Care management for Type 2 diabetes in the United States: a systematic review and meta-analysis

<p>Abstract</p> <p>Background</p> <p>This systematic review and meta-analysis aims at assessing the composition and performance of care management models evaluated in the last decade and their impact on patient important outcomes.</p> <p>Methods</p> <p>A comprehensive literature search of electronic bibliographic databases was performed to identify care management trials in type 2 diabetes. Random effects meta-analysis was used when feasible to pool outcome measures.</p> <p>Results</p> <p>Fifty-two studies were eligible. Most commonly reported were surrogate outcomes (such as HbA1c and LDL), followed by process measures (clinic visit or testing frequency). Less frequently reported were quality of life, patient satisfaction, self-care, and healthcare utilization. Most care management modalities were carved out from primary care. Meta-analysis demonstrated a statistically significant but trivial reduction of HbA1c (weighted difference in means -0.21%, 95% confidence interval -0.40 to -0.03, p < .03) and LDL-cholesterol (weighted difference in means -3.38 mg/dL, 95% confidence interval -6.27 to -0.49, p < .02).</p> <p>Conclusions</p> <p>Most care management programs for patients with type 2 diabetes are 'carved-out', accomplish limited effects on metabolic outcomes, and have unknown effects on patient important outcomes. Comparative effectiveness research of different models of care management is needed to inform the design of medical homes for patients with chronic conditions.</p

Stakeholder perceptions of using “opt-out” for tobacco use treatment in a cancer care setting: a qualitative evaluation of patients, providers, and desk staff

Abstract Background Continued tobacco use in cancer patients increases the risk of cancer treatment failure and decreases survival. However, currently, most cancer patients do not receive evidence-based tobacco treatment. A recently proposed “opt-out” approach would automatically refer all cancer patients who use tobacco to tobacco treatment, but its acceptability to cancer patients and providers is unknown. We aimed to understand stakeholder beliefs, concerns, and receptivity to using the “opt-out” approach for tobacco treatment referrals in a cancer care setting. Methods Semi-structured interviews were conducted with oncology patients, providers, and desk staff. The sample size was determined when theoretical saturation was reached. Given the differences among participant roles, separate interview guides were developed. Transcripts were analyzed using standard coding techniques for qualitative data using the Consolidated Framework for Implementation Research (CFIR) codebook. Emergent codes were added to the codebook to account for themes not represented by a CFIR domain. Coded transcripts were then entered into the qualitative analysis software NVivo to generate code reports for CFIR domains and emergent codes for each stakeholder group. Data were presented by stakeholder group and subcategorized by CFIR domains and emergent codes when appropriate. Results A total of 21 providers, 19 patients, and 6 desk staff were interviewed. Overall acceptance of the “opt out” approach was high among all groups. Providers overwhelmingly approved of the approach as it requires little effort from them to operate and saves clinical time. Desk staff supported the opt-out system and believed there are clinical benefits to patients receiving information about tobacco treatment. Many patients expressed support for using an opt-out approach as many smokers need assistance but may not directly ask for it. Patients also thought that providers emphasizing the benefits of stopping tobacco use to cancer treatment and survival would be an important factor motivating them to attend treatment. Conclusions While providers appreciated that the system required little effort on their part, patients clearly indicated that promotion of tobacco cessation treatment by their provider would be vital to enhance willingness to engage with treatment. Future implementation efforts of opt-out systems will require implementation strategies that promote provider engagement with their patients around smoking cessation while continuing to limit burden on providers

Additional file 4 of Stakeholder perceptions of using “opt-out” for tobacco use treatment in a cancer care setting: a qualitative evaluation of patients, providers, and desk staff

Additional file 4. Additional emergent codes for provider interviews developed by JO and HH after reading transcripts separately and identifying emergent thematic codes

Additional file 3 of Stakeholder perceptions of using “opt-out” for tobacco use treatment in a cancer care setting: a qualitative evaluation of patients, providers, and desk staff

Additional file 3. Interview Guide: Evaluation of a Presumed Consent Model for Tobacco Treatment among Mayo Clinic Cancer Center Providers

Additional file 6 of Stakeholder perceptions of using “opt-out” for tobacco use treatment in a cancer care setting: a qualitative evaluation of patients, providers, and desk staff

Additional file 6. Standards for Reporting Qualitative Research (SRQR)*

Additional file 5 of Stakeholder perceptions of using “opt-out” for tobacco use treatment in a cancer care setting: a qualitative evaluation of patients, providers, and desk staff

Additional file 5. Codebook for patient interviews were developed by JO and HH after reading transcripts separately and identifying emergent thematic codes

Additional file 2 of Stakeholder perceptions of using “opt-out” for tobacco use treatment in a cancer care setting: a qualitative evaluation of patients, providers, and desk staff

Additional file 2. Interview Guide: Evaluation of a Presumed Consent Model for Tobacco Treatment among Mayo Clinic Cancer Center Providers (desk staff)

Additional file 1 of Stakeholder perceptions of using “opt-out” for tobacco use treatment in a cancer care setting: a qualitative evaluation of patients, providers, and desk staff

Additional file 1. Interview Guide: Evaluation of a Presumed Consent Model for Tobacco Treatment among Mayo Clinic Cancer Center Patients

Patient experience after kidney transplant: a conceptual framework of treatment burden

Abstract Background Kidney transplant recipients face a lifelong regimen of medications, health monitoring and medical appointments. This work involved in managing one’s health and its impact on well-being are referred to as treatment burden. Excessive treatment burden can adversely impact adherence and quality of life. The aim of this study was to develop a conceptual framework of treatment burden after kidney transplantation. Qualitative interviews were conducted with kidney transplant recipients (n = 27) from three Mayo Clinic transplant centers. A semi-structured interview guide originally developed in patients with chronic conditions and tailored to the context of kidney transplantation was utilized. Themes of treatment burden after kidney transplantation were confirmed in two focus groups (n = 16). Results Analyses confirmed three main themes of treatment burden after kidney transplantation: 1) work patients must do to care for their health (e.g., attending medical appointments, taking medications), 2) challenges/stressors that exacerbate felt burden (e.g., financial concerns, health system obstacles) 3) impacts of burden (e.g., role/social activity limitations). Conclusions Patients describe a significant amount of work involved in caring for their kidney transplants. This work is exacerbated by individual, interpersonal and system-related factors. The framework will be used as a foundation for a patient-reported measure of treatment burden to promote better care after kidney transplantation

Data from: Shared decision-making as a cost-containment strategy: US physician reactions from a cross-sectional survey

Objective: To assess US physicians’ attitudes towards using shared decision-making (SDM) to achieve cost containment. Design: Cross-sectional mailed survey. Setting: US medical practice. Participants: 3897 physicians were randomly selected from the AMA Physician Masterfile. Of these, 2556 completed the survey. Main outcome measures: Level of enthusiasm for “Promoting better conversations with patients as a means of lowering healthcare costs”; degree of agreement with “Decision support tools that show costs would be helpful in my practice” and agreement with “should promoting SDM be legislated to control overall healthcare costs”. Results: Of 2556 respondents (response rate (RR) 65%), two-thirds (67%) were ‘very enthusiastic’ about promoting SDM as a means of reducing healthcare costs. Most (70%) agreed decision support tools that show costs would be helpful in their practice, but only 24% agreed with legislating SDM to control costs. Compared with physicians with billing-only compensation, respondents with salary compensation were more likely to strongly agree that decision support tools showing costs would be helpful (OR 1.4; 95% CI 1.1 to 1.7). Primary care physicians (vs surgeons, OR 1.4; 95% CI 1.0 to 1.6) expressed more enthusiasm for SDM being legislated as a means to address healthcare costs. Conclusions: Most US physicians express enthusiasm about using SDM to help contain costs. They believe decision support tools that show costs would be useful. Few agree that SDM should be legislated as a means to control healthcare costs