Maria Flamm

Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches

BackgroundSelf-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice.MethodsWe conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals’ views on the implementation of self-management support in practice.ResultsSelf-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients’ medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture.ConclusionsAlthough collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes.

Frequency of medication errors in primary care patients with polypharmacy.

BACKGROUND Chronic diseases affect more than half of the population ≥75 years of age in developed countries. Prescription medication use increases with age. Depending on definition, 25-80% of elderly are exposed to polypharmacy. Polypharmacy increases the risk of hospitalization, interactions and adverse drug reactions. OBJECTIVE To examine the frequency of medication errors in patients with polypharmacy treated in general practice. METHODS The medications of 169 patients with polypharmacy treated in 22 GP surgeries in Austria were analysed. The analysis identified (i) medication errors, including non-evidence-based medications, dosing errors and potentially dangerous interactions in all patients and (ii) potentially inappropriate medications (PIMs) in the subgroup of elderly patients (≥65 years). RESULTS The patients took on average 9.1±3.0 medications per day. The maximum, in one patient, was 20 medications per day. Some 93.5% had at least one non-evidence-based medication. On average, 2.7±1.66 medications per patient were found to be not indicated. At least one dosing error was found in 56.2% of all patients. One potential interaction of the most severe degree (category X interaction) was detected in 1.8% (n = 3) and two such interactions in 0.6% (n = 1). These combinations should have been avoided. Of the 169 patients, 158 were elderly (≥65 years). Of these seniors, 37.3% (n = 59) had at least one PIM according to the PRISCUS list for the elderly. CONCLUSION The frequency of medication errors is high in patients with polypharmacy in primary care. Development of strategies (e.g. external medication review) is required to counteract medication errors.

Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis

AIM The aim of the present study was to explore the impact of strategies to reduce polypharmacy on mortality, hospitalization and change in number of drugs. METHODS Systematic review and meta-analysis: a systematic literature search targeting patients ≥65 years with polypharmacy (≥4 drugs), focusing on patient-relevant outcome measures, was conducted. We included controlled studies aiming to reduce polypharmacy. Two reviewers independently assessed studies for eligibility, extracted data and evaluated study quality. RESULTS Twenty-five studies, including 10 980 participants, were included, comprising 21 randomized controlled trials and four nonrandomized controlled trials. The majority of the included studies aimed at improving quality or the appropriateness of prescribing by eliminating inappropriate and non-evidence-based drugs. These strategies to reduce polypharmacy had no effect on all-cause mortality (odds ratio 1.02; 95% confidence interval 0.84, 1.23). Only single studies found improvements, in terms of reducing the number of hospital admissions, in favour of the intervention group. At baseline, patients were taking, on average, 7.4 drugs in both the intervention and the control groups. At follow-up, the weighted mean number of drugs was reduced (-0.2) in the intervention group but increased (+0.2) in controls. CONCLUSIONS There is no convincing evidence that the strategies assessed in the present review are effective in reducing polypharmacy or have an impact on clinically relevant endpoints. Interventions are complex; it is still unclear how best to organize and implement them to achieve a reduction in inappropriate polypharmacy. There is therefore a need to develop more effective strategies to reduce inappropriate polypharmacy and to test them in large, pragmatic randomized controlled trials on effectiveness and feasibility.

Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study

BackgroundPatients do not always receive guideline-adherent therapy, yet little is known about the underlying causes on the patients’ side. We quantified non-guideline-adherent treatment of chronic diseases (diabetes mellitus, hypertension, cardiovascular disease, heart failure, atrial fibrillation) in primary care and analysed the causes from the physician’s as well as the patient’s view.MethodsWith the intention to analyze the frequency and causes of non-guideline-adherent treatment of patients with chronic diseases, we drew a random sample of 124 general practitioners (GP) in Salzburg, Austria, of which 58 (46.8%) participated. In the participating GP surgeries, we consecutively recruited 501 patients with at least one of the target-diseases and checked the guideline conformity of treatment using 9 quality indicators. We then interviewed the patients as well as the general practitioners regarding factors affecting deviation from guideline recommendations.ResultsOf the 501 patients, a total of 1224 quality indicators could be analysed. Non-adherence to guideline recommendations were present in 16.8% (n = 205, 95% CI 14.7 to 18.8%) of all quality indicators. In 61.5% of these cases (n = 126, 95% CI 53.0 to 70.0%) the treatment was wrongly judged as not recommended by the physicians. In 10.2% (n = 21, 95% CI 0 to 23.2%) physicians attributed non-adherence to patient’s non-compliance, and in 10.7% (n = 22, 95% CI 0 to 23.7%) to an adverse drug event, whereas only 5.4% (n = 11, 95% CI 0 to 18.7%) of non-adherence was related to an adverse drug event reported by the patients. Patients were unaware regarding the reason for non-adherent therapy in 64.4% (n = 132, 95% CI 56.2 to 72.6%) of the quality indicators. In 20.0% (n = 41, 95% CI 7.8 to 32.2%) patients regarded a drug as not needed.ConclusionsGuideline adherence in chronic care was relatively good in our study sample, but still leaving room for improvement. Physicians’ lack of knowledge and patients’ lack of awareness account for about 70% of non-adherence, indicating the necessity to improve physician education, and patient involvement. In about 30% of the quality indicators not fulfilled, non-adherence is due to other reasons like adverse drug events or patients not willing to take a recommended drug.

The effectiveness of the Austrian disease management programme for type 2 diabetes: a cluster-randomised controlled trial

BackgroundDisease management programmes (DMPs) are costly and impose additional work load on general practitioners (GPs). Data on their effectiveness are inconclusive. We therefore conducted a cluster-randomised controlled trial to evaluate the effectiveness of the Austrian DMP for diabetes mellitus type 2 on HbA1c and quality of care for adult patients in primary care.MethodsAll GPs of Salzburg-province were invited to participate. After cluster-randomisation by district, all patients with diabetes type 2 were recruited consecutively from 7-11/2007. The DMP, consisting mainly of physician and patient education, standardised documentation and agreement on therapeutic goals, was implemented in the intervention group while the control group received usual care. We aimed to show superiority of the intervention regarding metabolic control and process quality. The primary outcome measure was a change in HbA1c after one year. Secondary outcomes were days in the hospital, blood pressure, lipids, body mass index (BMI), enrolment in patient education and regular guideline-adherent examination. Blinding was not possible.Results92 physicians recruited 1489 patients (649 intervention, 840 control). After 401 ± 47 days, 590 intervention-patients and 754 controls had complete data. In the intention to treat analysis (ITT) of all 1489 patients, HbA1c decreased 0.41% in the intervention group and 0.28% in controls. The difference of -0.13% (95% CI -0.24; -0.02) was significant at p = 0.026. Significance was lost in mixed models adjusted for baseline value and cluster-effects (adjusted mean difference -0.03 (95% CI -0.15; 0.09, p = 0.607). Of the secondary outcome measures, BMI and cholesterol were significantly reduced in the intervention group compared to controls in ITT after adjustments (-0.53 kg/m²; 95% CI -1.03;-0.02; p = 0.014 and -0.10 mmol/l; 95% CI -0.21; -0.003; p = 0.043). Additionally, more patients received patient education (49.5% vs. 20.1%, p < 0.0001), eye- (71.0% vs. 51.2%, p < 0.0001), foot examinations (73.8% vs. 45.1%, p < 0.0001), and regular HbA1c checks (44.1% vs. 36.0%, p < 0.01) in the intervention group.ConclusionThe Austrian DMP implemented by statutory health insurance improves process quality and enhances weight reduction, but does not significantly improve metabolic control for patients with type 2 diabetes mellitus. Whether the small benefit seen in secondary outcome measures leads to better patient outcomes, remains unclear.Trial RegistrationCurrent Controlled trials Ltd., ISRCTN27414162.

Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: a systematic review

Elective surgery is usually preceded by preoperative diagnostics to minimize risk. The results are assumed to elicit preventive measures or even cancellation of surgery. Moreover, physicians perform preoperative tests as a baseline to detect subsequent changes. This systematic review aims to explore whether preoperative testing leads to changes in management or reduces perioperative mortality or morbidity in unselected patients undergoing elective, non-cardiac surgery. We systematically searched all relevant databases from January 2001 to February 2011 for studies investigating the relationship between preoperative diagnostics and perioperative outcome. Our methodology was based on the manual of the Ludwig Boltzmann Institute for Health Technology Assessment, the Scottish Intercollegiate Guidelines Network (SIGN) handbook, and the PRISMA statement for reporting systematic reviews. One hundred and one of the 25 281 publications retrieved met our inclusion criteria. Three test grid studies used a randomized controlled design and 98 studies used an observational design. The test grid studies show that in cataract surgery and ambulatory surgery, there are no significant differences between patients with indicated preoperative testing and no testing regarding perioperative outcome. The observational studies do not provide valid evidence that preoperative testing is beneficial in healthy adults undergoing non-cardiac surgery. There is no evidence derived from high-quality studies that supports routine preoperative testing in healthy adults undergoing non-cardiac surgery. Testing according to pathological findings in a patients medical history or physical examination seems justified, although the evidence is scarce. High-quality studies, especially large randomized controlled trials, are needed to explore the effectiveness of indicated preoperative testing.

Reported barriers to evaluation in chronic care: Experiences in six European countries.

INTRODUCTION The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries. METHODS We conducted 42 semi-structured interviews with key informants from Austria, Denmark, France, Germany, The Netherlands and Spain involved in decision-making and implementation of chronic disease management approaches. Interviews were complemented by a survey on approaches to chronic disease management in each country. Finally two project teams (France and the Netherlands) conducted in-depth case studies on various aspects of chronic care evaluation. RESULTS We identified three common challenges to evaluation of chronic disease management approaches: (1) a lack of evaluation culture and related shortage of capacity; (2) reluctance of payers or providers to engage in evaluation and (3) practical challenges around data and the heterogeity of IT infrastructure. The ability to evaluate chronic disease management interventions is influenced by contextual and cultural factors. CONCLUSIONS This study contributes to our understanding of some of the most common underlying barriers to chronic care evaluation by highlighting the views and experiences of stakeholders and experts in six European countries. Overcoming the cultural, political and structural barriers to evaluation should be driven by payers and providers, for example by building in incentives such as feedback on performance, aligning financial incentives with programme objectives, collectively participating in designing an appropriate framework for evaluation, and making data use and accessibility consistent with data protection policies.

Non-adherence to guidelines for preoperative testing in a secondary care hospital in Austria: the economic impact of unnecessary and double testing.

Context Preoperative evaluation is aimed at prevention of complications and risk stratification. Routine testing should be abandoned in favour of selective ordering according to contemporary guidelines. This study was conducted to calculate the possible economic impact of a Web-based preoperative diagnostic guideline prior to its implementation in the state of Salzburg, Austria. Design Prospective observational cohort study. Setting The study was carried out in a secondary care hospital in Salzburg (Schwarzach). Participants and main outcome measures Data from 1363 consecutive patients scheduled for elective surgery from 1 September to 30 November 2007 were collected: demographic data, medical history, surgical procedure, preoperative tests and findings. The data were entered into the preoperative diagnostic guideline software and the guideline-adherent recommendations were compared with the investigations performed, with special attention to duplicate examinations. Results A total of 5879 tests were documented and analysed. In 65.6% of patients, guideline-adherent evaluation would have indicated only basic requirements, but 3380 additional tests were carried out. In all, 81.7% of tests were identified as nonadherent based on the preoperative diagnostic guideline software and 226 duplicate tests were performed. Possible savings per 1000 patients would be &OV0556;26 287 if preoperative diagnostic guideline recommendations were followed exactly and &OV0556;1076 if duplicated tests were avoided. According to a generalised linear model (Gamma model), an increase of 1 year of age leads to an increase of costs by a factor of 1.020. Conclusion These data indicate a considerable potential for improvement in process quality and cost reduction by using structured preoperative assessment with computer-assisted implementation of a guideline.

The impact of preoperative testing for blood glucose concentration and haemoglobin A1c on mortality, changes in management and complications in noncardiac elective surgery: a systematic review.

BACKGROUND The risks associated with surgery are elevated in patients with diabetes mellitus. For this reason, preoperative diagnostics frequently include the measurement of blood glucose and haemoglobin A1c (HbA1c), but it is unclear whether these tests contribute to improved perioperative or postoperative outcomes. OBJECTIVES This systematic review aimed to evaluate the evidence that preoperative testing for blood glucose and HbA1c might influence the following outcome parameters: changes in clinical management; mortality; and the incidence of perioperative and postoperative complications in patients undergoing elective, noncardiac surgery. DESIGN We performed a systematic search of the literature from January 2001 to March 2013, thus updating a review carried out by the National Institute for Health and Clinical Excellence (NICE) up to the year 2001. ELIGIBILITY CRITERIA Controlled studies including cohort and case–control studies with a population of at least 60 patients were eligible. RESULTS The search retrieved 1346 records (including hand-search). Twenty-two studies met all inclusion criteria and were included in the review. Fifteen cohort and two case–control studies evaluated the effectiveness of preoperative blood glucose testing and nine studies the effectiveness of testing HbA1c. Four of the included studies evaluated both tests. There were no data derived from high-quality studies supporting routine preoperative testing for blood glucose or HbA1c in otherwise healthy adult patients undergoing elective noncardiac surgery. Only in vascular and orthopaedic surgery may screening identify patients at an increased risk. CONCLUSION Preoperative blood glucose testing and testing for HbA1c is not required in nondiabetic patients unless there are clinical sings arousing suspicion. Patients scheduled for vascular and orthopaedic surgery carry an elevated risk justifying preoperative testing for blood glucose or HbA1c as a screening tool.

Evaluating chronic disease management in real-world settings in six European countries: Lessons from the collaborative DISMEVAL project

Objective To describe the interventions, research methods and main findings of the international DISMEVAL project, in which the “real-world” impact of exemplary European disease management approaches was investigated in six countries using advanced analytic techniques. Design Across countries, the project captured a wide range of disease management strategies and settings; approaches to evaluation varied per country, but included, among others, difference-in-differences analysis and regression discontinuity analysis. Setting Austria, Denmark, France, Germany, The Netherlands, and Spain. Participants Health care providers and/or statutory insurance funds providing routine data from their disease management interventions, mostly retrospectively. Intervention(s) This study did not carry out an intervention but evaluated the impact of existing disease management interventions implemented in European care settings. Main outcome measure(s) Outcome measures were largely dependent on available routine data, but could concern health care structures, processes, and outcomes. Results Data covering 10 to 36 months were gathered concerning more than 154,000 patients with three conditions. The analyses demonstrated considerable positive effects of disease management on process quality (Austria, Germany), but no more than moderate improvements in intermediate health outcomes (Austria, France, Netherlands, Spain) or disease progression (Denmark) in intervention patients, where possible compared with a matched control group. Conclusions Assessing the “real-world” impact of chronic disease management remains a challenge. In settings where randomization is not possible and/or desirable, routine health care performance data can provide a valuable resource for practice-based evaluations using advanced analytic techniques.