Advancing integrated care evaluation in shifting contexts: blending implementation research with case study design in project SUSTAIN

Background: Despite many studies evaluating the effectiveness of integrated care, evidence remains inconsistent. There is increasing commentary pointing out the mismatch between the ability to capture the somewhat ‘illusive’ impact of integrated care initiatives and programmes, and the most appropriate way to do this. Focusing on methodology, this paper describes and critically reviews the experiences of SUSTAIN, a Horizon 2020 funded project (2015–2019) with the purpose of advancing knowledge and understanding of cross-European integrated care evaluation. SUSTAIN sought to improve integrated care initiatives for older people in seven countries, and to maximise the potential for knowledge transfer and application across Europe. The methods approach drew from implementation research, employing the participative Evidence Integration Triangle (EIT) and incorporating a mixed method, multiple embedded case study design. A core set of qualitative and quantitative indicators, alongside context and process data, were created and tested within four key project domains (person-centredness, prevention-orientation, safety and efficiency). The paper critically discusses the overall approach, highlighting the value of the EIT and case study design, and signalling the challenges of data collection with frail older people and stakeholder involvement at the sites, as well as difficulties developing the core set of indicators. Conclusions: Lessons learned and recommendations for advancing integrated care evaluation are put forward that focus on the status of integrated care as a complex intervention and a process. The use of implementation research methods and case study design are recommended as an additional evaluation approach for researchers to consider, alongside suggested ways of improving methods of data collection with frail populations and cost analys

Implementation of geriatric assessment and decision support in residential care homes: facilitating and impeding factors.

Background: Successfully introducing and maintaining care innovations may depend on the interplay between care setting, the intervention and specific circumstances. We studied the factors influencing the introduction and maintenance of a Multidisciplinary Integrated Care model in 10 Dutch residential care homes. Methods. Facilitating and impeding factors were studied and compared at the time of introduction of the interRAI-LTCF assessment method in residential care homes as well as three years later, by surveys and semi structured interviews among nurse staff, managers, and physicians. Results: Facilitating factors at introduction were positive opinions of staff and family physicians about the changes of the process of care and the anticipated improvement of quality of care. Staff was positive about the applicability of the software to support the interRAI-LTCF assessments. Impeding factors were time constraints to complete interRAI-LTCF assessments and insufficient computer equipment.In the maintenance phase, the positive attitude of the location manager and the perceived benefits of the care model and the interRAI-LTCF assessment method were most important. Impeding factors after 3 years remained the lack of time to complete the assessments and lack of sufficient computer equipment. Conclusions: Impeding and facilitating factors were comparable in the initial and maintenance phase. Adoption of the interRAI-LTCF assessment method depended on positive opinions of staff and management, continuing support of staff and the availability of sufficient computer equipment. © 2013 Boorsma et al.; licensee BioMed Central Ltd

Informational needs of general practitioners regarding discharge medication: Content, timing and pharmacotherapeutic advices

Objective: To investigate the needs of Dutch general practitioners on discharge medication, both regarding content, timing and the appreciation of pharma-cotherapeutic advices from clinical pharmacists. Setting: A general teaching hospital in Amsterdam, the Netherlands. Method: A prospective observational study was performed. A questionnaire with regard to the content, optimal timing (including way of information transfer) and appreciation of pharmacotherapeutic advices was posted to 464 general practitioners. One reminder was sent. Main outcome measure: Description of the needs of general practitioners was assessed. For each question and categories of comments frequency tables were made. The Fisher-exact test was used to study associations between the answers to the questions. Results: In total, 149 general practitioners (32%) responded. Most gene

A cross-sectional study to compare care needs of individuals with and without dementia in residential homes in the Netherlands

Background: Little is known about met and unmet needs of individuals in residential care, many of whom suffer from dementia. Unmet needs are associated with a decreased quality of life, worse mental health, dissatisfaction with services, and increased costs of care. The aim of this study was to compare the number and type of (unmet) needs of people with and without dementia in residential care in the Netherlands. Methods: 187 individuals in residents care or their relatives were interviewed to identify their care needs on 24 topics using the Camberwell Assessment of Needs for the Elderly (CANE) interview. Results: Individuals diagnosed with probable dementia reported more needs in total and more unmet needs in comparison with individuals without this diagnosis. More specifically, differences were found for the topics "accommodation", "money", "benefits", "medication management", "incontinence", "memory problems", "inadvertent self-harm", "company" and "daytime activities". Conclusions: It seems that the differences in care needs between individuals with and without dementia can be attributed to actual differences in physical and cognitive functioning. Residents with dementia reported more often unmet needs which might imply that care for people with dementia can still be better attuned to their needs

Impact of Communicating Familial Risk of Diabetes on Illness Perceptions and Self-Reported Behavioral Outcomes: A randomized controlled trial

OBJECTIVE: To assess the potential effectiveness of communicating familial risk of diabetes on illness perceptions and self-reported behavioral outcomes. RESEARCH DESIGN AND METHODS: Individuals with a family history of diabetes were randomized to receive risk information based on familial and general risk factors (n = 59) or general risk factors alone (n = 59). Outcomes were assessed using questionnaires at baseline, 1 week, and 3 months. RESULTS: Compared with individuals receiving general risk information, those receiving familial risk information perceived heredity to be a more important cause of diabetes (P <0.01) at 1-week follow-up, perceived greater control over preventing diabetes (P <0.05), and reported having eaten more healthily (P = 0.01) after 3 months. Behavioral intentions did not differ between the groups. CONCLUSIONS: Communicating familial risk increased personal control and, thus, did not result in fatalism. Although the intervention did not influence intentions to change behavior, there was some evidence to suggest it increases healthy behavio

Is It Time for a Change? A Cost-Effectiveness Analysis Comparing a Multidisciplinary Integrated Care Model for Residential Homes to Usual Care

OBJECTIVE: The objective of this study was to evaluate the cost-effectiveness of a Multidisciplinary Integrated Care (MIC) model compared to Usual Care (UC) in Dutch residential homes. METHODS: The economic evaluation was conducted from a societal perspective alongside a 6 month, clustered, randomized controlled trial involving 10 Dutch residential homes. Outcome measures included a quality of care weighted sum score, functional health (COOP WONCA) and Quality Adjusted Life-Years (QALY). Missing cost and effect data were imputed using multiple imputation. Bootstrapping was used to analyze differences in costs and cost-effectiveness. RESULTS: The quality of care sum score in MIC was significantly higher than in UC. The other primary outcomes showed no significant differences between the MIC and UC. The costs of providing MIC were approximately €225 per patient. Total costs were €2,061 in the MIC group and €1,656 for the UC group (mean difference €405, 95% -13; 826). The probability that the MIC was cost-effective in comparison with UC was 0.95 or more for ceiling ratios larger than €129 regarding patient related quality of care. Cost-effectiveness planes showed that the MIC model was not cost-effective compared to UC for the other outcomes. INTERPRETATION: Clinical effect differences between the groups were small but quality of care was significantly improved in the MIC group. Short term costs for MIC were higher. Future studies should focus on longer term economic and clinical effects. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN11076857

Supporting Older People to Live Safely at Home – Findings from Thirteen Case Studies on Integrated Care Across Europe

Introduction: While many different factors can undermine older people’s ability to live safely at home, safety as an explicit aspect of integrated care for older people living at home is an underexplored topic in research. In the context of a European project on integrated care, this study aims to improve our understanding of how safety is addressed in integrated care practices across Europe. Methods: This multiple case study included thirteen integrated care sites from seven European countries. The Framework Method guided content analyses of the case study reports. Activities were clustered into activities aimed at identifying and managing risks, or activities addressing specific risks related to older people’s functioning, behaviour, social environment, physical environment and health and social care receipt. Results: Case studies included a broad range of activities addressing older people’s safety. Although care providers felt they sufficiently addressed safety issues, older people were often concerned and insecure about their safety. Attention to the practical and social aspects of safety was often insufficient. Conclusions and discussion: Integrated care services across Europe address older people’s safety in many ways. Further integration of health and social care solutions is necessary to enhance older people’s perceptions of safety

Endothelial Dysfunction Plays a Key Role in Increasing Cardiovascular Risk in Type 2 Diabetes The Hoorn Study

In the pathogenesis of cardiovascular events, interaction between risk factors has seldom been identified. However, endothelial dysfunction on the one hand and type 2 diabetes mellitus, impaired glucose metabolism (IGM), and insulin resistance on the other may act synergistically (ie, interact) in the development of cardiovascular disease. We therefore investigated the interaction between endothelial dysfunction and type 2 diabetes mellitus, IGM, and insulin resistance with regard to risk of cardiovascular events. In a prospective population-based cohort (n=445; 69 years; 55% women; 23% type 2 diabetes mellitus, 28% IGM [by design]), endothelial dysfunction (brachial artery flow-mediated dilatation), glucose tolerance (oral glucose tolerance test), and insulin sensitivity (homeostasis model assessment for insulin resistance [HOMA2-IR]) were determined. After a median follow-up of 7.6 years, 106 participants had had a cardiovascular event. After adjustments, 1 SD less flow-mediated dilatation was associated with cardiovascular events in type 2 diabetes mellitus (hazard ratio 1.69 [95% confidence interval, 1.14-2.52]) and IGM (1.50 [0.95-2.37]) and among those in the highest HOMA2-IR tertile (1.92 [1.42-2.60]), but not in normal glucose metabolism (0.85 [0.63-1.16]) or among those in the lower 2 HOMA2-IR tertiles combined (0.85 [0.65-1.12]). Interaction between flow-mediated dilatation and type 2 diabetes mellitus, IGM, or insulin resistance was present on an additive (relative excess risk caused by interaction &gt;0) and on a multiplicative scale (P interactio