Delivering the WISE (Whole Systems Informing Self-Management Engagement) training package in primary care: learning from formative evaluation

Background

Several studies document disparities in access to care and quality of care for depression for African Americans. Research suggests that patient attitudes and clinician communication behaviors may contribute to these disparities. Evidence links patient-centered care to improvements in mental health outcomes; therefore, quality improvement interventions that enhance this dimension of care are promising strategies to improve treatment and outcomes of depression among African Americans. This paper describes the design of the BRIDGE (Blacks Receiving Interventions for Depression and Gaining Empowerment) Study. The goal of the study is to compare the effectiveness of two interventions for African-American patients with depression--a standard quality improvement program and a patient-centered quality improvement program. The main hypothesis is that patients in the patient-centered group will have a greater reduction in their depression symptoms, higher rates of depression remission, and greater improvements in mental health functioning at six, twelve, and eighteen months than patients in the standard group. The study also examines patient ratings of care and receipt of guideline-concordant treatment for depression.

Methods/Design

A total of 36 primary care clinicians and 132 of their African-American patients with major depressive disorder were recruited into a cluster randomized trial. The study uses intent-to-treat analyses to compare the effectiveness of standard quality improvement interventions (academic detailing about depression guidelines for clinicians and disease-oriented care management for their patients) and patient-centered quality improvement interventions (communication skills training to enhance participatory decision-making for clinicians and care management focused on explanatory models, socio-cultural barriers, and treatment preferences for their patients) for improving outcomes over 12 months of follow-up.

Discussion

The BRIDGE Study includes clinicians and African-American patients in under-resourced community-based practices who have not been well-represented in clinical trials to improve depression care. The patient-centered and culturally targeted approach to depression care is a relatively new one that has not been tested in most previous studies. The study will provide evidence about whether patient-centered accommodations improve quality of care and outcomes to a greater extent than standard quality improvement strategies for African Americans with depression.

Trial Registration

ClinicalTrials.gov NCT00243425     

No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.

OBJECTIVE: To determine the effectiveness of different types of interventions in improving health professional performance and health outcomes. DATA SOURCES: MEDLINE, SCISEARCH, CINAHL and the Research and Development Resource Base in CME were searched for trials of educational interventions in the health care professions published between 1970 and 1993 inclusive. STUDY SELECTION: Studies were selected if they provided objective measurements of health professional performance or health outcomes and employed random or quasi-random allocation methods in their study designs to assign individual subjects or groups. Interventions included such activities as conferences, outreach visits, the use of local opinion leaders, audit and feedback, and reminder systems. DATA EXTRACTION: Details extracted from the studies included the study design; the unit of allocation (e.g., patient, provider, practice, hospital); the characteristics of the targeted health care professionals, educational interventions and patients (when appropriate); and the main outcome measure. DATA SYNTHESIS: The inclusion criteria were met by 102 trials. Areas of behaviour change included general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization. Dissemination-only strategies, such as conferences or the mailing of unsolicited materials, demonstrated little or no changes in health professional behaviour or health outcome when used alone. More complex interventions, such as the use of outreach visits or local opinion leaders, ranged from ineffective to highly effective but were most often moderately effective (resulting in reductions of 20% to 50% in the incidence of inappropriate performance). CONCLUSION: There are no "magic bullets" for improving the quality of health care, but there are a wide range of interventions available that, if used appropriately, could lead to important improvements in professional practice and patient outcomes.     

A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045

Background

Disparities in health and healthcare are extensively documented across clinical conditions, settings, and dimensions of healthcare quality. In particular, studies show that ethnic minorities and persons with low socioeconomic status receive poorer quality of interpersonal or patient-centered care than whites and persons with higher socioeconomic status. Strong evidence links patient-centered care to improvements in patient adherence and health outcomes; therefore, interventions that enhance this dimension of care are promising strategies to improve adherence and overcome disparities in outcomes for ethnic minorities and poor persons.

Objective

This paper describes the design of the Patient-Physician Partnership (Triple P) Study. The goal of the study is to compare the relative effectiveness of the patient and physician intensive interventions, separately, and in combination with one another, with the effectiveness of minimal interventions. The main hypothesis is that patients in the intensive intervention groups will have better adherence to appointments, medication, and lifestyle recommendations at three and twelve months than patients in minimal intervention groups. The study also examines other process and outcome measures, including patient-physician communication behaviors, patient ratings of care, health service utilization, and blood pressure control.

Methods

A total of 50 primary care physicians and 279 of their ethnic minority or poor patients with hypertension were recruited into a randomized controlled trial with a two by two factorial design. The study used a patient-centered, culturally tailored, education and activation intervention for patients with active follow-up delivered by a community health worker in the clinic. It also included a computerized, self-study communication skills training program for physicians, delivered via an interactive CD-ROM, with tailored feedback to address their individual communication skills needs.

Conclusion

The Triple P study will provide new knowledge about how to improve patient adherence, quality of care, and cardiovascular outcomes, as well as how to reduce disparities in care and outcomes of ethnic minority and poor persons with hypertension.     

Impact of High Deductible Health Plans on Diabetes Care Quality and Outcomes: Systematic Review

ObjectiveTo provide a review of the impact of high deductible health plans (HDHPs) on the utilizations of services required for optimal management of diabetes and subsequent health outcomes.MethodsSystematic literature review of studies published between January 1, 2000, and May 7, 2021, was conducted that examined the impact of HDHP on diabetes monitoring (eg, recommended laboratory and surveillance testing), routine care (eg, ambulatory appointments), medication management (eg, medication initiation, adherence), and acute health care utilization (eg, emergency department visits, hospitalizations, incident complications).ResultsOf the 303 reviewed articles, 8 were relevant. These studies demonstrated that HDHPs lower spending at the expense of reduced high-value diabetes monitoring, routine care, and medication adherence, potentially contributing to the observed increases in acute health care utilization. Additionally, patient out-of-pocket costs for recommended screenings doubled, and total health care expenditures increased by 49.4% for HDHP enrollees compared with enrollees in traditional health plans. Reductions in disease monitoring and routine care and increases in acute health care utilization were greatest in lower-income patients. None of the studies examined the impact of HDHPs on access to diabetes self-management education, technology use, or glycemic control.ConclusionAlthough HDHPs reduce some health care utilization and costs, they appear to do so at the expense of limiting high-value care and medication adherence. Policymakers, providers, and payers should be more cognizant of the potential for negative consequences of HDHPs on patients’ health.     

Effect of a geriatric consultation service on management of patients in an acute care hospital.

Elderly patients present particular management challenges. We conducted a randomized clinical trial of the effect of a geriatric consultation service on the management of elderly patients in an acute care hospital. A total of 113 patients aged 75 years or more who met certain criteria were assigned to either receive (57 patients) or not receive (56) care by the service. At the end of their hospital stay the patients were assessed with regard to predetermined outcomes. The patients were followed up for 1 year after discharge to determine death rates and direct health care expenditures. The intervention group showed significantly greater improvement in mental status (p less than 0.01), were receiving fewer medications at discharge (p less than 0.05) and had lower short-term death rates (p less than 0.05) than the control group. A geriatric consultation service can improve the hospital care and health of the elderly.     

Physicians' participation in establishing criteria for hypertension management in the office: will patient outcomes be improved?

We designed this study to determine whether an intensive 1-day educational workshop involving family physicians in establishing essential criteria for hypertension management would significantly affect the short-term outcomes of hypertensive patients in their practices. Forty randomly selected physicians were separated into three groups: those who would be involved in establishing the criteria (15), those who would receive the criteria by mail (15) and those who would act as controls and not be aware of the criteria (10). We found no significant difference between the three groups in the number of hypertensive patients whose condition remained uncontrolled after the intervention. We conclude that physicians'' participation in the establishment of standards of care for conditions such as hypertension or their awareness of such standards does not independently result in significantly better patient outcomes. Consequently, we recommend that physicians and health care planners concerned with improving outcomes not rely on any single intervention strategy when planning change.     

Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial

Background

Delays in accessing care for malaria and other diseases can lead to disease progression, and user fees are a known barrier to accessing health care. Governments are introducing free health care to improve health outcomes. Free health care affects treatment seeking, and it is therefore assumed to lead to improved health outcomes, but there is no direct trial evidence of the impact of removing out-of-pocket payments on health outcomes in developing countries. This trial was designed to test the impact of free health care on health outcomes directly.

Methods and Findings

2,194 households containing 2,592 Ghanaian children under 5 y old were randomised into a prepayment scheme allowing free primary care including drugs, or to a control group whose families paid user fees for health care (normal practice); 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm. The primary outcome was moderate anaemia (haemoglobin [Hb] < 8 g/dl); major secondary outcomes were health care utilisation, severe anaemia, and mortality. At baseline the randomised groups were similar. Introducing free primary health care altered the health care seeking behaviour of households; those randomised to the intervention arm used formal health care more and nonformal care less than the control group. Introducing free primary health care did not lead to any measurable difference in any health outcome. The primary outcome of moderate anaemia was detected in 37 (3.1%) children in the control and 36 children (3.2%) in the intervention arm (adjusted odds ratio 1.05, 95% confidence interval 0.66–1.67). There were four deaths in the control and five in the intervention group. Mean Hb concentration, severe anaemia, parasite prevalence, and anthropometric measurements were similar in each group. Families who previously self-enrolled in the prepayment scheme were significantly less poor, had better health measures, and used services more frequently than those in the randomised group.

Conclusions

In the study setting, removing out-of-pocket payments for health care had an impact on health care-seeking behaviour but not on the health outcomes measured.Trial registration: ClinicalTrials.gov (#{"type":"clinical-trial","attrs":{"text":"NCT00146692","term_id":"NCT00146692"}}NCT00146692).     

Guías clínicas de fractura de cadera. Comparación de sus principales recomendaciones

Hip fracture is the most severe complication of osteoporosis, and despite being a frequent health problem, there is a wide variability in both the health care provided to these patients and the results achieved after their treatment. Clinical guidelines are a tool that helps to reduce this variability. The authors of this review try to give a panoramic and comparative view of the key recommendations proposed by the main guidelines for the hospital care of hip fracture patients. Recommendations on the care in the acute phase are reviewed, particularly the initial hospital management, use of tools, preventive measures to avoid medical complications, surgery related aspects, treatment of usual clinical problems, and shared orthopaedic and geriatric care. Circulating and putting into practice the main recommendations will help to improve the health care provided to these patients and obtain better outcomes.     

The Impact of Comprehensive Case Management on HIV Client Outcomes

In 1990, New York State instituted Comprehensive Medicaid Case Management, also known as Target Case Management (TCM), for people dealing with multiple comorbid conditions, including HIV. The goal of TCM is to assist clients in navigating the health care system to increase care engagement and treatment adherence for individuals with complex needs. HIV-positive individuals engaged in care are more likely to be virally suppressed, improving clinical outcomes and decreasing chances of HIV transmission. The purpose of this study was to understand the impact of TCM management on outcomes for people with HIV. Data were obtained from Amida Care, which operates not-for-profit managed care Medicaid and Medicare Special Needs Plans (SNPs) for HIV clients. Changes in clinical, cost, as well as medical and pharmacy utilization data among TCM clients were examined between January 2011 through September 2012 from the start of case management enrollment through the end of the study period (i.e., up to 6 months after disenrollment). Additionally, CD4 counts were compared between Amida Care TCM clients and non-TCM clients. Notable findings include increased CD4 counts for TCM clients over the one-year study period, achieving parity with non-TCM clients (i.e., Mean CD4 count > 500). When looking exclusively at TCM clients, there were increases in medication costs over time, which were concomitant with increased care engagement. Current findings demonstrate that TCM is able to achieve its goals of improving care engagement and treatment adherence. Subsequent policy changes resulting from the Affordable Care Act and the New York State Medicaid Redesign have made the Health Home the administrator of TCM services. Government entities charged with securing and managing TCM and care coordination for people with HIV should provide thoughtful and reasonable guidance and oversight in order to maintain optimal clinical outcomes for TCM clients and reduce the transmission of HIV.     

地市级妇幼保健机构部制改革问题与对策探讨

妇幼机构四大保健部设置,是国家卫生计生委在新妇幼机构规范化建设标准中提出,其目的是解决妇幼保健管理、认识和定位的误区,各妇幼保健机构在落实四大部设置中存在的困难。文章以秦皇岛市妇幼保健院部制改革为例,寻求探索解决地市妇幼保健机构实施四大保健部设置的方法。     

Scaling Up Paediatric HIV Care with an Integrated,Family-Centred Approach: An Observational Case Study from Uganda

Family-centred HIV care models have emerged as an approach to better target children and their caregivers for HIV testing and care, and further provide integrated health services for the family unit’s range of care needs. While there is significant international interest in family-centred approaches, there is a dearth of research on operational experiences in implementation and scale-up. Our retrospective case study examined best practices and enabling factors during scale-up of family-centred care in ten health facilities and ten community clinics supported by a non-governmental organization, Mildmay, in Central Uganda. Methods included key informant interviews with programme management and families, and a desk review of hospital management information systems (HMIS) uptake data. In the 84 months following the scale-up of the family-centred approach in HIV care, Mildmay experienced a 50-fold increase of family units registered in HIV care, a 40-fold increase of children enrolled in HIV care, and nearly universal coverage of paediatric cotrimoxazole prophylaxis. The Mildmay experience emphasizes the importance of streamlining care to maximize paediatric capture. This includes integrated service provision, incentivizing care-seeking as a family, creating child-friendly service environments, and minimizing missed paediatric testing opportunities by institutionalizing early infant diagnosis and provider-initiated testing and counselling. Task-shifting towards nurse-led clinics with community outreach support enabled rapid scale-up, as did an active management structure that allowed for real-time review and corrective action. The Mildmay experience suggests that family-centred approaches are operationally feasible, produce strong coverage outcomes, and can be well-managed during rapid scale-up.     

我国实施医师多点执业的政策分析与思考

医师多点执业试点工作正在各地逐步推开。文章依据国家新医改政策,以医师多点执业为基点,对医师多点执业现状和对医疗卫生系统的运行管理可能带来的影响进行综合分析,结合医疗单位的实际,提出意见建议。     

Including Ethnic Minorities in Mental Health Intervention Research: A Practical Approach to a Long-Standing Problem

This paper examines a controversy that arose while developing a supplement to Mental Health: A Report of the Surgeon General that was focused on ethnic minority mental health. The controversy involved whether and how to make recommendations about ethnic minorities seeking mental health care. We found that few studies provided information on outcomes of mental health care for ethnic minorities. In this paper, we discuss outcomes of mental health care for ethnic minorities and how to proceed in developing an evidence base for understanding mental health care and minorities. We conclude that entering representative (based on population) numbers of ethnic minorities in efficacy trials is unlikely to produce useful information on outcomes of care because the numbers will be too small to produce reliable findings. We also conclude that while conducting randomized efficacy trials for all mental health interventions for each ethnic group would be impractical, innovative and theoretically informed studies that focus on specific cultural groups are needed to advance the knowledge base. We call for theory-driven research focused on mental health disparities that has the potential for understanding disparities and improving outcomes for ethnic minority populations.     

Physicians in health care management: 1. Physicians as managers: roles and future challenges.

Physicians are increasingly expected to assume responsibility for the management of human and financial resources in health care, particularly in hospitals. Juggling their new management responsibilities with clinical care, teaching and research can lead to conflicting roles. However, their presence in management is crucial to shaping the future health care system. They bring to management positions important skills and values such as observation, problem-solving, analysis and ethical judgement. To improve their management skills physicians can benefit from management education programs such as those offered by the Physician-Manager Institute and several Canadian universities. To manage in the future environment they must increase their knowledge and skills in policy and political processes, financial strategies and management, human resources management, systems and program quality improvement and organizational design.     

Care management and mental health.

The community care reforms will produce a new kind of key worker who will organise and budget for packages of care: the care manager. Care management goes live in April 1993 but is still poorly rehearsed and its performance may yet disappoint. This overview sets out the origins of case management, its transformation into care management, and the principles guiding its practice. To spell out how the concept works, plans for care management in Southwark''s mental health services are described.     

甘肃康乐县基层卫生机构门诊临床路径管理探讨

为了有效发挥基层医疗卫生机构健康“守门人”职能,康乐县借助卫XI项目支持,积极开展基层医疗卫生机构门诊临床路径管理探索,有效发挥了新农合与定点医疗机构管理的协同作用,实现了医疗质量提高与费用控制的有效结合,并在规范诊疗行为、减低医疗服务成本、改善医患关系等方面发挥了积极作用。

     

Obesity disease management opportunities and barriers

Disease management, a system of coordinated health care interventions and communications for chronically ill populations, relies on patient education and case management to engage individuals in the management of their condition. Disease management also aims to enhance the quality of interactions between doctors and patients and advance evidence-based medicine. Because these programs' interventions frequently include helping individuals who suffer comorbidities associated with obesity to reduce their BMI, adaptation of disease management to populations with obesity seems a viable option. A major barrier for implementing disease management for obesity, however, is the lack of proven return on investment, which limits health plan and disease management organization interest. Purchaser demand may overcome this reluctance. Further research is needed to objectively test whether disease management interventions would be clinically effective for obese populations, produce positive financial outcomes for insurers, and enhance workplace productivity.     

Mental Health Outcomes of Psychosocial Intervention Among Traditional Health Practitioner Depressed Patients in Kenya

Task-shifting in mental health such as engaging Traditional Health Practitioners (THPs) in appropriate management of mental disorders is crucial in reducing global mental health challenges. This study aims to determine the outcomes of using evidence-based mental health Global Action Programme Intervention guide (mhGAP-IG) to provide psychosocial interventions among depressed patients seeking care from THPs. THPs were trained to deliver psychosocial interventions to their patients screening positive for mild to severe depression on Beck’s Depression Inventory (BDI). Assessments were conducted at 0, 6 and 12 weeks and Analysis of Variance (ANOVA) performed to determine the change in depression scores over the three time period. BDI mean score was 26.52 before intervention and reduced significantly at 6 (13%) and 12 (35%) weeks after intervention. 58 and 78% of patients showed reduction in symptoms of depression at 6 and 12 weeks. It is therefore crucial to engage THPs in the care of patients with depression and the need for inclusion of training packages; and other mental disorders in order to establish and maintain collaboration between THPs and conventional health workers and promote evidence-based care among marginalized populations. Moreover, further research on randomized control trials of mhGAP-IG intervention versus usual care is required.     

Assessment of the Quality of Antenatal Care Services Provided by Health Workers Using a Mobile Phone Decision Support Application in Northern Nigeria: A Pre/Post-Intervention Study

BackgroundGiven the shortage of skilled healthcare providers in Nigeria, frontline community health extension workers (CHEWs) are commonly tasked with providing maternal and child health services at primary health centers. In 2012, we introduced a mobile case management and decision support application in twenty primary health centers in northern Nigeria, and conducted a pre-test/post-test study to assess whether the introduction of the app had an effect on the quality of antenatal care services provided by this lower-level cadre.MethodsUsing the CommCare mobile platform, the app dynamically guides CHEWs through antenatal care protocols and collects client data in real time. Thirteen health education audio clips are also embedded in the app for improving and standardizing client counseling. To detect changes in quality, we developed an evidence-based quality score consisting of 25 indicators, and conducted a total of 266 client exit interviews. We analyzed baseline and endline data to assess changes in the overall quality score as well as changes in the provision of key elements of antenatal care.ResultsOverall, the quality score increased from 13.3 at baseline to 17.2 at endline (p<0.0001), out of a total possible score of 25, with the most significant improvements related to health counseling, technical services provided, and quality of health education.ConclusionThese study results suggest that the introduction of a low-cost mobile case management and decision support application can spur behavior change and improve the quality of services provided by a lower level cadre of healthcare workers. Future research should employ a more rigorous experimental design to explore potential longer-term effects on client health outcomes.     

Fair regression for health care spending

The distribution of health care payments to insurance plans has substantial consequences for social policy. Risk adjustment formulas predict spending in health insurance markets in order to provide fair benefits and health care coverage for all enrollees, regardless of their health status. Unfortunately, current risk adjustment formulas are known to underpredict spending for specific groups of enrollees leading to undercompensated payments to health insurers. This incentivizes insurers to design their plans such that individuals in undercompensated groups will be less likely to enroll, impacting access to health care for these groups. To improve risk adjustment formulas for undercompensated groups, we expand on concepts from the statistics, computer science, and health economics literature to develop new fair regression methods for continuous outcomes by building fairness considerations directly into the objective function. We additionally propose a novel measure of fairness while asserting that a suite of metrics is necessary in order to evaluate risk adjustment formulas more fully. Our data application using the IBM MarketScan Research Databases and simulation studies demonstrates that these new fair regression methods may lead to massive improvements in group fairness (eg, 98%) with only small reductions in overall fit (eg, 4%).