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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TL;DR: The findings highlight the importance of provider factors such as beliefs and attitudes, team location and work context in understanding variations in the provision of lifestyle intervention in PHC.
Abstract: Despite evidence for the effectiveness of interventions to modify lifestyle behaviours in the primary health care (PHC) setting, assessment and intervention for these behaviours remains low in routine practice. Little is known about the relative importance of various determinants of practice.
46 citations
"Long-term impact of a real-world co..." refers background in this paper
...Specific barriers to fully integrating lifestyle promotion in primary care have been shown to be intrapersonal (perceived effectiveness of interventions, attitudes and confidence), interpersonal (patient characteristics) and institutional (resources) [11,22-28]....
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TL;DR: Differences between professional groups in knowledge, extent of work with promotion of healthy lifestyles and lifestyle issues and provision of organizational support such as national guidelines should be considered for further implementation of lifestyle interventions in primary health care.
Abstract: BACKGROUND: Interventions that support patient efforts at lifestyle changes that reduce tobacco use, hazardous use of alcohol, unhealthy eating habits and insufficient physical activity represent i ...
42 citations
"Long-term impact of a real-world co..." refers background in this paper
...Specific barriers to fully integrating lifestyle promotion in primary care have been shown to be intrapersonal (perceived effectiveness of interventions, attitudes and confidence), interpersonal (patient characteristics) and institutional (resources) [11,22-28]....
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TL;DR: Developing and implementing cardiovascular disease management programmes is time-consuming and challenging, and shifting to a multidisciplinary, patient-centred care pathway approach to disease management is demanding for organisations, professionals and patients.
Abstract: Background : Disease management programmes are increasingly used to improve the efficacy and effectiveness of chronic care delivery. But, disease management programme development and implementation is a complex undertaking that requires effective decision-making. Choices made in the earliest phases of programme development are crucial, as they ultimately impact costs, outcomes and sustainability. Methods : To increase our understanding of the choices that primary healthcare practices face when implementing such programmes and to stimulate successful implementation and sustainability, we compared the early implementation of eight cardiovascular disease management programmes initiated and managed by healthcare practices in various regions of the Netherlands. Using a mixed-methods design, we identified differences in and challenges to programme implementation in terms of context, patient characteristics, disease management level, healthcare utilisation costs, development costs and health-related quality of life. Results : Shifting to a multidisciplinary, patient-centred care pathway approach to disease management is demanding for organisations, professionals and patients, and is especially vulnerable when sustainable change is the goal. Funding is an important barrier to sustainable implementation of cardiovascular disease management programmes, although development costs of the individual programmes varied considerably in relation to the length of the development period. The large number of professionals involved in combination with duration of programme development was the largest cost drivers. While Information and Communication Technology systems to support the new care pathways did not directly contribute to higher costs, delays in implementation indirectly did. Conclusions : Developing and implementing cardiovascular disease management programmes is time-consuming and challenging. Multidisciplinary, patient-centred care demands multifaceted changes in routine care. As care pathways become more complex, they also become more expensive. Better preparedness and training can prevent unnecessary delays during the implementation period and are crucial to reducing costs.
34 citations
TL;DR: The results indicate that gender possibly plays a role in the relationship between advice and the stage of change in Swedish health care, and already addressing alcohol habits appears to be associated with change.
Abstract: Alcohol habits are more rarely addressed than other health behavior topics in Swedish health care. This study examined whether differences between topics could be explained by their different associations with patient characteristics or by the differences in the prevalence of the disadvantageous health behavior, i.e., excessive alcohol use and smoking. The study moreover examined whether simply being asked questions about behavior, i.e., alcohol use or smoking, was associated with reported change. The study was based on a cross-sectional postal survey (n = 4 238, response rate 56.5 percent) representative of the adult population in Stockholm County in 2003. Retrospective self-reports were used to assess health care visits during the past 12 months, the questions and advice received there, patients characteristics, health behavior, and the present stage of change. Logistic regression analysis was used to estimate the associations among the 68 percent who had visited health care. Among the health care visitors, 23 percent reported being asked about their alcohol habits, and 3 percent reported receiving advice or/and support to modify their alcohol use - fewer than for smoking, physical exercise, or diet. When regression models adjusted for patient characteristics, the differences between health behaviors in the extent of questioning and advice remained. However, when the models also adjusted for smoking and alcohol consumption there was no difference between smoking and alcohol-related advice. In fact one-third of the present smokers and two-fifths of the persons dependent on alcohol reported having receiving advice the previous 12 months. Those who reported being asked questions or receiving advice more often reported a decreased alcohol use and similarly intended to cease smoking within 6 months. Questions about alcohol use were moreover related to a later stage of stage of change independently of advice among women but not among men. While most patients are never addressed, many in the target groups seem to be reached anyway. Besides advice, already addressing alcohol habits appears to be associated with change. The results also indicate that gender possibly plays a role in the relationship between advice and the stage of change.
26 citations
"Long-term impact of a real-world co..." refers background in this paper
...The rate of lifestyle promotion in routine primary care has been shown to vary from a few percent to about 30% of patients who receive lifestyle advice [15-20]....
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TL;DR: In this paper, a cross-sectional study was conducted to quantify access to preventive services in Southern Italy and to assess whether and how the provision of preventive care was influenced by any specific characteristics of patients.
Abstract: It is assumed that providing clinical preventive services to patients can identify or detect early important causes of adult mortality. The aim of this study was to quantify access to preventive services in Southern Italy and to assess whether and how the provision of preventive care was influenced by any specific characteristics of patients. In a cross-sectional study adults aged 18 years and over attending primary care physician (PCP) offices located in Southern Italy were interviewed from June through December 2007. Quality indicators of preventive health care developed from RAND's Quality Assessment Tools and Behavioral Risk Factor Surveillance System (BRFSS) were used. Multivariate analysis was performed to identify and to assess the role of patients' characteristics on delivery of clinical preventive services. A total of 1467 subjects participated in the study. Excepting blood pressure preventive check (delivered to 64.4% of eligible subjects) and influenza vaccination (recommended to 90.2% of elderly), the rates of delivery of clinical preventive services were low across all measures, particularly for screening and counseling on health habits. Rates for providing cancer screening tests at recommended times were 21.3% for colonoscopy, 51.5% for mammography and 52.4% for Pap smear. Statistical analysis showed clear disparities in the provision of clinical preventive services associated with age, gender, education level, perceived health status, current health conditions and primary care access measures. There is overwhelming need to develop and implement effective interventions to improve delivery of routine clinical preventive services.
19 citations
"Long-term impact of a real-world co..." refers background in this paper
...The rate of lifestyle promotion in routine primary care has been shown to vary from a few percent to about 30% of patients who receive lifestyle advice [15-20]....
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