Addressing the Health Needs of an Aging America: New Opportunities for Evidence-Based Policy Solutions

This report systematically maps research findings to policy proposals intended to improve the health of the elderly. The study identified promising evidence-based policies, like those supporting prevention and care coordination, as well as areas where the research evidence is strong but policy activity is low, such as patient self-management and palliative care. Future work of the Stern Center will focus on these topics as well as long-term care financing, the health care workforce, and the role of family caregivers

Impact of implementing a computerised quality improvement intervention in primary healthcare

Health systems worldwide experience large evidence practice gaps with underuse of proven therapies, overuse of inappropriate treatments and misuse of treatments due to medical error. Quality improvement (QI) initiatives have been shown to overcome some of these gaps. Computerised interventions, in particular, are potential enablers to improving system performance. However, implementation of these interventions into routine practice has resulted in mixed outcomes and those that have been successfully integrated into routine practice are difficult to sustain. The objective of this thesis is to understand how a multifaceted, computerised QI intervention for cardiovascular disease (CVD) prevention and management was implemented in Australian general practices and Aboriginal Community Controlled Health Services and assess the implications for scale-up of the intervention. The intervention was implemented as part of a large cluster-randomised controlled trial, the TORPEDO (Treatment of Cardiovascular Risk using Electronic Decision Support) study. The intervention was associated with improved guideline recommended cardiovascular risk factor screening rates but had mixed impact on improving medication prescribing rates. In this thesis, I designed a multimethod process and economic evaluation of the TORPEDO trial. The aims were to: i. Develop a theory-informed logic model to assist in the design of the overall evaluation to address study aims (Chapter 3). ii. Conduct a post-trial audit to quantify changes in cardiovascular risk factor screening and prescribing to high risk patients over an 18-month post-trial period and understand the impact of the intervention outside of a research trial setting (Chapter 4). vi iii. Use normalisation process theory to identify the underlying mechanisms by which the intervention did and did not have an impact on trial outcomes (Chapter 5). iv. Use video ethnography to explore how the intervention was used and cardiovascular risk communicated between patients and healthcare providers (Chapter 6). v. Conduct an economic evaluation to inform policy makers for delivering the intervention at scale through Primary Health Networks in New South Wales (Chapter 7). vi. Use a new theory to explain the factors that drove adoption and non-adoption of the intervention and assess what modifications may be needed to promote spread and scale-up (Chapter 8). I found variable outcomes during the post-trial period with a plateauing of improvements in guideline recommended screening practices but an ongoing improvement in prescribing to high risk patients. The group that continued to have the most benefit was patients at high CVD risk who were not receiving recommended medications at baseline. The delay in prescribing recommended medication suggests healthcare providers adopt a cautious approach when introducing new treatments. Six intervention primary healthcare services participated as case studies for the process evaluation. Qualitative and quantitative data sources were combined at each primary healthcare service to enable a detailed examination of intervention implementation from multiple perspectives. The process evaluation identified the complex interaction between several underlying mechanisms that influenced the implementation processes and explained the mixed trial outcomes: (1) organisational mission; (2) leadership; (3) the role of teams; (4) technical competence and dependability of the software tools. Further, there were different ‘active ingredients’ vii necessary during the initial implementation compared to those needed to sustain use of the intervention. In the video ethnography and post-consultation patient interviews, important insights were gained into how the intervention was used, and its interpretation by the doctor and patient. Through ethnographic accounts, the doctor’s communication of cardiovascular risk was not sufficient in engaging patients and having them act upon their high-risk status; effective communication required interactions be assessed, discussed and negotiated. The economic evaluation identified the cost implications of implementing the intervention as part of a Primary Health Network program in the state of New South Wales, Australia; and modelled data looked at the impact of small but statistically significant reductions in clinical risk factors based on the trial data. When scaled to a larger population the intervention has potential to prevent major CVD events at under AU$50,000 per CVD event averted largely due to the low costs of implementing the intervention. However, the clinical risk factor reductions were small and a stronger case for investment would be made if the effects sizes could be enhanced and sustained over time. The findings from chapters 4-6 provide insight into the intricacy of the barriers influencing implementation processes and adoption of the intervention. Taken together, these studies provide a detailed explanation of the processes that may be required to implement such an intervention at scale and the factors that might influence its impact and sustainability. The findings are expected to assist policy makers, administrators and health professionals in developing multiple interdependent QI strategies at the organisational, provider and consumer levels to improve primary healthcare system performance for cardiovascular disease management and prevention

eHealth in Chronic Diseases

This book provides a review of the management of chronic diseases (evaluation and treatment) through eHealth. Studies that examine how eHealth can help to prevent, evaluate, or treat chronic diseases and their outcomes are included

Waiting Room Health Promotion for Older Adults in Rural Primary Care

Background: Advances in health care technology have lead to adults living longer than in previous decades. Longer life expectancy in combination with the aging of the Baby Boomer generation is predicted to result in rapid and exponential growth among the older adult population. Adults in the U.S. over the age of 65 have on average five or more chronic illnesses, many of which are often poorly managed. Older adults who experience chronic diseases often report decreased quality of life, limitations in functional ability, loss of independence, and periods of decline and increasing disability. Health promotion efforts can help in delaying the onset of disability and preventing rapid decline associated with many chronic conditions. Purpose: The purpose of this project was to assess the effectiveness of the implementation of a brief waiting room health promotion activity that informs older adults about the benefits of walking, such as reducing the risk of chronic disease, improving mood, and maintaining weight, physical and cognitive function. This project took place at a federally qualified health center in Plainfield, Vermont. Methods: The target population for this educational intervention included patients, as well as family members and visitors to the primary care practice who were age 55 and older. All age-eligible participants were encouraged to participate regardless of health status or the presence of comorbid health conditions. The activity comprised of participants viewing a brief audiovisual educational activity explaining the health benefits of walking, supplemented with paper materials to support the health messages; the intervention was then followed by completion of a brief paper survey evaluation. Results: During the two-month period the health promotion activity was available, 56 individuals participated and completed the survey. Of the 56 participants, 87% indicated they either “strongly agreed” or “agreed” that watching the video increased knowledge about health-related benefits of walking. In total, approximately 73% of participants who participated in this health promotion activity agreed that they paid attention to educational materials in the waiting room setting. Approximately 57% of participants shared a health related goal that they created as a result of the health promotion activity. Conclusion: This project has suggested that implementation of waiting room health promotion activities, specifically for older adults, is a simple and cost-effective way to promote good health practices and provide patients with in-depth health care information that may not be addressed during the health care visit. Activities in the waiting room can help to supplement information provided during the clinical encounter, leaving patients more satisfied with their visits, and promoting positive behavior change

European consensus of criteria for the evaluation of good practices in chronic conditions

Los sistemas sanitarios reconocen las enfermedades crónicas como uno de sus grandes desafíos de salud del siglo XXI para los sistemas sanitarios. A pesar de ser en gran medida prevenibles, las enfermedades crónicas son importante causa de mortalidad y morbilidad en Europa. En 2015, más de 1,2 millones de personas en los países de la UE murieron por enfermedades y lesiones que podrían haberse evitado a través de políticas de salud pública más fuertes o de una atención médica más efectiva y menos fragmentada. La presente tesis doctoral reporta el desarrollo y resultados de una proceso de consenso internacional cuyo objetivo ha sido desarrollar criterios de evaluación para valorar el potencial de las prácticas clínicas e intervenciones y políticas sanitarias a la hora de disminuir la carga atribuible a las enfermedades crónicas en cuatro áreas de interés: Promoción de la salud y prevención primaria de condiciones crónicas; Intervenciones organizativas enfocadas al tratamiento de pacientes crónicos con condiciones clínicas múltiples; Intervenciones sobre el empoderamiento del paciente; e, Intervenciones y políticas orientadas a mejorar la diabetes (la diabetes se utiliza como condición paradigmática). Con objeto de acordar los criterios de evaluación y otorgarles relevancia distinta en función del dominio de interés, se desarrolló un consenso internacional mediante la técnica Delphi-modificada, en la que participaron 113 expertos de diferentes disciplinas procedentes de 23 países europeos. El proceso de consenso produjo 145 categoría de evaluación (28 categorías en el Delphi de Health promotion and primary prevention of chronic conditions, 50 en el de Organizational interventions aimed at dealing with complex chronic patients with multiple conditions, 28 en el de Patient empowerment interventions with chronic conditions y 39 categorías en el Delphi de diabetes as a case-study) orientadas a valorar cada uno de los citados dominios y ponderarlos en función de cada área de interés. El conjunto de criterios y categorías acordados para el caso paradigmático de Diabetes apoya la hipótesis de que los criterios de valoración son transferibles y aplicables a la evaluación de prácticas, intervenciones y políticas desarrolladas sobre otras condiciones crónicas. Consistentemente con lo observado en otras iniciativas europeas, en este consenso, los criterios relacionados con ‘diseño de la práctica’, ‘evaluación’, ‘sostenibilidad’ y ‘escalabilidad’ parecen ser componentes esenciales en el desarrollo e implementación de buenas prácticas en Europa. Por último, como virtualidad destacable de este proceso de consenso, el componente internacional de las decisiones consensuadas, apoya la posibilidad de que las prácticas evaluadas con los criterios y categorías acordados puedan ser transferidas a cualquier contexto europeo.<br /