Patient and provider acceptance of telecoaching in type 2 diabetes : a mixed-method study embedded in a randomised clinical trial

Background: Despite advances in diagnosis and treatment of type 2 diabetes, suboptimal metabolic control persists. Patient education in diabetes has been proved to enhance self-efficacy and guideline-driven treatment, however many people with type 2 diabetes do not have access to or do not participate in self-management support programmes. Tele-education and telecoaching have the potential to improve accessibility and efficiency of care, but there is a slow uptake in Europe. Patient and provider acceptance in a local context is an important precondition for implementation. The aim of the study was to explore the perceptions of patients, nurses and general practitioners (GPs) regarding telecoaching in type 2 diabetes. Methods: Mixed-method study embedded in a clinical trial, in which a nurse-led target-driven telecoaching programme consisting of 5 monthly telephone sessions of +/- 30 min was offered to 287 people with type 2 diabetes in Belgian primary care. Intervention attendance and satisfaction about the programme were analysed along with qualitative data obtained during post-trial semi-structured interviews with a purposive sample of patients, general practitioners (GPs) and nurses. The perceptions of patients and care providers about the intervention were coded and the themes interpreted as barriers or facilitators for adoption. Results: Of 252 patients available for a follow-up analysis, 97.5 % reported being satisfied. Interviews were held with 16 patients, 17 general practitioners (GPs) and all nurses involved (n = 6). Themes associated with adoption facilitation were: 1) improved diabetes control; 2) need for more tailored patient education programmes offered from the moment of diagnosis; 3) comfort and flexibility; 4) evidence-based nature of the programme; 5) established cooperation between GPs and diabetes educators; and 6) efficiency gains. Most potential barriers were derived from the provider views: 1) poor patient motivation and suboptimal compliance with "faceless" advice; 2) GPs' reluctance in the area of patient referral and information sharing; 3) lack of legal, organisational and financial framework for telecare. Conclusions: Nurse-led telecoaching of people with type 2 diabetes was well-accepted by patients and providers, with providers being in general more critical in their reflections. With increasing patient demand for mobile and remote services in healthcare,the findings of this study should support professionals involved in healthcare policy and innovation

Avoiding 30-day Readmissions of Acute MI Patients Utilizing Cardiac Rehabilitation

A significant number of Acute Myocardial Infarction (AMI) patients were readmitted to an urban San Francisco Medical Center within 5-7 days post discharge this year. Two of the main identified causes were symptom management issues and medication instructions, both of which are part of the discharge instructions. It’s not surprising that 80% of all discharge teaching is forgotten by patients by the time they hit the parking lot. With the recommended timeframe for post discharge follow up appointments at 48 to 72 hours post discharge and as those appointments are not typically available within the recommended timeframe, patients are more likely to be readmitted unless an alternative for post discharge follow up can be created. The intent of this project is to propose the implementation of a hospital based Cardiac Rehabilitation (CR) program that allows AMI patients to participate as early as 48 -72 hours post discharge. This first part, or intake to the CR program would reinforce discharge teaching inclusive of medication reconciliation, symptom management, and all other components taught at discharge. The evidence to be duplicated is that enrollment in a certified cardiac rehab program as early as 48 hours post discharge can prevent readmissions by enhancing the patient/family’s retention and understanding of discharge instructions that include symptom management and medicatio

Evidence for funding, organising and delivering health care services targeting secondary prevention and management of chronic conditions. CHERE Working Paper 2009/6

This paper is designed as an issues paper. Its aim is to set out what evidence is available regarding the effectiveness and efficiency of funding, organisation and delivery of services directed at preventing and managing chronic conditions, and identify what further information is required. The latter will then be used as a means of identifying gaps in information which can be addressed by research. The information is not presented as a comprehensive review of all available evidence but as a preliminary scoping of the results of the most recent literature.chronic conditions, prevention, funding

Increasing Enrollment of Cardiac Rehabilitation for Eligible Patients in the Outpatient Setting: A Toolkit

Background: Heart disease is the leading cause of death worldwide. It is responsible for serious cardiac events that can be fatal. When a patient experiences one cardiac event, they are more likely to have a second event. Therefore, secondary prevention programs such as cardiac rehabilitation (CR) have been proven to reduce mortality in these patients and enhance quality of life; however, they are severely underutilized. Purpose: The purpose of this integrative review and DNP project was to educate outpatient providers about the immense value of cardiac rehabilitation to eligible patients and develop a toolkit targeted to help providers recognize eligible patients, educate them and expedite enrollment. Methods: An educational intervention was virtually presented with a pre- and post-survey completed by 9 staff members of an outpatient cardiology office. Feedback was collected to determine efficacy of the presentation, change in provider perceptions, and the utility of the toolkit. Data was input into Excel and SPSS to determine statistical significance and organization of feedback. Results: By using the Health Belief Model as a framework, the Wilcoxon Signed Ranks Test determined that there was statistically significant (p=0.026) increase in perceived seriousness, susceptibility, and benefit after the educational intervention indicating that participants’ attitudes and beliefs about the importance of cardiac rehabilitation (CR) and can be affected with education, leading to the increased interest in improving referral rates for eligible patients. Conclusion: This project should serve as a tool to continue to educate outpatient providers of the value of CR, while the toolkit may be utilized to expedite enrollment and help reach national goals of increasing cardiac rehabilitation participation to 70%

The National Exercise Referral Framework

A 2013 Review of the HSE funded GP Exercise Referral Programme (GPERP) highlighted the need for a new National Exercise Referral Framework (NERF). The evidence suggests that exercise referral is an effective targeted health intervention for specific patients and with the increasing prevalence of chronic disease it is imperative that we examine, design and progress the implementation of scalable, sustainable evidence-based, interventions, integrated across the health system to improve the health and wellbeing of the population. The development of this proposed National Exercise Referral Framework, commissioned by Health Promotion and Improvement, was led by DCU involving a multi-disciplinary Working Group and supported by a HSE Cross-Divisional Group. We are grateful to the Working Group and in particular to Dr Catherine Woods and the team in DCU for their extensive work and commitment to this project. There are a number of practical steps now required to determine the feasibility of the proposed framework as a national model namely, identification of a sustainable funding model; design and development of chronic disease care pathways and a phased implementation plan that would build on the existing programmes. The Health & Wellbeing Division of the HSE will lead the next phase of this project

A Comparison of Cardiac Rehabilitation Services and Outcomes in the Great Lakes Central Region (Southwestern Ontario and Southeastern Michigan)

Cardiac rehabilitation (CR) is a secondary prevention program known to improve clinical outcomes and health-related quality of life in individuals with cardiovascular disease, yet participation and completion rates are suboptimal. Additionally, a CR model or models that is/are most efficient for all cohorts of participants has yet to be established. The purpose of this study was to compare models of care from four geographically close CR sites that span an international border through examination of program characteristics and database variables. Participants were also characterized and examined for potential predictors of program completion at one site. The most impactful findings were: 1) sites may want to consider collecting a standardized data battery during programming and implementing participation incentives to enhance program completion; 2) the collection of point/date of referral, travel distance, and availability of exercise equipment at home and gym membership, may want to be considered by all sites; and 3) increasing age and higher education were associated with program completion. This research will provide a foundation for comparisons of the “granular” program and participant details across sites to maximize participant and program success. As such, the expertise from all sites can be leveraged to lead discussions that strategize next steps in developing an ideal CR model or models that not only provide participant benefit, but also cost-efficient programming solutions

Practice Considerations for Adapting In-Person Groups to Telerehabilitation

The Coronavirus-2019 (COVID-19) pandemic has shifted research and healthcare system priorities, stimulating literature on implementation and evaluation of telerehabilitation for a variety of patient populations. While there is substantial literature on individual telerehabilitation, evidence about group telerehabilitation remains limited despite its increasing use by rehabilitation providers. Therefore, the purpose of this manuscript is to describe our expert team’s consensus on practice considerations for adapting in-person group rehabilitation to group telerehabilitation to provide rapid guidance during a pandemic and create a foundation for sustainability of group telerehabilitation beyond the pandemic’s end. &nbsp

Interventions to promote patient utilisation of cardiac rehabilitation

Background: International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation. Objectives: First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations. Search methods: Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index ‐ Science (CPCI‐S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions. Selection criteria: We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity. Data collection and analysis: Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random‐effects meta‐regression for each outcome and explored prespecified study characteristics. Main results: Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation. Low‐quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta‐regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face‐to‐face; P = 0.01) were influential in increasing enrolment. Low‐quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home‐based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate‐quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi‐centre studies were less effective than those given in single‐centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small‐study bias for enrolment (insufficient studies to test for this in the other outcomes). With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women‐tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment. Authors' conclusions: Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face‐to‐face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion

The Association Between the Medicare Bundled Payments Initiative and Cardiac Rehabilitation Enrollment

Cardiac rehabilitation (CR) represents a proven-effective intervention in secondary prevention that can stabilize, slow or reverse cardiovascular disease (CVD) progression, facilitate the ability of the patient to preserve or resume an active and functional contribution to the community, and reduce the risk of future cardiovascular events. Despite multiple guideline recommendations for CR and coverage by Medicare and most health plans, participation in CR remains low. Bundled payments are one of the suggested reforms designed to move health care providers toward to value-based care and is very applicable to the CR utilization in patients diagnosed with acute myocardial infarction (AMI) or have undergone through procedures of coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI), since it has the potential to catalyze and accelerate the establishment of innovative delivery models that could achieve greater communication and coordination among providers across the continuum of care and improve CR referral, enrollment and adherence. This study examined the association of Center for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BCPI) initiative and CR uptake, patient outcomes and health care utilization among Medicare beneficiaries, as well as the potential collateral effect on health disparities in CR uptake and health outcomes in patients who are female, living in rural areas, are non-white, or are dual-eligible in Medicare and Medicaid, by conducting difference-in-difference analysis to a secondary data set. In our analysis, we found that participation in the CMS BPCI initiative for cardiac episodes (AMI, CABG, PCI) was not associated with an increase in 3-month CR enrollment. The differential changes tended to be in both directions, though when we looked at hospitals by initiation of participation, the early-entrant cohort (i.e., Jan-BPCI) showed an observed improvement in 3-month CR enrollment rate. The disparities in CR enrollment regarding race, sex, socioeconomic status and rurality were demonstrated in our study. Though BPCI initiative has potential to reduce disparities in CR enrollment, our results did not show reduced disparities in CR enrollment among vulnerable groups regarding sex and SES, compared pre- and post- BPCI implementation. Our study suggests: 1) it is imperative to describe the plans for integration of process and outcome data in design of model and advance understanding of how these models might be implemented to improve health for future policy changes and new initiatives; and 2) it is imperative to advance understanding of how these models might be designed and implemented to reduce health disparities. The new bundled payments policy needs to be sufficiently flexible to allow and encourage health systems to determine and implement the best approaches to reduce disparities in their settings and populations

Jefferson Digital Commons quarterly report: January-March 2020

This quarterly report includes: New Look for the Jefferson Digital Commons Articles COVID-19 Working Papers Educational Materials From the Archives Grand Rounds and Lectures JeffMD Scholarly Inquiry Abstracts Journals and Newsletters Master of Public Health Capstones Oral Histories Posters and Conference Presentations What People are Saying About the Jefferson the Digital Common