Isabelle Vedel

Systematic mixed studies reviews: updating results on the reliability and efficiency of the Mixed Methods Appraisal Tool.

This commentary is an update of results regarding an novative critical appraisal tool, called the ‘Mixed ethods Appraisal Tool’ (MMAT), which were published two papers in the International Journal of Nursing udies. In August 2014, the first paper was mentioned as e of the ‘most cited articles’ on the journal’s website luye et al., 2009). The second paper reported a pilot test the MMAT reliability and efficiency (Pace et al., 2012). e MMAT checklist includes two screening questions and items corresponding to five methodological domains: alitative research, randomized controlled trials (RCTs), n-randomized studies (NRS), quantitative descriptive dies, and mixed methods studies (MMS). The MMAT is sed on a constructionist theory and has been content lidated: for each domain, items were developed from the erature as well as consultations and workshops with perts (Pace et al., 2012; Pluye et al., 2009, 2011). The MMAT is a unique tool (http://mixedmethodsappraisaltoolpublic.pbworks.com) that allows reviewers to concomitantly assess the methodological quality of studies with diverse designs (qualitative, quantitative and MMS) included in systematic mixed studies reviews (Crowe and Sheppard, 2011). Critical appraisal constitutes a key stage of systematic reviews, but appraising the methodological quality of studies with diverse designs remains challenging. The MMAT was designed to help overcome this challenge. The MMAT is recommended by the National Institute of Excellence in Health Services in Québec (INESS). To date, authors of more than 50 published systematic mixed studies reviews have used the MMAT, and MMAT developers have provided counsel on using the MMAT to 29 researchers, from multiple disciplines, in Australia, Belgium, Canada, China, Denmark, Germany, Netherlands, New Zealand, Switzerland, UK, and USA. Mixed studies review is a new, and increasingly popular, form of literature review that includes studies with diverse designs (qualitative, quantitative and mixed methods) and addresses complex review questions (Pluye and Hong, 2014). Mixed studies reviews consist of mixed methods research applied to the field of literature reviews, and combine the strengths of quantitative and qualitative research (http://toolkit4mixedstudiesreviews.pbworks. com). This commentary is aimed to update results on the reliability and efficiency of the MMAT, specifically the new 2011 version (MMAT-v2011) (Pluye et al., 2011). There is a growing need for a tool like the MMAT, and as per our two previous papers, a need for additional supporting evidence for the MMAT. In previous work, we tested the pilot version of the MMAT (Pace et al., 2012) and results indicated that R T I C L E I N F O

A novel model of integrated care for the elderly: COPA, Coordination of Professional Care for the Elderly

Despite strong evidence for the efficacy of integrated systems, securing the participation of health professionals, particularly primary care physicians (PCPs), has proven difficult. Novel approaches are needed to resolve these problems. We developed a model — COPA — that is based on scientific evidence and an original design process in which health professionals, including PCPs, and managers participated actively. COPA targets very frail community-dwelling elders recruited through their PCP. It was designed to provide a better fit between the services provided and the needs of the elderly in order to reduce excess healthcare use, including unnecessary emergency room (ER) visits and hospitalizations, and prevent inappropriate long-term nursing home placements. The model’s originality lies in: 1) having reinforced the role played by the PCP, which includes patient recruitment and care plan development; 2) having integrated health professionals into a multidisciplinary primary care team that includes case managers who collaborate closely with the PCP to perform a geriatric assessment (InterRAI MDS-HC) and implement care management programs; and 3) having integrated primary medical care and specialized care by introducing geriatricians into the community to see patients in their homes and organize direct hospitalizations while maintaining the PCP responsibility for medical decisions. Since COPA is currently the subject of both a quasi-experimental study and a qualitative study, we are also providing preliminary findings. These findings suggest that the model is feasible and well accepted by PCPs and patients. Moreover, our results indicate that the level of service utilization in COPA was less than what is reported at the national level, without any compromises in quality of care.

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis.

PURPOSE We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration. RESULTS We identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87–0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51–0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious. CONCLUSIONS Clinicians and managers who implement TCIs in primary care can incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option.

Case management for dementia in primary health care: a systematic mixed studies review based on the diffusion of innovation model

Background The purpose of this study was to examine factors associated with the implementation of case management (CM) interventions in primary health care (PHC) and to develop strategies to enhance its adoption by PHC practices. Methods This study was designed as a systematic mixed studies review (including quantitative and qualitative studies) with synthesis based on the diffusion of innovation model. A literature search was performed using MEDLINE, PsycInfo, EMBASE, and the Cochrane Database (1995 to August 2012) to identify quantitative (randomized controlled and nonrandomized) and qualitative studies describing the conditions limiting and facilitating successful CM implementation in PHC. The methodological quality of each included study was assessed using the validated Mixed Methods Appraisal Tool. Results Twenty-three studies (eleven quantitative and 12 qualitative) were included. The characteristics of CM that negatively influence implementation are low CM intensity (eg, infrequent follow-up), large caseload (more than 60 patients per full-time case manager), and approach, ie, reactive rather than proactive. Case managers need specific skills to perform their role (eg, good communication skills) and their responsibilities in PHC need to be clearly delineated. Conclusion Our systematic review supports a better understanding of factors that can explain inconsistent evidence with regard to the outcomes of dementia CM in PHC. Lastly, strategies are proposed to enhance implementation of dementia CM in PHC.

Barriers to Implementation of Case Management for Patients With Dementia: A Systematic Mixed Studies Review

PURPOSE Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation. METHODS We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool. RESULTS Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers. CONCLUSIONS Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services.

Patients’, family caregivers’, and professionals’ perspectives on quality of palliative care: A qualitative study

Background: The quality of palliative care is the foremost preoccupation of clinicians, decision-makers, and managers as well as patients and families. Major input from healthcare professionals is required to develop indicators for the quality of palliative care, but the involvement of patients and families is also recognized as essential, even though this is rarely achieved in practice. Aim: The objectives of this study were to identify (1) convergences and divergences in the points of view of different stakeholders (patients, families, healthcare professionals) relative to key elements of the quality of palliative care and (2) avenues for refining existing indicators of quality of palliative care. Design: Cross-sectional qualitative study. Setting/participants: There were six settings: two hospital-based palliative care units, one hospice, and three other medical units where a mobile palliative care team intervene. Semi-structured interviews were conducted among 61 patients, families, healthcare professionals, and managers. Results: Four major dimensions of quality of care are deemed critical by patients, their families, and professionals: comprehensive support for the patients themselves, clinical management, involvement of families, and care for the imminently dying person and death. Differences exist between various stakeholders regarding perceptions of some dimensions of quality of care. Avenues for improving current quality of care indicators are identified. Conclusion: Our study results can be used to refine or develop quality indicators that truly mirror the points of view of patients and their families and of healthcare professionals.

Impact on hospital admissions of an integrated primary care model for very frail elderly patients

Very frail elderly patients living in the community, present complex needs and have a higher rate of hospital admissions with emergency department (ED) visits. Here, we evaluated the impact on hospital admissions of the COPA model (CO-ordination Personnes Agées), which provides integrated primary care with intensive case management for community-dwelling, very frail elderly patients. We used a quasi-experimental study in an urban district of Paris with four hundred twenty-eight very frail patients (105 in the intervention group and 323 in the control group) with one-year follow-up. The primary outcome measures were the presence of any unplanned hospitalization (via the ED), any planned hospitalizations (direct admission, no ED visit) and any hospitalization overall. Secondary outcome measures included health parameters assessed with the RAI-HC (Resident Assessment Instrument-Home Care). Comparing the intervention group with the control group, the risk of having at least one unplanned hospital admission decreased at one year and the planned hospital admissions rate increased, without a significant change in total hospital admissions. Among patients in the intervention group, there was less risk of depression and dyspnea. The COPA model improves the quality of care provided to very frail elderly patients by reducing unplanned hospitalizations and improving some health parameters.

Fostering participation of general practitioners in integrated health services networks: incentives, barriers, and guidelines

BackgroundWhile the active participation of general practitioners (GPs) in integrated health services networks (IHSNs) plays a critical role in their success, little is known about the incentives and barriers to their actual participation.MethodsData were gathered through semi-structured interviews and a mail survey with GPs enrolled in SIPA (system of integrated care for older persons) at 2 sites in Montreal. A total of 61 GPs completed the questionnaire, from which 22 were randomly selected for the qualitative study, with active and non-active participation in the IHSN.ResultsThe key themes associated with GP participation were clinician characteristics, consequences perceived at the outset, the SIPA implementation process, relationships with the SIPA team and professional consequences. The incentive factors reported were collaborative practices, high rates of elderly and SIPA patients in their clienteles, concerns about SIPA, the selection of frail elderly patients, close relationships with the case manager, the perceived efficacy of SIPA, and improved professional practices. Barriers to GP participation included high expectations, GP recruitment, lack of information on SIPA, difficult relationships with SIPA geriatricians and deterioration of physician-patient relationships. Four profiles of participation were identified: 2 groups of participants active in SIPA and 2 groups of participants not active in SIPA. The active GPs were familiar with collaborative practices, had higher IHSN patient rates, expressed more concerns than expectations, reported satisfactory relationships with case managers and perceived the efficacy of SIPA. Both active and non-active GPs reported quality care in the IHSN and improved professional practice.ConclusionThroughout the implementation process, the participation of GPs in an IHSN depends on numerous professional (clinician characteristics) and organizational factors (GP recruitment, relationships with case managers). Our study provides guiding principles for establishing future integrated models of care. It suggests practical guidelines to support the active participation of GPs in these networks such as physicians with collaborative practices, recruitment of significant number of patients per physicians, the information provided and the accompaniment by geriatricians.

Family Physician–Case Manager Collaboration and Needs of Patients With Dementia and Their Caregivers: A Systematic Mixed Studies Review

PURPOSE Dementia case management (CM) in primary care is a complex intervention aimed at identifying the various needs of patients with dementia and their caregivers, as well as the organization and coordination of care. A key element of CM is the collaboration of family physicians with case managers. We conducted a systematic mixed-studies review to identify the needs of the patient-caregiver dyad and the effects of CM. METHODS We searched MEDLINE, PsycINFO, and EMBASE up to October 2014, regardless of the study design. Our main outcomes were needs of patients and their caregivers and the effects of CM on these needs. We used narrative syntheses to develop a taxonomy of needs and to describe the effects of CM on those needs. We used meta-analysis to calculate the prevalence of needs and the standardized mean differences to evaluate the effects of CM on the needs identified. RESULTS Fifty-four studies were included. We identified needs of the patient-caregiver dyad and needs of the patient and caregiver individually. CM addressed the majority of the identified needs. Still, some very common needs (eg, early diagnosis) are overlooked while other needs (eg, education on the disease) are well addressed. Fully establishing the value of CM is difficult given the small number of studies of CM in primary care. CONCLUSIONS There is good evidence that case managers, in collaboration with family physicians, have a pivotal role in addressing the needs of the patient-caregiver dyad.

Collaborating through Social Media to Create Health Awareness

This paper examines the role that individuals and organizations can play in creating awareness through the use of social media. In the healthcare context, creating cancer awareness is key in early detection of cancer as well as cancer prevention altogether. Using a multiple case study analysis, we are able to understand how collaboration through social media is used to promote such awareness. We find that social media is used to create an online community that drives the creation of cancer awareness in many different ways. This research has implications for organizations looking to use social media to promote awareness as it explains the building process and role of social media grassroots communities.