Team Effectiveness in Patient Health Management: An Overview of Reviews

Background: The desire to improve the quality of health care for an aging population with multiple chronic diseases is fostering a rapid growth in inter-professional team care, supported by health professionals, governments, businesses and public institutions. However, the weight of evidence measuring the impact of team care on patient and health system outcomes has not, heretofore, been clear. To address this deficiency, we evaluated published evidence for the clinical effectiveness of team care within a chronic disease management context in a systematic overview. Methods: A search strategy was built for Medline using medical subject headings and other relevant keywords. After testing for perform- ance, the search strategy was adapted to other databases (Cinhal, Cochrane, Embase, PsychInfo) using their specific descriptors. The searches were limited to reviews published between 1996 and 2011, in English and French languages. The results were analyzed by the number of studies favouring team intervention, based on the direction of effect and statistical significance for all reported outcomes. Results: Sixteen systematic and 7 narrative reviews were included. Diseases most frequently targeted were depression, followed by heart failure, diabetes and mental disorders. Effective- ness outcome measures most commonly used were clinical endpoints, resource utilization (e.g., emergency room visits, hospital admissions), costs, quality of life and medication adherence. Briefly, while improved clinical and resource utilization endpoints were commonly reported as positive outcomes, mixed directional results were often found among costs, medication adherence, mortality and patient satisfaction outcomes. Conclusions: We conclude that, although suggestive of some specific benefits, the overall weight of evidence for team care efficacy remains equivocal. Further studies that examine the causal interactions between multidisciplinary team care and clinical and economic outcomes of disease management are needed to more accurately assess its net program efficacy and population effectiveness

Economic evaluations of scaling up strategies of evidence-based health interventions : a systematic review protocol

Introduction: Scaling science aims to help roll out evidence-based research results on a wide scale to benefit more individuals. Yet, little is known on how to evaluate economic aspects of scaling up strategies of evidence-based health interventions. Methods and analysis: Using the Joanna Briggs Institute guidance on systematic reviews, we will conduct a systematic review of characteristics and methods applied in economic evaluations in scaling up strategies. To be eligible for inclusion, studies must include a scaling up strategy of an evidence-based health intervention delivered and received by any individual or organisation in any country and setting. They must report costs and cost-effectiveness outcomes. We will consider full or partial economic evaluations, modelling and methodological studies. We searched peer-reviewed publications in Medline, Web of Science, Embase, Cochrane Library Database, PEDE, EconLIT, INHATA from their inception onwards. We will search grey literature from international organisations, bilateral agencies, non-governmental organisations, consultancy firms websites and region-specific databases. Two independent reviewers will screen the records against the eligibility criteria and extract data using a pretested extraction form. We will extract data on study characteristics, scaling up strategies, economic evaluation methods and their components. We will appraise the methodological quality of included studies using the BMJ Checklist. We will narratively summarise the studies' descriptive characteristics, methodological strengths/weaknesses and the main drivers of cost-effectiveness outcomes. This study will help identify what are the trade-offs of scaling up evidence-based interventions to allocate resources efficiently

Annual population dynamics of mango fruit flies (Diptera: Tephritidae) in West Africa: Socio-economic aspects, host phenology and implications for management

Losses in West African commercial mango orchards due to fruit fly infestations have exceeded 50% by the middle of the crop season since 2005, resulting in considerable income loss for the growers. Materials and methods. In 2009, weekly monitoring of adult fruit fly species of economic significance was carried out in eight West African countries at 12 sites across five agro-ecological zones: (i) Humid Forest, (ii) Guinean savanna, (iii) Southern Sudan, (iv) Northern Sudan, and (v) Sahelian. Trapping was performed using methyl eugenol and terpinyl acetate in 288 Tephritraps, targeting Bactrocera invadens and Ceratitis cosyra. Results. The data showed that B. Invadens was present throughout the year in the Forest zone, abundant for 7 months, with a peak in May at the end of the mango season, C. cosyra being totally absent. In the Guinean savanna zone, B. invadens was abundant for 6-7 months, with a peak at the beginning of June coinciding with the season, with a few C. cosyra. In the Southern Sudan zone, B. invadens was abundant for 6 months, with a peak in mid-June during the season, C. cosyra peaking in April. In the Northern Sudan zone, B. invadens was abundant for 5 months, with a peak at the end of June at the end of the season, C. cosyra peaking in May. In the Sahelian zone, B. invadens was abundant for 4 months, peaking in August during the sea-son, C. cosyra peaking just before. These preliminary results showed that the exotic species, B. invadens, was present at high levels [mean peak of 378 flies per trap per day (FTD)] in all agro-eco-logical zones, while the native species, C. cosyra, preferred the drier zones of West Africa, with lower population levels (mean peak of 77 FTD).Conclusion. Detection trapping of male flies with parapheromones is a useful indicator of field population levels and could be used to deploy control measures (IPM package) in a timely manner when the Economic Injury Level is reached. Control strategies for these quarantine mango fruit fly species are discussed with respect to agro-ecological zones and the phenological stages of the mango tree. (Résumé d'auteur

The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting

BACKGROUND: Seven chronic disease prevention and management programs were implemented across Quebec with funding support from a provincial-private industry funding initiative. Given the complexity of implementing integrated primary care chronic disease management programs, a knowledge transfer meeting was held to share experiences across programs and synthesize common challenges and success factors for implementation. METHODS: The knowledge translation meeting was held in February 2014 in Montreal, Canada. Seventy-five participants consisting of 15 clinicians, 14 researchers, 31 knowledge users, and 15 representatives from the funding agencies were broken up into groups of 10 or 11 and conducted a strengths, weaknesses, opportunities, and threats analysis on either the implementation or the evaluation of these chronic disease management programs. Results were reported back to the larger group during a plenary and recorded. Audiotapes were transcribed and summarized using pragmatic thematic analysis. RESULTS AND DISCUSSION: Strengths to leverage for the implementation of the seven programs include: (1) synergy between clinical and research teams; (2) stakeholders working together; (3) motivation of clinicians; and (4) the fact that the programs are evidence-based. Weaknesses to address include: (1) insufficient resources; (2) organizational change within the clinical sites; (3) lack of referrals from primary care physicians; and (4) lack of access to programs. Strengths to leverage for the evaluation of these programs include: (1) engagement of stakeholders and (2) sharing of knowledge between clinical sites. Weaknesses to address include: (1) lack of referrals; (2) difficulties with data collection; and (3) difficulties in identifying indicators and control groups. Opportunities for both themes include: (1) fostering new and existing partnerships and stakeholder relations; (2) seizing funding opportunities; (3) knowledge transfer; (4) supporting the transformation of professional roles; (5) expand the use of health information technology; and (6) conduct cost evaluations. Fifteen recommendations related to mobilisation of primary care physicians, support for the transformation of professional roles, and strategies aimed at facilitating the implementation and evaluation of chronic disease management programs were formulated based on the discussions at this knowledge translation event. CONCLUSION: The results from this knowledge translation day will help inform the sustainability of these seven chronic disease management programs in Quebec and the implementation and evaluation of similar programs elsewhere

Chronic disease management programmes for adults with asthma (intervention Review)

BACKGROUND: The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education. OBJECTIVES: To evaluate the effectiveness of chronic disease management programmes for adults with asthma. SEARCH METHODS: Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews. SELECTION CRITERIA: We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months. DATA COLLECTION AND ANALYSIS: After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs). MAIN RESULTS: A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes. AUTHORS' CONCLUSIONS: There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation

Improving chronic illness care: Implementation and evaluation of interdisciplinary and patient-centred care

The prevalence of chronic diseases and conditions is steadily increasing in Canada and globally. Despite the availability of effective therapies, the management of chronic diseases remains far from optimal. Several reports and practice guidelines recommend that care should be patient-centred and delivered by health care teams as means to empower patients to engage in their own care decisions, enhance coordination of care, and make more efficient use of resources, ultimately leading to improved patient outcomes and safety. However, many challenges remain in implementing these approaches, including assessing and accumulating evidence on their effectiveness. The overall aim of this thesis is to contribute to evidence-informed patient-centred and interdisciplinary team (IDT) care in the context of quality chronic illness care through two interrelated research projects. Using a population-based survey, the first project assessed the level of support for patient-centred care (PCC) amongst the Canadian public and among health professionals. Significant associations were identified between support for PCC and support for both team-based care and the use of health information technology. These associations were identified from both the public and health professionals' perspectives. The second project used a convergent mixed methods design to investigate experiences of primary interdisciplinary care for low back pain. For the qualitative component, I employed a phenomenological approach to better understand the delivery and perceived impact of IDT care. The quantitative component used the Patient Assessment of Chronic Illness Care (PACIC) questionnaire to evaluate change in patient experience and to estimate the impact of patient and process variables on patient experience. The findings from the two components were reviewed for convergence, complementarity and discrepancy. Findings from project 1 suggest that implementation of health care teams supported by information and communication technologies are needed to deliver PCC. From the perspective of the participants in the qualitative inquiry of project 2, IDT care contributed to effective and patient-centred primary care. The quantitative component showed improved experience of care for the majority of the participants but did not demonstrate significant associations between change in experience of care and patient and process outcomes. Overall, implementing an IDT appears to be an appropriate approach to deliver PCC and improve the quality of chronic illness care. Based on these analyses, I propose strategies to help improve the implementation of IDT programs for low back pain. These recommendations can also inform similar primary care programs for other chronic conditions. Directions for future research include further evaluation of the structure and construct validity of the PACIC, and continued investigation of the relationships between PCC, patient experience, patient factors, and outcomes.Le nombre de cas de maladies et conditions chroniques ne cessent d'augmenter au Canada et dans le monde. Malgré le fait qu'il existe des traitements efficaces, la gestion des maladies chroniques (MCs) est loin d'être optimale. Dans ce domaine, un certain nombre de rapports et de directives recommandent que les traitements soient axés sur le patient et administrés par des professionnels de la santé travaillant en équipe afin de permettre aux patients de participer davantage à la prise de décisions, à la gestion de leur traitement et de tirer plus de profit des ressources mises à leur disposition. Tout cela permet de faire en sorte que les résultats des traitements des patients et leur bien-être soient de meilleure qualité. Il reste tout de même un certain nombre de défis à relever pour mettre ces approches en place, notamment l'évaluation et l'accumulation de données probantes sur l'efficacité réelle de ces approches. L'objectif de la présente thèse est de contribuer à l'amélioration de l'efficacité des soins administrés par des équipes interdisciplinaires (EIDs) et axés sur les patients, grâce à l'analyse des faits dans le cas de traitements de MCs, au moyen de deux projets de recherche concomitants. Le premier projet consiste, au moyen d'un sondage mené auprès du public canadien et des professionnels de la santé, à évaluer le niveau de soutien apporté aux soins axés sur le patient. J'ai identifié plusieurs associations entre le niveau de soutien aux soins axés sur le patient et le soutien aux soins dispensés en EIDs ainsi que l'utilisation de technologies d'information sur la santé. Ces associations sont identifiées selon les perceptions aussi bien des personnes concernées par ces maladies que les professionnels de la santé. Le deuxième projet consiste en un modèle convergent de recherche à méthode mixte conçues pour évaluer l'expérience vécue par les patients recevant des soins de santé primaires interdisciplinaires pour la douleur lombaire. En ce qui concerne la composante qualitative, j'ai utilisé une approche phénoménologique afin de mieux comprendre l'administration des soins prodigués par les EIDs, ainsi que l'incidence que ces soins ont sur les patients. La composante quantitative consiste en un questionnaire portant sur l'évaluation des soins lors de MCs afin d'évaluer l'expérience vécue par les patients et d'estimer l'impact des variables dans le cadre du processus de cette expérience. Les résultats de ces deux composantes ont été examinés pour déterminer les critères de convergence, de complémentarité ou de divergence. Les résultats du projet 1 indiquent que l'aide des EIDs, ainsi que les technologies d'information et de communication, sont nécessaires dans le cadre des soins axés sur les patients. Selon les patients dans l'étude qualitative du projet 2, les soins primaires administrés en EIDs ont permis de prodiguer des soins axés sur les patients de manière efficace. Les résultats de la composante quantitative ont indiqué une meilleure expérience de soins pour la plupart des patients, mais n'ont pas permis de démontrer une corrélation significative entre l'expérience des soins et les variables du processus de soins et résultats des patients. Dans l'ensemble, l'administration de soins par des EIDs semble être une approche adéquate pour prodiguer de meilleurs soins axés sur les patients atteints de MCs. Selon ces analyses, je suggère des stratégies permettant d'améliorer les programmes de soins administrés par des EIDs pour la douleur lombaire. Ces recommandations peuvent également être utiles pour des programmes de soins primaires dans le cadre d'autres MCs. Les recherches à venir incluent d'autres analyses de la validité de la structure et de la validité conceptuelle de l'évaluation des soins lors de MCs, ainsi que la continuation d'investigations sur la corrélation entre les soins axés sur les patients, l'expérience vécue par ces derniers, les facteurs liés aux patients et les résultats obtenus en la matière

Team Effectiveness in Patient Health Management: An Overview of Reviews

Background: The desire to improve the quality of health care for an aging population with multiple chronic diseases is fostering a rapid growth in inter-professional team care, supported by health professionals, governments, businesses and public institutions. However, the weight of evidence measuring the impact of team care on patient and health system outcomes has not, heretofore, been clear. To address this deficiency, we evaluated published evidence for the clinical effectiveness of team care within a chronic disease management context in a systematic overview. Methods: A search strategy was built for Medline using medical subject headings and other relevant keywords. After testing for perform- ance, the search strategy was adapted to other databases (Cinhal, Cochrane, Embase, PsychInfo) using their specific descriptors. The searches were limited to reviews published between 1996 and 2011, in English and French languages. The results were analyzed by the number of studies favouring team intervention, based on the direction of effect and statistical significance for all reported outcomes. Results: Sixteen systematic and 7 narrative reviews were included. Diseases most frequently targeted were depression, followed by heart failure, diabetes and mental disorders. Effective- ness outcome measures most commonly used were clinical endpoints, resource utilization (e.g., emergency room visits, hospital admissions), costs, quality of life and medication adherence. Briefly, while improved clinical and resource utilization endpoints were commonly reported as positive outcomes, mixed directional results were often found among costs, medication adherence, mortality and patient satisfaction outcomes. Conclusions: We conclude that, although suggestive of some specific benefits, the overall weight of evidence for team care efficacy remains equivocal. Further studies that examine the causal interactions between multidisciplinary team care and clinical and economic outcomes of disease management are needed to more accurately assess its net program efficacy and population effectiveness