Effects on patients of variations in the implementation of a cardiometabolic risk intervention program in Montréal. / Effets sur les patients des variations dans l'implantation d'un programme d'intervention sur le risque cardiométabolique à Montréal.

INTRODUCTION: In 2011, the Agence de la santé et des services sociaux de Montréal (ASSSM), in partnership with the region's Centres de santé et de services sociaux (CSSS), coordinated the implementation of a program on cardiometabolic risk based on the Chronic Care Model. The program, intended for patients suffering from diabetes or hypertension, involved a series of individual follow-up appointments, group classes and exercise sessions. Our study assesses the impact on patient health outcomes of variations in the implementation of some aspects of the program among the six CSSSs taking part in the study. METHODS: The evaluation was carried out using a quasi-experimental "before and after" design. Implementation variables were constructed based on data collected during the implementation analysis regarding resources, compliance with the clinical process set out in the regional program, the program experience and internal coordination within the care team. Differences in differences using propensity scores were calculated for HbA1c results, achieving the blood pressure (BP) target, and two lifestyle targets (exercise level and carbohydrate distribution) at the 6- and 12-month follow-ups, based on greater or lesser patient exposure to the implementation of various aspects of the program under study. RESULTS: The results focus on 1185 patients for whom we had data at the 6-month follow- up and the 992 patients from the 12-month follow-up. The difference in differences analysis shows no clear association between the extent of implementation of the various aspects of the program under study and patient health outcomes. CONCLUSION: The program produces effects on selected health indicators independent of variations in program implementation among the CSSSs taking part in the study. The results suggest that the effects of this type of program are more highly dependent on the delivery of interventions to patients than on the organizational aspects of its implementation.

INTRODUCTION: En 2011, l'Agence de la santé et des services sociaux de Montréal (ASSSM), en partenariat avec les Centres de santé et de services sociaux (CSSS) de la région, a coordonné la mise en oeuvre d'un programme sur le risque cardiométabolique s'inspirant du Chronic Care Model. Ce programme destiné aux patients diabétiques ou hypertendus comporte une séquence de suivis individuels, des cours de groupe et des séances d'activité physique. Notre étude évalue l'impact de la variation dans l'implantation de certains aspects du programme entre les six CSSS participant à l'étude sur les résultats de santé des patients. MÉTHODOLOGIE: L'évaluation a été réalisée à l'aide d'un devis quasi-expérimental « avantaprès ¼. Des variables d'implantation ont été construites à partir de données colligées lors de l'analyse d'implantation concernant les ressources, la conformité au processus clinique prévu dans le programme régional, l'expérience du programme et la coordination interne au sein de l'équipe de soins. Des différences de différences utilisant des scores de propension ont été calculées pour les résultats d'HbA1c, l'atteinte de la cible de tension artérielle (TA) et de deux cibles d'habitudes de vie (niveau d'activité physique et répartition des glucides alimentaires) à 6 mois et à 12 mois de suivi, en fonction de l'exposition des patients à un degré plus ou moins important d'implantation de divers aspects du programme à l'étude. RÉSULTATS: Les résultats portent sur les 1 185 patients pour lesquels on disposait de données de suivi à 6 mois et les 992 patients pour le suivi à 12 mois. Les analyses de différences de différences ne révèlent aucune association claire entre le degré d'implantation des divers aspects du programme à l'étude et les résultats de santé chez les patients. CONCLUSION: Le programme produit des effets sur les indicateurs de santé sélectionnés indépendamment des variations dans l'implantation du programme entre les CSSS participant à l'étude. Les résultats suggèrent que les effets d'un tel programme sont davantage tributaires de la prestation des interventions auprès des patients que des aspects organisationnels liés à son implantation.

Anticipating health innovations in 2030-2040: Where does responsibility lie for the publics?

Considering that public engagement is pivotal to the mission of Responsible Research and Innovation, this article's aim is to examine how members of the public conceive of the relationship between responsibility and prospective health technologies. We organized four face-to-face deliberative workshops and an online forum wherein participants were invited to comment on scenarios involving three fictional technologies in 2030 and 2040. Our analyses describe how participants anticipated these technologies' impacts and formulated two conditions for their use: they should (1) be embedded within professional care and services and (2) include social protection of individual freedom and privacy. By clarifying what technological direction shall be avoided and who shall act responsibly, these conditions emphasize our participants' understanding of society as much as their understanding of science. For new technologies to be deployed in socially responsible ways, public engagement methods should be developed alongside public governance and regulatory strategies.

Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes? / Mise en oeuvre d'un réseau intégré de prévention et de gestion du risque cardiométabolique en première ligne à Montréal : une plus grande coordination des soins avec les médecins de première ligne a-t-elle un impact sur les résultats de santé?

INTRODUCTION: Chronic disease management requires substantial services integration. A cardiometabolic risk management program inspired by the Chronic Care Model was implemented in Montréal for patients with diabetes or hypertension. One of this study's objectives was to assess the impact of care coordination between the interdisciplinary teams and physicians on patient participation in the program, lifestyle improvements and disease control. METHODS: We obtained data on health outcomes from a register of clinical data, questionnaires completed by patients upon entry into the program and at the 12-month mark, and we drew information on the program's characteristics from the implementation analysis. We conducted multiple regression analyses, controlling for patient sociodemographic and health characteristics, to measure the association between interdisciplinary team coordination with primary care physicians and various health outcomes. RESULTS: A total of 1689 patients took part in the study (60.1% participation rate). Approximately 40% of patients withdrew from the program during the first year. At the 12-month follow-up (n = 992), we observed a significant increase in the proportion of patients achieving the various clinical targets. The perception by the interdisciplinary team of greater care coordination with primary care physicians was associated with increased participation in the program and the achievement of better clinical results. CONCLUSION: Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.

INTRODUCTION: La gestion des maladies chroniques nécessite une grande intégration des services. Un programme de gestion du risque cardiométabolique inspiré du Chronic Care Model a été implanté à Montréal pour les patients atteints de diabète ou d'hypertension. Un des objectifs de notre étude était d'apprécier l'impact de la coordination des soins entre les équipes interdisciplinaires et les médecins sur la participation des patients au programme et sur l'amélioration des habitudes de vie et le contrôle de la maladie. MÉTHODOLOGIE: Nous avons utilisé des données sur les résultats de santé issues d'un registre de données cliniques et de questionnaires aux patients à leur entrée dans le programme et à 12 mois de suivi, ainsi que des données sur les caractéristiques du programme provenant de l'analyse de son implantation. Nous avons réalisé des analyses de régression multiple, contrôlant pour les caractéristiques sociodémographiques et de santé des patients, pour mesurer l'association entre la coordination de l'équipe interdisciplinaire avec les médecins de première ligne et différents résultats de santé. RÉSULTATS: Au total, 1689 patients ont participé à l'évaluation (taux de participation 60,1 %). Environ 40 % des patients ont abandonné le programme durant la première année. À 12 mois de suivi (n = 992), nous avons observé une augmentation significative de la proportion des patients atteignant les différentes cibles cliniques. La perception par l'équipe interdisciplinaire d'une meilleure coordination des soins avec les médecins de première ligne était associée à une plus grande participation des patients au programme et à l'atteinte de meilleurs résultats cliniques. CONCLUSION: Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.

The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting.

BACKGROUND: Seven chronic disease prevention and management programs were implemented across Quebec with funding support from a provincial-private industry funding initiative. Given the complexity of implementing integrated primary care chronic disease management programs, a knowledge transfer meeting was held to share experiences across programs and synthesize common challenges and success factors for implementation. METHODS: The knowledge translation meeting was held in February 2014 in Montreal, Canada. Seventy-five participants consisting of 15 clinicians, 14 researchers, 31 knowledge users, and 15 representatives from the funding agencies were broken up into groups of 10 or 11 and conducted a strengths, weaknesses, opportunities, and threats analysis on either the implementation or the evaluation of these chronic disease management programs. Results were reported back to the larger group during a plenary and recorded. Audiotapes were transcribed and summarized using pragmatic thematic analysis. RESULTS AND DISCUSSION: Strengths to leverage for the implementation of the seven programs include: (1) synergy between clinical and research teams; (2) stakeholders working together; (3) motivation of clinicians; and (4) the fact that the programs are evidence-based. Weaknesses to address include: (1) insufficient resources; (2) organizational change within the clinical sites; (3) lack of referrals from primary care physicians; and (4) lack of access to programs. Strengths to leverage for the evaluation of these programs include: (1) engagement of stakeholders and (2) sharing of knowledge between clinical sites. Weaknesses to address include: (1) lack of referrals; (2) difficulties with data collection; and (3) difficulties in identifying indicators and control groups. Opportunities for both themes include: (1) fostering new and existing partnerships and stakeholder relations; (2) seizing funding opportunities; (3) knowledge transfer; (4) supporting the transformation of professional roles; (5) expand the use of health information technology; and (6) conduct cost evaluations. Fifteen recommendations related to mobilisation of primary care physicians, support for the transformation of professional roles, and strategies aimed at facilitating the implementation and evaluation of chronic disease management programs were formulated based on the discussions at this knowledge translation event. CONCLUSION: The results from this knowledge translation day will help inform the sustainability of these seven chronic disease management programs in Quebec and the implementation and evaluation of similar programs elsewhere.

Barriers and Facilitators for Primary Care Reform in Canada: Results from a Deliberative Synthesis across Five Provinces.

INTRODUCTION: Since 2000, primary care (PC) reforms have been implemented in various Canadian provinces. Emerging organizational models and policies are at various levels of implementation across jurisdictions. Few cross-provincial analyses of these reforms have been realized. The aim of this study is to identify the factors that have facilitated or hindered implementation of reforms in Canadian provinces between 2000 and 2010. METHODS: A literature and policy scan identified evaluation studies across Canadian jurisdictions. Experts from British Columbia, Manitoba, Nova Scotia, Ontario and Quebec were asked to review the scope of published evaluations and draft provincial case descriptions. A one-day deliberative forum was held, bringing together researchers (n = 40) and decision-makers (n = 20) from all the participating provinces. RESULTS: Despite a relative lack of published evaluations, our results suggest that PC reform has varied with regard to the scope and the policy levers used to implement change. Some provinces implemented specific PC models, while other provinces designed overarching policies aiming at changing professional behaviour and practice. The main perceived barriers to reform were the lack of financial investment, resistance from professional associations, too overtly prescriptive approaches lacking adaptability and an overly centralized governance model. The main perceived facilitators were a strong financial commitment using various allocation and payment approaches, the cooperation of professional associations and an incremental emergent change philosophy based on a strong decentralization of decisions allowing adaptation to local circumstances. So far the most beneficial results of the reforms seem to be an increase in patients' affiliation with a usual source of care, improved experience of care by patients and a higher workforce satisfaction. CONCLUSION: PC reforms currently under consideration in other jurisdictions could learn from the factors identified as promoting or hindering change in the provinces that have been most proactive.