaire: Exploring the factor structure in French-speaking patients with multimorbidity.

BACKGROUND: The Patient Perception of Patient-Centeredness (PPPC) questionnaire was revised, and there is a need for the questionnaire to be tested in diverse primary care populations. OBJECTIVES: This study aimed to examine the factor structure of the Revised PPPC questionnaire (PPPC-R) in French-speaking patients with multimorbidity. DESIGN: Secondary analysis from baseline data of the French arm of Patient-Centered Innovations for Persons with Multimorbidity Study (PACEinMM Study). SETTING AND PARTICIPANTS: Participants were adult patients with multimorbidity attending primary health-care settings. OUTCOME MEASURES: Exploratory factor analyses were applied to examine the factor structure of the PPPC-R. Cronbach's alpha values were calculated to assess the internal consistency of the whole questionnaire and of each factor explored. RESULTS: There were 301 participants, mean age 61.0, 53.2% female. The PPPC-R showed very good internal consistency, with three factors: Patient-Centered Clinical Method (PCCM) Component 1-Exploring the health, disease and illness experience + PCCM Component 4-Enhancing the patient-clinician relationship (Factor 1); PCCM Component 2-Understanding the whole person (Factor 2); and PCCM Component 3-Finding common ground (Factor 3). There was a good internal consistency within each factor (Cronbach's α = 0.87 for 8 items in Factor 1, 0.77 for 5 items in Factor 2 and 0.87 for 5 items in Factor 3). DISCUSSION AND CONCLUSIONS: The French PPPC-R factor structure was in accordance with the underpinning conceptual model and presented with three factors. Further assessment of its validity and reproducibility are needed to allow its use as a measure of patient's perception of patient-centeredness.

Multimorbidity, polypharmacy and primary prevention in community-dwelling adults in Quebec: a cross-sectional study.

BACKGROUND: Polypharmacy carries the risk of adverse events, especially in people with multimorbidity. OBJECTIVE: To investigate the prevalence of polypharmacy in community-dwelling adults, the association of multimorbidity with polypharmacy and the use of medications for primary prevention. METHODS: Cross-sectional analysis of the follow-up data from the Program of Research on the Evolution of a Cohort Investigating Health System Effects (PRECISE) in Quebec, Canada. Multimorbidity was defined as the presence of three or more chronic diseases and polypharmacy as self-reported concurrent use of five or more medications. Primary prevention was conceptualized as the use of statin or low-dose antiplatelets without a reported diagnostic of cardiovascular disease. RESULTS: Mean age 56.7 ± 11.6, 62.5% female, 30.3% had multimorbidity, 31.9% had polypharmacy (n = 971). The most common drugs used were statins, renin-angiotensin system inhibitors and psychotropics. Compared to participants without any chronic disease, the adjusted odds ratios (ORs) for having polypharmacy were 2.78 [95% confidence interval (CI): 1.23-6.28] in those with one chronic disease, 8.88 (95% CI: 4.06-19.20) in those with two chronic diseases and 25.31 (95% CI: 11.77-54.41) in those with three or more chronic diseases, P < 0.001. In participants without history of cardiovascular diseases, 16.2% were using antiplatelets and 28.5% were using statins. Multimorbidity was associated with increased likelihood of using antiplatelets (adjusted OR: 2.98, 95% CI: 1.98-4.48, P < 0.001) and statins (adjusted OR: 3.76, 95% CI: 2.63-5.37, P < 0.001) for primary prevention. CONCLUSION: There was a high prevalence of polypharmacy in community-dwelling adults in Quebec and a strong association with multimorbidity. The use of medications for primary prevention may contribute to polypharmacy and raise questions about safety.

A multidisciplinary self-management intervention among patients with multimorbidity and the impact of socioeconomic factors on results.

BACKGROUND: Limited studies exist on successful interventions for patients with multimorbidity. Even more limited is the knowledge on how socioeconomic factors have an impact on these interventions. The objective of this study was to analyze the effect of a multidisciplinary self-management intervention among patients with multimorbidity and the impact of socioeconomic factors on the results. METHODS: Secondary data analysis limited to multimorbid patients from of a pragmatic randomized trial evaluating an intervention that included patients (18 to 75 yrs.) from eight primary care practices in Quebec, Canada. The intervention included self-management support and patient-centred motivational approaches. Self-management was evaluated using the Health Education Impact Questionnaire (heiQ) which measures eight different domains. Changes in heiQ were analyzed following the three-month intervention with univariate and multivariate logistic regressions. RESULTS: Participants with three or more chronic conditions (n = 281), randomized to intervention or control groups, were included in this analysis. The effect of the intervention on the likelihood of an improvement in self-management was significant in six heiQ domains in the univariate analysis (Odd ratio; 95% CI): Health-directed behaviour (2.03; 1.16-3.55), Emotional well-being (1.97; 1.05-3.68), Self-monitoring and insight (2.35; 1.02-5.40), Constructive attitudes and approaches (2.91; 1.45-5.84), Skill and technique acquisition (1.96; 1.13-3.39), and Health services navigation (2.52; 1.21-5.21). After controlling for age and gender the results remained essentially the same. After additional adjustments for family income, education and self-perceived financial status, the likelihood of an improvement was no longer significant in the domains Emotional well-being and Self-monitoring and insight. CONCLUSIONS: The intervention produced significant improvements in multimorbid patients for most domains of self-management. Socioeconomic factors had a minor impact on the results. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01319656.

Integration of chronic disease prevention and management services into primary care (PR1MaC): findings from an embedded qualitative study.

BACKGROUND: The PR1MaC study was conducted to evaluate the integration of Chronic Disease Prevention and Management services into primary care practices and was reported effective. The aim of this study was to further explore the effects of the PR1MaC intervention on patients and their family. METHODS: We conducted a qualitative study embedded in a randomized controlled trial. The trial was implemented in eight primary health care practices in the Saguenay region, Quebec, Canada. The interdisciplinary patient-centred team-based intervention included self-management support and a motivational approach. We conducted focus groups and semi-directed individual interviews with patients, family members and healthcare professionals. RESULTS: Perceived positive effects can be grouped into six major themes: awareness, improved knowledge, improved motivation and empowerment, adoption of healthy behaviours, improvement of health status and improvement of quality of life. On the negative side, some participants reported lack of sustainability of newly acquired benefits in the months following the intervention. CONCLUSIONS: Integrating chronic disease prevention and management services into primary care settings had impacts on patients and their family members. These findings are consistent with findings that were reported in the quantitative study. Further studies should address longterm sustainabilility in terms of benefits for the patients. TRIAL REGISTRATION: ClinicalTrials.gov, no.: NCT01319656 .

Chronic disease prevention and management programs in primary care: Realist synthesis of 6 programs in Quebec.

OBJECTIVE: To identify the mechanisms associated with success and failure of chronic disease prevention and management (CDPM) programs, as well as their key contexts. DESIGN: Realist synthesis. SETTING: Six primary care CDPM programs funded between 2011 and 2013 in Quebec. PARTICIPANTS: Patients, health providers, program leaders, and other stakeholders involved in CDPM programs. METHODS: A collaborative research process was implemented, involving representatives from the executive and advisory committees: researchers, health care providers, decision makers, and patients and families. Leaders were asked to provide all documents related to their programs to the research team. The documents were selected depending on their relevance and rigour. The thematic analysis of each program consisted of identifying the outcomes and mechanisms, as well as the specific contexts associated with these outcomes. Results for each program were validated by its leader before synthesizing the results of all programs together. MAIN FINDINGS: A total of 108 documents (eg, grant applications, scientific reports) were collected from the programs. Positive and negative outcomes were observed at the patient, health care provider, and health care system levels. Four main mechanism categories were associated with outcomes: patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners. The main contextual factors that influenced the successes of these mechanisms were related to patients (multimorbidity, involvement of family caregivers), to health care providers (professional training, culture of interprofessional collaboration, mobilization of family physician), and to health care organizations (coordination between services, history of collaboration between partners, funding). CONCLUSION: This study confirms the essential role of patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners when caring for patients with chronic diseases. It constitutes a relevant contribution for stakeholders involved in primary care transformation and should be used to inform the sustainability and scaling up of CDPM programs.

The "Patient-centered coordination by a care team" questionnaire achieves satisfactory validity and reliability.

Increasing prevalence of chronic conditions and multimorbidity challenges health care systems and calls for patient-centered coordination of care. Implementation and evaluation of health policies focusing on the development of patient-centered coordination of care needs valid instruments measuring this dimension of care. The aim of this validation study was to assess the psychometric properties of the French version of the 14-item Patient-Centered Coordination by a Care Team (PCCCT) questionnaire in a primary care setting. PCCCT provides a total score from 0 (worst coordination) to 42 (best coordination). 165 adult patients consulting in primary care with one or more chronic condition(s) completed questionnaires (including PCCCT) at recruitment. After three weeks, participants completed PCCCT again, either by mail (group A) or during a telephone interview (group B). At recruitment, the mean (SD) PCCCT score was 33.3 (7.7). Exploratory factor analysis revealed a 2-dimension structure, 8 items relating to patient involvement and 6 items relating to coordination (factors loadings ranging from 0.34 to 0.88). PCCCT score correlated significantly with subscales of Haggerty's continuity questionnaire, Spearman correlation coefficients (95% confidence interval) ranging from 0.40 (0.22-0.57) to 0.52 (0.38-0.63). Internal consistency was excellent: Cronbach alpha 0.90 (0.79-0.92). Reliability was good, with an intraclass correlation coefficient of 0.68 (0.55-0.78) for test-retest reliability (group A) and of 0.65 (0.46-0.79) for reliability between the self-administered and the interviewer-administered versions of the questionnaire (group B,). The PCCCT questionnaire presents satisfactory validity and reliability; it can be used for the evaluation of health organizations involving team work in primary care.

It Takes Two to Tango: Researchers and Decision-Makers Collaborating to Implement Practice Changes for Patients with Multimorbidity.

An integrated knowledge translation strategy is a key factor in fostering the implementation of practice changes. Building on a 15-year history of projects that include close collaboration between researchers and decision-makers in the Saguenay region of Quebec (Canada), the authors identify several key elements that resulted in practice changes in primary care and improved outcomes for patients with multimorbidity.

Validation of a French-language version of the health education impact Questionnaire (heiQ) among chronic disease patients seen in primary care: a cross-sectional study.

BACKGROUND: The Health Education Impact Questionnaire (heiQ) allows for the evaluation of the effects of education interventions provided to patients with chronic diseases. This study describes the process for the cross-cultural adaptation and validation of the heiQ into French (heiQ-Fv). METHODS: We undertook a systematic translation process followed by a validation study based on the secondary analysis of cross-sectional data from a longitudinal study. Participants in the validation study were adult patients from primary care clinics in Quebec, Canada, with one or more of the following diseases: diabetes, asthma, chronic obstructive pulmonary disease, cardiovascular disease; or one or more risk factors for these diseases. Main outcomes of the study were the French version of the heiQ-Fv and the validation analyses that included internal consistency, test-retest reliability, confirmatory factor analysis (CFA) and concomitant validity. RESULTS: The validation analysis was conducted on results from 332 participants. Cronbach's alphas (internal consistency) for seven domains of the heiQ-Fv varied from 0.80 to 0.89; one domain scored 0.69. The test-retest analysis (n = 50) yielded intra-class correlation coefficients from 0.66 to 0.86. The CFA of the eight heiQ domains with the hypothesis of no correlation between the domains yielded a model that did not exhibit acceptable fit values. A model with the hypothesis of all domains correlated exhibited acceptable fit values (scaled chi-square = 1210.15, degrees of freedom = 712, p < 0.001; CFI = 0.98; RMSEA = 0.06; SRMR = 0.065). Results show a moderate correlation (concomitant validity) between five domains of the heiQ-Fv and the Self-Efficacy for Managing Chronic Diseases. We also found a moderate to strong correlation between the Emotional Wellbeing domain of the heiQ and the Kessler Psychological Distress Scale (K6) (r = 0.61; 95 % CI: 0.52 -0.69, p < 0.01). CONCLUSIONS: The heiQ was translated into French using a rigorous translation process; the French-language version showed good psychometric properties. Health professionals and researchers in primary care settings may use the heiQ-FV to evaluate the impact of educational programs on patients with chronic diseases.

Lifestyle factors and multimorbidity: a cross sectional study.

BACKGROUND: Lifestyle factors have been associated mostly with individual chronic diseases. We investigated the relationship between lifestyle factors (individual and combined) and the co-occurrence of multiple chronic diseases. METHODS: Cross-sectional analysis of results from the Program of Research on the Evolution of a Cohort Investigating Health System Effects (PRECISE) in Quebec, Canada. Subjects aged 45 years and older. A randomly-selected cohort in the general population recruited by telephone. Multimorbidity (3 or more chronic diseases) was measured by a simple count of self-reported chronic diseases from a list of 14. Five lifestyle factors (LFs) were evaluated: 1) smoking habit, 2) alcohol consumption, 3) fruit and vegetable consumption, 4) physical activity, and 5) body mass index (BMI). Each LF was given a score of 1 (unhealthy) if recommended behavioural targets were not achieved and 0 otherwise. The combined effect of unhealthy LFs (ULFs) was evaluated using the total sum of scores. RESULTS: A total of 1,196 subjects were analyzed. Mean number of ULFs was 2.6 ± 1.1 SD. When ULFs were considered separately, there was an increased likelihood of multimorbidity with low or high BMI [Odd ratio (95% Confidence Interval): men, 1.96 (1.11-3.46); women, 2.57 (1.65-4.00)], and present or past smoker [men, 3.16 (1.74-5.73)]. When combined, in men, 4-5 ULFs increased the likelihood of multimorbidity [5.23 (1.70-16.1)]; in women, starting from a threshold of 2 ULFs [1.95 (1.05-3.62)], accumulating more ULFs progressively increased the likelihood of multimorbidity. CONCLUSIONS: The present study provides support to the association of lifestyle factors and multimorbidity.

Evaluating the integration of chronic disease prevention and management services into primary health care.

BACKGROUND: The increasing number of patients with chronic diseases represents a challenge for health care systems. The Chronic Care Model suggests a multi-component remodelling of chronic disease services to improve patient outcomes. To meet the complex and ongoing needs of patients, chronic disease prevention and management (CDPM) has been advocated as a key feature of primary care producing better outcomes, greater effectiveness and improved access to services compared to other sectors. The objective of this study is to evaluate the adaptation and implementation of an intervention involving the integration of chronic disease prevention and management (CDPM) services into primary health care. METHODS/DESIGN: The implementation of the intervention will be evaluated using descriptive qualitative methods to collect data from various stakeholders (decision-makers, primary care professionals, CDPM professionals and patients) before, during and after the implementation. The evaluation of the effects will be based on a combination of experimental designs: a randomized trial using a delayed intervention arm (n = 326), a before-and-after design with repeated measures (n = 163), and a quasi-experimental design using a comparative cohort (n = 326). This evaluation will utilize self-report questionnaires measuring self-efficacy, empowerment, comorbidity, health behaviour, functional health status, quality of life, psychological well-being, patient characteristics and co-interventions. The study will take place in eight primary care practices of the Saguenay region of Quebec (Canada). To be included, patients will have to be referred by their primary care provider and present at least one of the following conditions (or their risk factors): diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, asthma. Patients presenting serious cognitive problems will be excluded. DISCUSSION: In the short-term, improved patient self-efficacy and empowerment are expected. In the mid-term, we expect to observe an improvement in health behaviour, functional health status, quality of life and psychological well-being. At the organizational level, the project should lead to coordinated service delivery, improved patient follow-up mechanisms and enhanced interprofessional collaboration. Integration of CDPM services at the point of care in primary care practices is a promising innovation in care delivery that needs to be thoroughly evaluated. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01319656.

Social Vulnerability in Patients with Multimorbidity: A Cross-Sectional Analysis.

BACKGROUND: Social aspects play an important role in individual health and should be taken into consideration in the long-term care for people with multimorbidity. PURPOSES: To describe social vulnerability, to examine its correlation with the number of chronic conditions, and to investigate which chronic conditions were significantly associated with the most socially vulnerable state in patients with multimorbidity. METHODS: Cross-sectional analysis from the baseline data of the Patient-Centred Innovations for Persons with Multimorbidity (PACEinMM) Study. Participants were patients attending primary healthcare settings in Quebec, Canada. A social vulnerability index was applied to identify social vulnerability level. The index value ranges from 0 to 1 (1 as the most vulnerable). Spearman's rank correlation coefficient was calculated for the correlation between the social vulnerability index and the number of chronic conditions. Logistic regression was applied to investigate which chronic conditions were independently associated with the most socially vulnerable state. RESULTS: There were 301 participants, mean age 61.0 ± 10.5, 53.2% female. The mean number of chronic health conditions was 5.01 ± 1.82, with the most common being hyperlipidemia (78.1%), hypertension (69.4%), and obesity (54.2%). The social vulnerability index had a median value of 0.13 (range 0.00⁻0.78). There was a positive correlation between the social vulnerability index and the number of chronic conditions (r = 0.24, p < 0.001). Obesity, depression/anxiety, and cardiovascular diseases were significantly associated with the most socially vulnerable patients with multimorbidity. CONCLUSIONS: There was a significant correlation between social vulnerability and the total number of chronic conditions, with depression/anxiety, obesity, and cardiovascular diseases being the most related to social vulnerability.

Integration of chronic disease prevention and management services into primary care: a pragmatic randomized controlled trial (PR1MaC).

BACKGROUND: Chronic disease prevention and management programs are usually single-disease oriented. Our objective was to evaluate an intervention that targeted multiple chronic conditions and risk factors. METHODS: We conducted a pragmatic randomized controlled trial involving patients aged 18-75 years with at least 1 of the targeted chronic conditions or risk factors from 8 primary care practices in the Saguenay region of Quebec, Canada, to evaluate an intervention that included self-management support and patient-centred motivational approaches. Self-management (primary outcome) was evaluated using the Health Education Impact Questionnaire (heiQ). Secondary outcomes included self-efficacy, health-related quality of life, psychological distress and health behaviours. RESULTS: Three hundred thirty-two patients were recruited and randomly assigned (n = 166 for both intervention and control groups) and evaluated after 3 months. The intervention group showed improvement in 6 of the 8 heiQ domains: health-directed behaviour (relative risk [RR] 1.71, 95% confidence interval [CI] 1.13 to 2.59), emotional well-being (RR 1.73, 95% CI 1.07 to 2.79), self-monitoring and insight (RR 2.40, 95% CI 1.19 to 4.86), constructive attitudes and approaches (RR 2.40, 95% CI 1.37 to 4.21), skill and technique acquisition (RR 1.70, 95% CI 1.14 to 2.53), and health service navigation (RR 1.93, 95% CI 1.08 to 3.47). Improvement was also observed in the Physical Component Summary (p = 0.017) and the Single Index (p = 0.041) of the 12-Item Short Form Health Survey (version 2). The intervention group improved in fruit and vegetable consumption (odds ratio [OR] 2.36, 95% CI 1.41 to 3.95) and physical activity (OR 3.81, 95% CI 1.65 to 8.76). One-year improvement was maintained in the intervention group for several outcomes. INTERPRETATION: It is possible to implement an intervention integrating chronic disease prevention and management services into primary care settings. We obtained positive and promising results using this intervention. Trial registration: ClinicalTrials.gov, no.: NCT01319656.

Genealogical analysis as a new approach for the investigation of drug intolerance heritability.

Genealogical analysis has proven a useful method to understand the origins and frequencies of hereditary diseases in many populations. However, this type of analysis has not yet been used for the investigation of drug intolerance among patients suffering from inherited disorders. This study aims to do so, using data from familial hypercholesterolemia (FH) patients receiving high doses of statins. The objective is to measure and compare various genealogical parameters that could shed light on the origins and heritability of muscular intolerance to statins using FH as a model. Analysis was performed on 224 genealogies from 112 FH subjects carrying either the low-density lipoprotein receptor (LDLR) prom_e1 deletion>15 kb (n=28) or c.259T>G (p.Trp87Gly) (n=84) mutations and 112 non-FH controls. Number of ancestors, geographical origins and genetic contribution of founders, inbreeding and kinship coefficients were calculated using the S-Plus-based GENLIB software package. For both mutations, repeated occurrences of the same ancestors are more frequent among the carriers' genealogies than among the controls', but no difference was observed between tolerant and intolerant subjects. Founders who may have introduced both mutations in the population appear with approximately the same frequencies in all genealogies. Kinship coefficients are higher among carriers, with no difference according to statins tolerance. Inbreeding coefficients are slightly lower among >15-kb deletion carriers than among c.259 T>G carriers, but the differences between tolerants and intolerants are not significant. These findings suggest that although muscular intolerance to statins shows a family aggregation, it is not transmitted through the same Mendelian pattern as LDLR mutations.

Low plasma adiponectin exacerbates the risk of premature coronary artery disease in familial hypercholesterolemia.

Familial hypercholesterolemia (FH) is characterized by increased risk for premature coronary artery disease (CAD). This risk is exacerbated in the presence of abdominal obesity and insulin resistance. Low adiponectin is part of the clustering of metabolic abnormalities associated with abdominal obesity and insulin resistance. The present study, therefore, aims to examine the relationship between plasma adiponectin and age at CAD diagnosis in FH patients. Plasma adiponectin was measured by ELISA in 568 non-diabetic FH individuals of French-Canadian origin. CAD was defined according to strict clinical criteria. Prior to analyses, patients were grouped according to age and gender-specific tertiles of plasma adiponectin levels. Multivariate Cox proportional hazards regression was used to estimate the association between plasma adiponectin levels and age at diagnosis of CAD. Overall, FH patients in the lowest tertile of plasma adiponectin exhibited CAD at a significantly younger age (hazard ratio=1.73, confidence interval 95%: [1.19-2.53]; p=0.004). These results suggest that low plasma adiponectin is associated with an increased risk of premature CAD over and above the already exaggerated risk seen in FH patients.