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BACKGROUND: The healthcare system is under tremendous pressure. One possible solution towards relieving some of this pressure is to use Positive Health, which takes 'health' as a starting point, rather than 'illness'. Positive Health provides opportunities for stimulating integrated care. METHODS: Three cases in the Netherlands are studied in this paper. Their way of working with Positive Health is investigated through semi-structured and narrative interviews, using realist-evaluation and thematic analyses. RESULTS: Seven 'working elements' are identified that enhance the chances of successfully implementing Positive Health in practice (part 1). The interviews show that healthcare professionals have noticed that people adopt a healthier lifestyle and gain a greater degree of control over their own health. This boosts job satisfaction for healthcare professionals too. The organisations and professionals involved are enthusiastic about working with Positive Health, but still experience barriers (part 2). CONCLUSIONS: The results of this study imply that implementing Positive Health in practice can facilitate collaboration between organisations and professionals from different disciplines, such as healthcare, welfare, and municipal health services. Operating from the perspective of a shared goal, professionals from different disciplines will find it easier to jointly organise activities to foster citizens' health. Additionally, more attention is paid to non-medical problems affecting people's well-being, such as loneliness or financial problems.
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Interviews as Topic , Netherlands , Humans , Qualitative Research , Female , Health Promotion/methods , Health Promotion/organization & administration , Male , Delivery of Health Care, Integrated/organization & administration , Organizational Case Studies , Job Satisfaction , Delivery of Health Care/organization & administrationABSTRACT
The burden of chronic disease in Europe continues to grow. A major challenge facing national governments is how to tackle the risk factors of sedentary lifestyle, alcohol abuse, smoking, and unhealthy diet. These factors are complex and necessitate intersectoral collaboration to strengthen health promotion, counter-act the social determinants of health, and reduce the prevalence of chronic disease. European countries have diverse intersectoral collaboration to encourage health promotion activities. In the Joint Action CHRODIS-PLUS success factors for intersectoral collaboration within and outside healthcare which strengthen health promotion activities were identified with a mixed method design via a survey of 22 project partners in 14 countries and 2 workshops. In six semi-structured interviews, the mechanisms underlying these success factors were examined. These mechanisms can be very context-specific but do give more insight into how they can be replicated. In this paper, 20 health promotion interventions from national programs in CHRODIS PLUS are explored. This includes community interventions, policy actions, integrated approaches, capacity building, and training activities. The interventions involved collaboration across three to more than six sectors. The conclusion is a set of seven recommendations that are considered to be essential for fostering intersectoral collaboration to improve health-promoting activities.
Subject(s)
Health Promotion , Intersectoral Collaboration , Delivery of Health Care , Europe , HumansABSTRACT
Many initiatives integrating health and social care have been implemented in order to provide adequate care and support to older people living at home. Further development of existing initiatives requires iterative processes of developing, implementing and evaluating improvements to current practice. This case study provides insight into the process of improving an existing integrated care initiative in the Netherlands. Using a participatory approach, researchers and local stakeholders collaborated to develop and implement activities to further improve collaboration between health and social care professionals. Improvement activities included interprofessional meetings focussing on reflection and mutual learning and workplace visits. Researchers evaluated the improvement process, using data triangulation of multiple qualitative and quantitative data sources. According to participating professionals, the improvement activities improved their communication and collaboration by establishing mutual understanding and trust. Enabling factors included the safe and informal setting in which the meetings took place and the personal relationships they developed during the project. Different organisational cultures and interests and a lack of ownership and accountability among managers hindered the improvement process, whereas issues such as staff shortages, time constraints and privacy regulations made it difficult to implement improvements on a larger scale. Still, the participatory approach encouraged the development of partnerships and shared goals on the level of both managers and professionals. This case study highlights that improving communication between professionals is an important first step in improving integrated care. In addition, it shows that a participatory approach, in which improvements are co-created and tailored to local priorities and needs, can help in the development of shared goals and trust between stakeholders with different perspectives. However, stakeholders' willingness and ability to participate in such an improvement process is challenged by many factors.
Subject(s)
Delivery of Health Care, Integrated/standards , Home Care Services , Quality Improvement/organization & administration , Social Support , Aged , Aged, 80 and over , Communication , Humans , Interprofessional Relations , Interviews as Topic , Netherlands , Qualitative Research , Social Responsibility , TrustABSTRACT
INTRODUCTION: In several countries, initiatives to detect frailty among older citizens at an early stage are being implemented to enable proactive intervention and, consequently, to support independent living for as long as possible. Alignment and collaboration between the various actors are crucial. We aimed to provide insight in factors that impede or facilitate collaboration at a local level as perceived by the different actors and we explore their experiences. METHODS: Semi-structured interviews were conducted with 37 representatives of three groups active in proactive elderly care in the Netherlands: (i) commissioners, (ii) service providers, and (iii) other stakeholders (e.g. public health advisors, academics). The Framework Method was used to analyse data. RESULTS: Interviewees perceived many factors hampering or facilitating collaboration. Overall, the factors mentioned were quite similar for the different groups. Facilitators and barriers were related to culture and professionals (e.g. knowledge of early detection approaches, mutual trust), organizations (e.g. shared vision or patient information system) and context (e.g. financing). DISCUSSION AND CONCLUSION: Collaborating on early detection appears to be a multifaceted challenge. However, as different stakeholders hold similar views, there seem to be several starting-points to improve collaboration. First steps shall include getting to know each other and developing a shared vision on early detection.
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Frail elderly with polypharmacy are at greater risk of preventable medication-related health damage. To improve medication safety, the healthcare field prepared, in consultation with the Dutch Health Care Inspectorate, a number of guidelines and standards containing conditions for safe prescribing. According to these standards the active involvement of patients by health care professionals is essential for good pharmacotherapeutic care. However, two studies with patients show that there is still room for improvement. According to patients, they can be (even) better informed about changes in their medication. Also the caregivers could communicate more clearly who is the central contact point and who is ultimately responsible for the medication. Patients are not sufficiently informed on this. Furthermore, there is uncertainty about how and why medication reviews are performed. More explanation to patients about this is desirable. In addition, patients experience that keeping their medication list up to date and transferring medication data between health care providers could be improved. Finally, a group of patients welcomes the opportunity to co-decide on changes in their medication. In order to prescribe safely, it is crucial that caregivers actively involve patients in pharmacotherapeutic care and really enter into conversation with them about their medication.
Subject(s)
Communication , Frail Elderly , Polypharmacy , Aged , Caregivers/psychology , HumansABSTRACT
BACKGROUND: A wide range of initiatives on early detection and intervention have been developed to proactively identify problems related to health and wellbeing in (frail) older people, with the aim of supporting them to live independently for as long as possible. Nevertheless, it remains unclear what the best way is to design such initiatives and how older people's needs and preferences can be best addressed. This study aimed to address this gap in the literature by exploring: 1) older people's perspectives on health and living environment in relation to living independently at home; 2) older people's needs and preferences in relation to initiating and receiving care and support; and 3) professionals' views on what would be necessary to enable the alignment of early detection initiatives with older people's own needs and preferences. METHODS: In this qualitative study, we conducted semi-structured interviews with 36 older people and 19 professionals in proactive elderly care. Data were analysed using the framework analysis method. RESULTS: From the interviews with older people important themes in relation to health and living environment emerged, such as maintaining independence, appropriate housing, social relationships, a supporting network and a sense of purpose and autonomy. Older people preferred to remain self-sufficient, and they would rather not ask for help for psychological or social problems. However, the interviews also highlighted that they were not always able or willing to anticipate future needs, which can hinder early detection or early intervention. At the same time, professionals indicated that older people tend to over-estimate their self-reliance and therefore advocated for early detection and intervention, including social and psychological issues. CONCLUSION: Older people have a broad range of needs in different domains of life. Discrepancies exist between older people and professionals with regard to their views on timing and scope of early detection initiatives. This study aimed to reveal starting-points for better alignment between initiatives and older people's needs and preferences. Such starting points may support policy makers and care professionals involved in early detection initiatives to make more informed decisions.
Subject(s)
Early Diagnosis , Health Status , Independent Living , Aged , Aged, 80 and over , Attitude of Health Personnel , Attitude to Health , Female , Frail Elderly , Health Services Needs and Demand , Humans , Male , Middle Aged , Qualitative ResearchABSTRACT
BACKGROUND: More focus on patient-centeredness in care for patients with type 2 diabetes requests increasing attention to diabetes quality management processes on patient-centeredness by managers in primary care groups and outpatient clinics. Although patient-centered care is ultimately determined by the quality of interactions between patients and clinicians at the practice level, it should be facilitated at organizational level too. This nationwide study aimed to assess the state of diabetes quality management on patient-centeredness at organizational level and its possibilities to improve after a tailored intervention. METHODS: This before-after study compares the quality management on patient-centeredness within Dutch diabetes care groups and outpatient clinics before and after a 1-year stepwise intervention. At baseline, managers of 51 diabetes primary care groups and 28 outpatient diabetes clinics completed a questionnaire about the organization's quality management program. Patient-centeredness (0%-100%) was operationalized in six subdomains: facilitating self-management support, individualized care plan support, patients' access to medical files, patient education policy, safeguarding patients' interests, and formal patient involvement. The intervention consisted of feedback and benchmark and if requested a telephone call and/or a consultancy visit. After 1 year, the managers completed the questionnaire again. The 1-year changes were examined by dependent (non) parametric tests. RESULTS: Care groups improved significantly on patient-centeredness (from 47.1% to 53.3%; P=0.002), and on its subdomains "access to medical files" (from 42.0% to 49.4%), and "safeguarding patients' interests" (from 58.1% to 66.2%). Outpatient clinics, which scored higher at baseline (66.7%) than care groups, did not improve on patient-centeredness (65.6%: P=0.54) or its subdomains. "Formal patient involvement" remained low in both care groups (23.2%) and outpatient clinics (33.9%). CONCLUSION: After a simple intervention, care groups significantly improved their quality management on patient-centeredness, but outpatient clinics did not. Interventions to improve quality management on patient-centeredness in diabetes care organizations should differ between primary and secondary care.
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BACKGROUND/AIMS: This study examines the feasibility of a preoperative exercise program to improve the physical fitness of a patient before gastrointestinal surgery. METHODS: An outpatient exercise program was developed to increase preoperative aerobic capacity, peripheral muscle endurance and respiratory muscle function in patients with pancreatic, liver, intestinal, gastric or esophageal cancer. During a consult at the outpatient clinic, patients were invited to participate in the exercise program when their surgery was not scheduled within 2 weeks. RESULTS: The 115 participants followed on average 5.7 (3.5) training sessions. Adherence to the exercise program was high: 82% of the planned training sessions were attended, and no adverse events occurred. Mixed model analyses showed a significant increase of maximal inspiratory muscle strength (84.1-104.7 cm H2O; p = 0.00) and inspiratory muscle endurance (35.0-39.5 cm H2O; p = 0.00). No significant changes were found in aerobic capacity and peripheral muscle strength. CONCLUSION: This exercise program in patients awaiting oncological surgery is feasible in terms of participation and adherence. Inspiratory muscle function improved significantly as a result of inspiratory muscle training. The exercise program however failed to result in improved aerobic capacity and peripheral muscle strength, probably due to the limited number of training sessions as a result of the restricted time interval between screening and surgery.
Subject(s)
Digestive System Neoplasms/physiopathology , Digestive System Surgical Procedures , Exercise/physiology , Physical Fitness/physiology , Aged , Digestive System Neoplasms/surgery , Elective Surgical Procedures , Feasibility Studies , Female , Humans , Male , Middle Aged , Muscle Strength , Oxygen Consumption , Patient Compliance , Physical Endurance/physiology , Preoperative Period , Respiratory Muscles/physiologyABSTRACT
OBJECTIVE: To describe comprehensive care programs targeting multimorbid and/or frail patients and to estimate their effectiveness regarding improvement of patient and caregiver related outcomes, healthcare utilization and costs. METHODS: Systematic search in six electronic databases for scientific papers published between January 2011 and March 2014, supplemented by reference tracking. Wagner's Chronic Care Model (CCM) was used to operationalize comprehensive care. The quality of the included studies was assessed, and a best-evidence synthesis was applied. RESULTS: Nineteen publications were included describing effects of eighteen comprehensive care programs for multimorbid or frail patients, of which only one was implemented in a European country. Programs varied in target groups, settings, interventions and number of CCM components addressed. Providing comprehensive care might result in more patient satisfaction, less depressive symptoms, a better health-related quality of life or functioning of multimorbid or frail patients, but the evidence is insufficient. There is no evidence that comprehensive care reduces the number of primary care or GP visits or healthcare costs. Regarding the use of inpatient care, the evidence was insufficient. No evidence was found for a beneficial effect of comprehensive care on caregiver-related outcomes. CONCLUSION: Despite the fact that over the years several (good-quality) studies have been performed to estimate the value of comprehensive care for multimorbid and/or frail patients, evidence for their effectiveness remains insufficient. More good-quality studies and/or studies allowing meta-analysis are needed to determine which specific target groups at what moment will benefit from comprehensive care. Moreover, evaluation studies could improve by using more appropriate outcome measures, e.g. measures that relate to patient-defined (personal) goals of care.
Subject(s)
Comprehensive Health Care/organization & administration , Health Care Costs , Multiple Chronic Conditions/therapy , Outcome and Process Assessment, Health Care , Cost-Benefit Analysis , Global Health , HumansABSTRACT
OBJECTIVE: Presently, little is known about the characteristics and impact of integrated care programs for patients with psychological comorbidity. The aim was to provide an overview of these integrated care programs and their effectiveness. METHODS: Systematic literature review including papers published between 1995 and 2014. An integrated care program had to consist of interventions related to at least two out of the six components of the Chronic Care Model. Programs had to address patients with psychological comorbidity, which is a psychological disease next to a somatic chronic disease. A meta-analysis was performed on depression treatment response and a best evidence synthesis was performed on other outcomes. RESULTS: Ten programs were identified, which mostly addressed comorbid depression and consisted of interventions related to three to five components of the Chronic Care Model. Meta-analysis showed significantly higher odds for depression treatment response for patients receiving integrated care (OR: 2.49, 95%CI [1.66-3.75]). Best evidence synthesis suggested moderate evidence for cost-effectiveness and for a beneficial effect on patient satisfaction and emotional well-being. Insufficient evidence was found for a beneficial effect on health-related quality of life, medication adherence, Hb1Ac levels and mortality. CONCLUSION: There are few studies evaluating integrated care programs for patients with psychological comorbidity. Although these studies suggest that integrated care programs could positively affect several patient outcomes and could be cost-effective, additional studies are recommended to further assess the value of integrated care for this patient group. This is especially important since the number of people with psychological comorbidity is rising.
Subject(s)
Delivery of Health Care, Integrated , Mental Disorders/complications , Comorbidity , Cost-Benefit Analysis , Humans , Quality of Life , Treatment OutcomeABSTRACT
OBJECTIVES: To enhance the quality of diabetes care in the Netherlands, so-called care groups with three to 250 general practitioners emerged to organise and coordinate diabetes care. This introduced a new quality management level in addition to the quality management of separate general practices. We hypothesised that this new level of quality management might be associated with the aggregate performance indicators on the patient level. Therefore, we aimed to explore the association between quality management at the care group level and its aggregate performance indicators. DESIGN: A cross-sectional study. SETTING: All Dutch care groups (n=97). PARTICIPANTS: 23 care groups provided aggregate register-based performance indicators of all their practices as well as data on quality management measured with a questionnaire filled out by 1 or 2 of their quality managers. PRIMARY OUTCOMES: The association between quality management, overall and in 6 domains ('organisation of care', 'multidisciplinary teamwork', 'patient centredness', 'performance management', 'quality improvement policy' and 'management strategies') on the one hand and 3 process indicators (the percentages of patients with at least 1 measurement of glycated haemoglobin, lipid profile and systolic blood pressure), and 3 intermediate outcome indicators (the percentages of patients with glycated haemoglobin below 53â mmol/mol (7%); low-density lipoprotein cholesterol below 2.5â mmol/L; and systolic blood pressure below 140â mmâ Hg) by weighted univariable linear regression. RESULTS: The domain 'management strategies' was significantly associated with the percentage of patients with a glycated haemoglobin <53â mmol/mol (ß 0.28 (0.09; 0.46) p=0.01) after correction for multiple testing. The other domains as well as overall quality management were not associated with aggregate process or outcome indicators. CONCLUSIONS: This first exploratory study on quality management showed weak or no associations between quality management of diabetes care groups and their performance. It remains uncertain whether this second layer on quality management adds to better quality of care.
Subject(s)
Delivery of Health Care/organization & administration , Delivery of Health Care/standards , Diabetes Mellitus, Type 2/therapy , Glycated Hemoglobin/metabolism , Quality Indicators, Health Care , Blood Glucose/metabolism , Blood Pressure , Cholesterol, LDL/blood , Cross-Sectional Studies , Diabetes Mellitus, Type 2/blood , Disease Management , Humans , Netherlands , Quality Improvement , Surveys and QuestionnairesABSTRACT
Pharmacotherapeutic care of the elderly and psychiatric patients is complex and risky, because polypharmacy, the chronic use of five or more medications by a patient, is highly prevalent in these groups. Polypharmacy is a risk factor for medication related hospital admissions. The Dutch Health Care Inspectorate (IGZ) adopted 'improving care for the elderly' and 'improving medication safety' as spearheads. In order to provide input to IGZ enforcement policy, RIVM investigated the risks of polypharmacy as well as the measures that might limit these risks. This study shows that over- and undertreatment frequently occur. This may be caused by the fact that a physician sometimes does not know which medicines for a patient were prescribed, changed or stopped by other physicians. It was also found that psychiatric patients often experience side effects or interactions that are specific to psychiatric medicines, sometimes in combination with somatic medication. Various guidelines to improve medication safety are available, but several bottlenecks hamper the implementation, for example in the area of collaboration, direction and transfer of information on medication. But also ICT is insufficiently facilitating and physicians have too little knowledge of polypharmacy in the frail populations. The health care sector is taking various initiatives to remove bottlenecks. IGZ will from 2015 in all health care domains focus on four guidelines that describe the conditions for sensibly prescribing medication to frail people with polypharmacy.
Subject(s)
Frail Elderly , Health Services for the Aged/standards , Polypharmacy , Practice Patterns, Physicians' , Aged , Aged, 80 and over , Drug Interactions , Drug Prescriptions , Humans , Inappropriate Prescribing , Medication Adherence , Netherlands , Quality of Health Care , Risk FactorsABSTRACT
INTRODUCTION: Despite the expected beneficial effects on quality of care, patient involvement in diabetes care groups, which deliver a bundled paid integrated care programme for diabetes type 2, seems to be limited. The aim of this study was to gain insight into levels and methods of patient involvement, into facilitators and barriers, and into the future preferences of care groups and patient representatives. THEORY AND METHODS: Semi-structured interviews were held with 10 representatives of care groups and 11 representatives of patient advocacy groups. An adapted version of Arnstein's ladder of citizen participation was used to define five levels of patient involvement. RESULTS: Patient involvement in care groups was mostly limited to informing and consulting patients. Higher levels, i.e., advising, co-producing and decision-making, were less frequently observed. Care groups and patient representatives perceived largely the same barriers and facilitators and had similar preferences regarding future themes and design of patient involvement. CONCLUSION: Constructive collaboration between diabetes care groups and patient representatives to enhance patient involvement in the future seems viable. Several issues such as the lack of evidence for effectiveness of patient involvement, differences in viewpoints on the role and responsibilities of care groups and perceived barriers need to be addressed.
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OBJECTIVE: To assess the change in level of diabetes quality management in primary care groups and outpatient clinics after feedback and tailored support. RESEARCH DESIGN AND METHODS: This before-and-after study with a 1-year follow-up surveyed quality managers on six domains of quality management. Questionnaires measured organization of care, multidisciplinary teamwork, patient centeredness, performance results, quality improvement policy, and management strategies (score range 0-100%). Based on the scores, responders received feedback and a benchmark and were granted access to a toolbox of quality improvement instruments. If requested, additional support in improving quality management was available, consisting of an elucidating phone call or a visit from an experienced consultant. After 1 year, the level of quality management was measured again. RESULTS: Of the initially 60 participating care groups, 51 completed the study. The total quality management score improved from 59.8% (95% CI 57.0-62.6%) to 65.1% (62.8-67.5%; P < 0.0001). The same applied to all six domains. The feedback and benchmark improved the total quality management score (P = 0.001). Of the 44 participating outpatient clinics, 28 completed the study. Their total score changed from 65.7% (CI 60.3-71.1%) to 67.3% (CI 62.9-71.7%; P = 0.30). Only the results in the domain multidisciplinary teamwork improved (P = 0.001). CONCLUSIONS: Measuring quality management and providing feedback and a benchmark improves the level of quality management in care groups but not in outpatient clinics. The questionnaires might also be a useful asset for other diabetes care groups, such as Accountable Care Organizations.
Subject(s)
Ambulatory Care/standards , Diabetes Mellitus, Type 2/therapy , Ambulatory Care Facilities/standards , Controlled Before-After Studies , Feedback , Follow-Up Studies , Humans , Netherlands , Patient Care Team , Quality of Health Care , Surveys and Questionnaires , Total Quality ManagementABSTRACT
BACKGROUND: In recent years, most Dutch general practitioners started working under the umbrella of diabetes care groups, responsible for the organisation and coordination of diabetes care. The quality management of these new organisations receives growing interest, although its association with quality of diabetes care is yet unclear. The best way to measure quality management is unknown and it has not yet been studied at the level of outpatient clinics or care groups. We aimed to assess quality management of type 2 diabetes care in care groups and outpatient clinics. RESULTS: Quality management was measured with online questionnaires, containing six domains (see below). They were divided into 28 subdomains, with 59 (care groups) and 57 (outpatient clinics) questions respectively. The mean score of the domains reflects the overall score (0-100%) of an organisation. Two quality managers of all Dutch care groups and outpatient clinics were invited to fill out the questionnaire.Sixty care groups (response rate 61.9%) showed a mean score of 59.6% (CI 57.1-62.1%). The average score in 52 outpatient clinics (response rate 50.0%) was 61.9% (CI 57.5-66.8%).Mean scores on the six domains for care groups and outpatient clinics respectively were: 'organisation of care' 71.9% (CI 68.8-74.9%), 76.8% (CI 72.8-80.7%); 'multidisciplinary teamwork' 67.1% (CI 62.4-71.9%), 71.5% (CI 65.3-77.8%); 'patient centeredness' 46.7% (CI 42.6-50.7%), 62.5% (CI 57.7-67.2%); 'performance management' 63.3% (CI 61.2-65.3%), 50.9% (CI 44.2-57.5%); 'quality improvement policy' 52.6% (CI 49.2-56.1%), 50.9% (CI 44.6-57.3%); and 'management strategies' 56.0% (CI 51.4-60.7%), 59.0% (CI 52.8-65.2%). On subdomains, care groups scored highest on 'care program' (83.3%) and 'measured outcomes' (98.3%) and lowest on 'patient safety' (15.1%) and 'patient involvement' (17.7%). Outpatient clinics scored high on the presence of a 'diabetic foot team' (81.6%) and the support in 'self-management' (81.0%) and low on 'patient involvement' (26.8%) and 'inspection of medical file' (28.0%). CONCLUSIONS: This nationwide assessment reveals that the level of quality management in diabetes care varies between several subdomains in both diabetes care groups and outpatient clinics.
Subject(s)
Ambulatory Care Facilities , Diabetes Mellitus, Type 2/therapy , Group Processes , Quality of Health Care , Cross-Sectional Studies , Humans , Netherlands , Reproducibility of Results , Surveys and QuestionnairesABSTRACT
BACKGROUND: Worldwide, the organisation of diabetes care is changing. As a result general practices and diabetes teams in hospitals are becoming part of new organisations in which multidisciplinary care programs are implemented. In the Netherlands, 97 diabetes care groups and 104 outpatient clinics are working with a diabetes care program. Both types of organisations aim to improve the quality of diabetes care. Therefore, it is essential to understand the comprehensive elements needed for optimal quality management at organisational level. This study aims to assess the current level of diabetes quality management in both care groups and outpatient clinics and its improvement after providing feedback on their quality management system and tailored support. METHODS/DESIGN: This study is a before-after study with a one-year follow-up comparing the levels of quality management before and after an intervention to improve diabetes quality management. To assess the status of quality management, online questionnaires were developed based on current literature. They consist of six domains: organisation of care, multidisciplinary teamwork, patient centeredness, performance management, quality improvement policy and management strategies. Based on the questionnaires, respondents will receive feedback on their score in a radar diagram and an elucidating table. They will also be granted access to an online toolbox with instruments that proved to be effective in quality of care improvement and with practical examples. If requested, personal support in implementing these tools will be available. After one year quality management will be measured again using the same questionnaire. DISCUSSION: This study will reveal a nationwide picture of quality management in diabetes care groups and outpatient clinics in the Netherlands and evaluate the effect of offering tailored support. The operationalisation of quality management on organisational level may be of interest for other countries as well.
Subject(s)
Ambulatory Care Facilities , Diabetes Mellitus, Type 2/therapy , Quality Improvement , Quality of Health Care/organization & administration , Follow-Up Studies , Humans , Interdisciplinary Communication , Netherlands , Patient Care Team/organization & administration , Surveys and QuestionnairesABSTRACT
RATIONALE, AIMS AND OBJECTIVES: Clinical diversity and methodological heterogeneity exists between studies on chronic care management. This study aimed to examine the effectiveness of chronic care management in chronic obstructive pulmonary disease (COPD) while taking heterogeneity into account, enabling the understanding of and the decision making about such programmes. Three investigated sources of heterogeneity were study quality, length of follow-up, and number of intervention components. METHODS: We performed a review of previously published reviews and meta-analyses on COPD chronic care management. Their primary studies that were analyzed as statistical, clinical and methodological heterogeneity were present. Meta-regression analyses were performed to explain the variances among the primary studies. RESULTS: Generally, the included reviews showed positive results on quality of life and hospitalizations. Inconclusive effects were found on emergency department visits and no effects on mortality. Pooled effects on hospitalizations, emergency department visits and quality of life of primary studies did not reach significant improvement. No effects were found on mortality. Meta-regression showed that the number of components of chronic care management programmes explained present heterogeneity for hospitalizations and emergency department visits. Four components showed significant effects on hospitalizations, whereas two components had significant effects on emergency department visits. Methodological study quality and length of follow-up did not significantly explain heterogeneity. CONCLUSIONS: This study demonstrated that COPD chronic care management has the potential to improve outcomes of care; heterogeneity in outcomes was explained. Further research is needed to elucidate the diversity between COPD chronic care management studies in terms of the effects measured and strengthen the support for chronic care management.
Subject(s)
Disease Management , Long-Term Care , Pulmonary Disease, Chronic Obstructive , Hospitalization/statistics & numerical data , Humans , Long-Term Care/methods , Long-Term Care/organization & administration , Meta-Analysis as Topic , Mortality , Outcome Assessment, Health Care , Pulmonary Disease, Chronic Obstructive/mortality , Pulmonary Disease, Chronic Obstructive/physiopathology , Pulmonary Disease, Chronic Obstructive/psychology , Pulmonary Disease, Chronic Obstructive/therapy , Quality Improvement , Quality of Life , Treatment OutcomeABSTRACT
PURPOSE: The study aims to support decision making on how best to redesign diabetes care by investigating three potential sources of heterogeneity in effectiveness across trials of diabetes care management. METHODS: Medline, CINAHL and PsycInfo were searched for systematic reviews and empirical studies focusing on: (1) diabetes mellitus; (2) adult patients; and (3) interventions consisting of at least two components of the chronic care model (CCM). Systematic reviews were analysed descriptively; empirical studies were meta-analysed. Pooled effect measures were estimated using a meta-regression model that incorporated study quality, length of follow-up and number of intervention components as potential predictors of heterogeneity in effects. RESULTS: Overall, reviews (n = 15) of diabetes care programmes report modest improvements in glycaemic control. Empirical studies (n = 61) show wide-ranging results on HbA1c, systolic blood pressure and guideline adherence. Differences between studies in methodological quality cannot explain this heterogeneity in effects. Variety in length of follow-up can explain (part of) the variability, yet not across all outcomes. Diversity in the number of included intervention components can explain 8-12% of the heterogeneity in effects on HbA1c and systolic blood pressure. CONCLUSIONS: The outcomes of chronic care management for diabetes are generally positive, yet differ considerably across trials. The most promising results are attained in studies with limited follow-up (<1 year) and by programmes including more than two CCM components. These factors can, however, explain only part of the heterogeneity in effectiveness between studies. Other potential sources of heterogeneity should be investigated to ensure implementation of evidence-based improvements in diabetes care.
Subject(s)
Diabetes Mellitus , Disease Management , Guideline Adherence/statistics & numerical data , Long-Term Care , Adult , Blood Pressure Determination , Diabetes Mellitus/diagnosis , Diabetes Mellitus/therapy , Empirical Research , Glycated Hemoglobin/analysis , Humans , Long-Term Care/methods , Long-Term Care/organization & administration , Models, Statistical , Outcome Assessment, Health Care , Quality Improvement , Treatment OutcomeABSTRACT
BACKGROUND: Multimorbidity is increasingly recognized as a major public health challenge of modern societies. However, knowledge about the size of the population suffering from multimorbidity and the type of multimorbidity is scarce. The objective of this study was to present an overview of the prevalence of multimorbidity and comorbidity of chronic diseases in the Dutch population and to explore disease clustering and common comorbidities. METHODS: We used 7 years data (2002-2008) of a large Dutch representative network of general practices (212,902 patients). Multimorbidity was defined as having two or more out of 29 chronic diseases. The prevalence of multimorbidity was calculated for the total population and by sex and age group. For 10 prevalent diseases among patients of 55 years and older (N = 52,014) logistic regressions analyses were used to study disease clustering and descriptive analyses to explore common comorbid diseases. RESULTS: Multimorbidity of chronic diseases was found among 13% of the Dutch population and in 37% of those older than 55 years. Among patients over 55 years with a specific chronic disease more than two-thirds also had one or more other chronic diseases. Most disease pairs occurred more frequently than would be expected if diseases had been independent. Comorbidity was not limited to specific combinations of diseases; about 70% of those with a disease had one or more extra chronic diseases recorded which were not included in the top five of most common diseases. CONCLUSION: Multimorbidity is common at all ages though increasing with age, with over two-thirds of those with chronic diseases and aged 55 years and older being recorded with multimorbidity. Comorbidity encompassed many different combinations of chronic diseases. Given the ageing population, multimorbidity and its consequences should be taken into account in the organization of care in order to avoid fragmented care, in medical research and healthcare policy.