Long-term impact of a real-world coordinated lifestyle promotion initiative in primary care: a quasi-experimental cross-sectional study
TL;DR: Lifestyle teams were perceived to have an important role at the centres in driving the lifestyle promotion work forward and being a forum for knowledge exchange but had limited impact on lifestyle promotion practices.
Abstract: Background
Integration of lifestyle promotion in routine primary care has been suboptimal. Coordinated care models (e.g. screening, brief advice and referral to in-house specialized staff) could facilitate lifestyle promotion practice; they have been shown to increase the quality of services and reduce costs in other areas of care. This study evaluates the long-term impact of a coordinated lifestyle promotion intervention with a multidisciplinary team approach in a primary care setting.
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Journal Article•
TL;DR: Preventive interventions have yielded dramatic improvements in population health, with substantial benefits in patient-oriented outcomes including death from infectious disease and infant mortality.
Abstract: Historically, preventive interventions have yielded dramatic improvements in population health, with substantial benefits in patient-oriented outcomes including death from infectious disease and infant mortality. As medicine evolves, greater numbers of preventive and screening recommendations are
30 citations
TL;DR: Utilizing CQI methods in implementation research would appear to be well-suited to drive improvements in service delivery for unhealthy alcohol use, although the body of literature describing such studies is still small.
Abstract: Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements. We conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes. Fifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements. Utilizing CQI methods in implementation research would appear to be well-suited to drive improvements in service delivery for unhealthy alcohol use. However, the body of literature describing such studies is still small. More well-designed research, including hybrid studies of both implementation and patient outcomes, will be needed to draw clearer conclusions on the optimal approach for implementing screening and treatment for unhealthy alcohol use. (PROSPERO registration ID: CRD42018110475).
19 citations
TL;DR: The Spanish version of the Organizational Readiness for Knowledge Translation questionnaire exhibits very strong reliability and good validity, although it needs to be validated in a larger sample and in different implementation contexts.
Abstract: Organizational readiness to change healthcare practice is a major determinant of successful implementation of evidence-based interventions. However, we lack of comprehensive, valid, and reliable instruments to measure it. We assessed the validity and reliability of the Spanish version of the Organizational Readiness for Knowledge Translation (OR4KT) questionnaire in the context of the implementation of the Prescribe Vida Saludable III project, which seeks to strengthen health promotion and chronic disease prevention in primary healthcare organizations of the Osakidetza (Basque Health Service, Spain). A cross-sectional study was conducted including 127 professionals from 20 primary care centers within Osakidetza. They filled in the OR4KT questionnaire twice in a 15- to 30-day period to test repeatability. In addition, we used the Survey of Organizational Attributes for Primary Care (SOAPC) and we documented the number of healthcare professionals who formally engaged in the Prescribe Vida Saludable III project within each participating center to assess concurrent validity. Cronbach’s alpha for the overall OR4KT was .95, and the overall repeatability coefficient was 6.95%, both excellent results. Confirmatory factor analysis supported the underlying theoretical structure of 6 dimensions and 23 sub-dimensions. There were positive moderate-to-high internal correlations between these six dimensions, and there was evidence of good concurrent validity (correlation coefficient of .76 with SOAPC, and .80 with the proportion of professionals engaged by center). A score higher than 64 (out of 100) would be indicative of an organization with high level of readiness to implement the intervention (sensitivity = .75, specificity = 1). The Spanish version of the OR4KT exhibits very strong reliability and good validity, although it needs to be validated in a larger sample and in different implementation contexts.
10 citations
TL;DR: The findings showed how the development phase influenced the implementation and embedding processes, which add aspects to the General Theory of Implementation, and highlighted the importance of identifying and engaging key stakeholders early in an implementation process.
Abstract: Background: Primary care is increasingly being encouraged to integrate healthy lifestyle promotion in routine care. However, implementation has been suboptimal. Coordinated care could facilitate li ...
8 citations
Cites background from "Long-term impact of a real-world co..."
...Lifestyle team centres were more likely to agree that lifestyle promotion issues were prioritized at their workplace and that there were sufficient competency at their workplace regarding lifestyle promotion [30]....
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Dissertation•
01 Jan 2018
TL;DR: An alcohol intervention model that predicts life years, quality adjusted life years (QALYs), and healthcare costs classified by the Alcohol Use Disorder Identification Test (AUDIT) screening tool and other various risk factors related to alcohol consumption was developed and transferred to the Thai setting.
Abstract: Objectives To develop an alcohol intervention model that predicts life years (LYs), quality adjusted life years (QALYs), and healthcare costs classified by the Alcohol Use Disorder Identification Test (AUDIT) screening tool and other various risk factors related to alcohol consumption. Furthermore, the developed model was transferred to the Thai setting.
Methods Eight Scottish Health Surveys from 1995-2012 were linked to Scottish morbidity records and death records for the period 1981 to the end of 2013. Parametric survival analysis was used to estimate the hazard risks of first alcohol-related and non-alcohol related hospitalisations and deaths. For men and women, multivariate data analyses were applied separately for each gender in modelling the utility score, risks of subsequent hospitalisation and annual healthcare costs within the follow-up period. Risk profiles were used for the covariates of the models as follows: age, socio-economic status, health condition, alcohol drinking (i.e. AUDIT and binge drinking), smoking, body mass index, and physical activity. According to the under-reporting bias of alcohol consumption among the survey population, this study adjusted the reported alcohol consumption using alcohol sales data. Multiple imputation approach was applied to deal with missing data. A health-state transition model with annual cycle length was developed to predict LYs, QALYs, lifetime costs, and cost-effectiveness. Probabilistic sensitivity analysis was also performed to deal with parameter uncertainty. Moreover, a methodological transferability protocol of the Thai study was detailed.
Results The sample size of the cohort was 46,230. The developed model showed the association between drinking and alcohol-related and non-alcohol related hospitalisations and deaths which were calculated as LYs and QALYs. Other risk factors were also taken into account that would likely affect the outcomes of interest. The modelling showed that an increasing AUDIT score and the number of cigarettes per day were associated with an increased risk of first alcohol-attributable hospitalisation. Predicted outcomes for a male aged 30 year with high-risk drinking levels (AUDIT >7) were worse than males with low risk drinking (AUDIT ≤7), with approximately 5 LY gained and 7 QALY gained. The same results for females were obtained for high-risk drinking (AUDIT >4) compared to low-risk drinking (AUDIT ≤4), with approximately 10 LY gained and 12 QALY gained. Furthermore, an economic evaluation was performed to compare the no-intervention situation with a hypothetical health promotion intervention - which aimed to stop drinking (measured by the AUDIT) and smoking (measured by the number of cigarettes per day) behaviours. To compare the costs and benefits of the hypothetical intervention and no intervention over the lifetime period, a within-trial analysis combined with the developed model was able to capture both short- and longer-term consequences (i.e. LYs, QALYs, and healthcare costs) of the intervention. Finally, the model was able to compare cost-effectiveness ratio between risk behaviours without the new intervention and the modified risk behaviours when the new intervention is implemented.
Conclusions The study highlights the potential and importance of developing health economic models utilising data from routine national health surveys linked to national hospitalisation and death records. The developed framework can be used for further economic evaluation of alcohol interventions and other health behaviour change interventions. The framework can further be transferred to other country settings.
4 citations
Cites background from "Long-term impact of a real-world co..."
...…complex multi-levels of components, i.e. the policy, environment, and individual levels, evaluating these interventions requires evidence beyond efficacy trials to measure the potential impacts of the interventions, especially in real-world settings (Koorts and Gillison, 2015, Thomas et al., 2014)....
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References
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1,345 citations
TL;DR: This research offers a framework for those who would seek to use the results of research studies in routine healthcare settings to design and conduct interventions aimed at improving the use of research findings by individual healthcare professionals or teams.
853 citations
"Long-term impact of a real-world co..." refers background in this paper
...The introduction of new practices under real-world conditions has been found to be challenging [21]....
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TL;DR: A comprehensive, integrated checklist of determinants of practice (the TICD checklist) is described that aims to be comprehensive and to build on the strengths of each of the 12 included checklists.
Abstract: Background: Determinants of practice are factors that might prevent or enable improvements. Several checklists, frameworks, taxonomies, and classifications of determinants of healthcare professional practice have been published. In this paper, we describe the development of a comprehensive, integrated checklist of determinants of practice (the TICD checklist). Methods: We performed a systematic review of frameworks of determinants of practice followed by a consensus process. We searched electronic databases and screened the reference lists of key background documents. Two authors independently assessed titles and abstracts, and potentially relevant full text articles. We compiled a list of attributes that a checklist should have: comprehensiveness, relevance, applicability, simplicity, logic, clarity, usability, suitability, and usefulness. We assessed included articles using these criteria and collected information about the theory, model, or logic underlying how the factors (determinants) were selected, described, and grouped, the strengths and weaknesses of the checklist, and the determinants and the domains in each checklist. We drafted a preliminary checklist based on an aggregated list of determinants from the included checklists, and finalized the checklist by a consensus process among implementation researchers. Results: We screened 5,778 titles and abstracts and retrieved 87 potentially relevant papers in full text. Several of these papers had references to papers that we also retrieved in full text. We also checked potentially relevant papers we had on file that were not retrieved by the searches. We included 12 checklists. None of these were completely comprehensive when compared to the aggregated list of determinants and domains. We developed a checklist with 57 potential determinants of practice grouped in seven domains: guideline factors, individual health professional factors, patient factors, professional interactions, incentives and resources, capacity for organisational change, and social, political, and legal factors. We also developed five worksheets to facilitate the use of the checklist. Conclusions: Based on a systematic review and a consensus process we developed a checklist that aims to be comprehensive and to build on the strengths of each of the 12 included checklists. The checklist is accompanied with five worksheets to facilitate its use in implementation research and quality improvement projects.
661 citations
01 Jun 2007
TL;DR: A working definition of care coordination is developed, applied to a review of systematic reviews, and theoretical frameworks that might predict or explain how care coordination mechanisms are influenced by factors in the health care setting and how they relate to patient outcomes and health care costs are identified.
Abstract: Context Quality problems and spiraling costs have resulted in widespread interest in solutions that improve the effectiveness and efficiency of the health care system. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially accomplishing these improvements. Objectives The objectives of this project were to develop a working definition of care coordination, apply it to a review of systematic reviews, and identify theoretical frameworks that might predict or explain how care coordination mechanisms are influenced by factors in the health care setting and how they relate to patient outcomes and health care costs. Data Sources and Review Methods We used literature databases, Internet searches, and personal contacts to assemble background information on ongoing care coordination programs; potential definitions; conceptual frameworks and related empirical evidence; and care coordination measures. We also conducted literature searches through September 30, 2006 of MEDLINE®, and November 15, 2006 for CINAHL®, Cochrane database of systematic reviews, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, PsychInfo, Sociological Abstracts, and Social Services Abstracts to identify systematic reviews of care coordination interventions. We excluded systematic reviews with a narrow focus, namely those conducted solely in the inpatient setting, or where the only two participants involved in care were the patient and a health care provider. Results We identified numerous ongoing programs in the private and public sector, most of which have not yet been evaluated. We identified over 40 definitions of care coordination and related terminology, and developed a working definition drawing together common elements: Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. We used this definition to develop our inclusion/exclusion criteria for selecting potentially relevant systematic reviews. Our literature search yielded 4,730 publications, of which 75 systematic reviews evaluating care coordination interventions, either fully or as a part of the review, met inclusion criteria. From these, we identified 20 different coordination interventions (e.g., multidisciplinary teams, case management, disease management) covering 12 clinical populations (e.g., mental health, heart disease, diabetes) and conducted in multiple settings (e.g., outpatient, community, home). Finally, we identified four conceptual frameworks (Andersen's behavioral framework, Donabedian's structure-process-outcome framework, Nadler/Tushman and others' Organizational design framework with Wagner's Chronic Care Model provided as an example of such design, and Gittell's Relational coordination framework) with potential applicability to studying care coordination by assessing baseline characteristics of the environment, specific coordination mechanism alternatives, and outcomes. The strongest evidence shows benefit of care coordination interventions for patients who have congestive heart failure, diabetes mellitus, severe mental illness, a recent stroke, or depression, though evidence about key intervention components is lacking. Conclusions Care coordination interventions represent a wide range of approaches at the service delivery and systems level. Their effectiveness is most likely dependent upon appropriate matching between intervention and care coordination problem, though more conceptual, empirical and experimental research is required to explore this hypothesis.
660 citations
"Long-term impact of a real-world co..." refers background in this paper
...Coordinated care has been shown to improve service continuity and collaboration, increase the quality of services and reduce costs in mental health and chronic care [32,35]....
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...Approaches to coordinated care have typically involved multidisciplinary teams, care management and disease management [32,34]....
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...The aim of coordinated care is to improve access, efficiency and quality of care [32]....
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TL;DR: A conceptual framework is proposed to guide and prioritize this process of abandoning ineffective medical practices, shifting emphasis toward the principles of evidence-based medicine, acknowledging that evidence may still be misinterpreted or distorted by recalcitrant proponents of entrenched practices and other biases.
Abstract: Abandoning ineffective medical practices and mitigating the risks of untested practices are important for improving patient health and containing healthcare costs. Historically, this process has relied on the evidence base, societal values, cultural tensions, and political sway, but not necessarily in that order. We propose a conceptual framework to guide and prioritize this process, shifting emphasis toward the principles of evidence-based medicine, acknowledging that evidence may still be misinterpreted or distorted by recalcitrant proponents of entrenched practices and other biases.
600 citations