Context, mechanisms and outcomes of integrated care for diabetes mellitus type 2:A systematic review

Background: Integrated care interventions for chronic conditions can lead to improved outcomes, but it is not clear when and why this is the case. This study aims to answer the following two research questions: First, what are the context, mechanisms and outcomes of integrated care for people with type 2 diabetes? Second, what are the relationships between context, mechanisms and outcomes of integrated care for people with type 2 diabetes? Methods: A systematic literature search was conducted for the period 2003-2013 in Cochrane and PubMed. Articles were included when they focussed on integrated care and type 2 diabetes, and concerned empirical research analysing the implementation of an intervention. Data extraction was performed using a common data extraction table. The quality of the studies was assessed with the Mixed Methods Appraisal Tool. The CMO model (context + mechanism = outcome) was used to study the relationship between context factors (described by the barriers and facilitators encountered in the implementation process and categorised at the six levels of the Implementation Model), mechanisms (defined as intervention types and described by their number of Chronic Care Model (sub-) components) and outcomes (the intentional and unintentional effects triggered by mechanism and context). Results: Thirty-two studies met the inclusion criteria. Most reported barriers to the implementation process were found at the organisational context level and most facilitators at the social context level. Due to the low number of articles reporting comparable quantitative outcome measures or in-depth qualitative information, it was not possible to make statements about the relationship between context, mechanisms and outcomes. Conclusions: Efficient resource allocation should entail increased investments at the organisational context level where most barriers are expected to occur. It is likely that investments at the social context level will also help to decrease the development of barriers at the organisational context level, especially by increasing staff involvement and satisfaction. If future research is to adequately inform practice and policy regarding the impact of these efforts on health outcomes, focus on the actual relationships between context, mechanisms and outcomes should be actively incorporated into study designs

Advancing current approaches to disease management evaluation:Capitalizing on heterogeneity to understand what works and for whom

BACKGROUND: Evaluating large-scale disease management interventions implemented in actual health care settings is a complex undertaking for which universally accepted methods do not exist. Fundamental issues, such as a lack of control patients and limited generalizability, hamper the use of the ‘gold-standard’ randomized controlled trial, while methodological shortcomings restrict the value of observational designs. Advancing methods for disease management evaluation in practice is pivotal to learn more about the impact of population-wide approaches. Methods must account for the presence of heterogeneity in effects, which necessitates a more granular assessment of outcomes. METHODS: This paper introduces multilevel regression methods as valuable techniques to evaluate ‘real-world’ disease management approaches in a manner that produces meaningful findings for everyday practice. In a worked example, these methods are applied to retrospectively gathered routine health care data covering a cohort of 105,056 diabetes patients who receive disease management for type 2 diabetes mellitus in the Netherlands. Multivariable, multilevel regression models are fitted to identify trends in clinical outcomes and correct for differences in characteristics of patients (age, disease duration, health status, diabetes complications, smoking status) and the intervention (measurement frequency and range, length of follow-up). RESULTS: After a median one year follow-up, the Dutch disease management approach was associated with small average improvements in systolic blood pressure and low-density lipoprotein, while a slight deterioration occurred in glycated hemoglobin. Differential findings suggest that patients with poorly controlled diabetes tend to benefit most from disease management in terms of improved clinical measures. Additionally, a greater measurement frequency was associated with better outcomes, while longer length of follow-up was accompanied by less positive results. CONCLUSIONS: Despite concerted efforts to adjust for potential sources of confounding and bias, there ultimately are limits to the validity and reliability of findings from uncontrolled research based on routine intervention data. While our findings are supported by previous randomized research in other settings, the trends in outcome measures presented here may have alternative explanations. Further practice-based research, perhaps using historical data to retrospectively construct a control group, is necessary to confirm results and learn more about the impact of population-wide disease management

The effectiveness of chronic care management for heart failure: meta-regression analyses to explain the heterogeneity in outcomes

Objective: To support decision making on how to best redesign chronic care by studying the heterogeneity in effectiveness across chronic care management evaluations for heart failure.\ud \ud Data Sources: Reviews and primary studies that evaluated chronic care management interventions.\ud \ud Study design: A systematic review including meta-regression analyses to investigate three potential sources of heterogeneity in effectiveness: study quality, length of follow-up, and number of Chronic Care Model (CCM) components.\ud \ud Principal findings: Our meta-analysis showed that chronic care management reduces mortality by a mean of 18% (95% CI: 0.72-0.94) and hospitalization by a mean of 18% (95% CI: 0.76-0.93) and improves quality of life by 7.14 points (95% CI: -9.55 - -4.72) on the Minnesota Living with Heart Failure questionnaire. We could not explain the considerable differences in hospitalization and quality of life across the studies.\ud \ud Conclusion: Chronic care management significantly reduces mortality. Positive effects on hospitalization and quality of life were shown, however, with substantial heterogeneity in effectiveness. This heterogeneity is not explained by study quality, length of follow-up, or the number of CCM components. More attention to the development and implementation of chronic care management is needed to support informed decision making on how to best redesign chronic care

Immunocytochemical characterization of explant cultures of human prostatic stromal cells

The study of stromal-epithelial interactions greatly depends on the ability to culture both cell types separately, in order to permit analysis of their interactions under defined conditions in reconstitution experiments. Here we report the establishment of explant cultures of human prostatic stromal cells and their immunocytochemical characterization. As determined by antibodies to keratin and prostate specific acid phosphatase, only small numbers (<5%) of epithelial cells were present in primary cultures; subsequent passaging further reduced epithelial cell contamination. Antibodies against intermediate filament proteins (keratins, vimentin, and desmin) and smooth muscle actin microfilaments demonstrated that stromal cells from benign prostatic hyperplasia and prostate carcinoma differed in regard to their differentation markers. Two contrasting phenotypes were identified in cultures derived from these two different lesions: One, exhibiting fibroblastic features, was predominant in cultures derived from benign lesions and a second, showing varying degrees of smooth muscle differentiation, was more abundant in carcinoma-derived cultures. These findings are indicative of a remarkable divergence in the stromal-epithelial relationships associated with these pathological conditions and may provide us with a potential tool for studying these processes

Extraction of steviol glycosides from fresh Stevia using acidified water; clarification followed by ultrafiltration and nanofiltration

As part of the PPS Kleinschalige bioraffinage project (WP1b), fresh Stevia material was used in the extraction of steviol glycosides using water acidified through conversion of sugar by microorganisms naturally present on the plant. Two successive harvests from the same plot were used. Previous experiments had resulted in high steviol glycoside extraction rates of 80 % to 90 % but the purity of the final extract was low (15 % to 20 % of steviol glycosides in the dry matter). The first batch of plants was used to test a clarification step by filtration on a small scale. A second batch of plants was used to perform clarification, purification using ultrafiltration, and concentration by nanofiltration on a larger scale