Sandra Rees

Interventions to Improve Influenza and Pneumococcal Vaccination Rates Among Community-Dwelling Adults: A Systematic Review and Meta-Analysis

PURPOSE Influenza and pneumococcal vaccination rates remain below national targets. We systematically reviewed the effectiveness of quality improvement interventions for increasing the rates of influenza and pneumococcal vaccinations among community-dwelling adults. METHODS We included randomized and nonrandomized studies with a concurrent control group. We estimated pooled odds ratios using random effects models, and used the Downs and Black tool to assess the quality of included studies. RESULTS Most studies involved elderly primary care patients. Interventions were associated with improvements in the rates of any vaccination (111 comparisons in 77 studies, pooled odds ratio [OR] = 1.61, 95% CI, 1.49-1.75), and influenza (93 comparisons, 65 studies, OR = 1.46, 95% CI, 1.35-1.57) and pneumococcal (58 comparisons, 35 studies, OR = 2.01, 95% CI, 1.72-2.3) vaccinations. Interventions that appeared effective were patient financial incentives (influenza only), audit and feedback (influenza only), clinician reminders, clinician financial incentives (influenza only), team change, patient outreach, delivery site changes (influenza only), clinician education (pneumococcus only), and case management (pneumococcus only). Patient outreach was more effective if personal contact was involved. Team changes were more effective where nurses administered influenza vaccinations independently. Heterogeneity in some pooled odds ratios was high, however, and funnel plots showed signs of potential publication bias. Study quality varied but was not associated with outcomes. CONCLUSIONS Quality improvement interventions, especially those that assign vaccination responsibilities to nonphysician personnel or that activate patients through personal contact, can modestly improve vaccination rates in community-dwelling adults. To meet national policy targets, more-potent interventions should be developed and evaluated.

Controlled trial of a collaborative primary care team model for patients with diabetes and depression: Rationale and design for a comprehensive evaluation

BackgroundWhen depression accompanies diabetes, it complicates treatment, portends worse outcomes and increases health care costs. A collaborative care case-management model, previously tested in an urban managed care organization in the US, achieved significant reduction of depressive symptoms, improved diabetes disease control and patient-reported outcomes, and saved money. While impressive, these findings need to be replicated and extended to other healthcare settings. Our objective is to comprehensively evaluate a collaborative care model for comorbid depression and type 2 diabetes within a Canadian primary care setting.Methods/designWe initiated the TeamCare model in four Primary Care Networks in Northern Alberta. The intervention involves a nurse care manager guiding patient-centered care with family physicians and consultant physician specialists to monitor progress and develop tailored care plans. Patients eligible for the intervention will be identified using the Patient Health Questionnaire-9 as a screen for depressive symptoms. Care managers will then guide patients through three phases: 1) improving depressive symptoms, 2) improving blood glucose, blood pressure and cholesterol, and 3) improving lifestyle behaviors. We will employ the RE-AIM framework for a comprehensive and mixed-methods approach to our evaluation. Effectiveness will be assessed using a controlled “on-off” trial design, whereby eligible patients would be alternately enrolled in the TeamCare intervention or usual care on a monthly basis. All patients will be assessed at baseline, 6 and 12 months. Our primary analyses will be based on changes in two outcomes: depressive symptoms, and a multivariable, scaled marginal model for the combined outcome of global disease control (i.e., A1c, systolic blood pressure, LDL cholesterol). Our planned enrolment of 168 patients will provide greater than 80% power to observe clinically important improvements in all measured outcomes. Direct costing of all intervention components and measurement of all health care utilization using linked administrative databases will be used to determine the cost-effectiveness of the intervention relative to usual care.DiscussionOur comprehensive evaluation will generate evidence to reliability, effectiveness and sustainability of this collaborative care model for patients with chronic diseases and depression.Trials registrationClintrials.gov Identifier: NCT01328639

Collaborative Care Versus Screening and Follow-up for Patients With Diabetes and Depressive Symptoms: Results of a Primary-Care Based Comparative Effectiveness Trial

OBJECTIVE Depressive symptoms are common and, when coexisting with diabetes, worsen outcomes and increase health care costs. We evaluated a nurse case-manager–based collaborative primary care team model to improve depressive symptoms in diabetic patients. RESEARCH DESIGN AND METHODS We conducted a controlled implementation trial in four nonmetropolitan primary care networks. Eligible patients had type 2 diabetes and screened positive for depressive symptoms, based on a Patient Health Questionnaire (PHQ) score of ≥10. Patients were allocated using an “on-off” monthly time series. Intervention consisted of case-managers working 1:1 with patients to deliver individualized care. The main outcome was improvement in PHQ scores at 12 months. A concurrent cohort of 71 comparable patients was used as nonscreened usual care control subjects. RESULTS Of 1,924 patients screened, 476 (25%) had a PHQ score >10. Of these, 95 were allocated to intervention and 62 to active control. There were no baseline differences between groups: mean age was 57.8 years, 55% were women, and the mean PHQ score was 14.5 (SD 3.7). Intervention patients had greater 12-month improvements in PHQ (7.3 [SD 5.6]) compared with active-control subjects (5.2 [SD 5.7], P = 0.015). Recovery of depressive symptoms (i.e., PHQ reduced by 50%) was greater among intervention patients (61% vs. 44%, P = 0.03). Compared with trial patients, nonscreened control subjects had significantly less improvement at 12 months in the PHQ score (3.2 [SD 4.9]) and lower rates of recovery (24%, P < 0.05 for both). CONCLUSIONS In patients with type 2 diabetes who screened positive for depressive symptoms, collaborative care improved depressive symptoms, but physician notification and follow-up was also a clinically effective initial strategy compared with usual care.

Applying the RE-AIM framework to the Alberta's Caring for Diabetes Project: a protocol for a comprehensive evaluation of primary care quality improvement interventions

Introduction Diabetes represents a major public health and health system burden. As part of the Albertas Caring for Diabetes (ABCD) Project, two quality-improvement interventions are being piloted in four Primary Care Networks in Alberta. Gaps between health research, policy and practice have been documented and the need to evaluate the impact of public health interventions in real-world settings to inform decision-making and clinical practice is paramount. In this article, we describe the application of the RE-AIM framework to evaluate the interventions beyond effectiveness. Methods and analysis Two quality-improvement interventions were implemented, based on previously proven effective models of care and are directed at improving the physical and mental health of patients with type-2 diabetes. Our goal is to adapt and apply the RE-AIM framework, using a mixed-methods approach, to understand the impact of the interventions to inform policy and clinical decision-making. We present the proposed measures, data sources and data management and analysis strategies used to evaluate the interventions by RE-AIM dimension. Ethics and dissemination Ethics approval for the ABCD Project has been granted from the Health Research Ethics Board (HREB #PRO00012663) at the University of Alberta. The RE-AIM framework will be used to structure our dissemination activities by dimension. Results It will be presented at relevant conferences and prepared for publication in peer-reviewed journals. Various products, such as presentations, briefing reports and webinars, will be developed to inform key stakeholders of the findings. Presentation of findings by RE-AIM dimension will facilitate discussion regarding the public health impact of the two interventions within the primary care context of Alberta and lessons learned to be used in programme planning and care delivery for patients with type-2 diabetes. It will also promote the application of evaluation models to better assess the impact of community-based primary healthcare interventions through our dissemination activities.

The Alberta's Caring for Diabetes (ABCD) Study: Rationale, Design and Baseline Characteristics of a Prospective Cohort of Adults with Type 2 Diabetes

OBJECTIVE To better understand the factors that affect care and outcomes in patients with type 2 diabetes, we developed the prospective Albertas Caring for Diabetes (ABCD) cohort to collect, monitor and analyze data concerning several sociodemographic, behavioural, psychosocial, clinical and physiological factors that might influence diabetes care and outcomes. METHODS We recruited 2040 individuals with type 2 diabetes through primary care networks, diabetes clinics and public advertisements. Data are being collected through self-administered surveys, including standardized measures of health status and self-care behaviours, and will eventually be linked to laboratory and administrative healthcare data and other novel databases. RESULTS The average age of respondents was 64.4 years (SD=10.7); 45% were female, and 91% were white, with average duration of diabetes of 12 years (SD=10.0). The majority (76%) were physically inactive, and 10% were smokers. Most (88%) reported 2 or more chronic conditions in addition to diabetes, and 18% screened positively for depressive symptoms. The majority (92%) consented to future linkage with administrative data. Based on the literature and comparison with other surveys, the cohort appeared to fairly represent the general Alberta population with diabetes. CONCLUSIONS The ABCD cohort will serve as the basis for explorations of the multidimensional and dynamic nature of diabetes care and complications. These data will contribute to broader scientific literature and will also help to identify local benchmarks and targets for intervention strategies, helping to guide policies and resource allocation related to the care and management of patients with type 2 diabetes in Alberta, Canada.

Contextualizing the Effectiveness of a Collaborative Care Model for Primary Care Patients with Diabetes and Depression (Teamcare): A Qualitative Assessment Using RE-AIM

OBJECTIVE We evaluated the implementation of an efficacious collaborative care model for patients with diabetes and depression in a controlled trial in 4 community-based primary care networks (PCNs) in Alberta, Canada. Similar to previous randomized trials, the nurse care manager-led TeamCare intervention demonstrated statistically significant improvements in depressive symptoms compared with usual care. We contextualized TeamCares effectiveness by describing implementation fidelity at the organizational and patient levels. METHODS We used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate TeamCare. Qualitative methods used to collect data regarding the RE-AIM dimensions of Implementation and Effectiveness included interviews with PCN staff and specialists (n=36), research team reflections (n=4) and systematic documentation. We used content analysis, and Nvivo 10 for data management. RESULTS TeamCare was implemented as intended but with suboptimal fidelity. Deviations from the model included limited degrees of collaborative care practised within the PCNs, including varying physician participation, limited comfort in practising collaborative care and discontinuity of care managers. Despite suboptimal fidelity, respondents identified several implementation facilitators at the organizational level: training, ongoing implementation support, professional and personal qualities of the care manager and pre-existing relationships. Without knowledge of the effectiveness of the intervention in our controlled trial, respondents anticipated improved patient outcomes due to the main intervention components, including active patient follow up, specialist consultation and treat-to-target principles. CONCLUSIONS Despite suboptimal implementation in Albertas primary care context, TeamCare resulted in improved outcomes similar to those demonstrated in previous randomized trials. A stronger culture of collaborative care would likely have yielded greater implementation fidelity and possibly better outcomes.

Engaging Patients and Clinicians in Establishing Research Priorities for Gestational Diabetes Mellitus.

OBJECTIVES We involved patients and clinicians in Alberta, Canada, to establish research priorities in gestational diabetes mellitus (GDM), using an approach based on a model proposed by the James Lind Alliance (JLA). METHODS We adapted the 4-step JLA process to engage women with GDM and clinicians to identify uncertainties about the management of GDM. Uncertainties were identified through a survey and a review of the clinical practice guidelines (CPG). Uncertainties were short-listed by a steering committee, followed by a 1-day facilitated workshop using a nominal group format and involving a similar number of patients and clinicians, who identified the top 10 research priorities. RESULTS Across the various survey formats, 75 individuals submitted 389 uncertainties, the majority (44; 59%) coming from patients. We removed 9 questions as being out of scope or unclear, and 41 were identified on a review of CPG, resulting in a total of 421 uncertainties. After the priority setting process, the final top 10 research priorities included questions about a simpler, more accurate and convenient screening test; risk factors for GDM; improving postpartum diabetes screening; the impact of GDM on the future health of the children; lifestyle challenges and mental health issues; safety, effectiveness and/or impact of diet and/or medication treatments; appropriate timing for delivery; and how care is provided, organized or communicated. CONCLUSIONS These top 10 research priorities were informed through a comprehensive and transparent process involving women who have experienced GDM as well as clinicians, and they may be regarded as research priorities for GDM.

Challenges in Identifying Patients with Type 2 Diabetes for Quality-Improvement Interventions in Primary Care Settings and the Importance of Valid Disease Registries

OBJECTIVE Patient registries are considered an important foundation of chronic disease management, and diabetes patient registries are associated with better processes and outcomes of care. The purpose of this article is to describe the development and use of registries in the Albertas Caring for Diabetes (ABCD) project to identify and reach target populations for quality-improvement interventions in the primary care setting. METHODS We applied the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework and expanded the definition of reach beyond the individual (i.e. patient) level to include the ability to identify target populations at an organizational level. To characterize reach and the implementation of registries, semistructured interviews were conducted with key informants, and a usual-care checklist was compiled for each participating Primary Care Network (PCN). Content analysis was used to analyze qualitative data. RESULTS Using registries to identify and recruit participants for the ABCD interventions proved challenging. The quality of the registries depended on whether physicians granted PCN access to patient lists, the strategies used in development, the reliability of diagnostic information and the data elements collected. In addition, once a diabetes registry was developed, there was limited ability to update it. CONCLUSIONS Proactive management of chronic diseases like diabetes requires the ability to reach targeted patients at the population level. We observed several challenges to the development and application of patient registries. Given the importance of valid registries, strong collaborations and novel strategies that involve policy-makers, PCNs and providers are needed to help find solutions to improve registry quality and resolve maintenance issues.

A qualitative study examining healthcare managers and providers’ perspectives on participating in primary care implementation research

BackgroundPrimary care reforms should be supported by high-quality evidence across the entire life cycle of research. Front-line healthcare providers play an increasing role in implementation research. We recently evaluated two interventions for people with type 2 diabetes (T2D) in partnership with four Primary Care Networks (PCNs) in Alberta, Canada. Here, we report healthcare professionals perspectives on participating in primary care implementation research.MethodsGuided by the RE-AIM framework, we collected qualitative data before, during, and after both interventions. We conducted 34 in-person or telephone interviews with 17 individual PCN professionals. We used content analysis to identify emerging codes and concepts.ResultsTwo major themes emerged from the data. First, healthcare managers were eager to conduct implementation research in a primary care setting. Second, regardless of willingness to conduct research, there were challenges to implementing experimental study designs for both interventions. PCN professionals presumed the interventions were better than usual care, expressed role conflict, and reported administrative burdens related to research participation. Perceptions of patient vulnerability and an obligation to intervene exacerbated these issues.ConclusionsHealthcare professionals with limited practical research experience might not foresee the challenges in implementing experimental study designs in primary care settings to generate high-quality evidence. These issues are intensified when healthcare professionals perceive target patient populations as vulnerable and in need of intervention based on the presenting illness. Possible solutions include further research training, involving healthcare professionals in study design development, and using non-clinical staff to conduct research activities, particularly among acutely unwell patient populations.