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.
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.
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.
Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.
Aims
Few investigations have been conducted to identify genetic determinants of common, polygenetic forms of heart failure (HF), and only a limited number of these genetic associations have been ...validated by multiple groups.
Methods and results
We performed a case–control study to further investigate the potential impact of 14 previously reported candidate genes on the risk of HF and specific HF sub‐types. We also performed an exploratory genome‐wide study. We included 799 patients with HF and 1529 controls. After adjusting for age, sex, and genetic ancestry, we found that the C allele of rs2234962 in BAG3 was associated with a decreased risk of idiopathic dilated cardiomyopathy (odds ratio 0.42, 95% confidence interval 0.25–0.68, P = 0.0005), consistent with a previous report. No association for the other primary variants or exploratory genome‐wide study was found.
Conclusions
Our findings provide independent replication for the association between a common coding variant (rs2234962) in BAG3 and the risk of idiopathic dilated cardiomyopathy.
Aims
The Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) programme consisted of three parallel, randomized, double‐blind clinical trials comparing candesartan ...with placebo in patients with heart failure (HF) categorized according to left ventricular ejection fraction and tolerability to an angiotensin‐converting enzyme inhibitor. We conducted a pharmacogenomic study of the CHARM trials with the objective of identifying genetic predictors of HF progression and of the efficacy and safety of treatment with candesartan.
Methods
We performed genome‐wide association studies in 2727 patients of European ancestry from CHARM‐Overall and stratified by CHARM study according to preserved and reduced ejection fraction and according to assignment to the interventional treatment with candesartan. We tested genetic association with the composite endpoint of cardiovascular death or hospitalization for heart failure for drug efficacy in candesartan‐treated patients and for HF progression using patients from both candesartan and placebo arms. The safety endpoints for response to candesartan were hyperkalaemia, renal dysfunction, hypotension, and change in systolic blood pressure between baseline and 6 weeks of treatment. To support our observations, we conducted a genome‐wide gene‐level collapsing analysis from whole‐exome sequencing data with the composite cardiovascular endpoint.
Results
We found that the A allele (14% allele frequency) of the genetic variant rs66886237 at 8p21.3 near the gene GFRA2 was associated with the composite cardiovascular endpoint in 1029 HF patients with preserved ejection fraction from the CHARM‐Preserved study (hazard ratio: 1.91, 95% confidence interval: 1.55–2.35; P = 1.7 × 10−9). The association was independent of candesartan treatment, and the genetic variant was not associated with the cardiovascular endpoint in patients with reduced ejection fraction. None of the genome‐wide association studies for candesartan safety or efficacy conducted in patients treated with candesartan passed the significance threshold. We found no significant association from the gene‐level collapsing analysis.
Conclusions
We have identified a candidate genetic variant potentially predictive of the progression of heart failure in patients with preserved ejection fraction. The findings require further replication, and we cannot exclude the possibility that the results may be chance findings.
Size of primary health care (PHC) practices is often used as a proxy for various organizational characteristics related to provision of care. The objective of this article is to identify some of ...these organizational characteristics and to determine the extent to which they mediate the relationship between size of PHC practice and patients’ experience of care, preventive services, and unmet needs. In 2010, we conducted population and organization surveys in 2 regions of the province of Quebec. We carried out multilevel linear and logistic regression analyses, adjusting for respondents’ individual characteristics. Size of PHC practice was associated with organizational characteristics and resources, patients’ experience of care, unmet needs, and preventive services. Overall, the larger the size of a practice, the higher the accessibility, but the lower the continuity. However, these associations faded away when organizational variables were introduced in the analysis model. This result supports the hypothesized mediating effect of organizational characteristics on relationships between practice size and patients’ experience of care, preventive services, and unmet needs. Our results indicate that size does not add much information to organizational characteristics. Using size as a proxy for organizational characteristics can even be misleading because its relationships with different outcomes are highly variable.
Physicians’ gender can have an impact on many aspects of patient experience of care. Organization processes through which the influence of gender is exerted have not been fully explored. The aim of ...this article is to compare primary health care (PHC) organizations in which female or male doctors are predominant regarding organization and patient characteristics, and to assess their influence on experience of care, preventive care delivery, use of services, and unmet needs. In 2010, we conducted surveys of a population stratified sample (N = 9180) and of all PHC organizations (N = 606) in 2 regions of the province of Québec, Canada. Patient and organization variables were entered sequentially into multilevel regression analyses to measure the impact of gender predominance. Female-predominant organizations had younger doctors and nurses with more expanded role; they collaborated more with other PHC practices, used more tools for prevention, and allotted more time to patient visits. However, doctors spent fewer hours a week at the practice in female-predominant organizations. Patients of these organizations reported lower accessibility. Conversely, they reported better comprehensiveness, responsiveness, counseling, and screening, but these effects were mainly attributable to doctors’ younger age. Their reporting unmet needs and emergency department attendance tended to decrease when controlling for patient and organization variables other than doctors’ age. Except for accessibility, female-predominant PHC organizations are comparable with their male counterparts. Mean age of doctors was an important confounding variable that mitigated differences, whereas other organization variables enhanced them. These findings deserve consideration to better understand and assess the impacts of the growing number of female-predominant PHC organizations on the health care system.
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
». 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.
We analyzed DNA from polymorphonuclear (PMN) cells, monocytes, B cells, and T cells of 107 individuals with clonal hematopoiesis of indeterminate potential (CHIP) to perform lineage restriction ...analysis of different gene mutations. Three lineage categories were defined: myeloid (PMN with or without monocytes), myelolympho-B (myeloid and B cells), and multipotent (myeloid, B and T cells). Six individuals with aberrant patterns were excluded from analysis. Ninety-four had a single mutation (56 in DNMT3A, 24 in TET2, 7 in other genes JAK2, ASXL1, CBL or TP53). Fourteen had multiple mutations. The lineage restriction patterns of single DNMT3A- or TET2-mutated individuals were different. The proportion of myeloid restricted mutations was higher for TET2 (54.2%, 13 of 24) than for DNMT3A (23.2%, 13 of 56) (P < .05). It was similar for myelolympho-B category but with a 1.5 fold greater proportion of myeloid cells for TET2 individuals (P < .05). Importantly, 0% (0 of 24) of the individuals with TET2 mutation in the multipotent category in contrast to 35.7% (20 of 56) for DNMT3A (P < .01). The clone size predicted multipotent pattern for DNMT3A suggesting a time delay for extensive lineage clonal dominance. These distinctive features may be important in deciphering the transformation mechanisms of these frequent mutations.
•TET2 mutations confer a myeloid proliferation bias.•DNMT3A mutations occur in a multipotent stem cell.
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Epigenetic alteration may play a role in age-associated dysfunction of stem cells and predispose to the development of hematological cancers. We analyzed global levels of hematopoietic ...5-hydroxymethylcytosine (5hmC) and 5-methylcytosine (5mC) in a cross-sectional study comprising 198 unrelated individuals from four age categories (neonates, 25–30, 70–75, and >90 years old) by liquid chromatography-electrospray ionization-tandem mass spectrometry with multiple reaction monitoring. X-chromosome inactivation (XCI) ratios and telomere length (TL) were measured in all individuals by polymerase chain reaction. Sequencing of epigenetic regulator genes (including TET2 , DNMT3A , ASXL1 , IDH1 , IDH2 , and WT1 ) was performed in the two older subcohorts. We found that global 5hmC levels declined with age in human blood cells (27.5% reduction from birth to old age, p < 0.0005). The levels of 5mC underwent a more modest reduction (2.4% drop) between newborns and the elderly ( p < 0.0005). Low 5hmC was associated with increased skewing of XCI (age-adjusted p = 0.0304) and reduced TL (age-adjusted p = 0.0354), both surrogate markers of clonal dominance. Of the 100 individuals over the age of 70, 16 had somatic mutations in TET2 , 14 in DNMT3A , and none in IDH1 , IDH2 , or WT1 . Individuals with TET2 mutations had significantly lower 5hmC (relative to unmutated individuals), whereas DNMT3A -mutated subjects did not. However, mutations in TET2 cannot account solely for the decline in 5hmC levels observed with aging because unmutated older individuals also had lower 5hmC levels compared with younger individuals. This suggests that the age-associated decline in 5hmC is multifactorial. Larger prospective studies are needed to determine whether 5hmC reduction is a biomarker of hematological cancer development.
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
Une plus grande coordination des services aux patients entre des équipes
interdisciplinaires et les médecins de première ligne se traduit par des effets bénéfiques
chez les patients.
Abstract Background Outpatient follow-up has been a key intervention point in addressing gaps in care after hospital discharge. We sought to estimate the association between enrolment in new ...team-based primary care practices and 30-day postdischarge physician follow-up among older patients and patients with chronic illnesses who were admitted to hospital in Quebec, Canada. Methods Patients were selected into this cohort if a primary care physician enrolled them as a "vulnerable patient" between November 2002 and January 2005. Data for this analysis included province-wide health insurance claims for inpatient and outpatient services delivered between November 2002 and January 2009 in Quebec. The primary analysis examined time to the first outpatient postdischarge follow-up service provided by either a primary care physician or a medical specialist. We used marginal structural models to estimate adjusted rates of follow-up with a primary care physician or with a medical specialist by primary care delivery models. Results We extracted billing data for 312 377 patients that represented 620 656 index admissions for any cause from 2002 to 2009. Rates of 30-day follow-up were 374 visits to primary care physicians and 422 visits to medical specialists per 1000 discharges. Rates of primary care physician follow-up were similar across primary care delivery models, except for patients with very high morbidity; these patients had significantly higher rates of follow-up with a primary care physician if they were enrolled in team-based primary care practices (30-d rate difference RD 13.3 more follow-up visits per 1000 discharges, 95% confidence interval CI 6.8 to 19.8). Rates of follow-up with a medical specialist were lower among patients enrolled in team-based practices, particularly within 15 days of hospital discharge (15-d RD 25.1 fewer follow-up visits per 1000 discharges, 95% CI 21.1 to 29.1). Interpretation Our study found lower rates of postdischarge follow-up with a medical specialist among older patients and patients with chronic illness who were enrolled in team-based primary care practices compared with those enrolled in traditional primary care practices. Future research is needed to better understand the role of primary health care service organization in improving acute postdischarge care.
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