Determinants of Patient Activation in Hospitalized Multimorbid Patients

Post-hospitalization care transition is a vulnerable time for multimorbid patients. Self-management challenges happen due to acute symptoms and complex new treatment plans. Literature suggests higher activated patients have better outcomes; however, there is little research that identifies determinants that predict patient activation in the multimorbid hospitalized patient. Understanding predictive factors will facilitate planning interventions that promote self-management of multimorbid conditions. The purpose of this dissertation was to identify determinants that predict patient activation in patients with multimorbidity at discharge from the hospital. A descriptive, predictive research study was conducted with 200 hospitalized multimorbid patients discharged to home. Their mean age was 63.7 (SD = 14.2); they were primarily Caucasian (n = 188, 94%); and female (n = 117, 58.5%). The mean Patient Activation Measure (PAM) score was 60.3 (SD = 14.6); 40 were level 1 (20%); 39 were level 2 (19.5%), 52 were level 3 (26%), and 69 were level 4 (34.5%). There were significant relationships between PAM levels and several determinants. Patients in lower PAM levels needed more assistance understanding health care materials; were more depressed; more fatigued; less satisfied with their social role; and less satisfied with their chronic illness care. Patients in lower PAM levels were rehospitalized and visited the emergency department within 30-days post-discharge more frequently than level 4 activation patients. Multinomial logistical regression indicated that the predictors as a set distinguished between levels of patient activation (χ2 = 73.34 (3), p = .001). Patients in level 1 were more likely to need assistance reading health care material compared to level 4 patients. Level 2 and 3 patients were less likely to be satisfied with their chronic illness care than level 4 patients. This study demonstrates that lower patient activation level patients have lower literacy levels, are less satisfied with their chronic illness care, and have more health care utilization 30-days post-discharge. Focusing on literacy and satisfaction with chronic illness care may improve patient outcomes

An intelligent mHealth-based adjunct to improve the management of patients with cardiovascular disease

Regular recording of vital signs, modification of lifestyle behaviour and monitoring of health progress has been shown to be effective to better manage patients with cardiovascular disease (CVD). Despite this, there remain significant hospital readmissions due to CVD exacerbations. This thesis investigated if the readmission rate of CVD patients could be reduced through remote longitudinal monitoring of physiological measurements and by offering a mobile health (mHealth)-based adjunct to assist in lifestyle modification. The thesis also investigated if there was a relationship between patient engagement and their clinical outcomes. To improve the remote management of CVD patients, the architecture of an intelligent mHealth adjunct called Total Cardiac Care (TCC) was developed based around a smartphone app and wireless peripherals to record physiological data and patient activity. The system also enabled the clinician to regularly monitor the patients’ condition using a web portal, facilitating the timely interventions when deemed necessary. The proposed system feasibility was investigated in a pilot trial, where it was widely accepted by both younger and older CVD patients with a high satisfaction rate (89.5%). The participants also had a high engagement rate with the different monitoring features (BP 77.2%, weight 74.3% and activity 84.8%). The results of a randomised controlled trial in which CVD patients (n = 164) were randomly assigned to either the mHealth intervention group or a traditional care control group identified a significant reduction in the 6-month all-cause (21 vs 41, risk reduction 49%, p = 0.015) and cardiac readmission (11 vs 25, risk reduction 56%, p = 0.025) risk when comparing the intervention cohort against the control cohort. These results suggest that the mHealth adjunct could increase the CVD patient’s engagement and the monitoring of physiological measurements and activity along with modified lifestyle behaviour over the long term could improve their cardiac health and decrease adverse events. To predict the CVD patient’s exacerbation, a model capable of detecting worsening events based on the critical change in the longitudinal physiological trends was developed using telemonitoring data collected from the intervention cohort. The model correctly predicted the CVD exacerbation events with 86.4% sensitivity, 58.4% specificity and 59.7% accuracy. This highlights that the integration of an exacerbation prediction model with the mHealth adjunct could enhance the quality of remote monitoring care provided to CVD patients

Transactions of 2019 International Conference on Health Information Technology Advancement Vol. 4 No. 1

The Fourth International Conference on Health Information Technology Advancement Kalamazoo, Michigan, October 31 - Nov. 1, 2019. Conference Co-Chairs Bernard T. Han and Muhammad Razi, Department of Business Information Systems, Haworth College of Business, Western Michigan University Kalamazoo, MI 49008 Transaction Editor Dr. Huei Lee, Professor, Department of Computer Information Systems, Eastern Michigan University Ypsilanti, MI 48197 Volume 4, No. 1 Hosted by The Center for Health Information Technology Advancement, WM

Bridging the Gaps: Exploring Factors Associated With Goal Achievement Within an Accountable Care Organization Care Coordination Program

Background: Healthcare cost in the U.S. has been increasing at an unsustainable rate due to the growing population diagnosed with multiple chronic conditions and a fragmented healthcare system. The high-risk patient population includes persons who over utilize the healthcare system with frequent avoidable hospitalizations, emergency room visits, and exacerbations of their chronic conditions. This high-risk population makes up five percent of the U.S. but accounts for over fifty percent of all healthcare spending. Care coordination models have emerged to focus proactive health interventions for the highest-risk patient populations to reduce overutilization and empower patients to improve long-term health. Evidence has shown care coordination models are essential for achieving quality and safety outcomes for patients and their families, but first, the patient must agree to enroll in the care coordination program to receive the support provided by the care coordination services. Methods: A retrospective secondary data study design was used from Emory Healthcare Ambulatory Care Coordination Department. Multivariate logistic regressions were conducted to examine whether race, age, sex, and primary insurance type significantly predicted enrollment and achievement of the program care plan goals. A multivariate logistic regression was also conducted to examine if the average communication time significantly affected the patient’s achievement of their care plan goals. Results: The overall models demonstrated that race, age, sex, and primary insurance type were significant predictors of patient enrollment and achievement of care plan goals (p \u3c .001). The average communication between the care coordinator and the patient also significantly predicted the patient achieving care plan goals (p \u3c .001), but there was no significance for average talk times over 90 minutes. Conclusion: The study results will serve as a benchmark for the Emory Healthcare Care Coordination Department and create a foundation for further research to inform effective strategies to utilize proactive outreach and promote the enrollment of a diverse patient population. It will be essential to continue longitudinal studies of the enrolled patient population further to inform the long-term cost savings effects of the program

Fusion, 2022

https://hsrc.himmelfarb.gwu.edu/smhs_fusion/1014/thumbnail.jp

Influence of Motivational Text Messages on Adherence to Continuous Positive Airway Pressure Therapy

Obstructive sleep apnea (OSA) is a condition affecting an estimated 22% of men and 17% of women. Individuals with OSA have periodic bouts of apneas and hypopneas while sleeping that negatively impacts their sleep quality and neurohormonal function. As a result, individuals with OSA are at increased risk for diseases including diabetes, cancer, stroke, myocardial infarction, and depression. Continuous positive airway pressure (CPAP) therapy is an effective treatment for but adherence rates are low at an estimated 60%.The purpose of this pilot study was to examine the effects of a four-week text message-based intervention on an individual\u27s CPAP device adherence, OSA symptom management, and outcome expectations when compared to participants receiving generic text messages. Participants were randomized to an experimental group (EG) (n=29) or to a control group (CG) (n=28). The EG received one motivational text message every week for four weeks based on concepts derived from the theory of planned behavior (TPB). The CG received one text message every week for four weeks with objective information (average use in hours per week). Total mask-on time and CPAP adherence status were measured using CPAP device real-time data. Symptom management and CPAP use expectations were evaluated using Apnea Belief Scale (ABS), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10).There was no significant difference in total mask-on time between the two groups (p=.64). The proportion of participants classified as adherent did not differ between the two groups (p=.17). Differences in ABS, ESS, and FOSQ-10 scores between groups were also not significant (ANOVA, ABS: p =.47; ESS: p =.81; FOSQ: p =0.97).The pilot study identified trends toward improved CPAP adherence with use of TPB-based text messages. For example, the experimental group’s adherence rate was 14.8% higher than control group’s adherence rate. The lack of significance in the 3 instruments may have occurred because they measured actual behavior (CPAP use) and not what effect the intervention had on changing the behavior. More research is needed to elucidate the impact of TPB-based text messages on improving CPAP adherence and outcomes for individuals with OSA

Do patients behave as expected on a healthcare market in transition? : consequences of expanding patient choice and introducing telemedicine in primary healthcare

Background: Political governance and technological development have transitioned the Swedish primary healthcare market from a centrally planned, community-oriented model with limited choice for patients to a quasi-market with extensive patient choice. Starting in 2007, reforms promoting patient choice in primary healthcare were gradually introduced in multiple regions in Sweden, and in 2010, all regions across the country were legally required to enable patient choice. Provision of telemedicine – in this thesis defined as healthcare consultations via video calls or text messaging where the patient and the healthcare personnel are spatially separated – emerged in primary healthcare when patient choice was further expanded in 2015. From this point, choice was no longer limited to a certain geographical region, but could extend to primary healthcare providers throughout the country. Aim: The aim of this thesis was to shed light on the consequences of expanding patient choice and introducing telemedicine in primary healthcare by empirically investigating patient behaviors in response to these changes. Methods: To approach the aim, I departed from four assumptions about patient behavior which related to four central themes in healthcare: quality, continuity, equity, and demand. The assumptions I investigated were: Quality assumption: Patients are sensitive to quality in their choice of primary healthcare provider. Continuity assumption: Lack of informational continuity leads to worse health outcomes. Equity assumption: Telemedicine consultations are used to a greater extent by individuals with lower healthcare needs. Demand assumption: Use of telemedicine consultations increases the overall consumption of primary healthcare. In all studies of the thesis, comprehensive total population registries were used to investigate patient behaviors. In the quality study, Study I, we investigated whether quality influenced choice of primary healthcare provider by exploring the trade-off between distance to chosen primary healthcare provider and subjective and objective quality measures. We investigated choice of provider in 2017 and included all residents of Region Stockholm who had been in contact with primary healthcare at least once in 2016 or 2017 in the study population (n=1.4 million). The trade-off was studied using a conditional logit analysis. In the continuity study, Study II, logistic regression was applied to investigate if patients who had had their inpatient diagnosis recorded in primary healthcare as well – a measure of informational continuity – filled prescriptions of recommended pharmacotherapies to a greater extent than patients whose diagnosis was not recorded. The study population consisted of 19,072 individuals with an inpatient diagnosis of stroke, transient ischaemic attack, or acute coronary syndrome during the period 2010–2013. In the equity study, Study III, we explored the characteristics of users of telemedicine consultations by investigating the socioeconomic, demographic, and contextual determinants for having made at least one telemedicine consultation in 2018. For comparison, face-to-face physician consultations in primary healthcare were included in the study, as well as digiphysical physician consultations, i.e., telemedicine consultations offered by traditional primary healthcare providers also offering face-to-face visits, and telephone consultations by nurses. All residents of Region Stockholm who were registered with a primary healthcare provider (n=2.0 million) were included in the study population. In the demand study, Study IV, we investigated healthcare consumption following a telemedicine consultation and a face-to-face consultation, respectively. The study population included all individuals who had ≥ 1 physician consultation (telemedicine or face-to-face) during the first half of 2018. Telemedicine users were matched 1:2 to users of face-to-face visits on diagnosis and demographic and socioeconomic variables. Their healthcare consumption, in terms of physician consultations, was compared in an interrupted time series analysis. Findings: The findings of the thesis lent some support to the four assumptions about patient behavior on the primary healthcare market in transition. In the quality study, the findings suggested that quality had a small impact on choice of provider. However, other aspects – such as the care needs of the individuals registered with a primary healthcare provider – seemed much more important. In the continuity study, the findings revealed a clear positive association between recorded diagnosis and use of recommended pharmacotherapies, indicating that informational continuity is beneficial for patient health. Regarding the equity and demand studies, the findings showed that the use of telemedicine was not equally distributed in the population and that telemedicine users increased their healthcare consumption after a physician consultation more than the matched control group consisting of users of only face-to-face consultations. Conclusions: The findings suggest that the market mechanism “choice” is not sufficient to ensure quality in primary healthcare. The mechanism might be enforced by better information to patients, but quality should be ensured through other measures. Informational continuity seems beneficial for patients and should be encouraged. The measure “recorded diagnosis” does seem to have a valid role as a follow-up indicator in primary healthcare and the level of diagnosis recording could most likely be improved. Regarding telemedicine, it is important to ensure that the fast technological development does not create a digital divide in healthcare. It will grow increasingly important to ensure that those who need an alternative to a digital channel – whether it is for seeing a physician or booking an appointment – are not deprived of this. In addition, measures to promote access to the groups in the population with a particularly low level of telemedicine consumption should be considered in order to ensure that all groups have access to the health services that best suits their needs. Telemedicine and digital innovations have a lot of potential but are also associated with a risk of overuse. The research highlights the need to promptly investigate the costs and benefits of telemedicine, so that its use can be encouraged when it is most cost-efficient and limited when it is not. The methods applied in this thesis may be useful to monitor the development of the area