Introduction: Continuity of care – relational, informational and management – is a defining characteristic of integrated care. With input from all stakeholders, we developed and implemented a ...data-supported, system-wide change management strategy in support of continuity. Policy context and objective: The province of Alberta, Canada has a single publically funded healthcare system. While the health system is largely structurally integrated, primary care is provided in a joint partnership between the health system and networks of primary care physicians and their teams. Specialists are independent and paid on a fee-for-service basis. People are free to choose and move between primary care providers. The purpose of this initiative was to facilitate continuity of care, in all its forms, across the broad health care system. Approach and Stakeholders: This initiative was started by collection and analysis of provincial data. This demonstrated the critical role of relational continuity in improving patient and population health. Analysis demonstrated that relational continuity of 75% or more reduced mortality, after adjustment, by approximately 50%. In addition, there was an incremental benefit of continuity with increasing patient complexity. These findings, plus literature data, were used, in accordance with change management principles, to create a compelling case for change. Importantly, patient input was also used to support change. Data was shared with our formal patient advisory councils representing both geography and specific patient groups such as seniors. Results of these meetings revealed 88% “strong support” for continuity. Patient experience and public focus group input was also used to create the next stage of the change management strategy. Highlights: After all input, including that from providers and community organizations was collected, leaders in the health system met and agreed on a collective strategy. The health system agreed to establish informational and management continuity (transitions) as a priority. In addition, the system encouraged and made changes to facilitate relational continuity. Between the health system and government, a multi-billion dollar investment was made into a province-wide clinical information system to support informational continuity. All organizations collaborated on public messaging and support for relational continuity. This province-wide process is well underway with all parties agreeing to set a target of 80% relational continuity within 1 year. In addition, the medical association is publishing what we believe to be the first formal clinical practice guideline on continuity in the world. Initial efforts are already demonstrating an impact on hospital admissions, length of stays, ER visit rates, and reductions in in-hospital waits for long-term care (to date 25% reduction). Transferability: Because this initiative was done collaboratively, rather than by compulsion, and with a formal, strategic change management strategy, this initiative, or components thereof, could be applied in various health care systems. Conclusions: The collaborative efforts of many players, with strong public input, has had an impact on integration and health system outcomes. Equally important, the process and its successes have created a positive culture across the healthcare landscape. Patient and public input was a critical factor in the change management strategy.
People with chronic diseases experience barriers to managing their diseases and accessing available health services. Patient navigator programs are increasingly being used to help people with chronic ...diseases navigate and access health services.
The objective of this review was to summarize the evidence for patient navigator programs in people with a broad range of chronic diseases, compared to usual care.
We searched MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO, and Social Work Abstracts from inception to August 23, 2017. We also searched the reference lists of included articles. We included original reports of randomized controlled trials of patient navigator programs compared to usual care for adult and pediatric patients with any one of a defined set of chronic diseases.
From a total of 14,672 abstracts, 67 unique studies fit our inclusion criteria. Of these, 44 were in cancer, 8 in diabetes, 7 in HIV/AIDS, 4 in cardiovascular disease, 2 in chronic kidney disease, 1 in dementia and 1 in patients with more than one condition. Program characteristics varied considerably. Primary outcomes were most commonly process measures, and 45 of 67 studies reported a statistically significant improvement in the primary outcome.
Our findings indicate that patient navigator programs improve processes of care, although few studies assessed patient experience, clinical outcomes or costs. The inability to definitively outline successful components remains a key uncertainty in the use of patient navigator programs across chronic diseases. Given the increasing popularity of patient navigators, future studies should use a consistent definition for patient navigation and determine which elements of this intervention are most likely to lead to improved outcomes.
PROSPERO #CRD42013005857.
OBJECTIVE: To evaluate the effect of adding pharmacists to primary care teams on the management of hypertension and other cardiovascular risk factors in patients with type 2 diabetes. RESEARCH DESIGN ...AND METHODS: We conducted a randomized controlled trial with blinded ascertainment of outcomes within primary care clinics in Edmonton, Canada. Pharmacists performed medication assessments and limited history and physical examinations and provided guideline-concordant recommendations to optimize medication management. Follow-up contact was completed as necessary. Control patients received usual care. The primary outcome was a ≥10% decrease in systolic blood pressure at 1 year. RESULTS: A total of 260 patients were enrolled, 57% were women, the mean age was 59 years, diabetes duration was 6 years, and blood pressure was 129/74 mmHg. Forty-eight of 131 (37%) intervention patients and 30 of 129 (23%) control patients achieved the primary outcome (odds ratio 1.9 95% CI 1.1-3.3; P = 0.02). Among 153 patients with inadequately controlled hypertension at baseline, intervention patients (n = 82) were significantly more likely than control patients (n = 71) to achieve the primary outcome (41 50% vs. 20 28%; 2.6 1.3-5.0; P = 0.007) and recommended blood pressure targets (44 54% vs. 21 30%; 2.8 1.4-5.4; P = 0.003). The 10-year risk of cardiovascular disease, based on changes to the UK Prospective Diabetes Study Risk Engine, were predicted to decrease by 3% for intervention patients and 1% for control patients (P = 0.005). CONCLUSIONS: Significantly more patients with type 2 diabetes achieved better blood pressure control when pharmacists were added to primary care teams, which suggests that pharmacists can make important contributions to the primary care of these patients.
Introduction: The volunteer (third) sector provides double the care in the community than does the healthcare system. However, within the geographic jurisdictions that a health system operates, ...there may be thousands of third sector organizations. In order to best meet individual and population medical and social needs, care provided by the third sector needs to be integrated with health system care. This can be challenging given the complexity of a health care system and the number of third sector organizations. The process by which the province of Alberta, Canada approached this integration challenge is described below.
Target audience: This topic is pertinent to those working at a systems level in healthcare, government and the third sector.
Who was engaged: In developing this approach government, health system planners, and a variety of third sector representatives, typically “umbrella” organizations representing a number of individual groups, were involved.
What was done: With a single healthcare system divided into five administrative zones, we used the approach of doing centrally, zonally and locally that which made sense to do at those levels. Third sector actors functioning at those levels were engaged with their health system counterparts. Joint committees, accountable only to the members, were typically established to set a common vision and to coordinate activities in support of that joint vision. Wherever possible, an asset-based community development approach was used to identify what services existed at the various levels, service deficits, the wants and needs of individuals and communities, and the way in which the community could be supported to address those needs and wishes. From an infrastructure perspective, the health system, government and third sector leadership established mechanisms to facilitate cooperation.
Results: Creating formal linkages between the health system and third sector, at all levels, was extremely helpful for the healthcare system to understand community needs and factors impacting health. The third sector found the relationship helpful to focus their efforts on programs or interventions which most effectively impacted health and wellness. Individuals and communities benefitted from an integrated approach to health and wellness.
Learnings: Giving up control, on the part of the health system, was initially uncomfortable. However, the effectiveness of joint committees accountable to the members, rather than to a hierarchy, was found to be an extremely effective way of working together. At a more local level, allowing communities to determine priorities and approaches similarly resulted in much more effective and productive relationships in meeting the needs of the community, the healthcare system and its providers. Components of the quadruple/quintuple aim were much more effectively addressed than by using a medical model of community engagement.
Next steps: From a health system perspective, we plan to use this approach at a community level. However, we find that our workforce will need to be adapted to include those who have skills in developing and maintaining relationships, are comfortable working in complex systems and with uncertainty, and an ability to adapt in keeping with a learning health system.
ABSTRACT BACKGROUND Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus ...conventional primary care. METHODS We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months. RESULTS Adults receiving care within a primary care network ( n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care ( n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio RR 0.98, 95% confidence interval CI 0.96–0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93–0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03–1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07–1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years. INTERPRETATION Care within a primary care network was associated with fewer emergency department visits and fewer hospital days.
Objective To determine whether time spent outdoors was associated with increased moderate-to-vigorous physical activity (MVPA) and related health benefits in youth. Study design We performed a ...cross-sectional study of 306 youth aged 13.6 ± 1.4 years. The exposure of interest was self-reported time spent outdoors after school, stratified into three categories: none, some, and most/all of the time. The main outcome of interest was accelerometer-derived MVPA (Actical: 1500 to >6500 counts/min). Secondary outcomes included sedentary behavior, cardiorespiratory fitness, overweight status, and blood pressure. Results Among the 306 youth studied, those who reported spending most/all of their after-school time outdoors (n = 120) participated in more MVPA (61.0 ± 24.3 vs 39.9 ± 19.1 min/day; adjusted P < .001), were more likely to achieve the recommended minimum 60 min/day of MVPA (aOR 2.8; 95% CI, 1.3-6.4), spent less time in sedentary activities (539 ± 97 min/day vs 610 ± 146 min/day; adjusted P < .001), and had higher cardiorespiratory fitness (49 ± 5 vs 45 ± 6 mL/kg/min; adjusted P < .001) than youth who reported no time outdoors (n = 52). No differences in overweight/obesity or blood pressure were observed across the groups. Conclusions Time spent outdoors is positively associated with MVPA and cardiorespiratory fitness in youth and negatively associated with sedentary behavior. Experimental trials are needed to determine whether strategies designed to increase time spent outdoors exert a positive influence on physical activity and fitness levels in youth.
OBJECTIVE: To determine the effect of metformin on the acute metabolic response to submaximal exercise, the effect of exercise on plasma metformin concentrations, and the interaction between ...metformin and exercise on the subsequent response to a standardized meal. RESEARCH DESIGN AND METHODS: Ten participants with type 2 diabetes were recruited for this randomized crossover study. Metformin or placebo was given for 28 days, followed by the alternate condition for 28 days. On the last 2 days of each condition, participants were assessed during a nonexercise and a subsequent exercise day. Exercise took place in the morning and involved a total of 35 min performed at three different submaximal intensities. RESULTS: Metformin increased heart rate and plasma lactate during exercise (both P less-than or equal to 0.01) but lowered respiratory exchange ratio (P = 0.03) without affecting total energy expenditure, which suggests increased fat oxidation. Metformin plasma concentrations were greater at several, but not all, time points on the exercise day compared with the nonexercise day. The glycemic response to a standardized meal was reduced by metformin, but the reduction was attenuated when exercise was added (metformin x exercise interaction, P = 0.05). Glucagon levels were highest in the combined exercise and metformin condition. CONCLUSIONS: This study reveals several ways by which metformin and exercise therapies can affect each other. By increasing heart rate, metformin could lead to the prescription of lower exercise workloads. Furthermore, under the tested conditions, exercise interfered with the glucose-lowering effect of metformin.
The primary objective of this longitudinal study was to determine the association between cardiorespiratory fitness and the risk of overweight status in youth. To accomplish this aim we analyzed data ...from annual school‐based surveys of cardiorespiratory fitness and anthropometry conducted between 2004 and 2006. The first analysis was performed on a cohort of 902 youth aged 6–15 years followed for 12 months to assess the association between cardiorespiratory fitness levels determined from a graded maximal field test and the risk of becoming overweight. The second analysis was conducted on a cohort of 222 youth followed for 2 years to assess the continuous association between annual changes fitness and weight gain. Children with low cardiorespiratory fitness were characterized by higher waist circumference and disproportionate weight gain over the 12‐month follow‐up period (P < 0.05). Within the entire cohort, the 12‐month risk of overweight classification was 3.5‐fold (95% confidence = 2.0–6.0, P < 0.001) higher in youth with low cardiorespiratory fitness, relative to fit peers. A time series mixed effects regression model revealed that reductions in cardiorespiratory fitness were significantly and independently associated with increasing BMI (r = −0.18, P < 0.05) in youth. Accordingly, low cardiorespiratory fitness and reductions in fitness over time are significantly associated with weight gain and the risk of overweight in children 6–15 years old. An assessment of cardiorespiratory fitness using a common field test may prove useful for the identification of youth at risk of overweight and serve as a potential target for obesity prevention.
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