Implementing a case management intervention for frequent users of the emergency department (I-CaM): An effectiveness-implementation hybrid trial study protocol

Background: ED overcrowding represents a significant public health problem in developed countries. Frequent users of the emergency departments (FUEDs; reporting 5 or more ED visits in the past year) are often affected by medical, psychological, social, and substance use problems and account for a disproportionately high number of ED visits. Past research indicates that case management (CM) interventions are a promising way to reduce ED overcrowding and improve FUEDs' quality of life. There is, however, very limited knowledge about how to disseminate and implement this intervention on a large scale to diverse clinical settings, including community hospitals and non-academic centers. This paper describes the protocol of a research project aiming to implement a CM intervention tailored to FUEDs in the public hospitals with ED in the French-speaking region of Switzerland and evaluate both the implementation process and effectiveness of the CM intervention. Methods: This research project uses a hybrid study design assessing both implementation and clinical outcomes. The implementation part of the study uses mixed methods a) to describe quantitatively and qualitatively factors that influence the implementation process, and b) to examine implementation effectiveness. The clinical part of the study uses a within-subject design (pre-post intervention) to evaluate participants' trajectories on clinical variables (e.g., quality of life, ED use) after receiving the CM intervention. We designed the study based on two implementation science frameworks. The Generic Implementation Framework guided the overall research protocol design, whereas the RE-AIM (reach, efficacy, adoption, implementation and maintenance) framework guided the implementation and effectiveness evaluations. Discussion: This research project will contribute to implementation science by providing key insights into the processes of implementing CM into broader practice. This research project is also likely to have both clinical and public health implications. Trial registration: NCT03641274, Registered 20 August 2018

Patterns of multimorbidity in working Australians

Background: Multimorbidity is becoming more prevalent. Previously-used methods of assessing multimorbidity relied on counting the number of health conditions, often in relation to an index condition (comorbidity), or grouping conditions based on body or organ systems. Recent refinements in statistical approaches have resulted in improved methods to capture patterns of multimorbidity, allowing for the identification of nonrandomly occurring clusters of multimorbid health conditions. This paper aims to identify nonrandom clusters of multimorbidity.Methods: The Australian Work Outcomes Research Cost-benefit (WORC) study cross-sectional screening dataset (approximately 78,000 working Australians) was used to explore patterns of multimorbidity. Exploratory factor analysis was used to identify nonrandomly occurring clusters of multimorbid health conditions.Results: Six clinically-meaningful groups of multimorbid health conditions were identified. These were: factor 1: arthritis, osteoporosis, other chronic pain, bladder problems, and irritable bowel; factor 2: asthma, chronic obstructive pulmonary disease, and allergies; factor 3: back/neck pain, migraine, other chronic pain, and arthritis; factor 4: high blood pressure, high cholesterol, obesity, diabetes, and fatigue; factor 5: cardiovascular disease, diabetes, fatigue, high blood pressure, high cholesterol, and arthritis; and factor 6: irritable bowel, ulcer, heartburn, and other chronic pain. These clusters do not fall neatly into organ or body systems, and some conditions appear in more than one cluster.Conclusions: Considerably more research is needed with large population-based datasets and a comprehensive set of reliable health diagnoses to better understand the complex nature and composition of multimorbid health conditions

Co- and multimorbidity patterns in primary care based on episodes of care: results from the German CONTENT project

Contains fulltext : 69171.pdf (publisher's version ) (Open Access)BACKGROUND: Due to technological progress and improvements in medical care and health policy the average age of patients in primary care is continuously growing. In equal measure, an increasing proportion of mostly elderly primary care patients presents with multiple coexisting medical conditions. To properly assess the current situation of co- and multimorbidity, valid scientific data based on an appropriate data structure are indispensable. CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) is an ambitious project in Germany to establish a system for adequate record keeping and analysis in primary care based on episodes of care. An episode is defined as health problem from its first presentation by a patient to a doctor until the completion of the last encounter for it. The study aims to describe co- and multimorbidity as well as health care utilization based on episodes of care for the study population of the first participating general practices. METHODS: The analyses were based on a total of 39,699 patients in a yearly contact group (YCG) out of 17 general practices in Germany for which data entry based on episodes of care using the International Classification of Primary Care (ICPC) was performed between 1.1.2006 and 31.12.2006. In order to model the relationship between the explanatory variables (age, gender, number of chronic conditions) and the response variables of interest (number of different prescriptions, number of referrals, number of encounters) that were applied to measure health care utilization, we used multiple linear regression. RESULTS: In comparison to gender, patients' age had a manifestly stronger impact on the number of different prescriptions, the number of referrals and number of encounters. In comparison to age (beta = 0.043, p < 0.0001), multimorbidity measured by the number of patients' chronic conditions (beta = 0.51, p < 0.0001) had a manifestly stronger impact the number of encounters for the observation period. Moreover, we could observe that the number of patients' chronic conditions had a significant impact on the number of different prescriptions (beta = 0.226, p < 0.0001) as well as on the number of referrals (beta = 0.3, p < 0.0001). CONCLUSION: Documentation in primary care on the basis of episodes of care facilitates an insight to concurrently existing health problems and related medical procedures. Therefore, the resulting data provide a basis to obtain co- and multimorbidity patterns and corresponding health care utilization issues in order to understand the particular complex needs caused by multimorbidity

What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom

Background Emergency ambulance services are integral to providing a service for those with unplanned urgent and life-threatening health conditions. However, high use of the service by a small minority of patients is a concern. Our objectives were to describe: service-wide and local policies or pathways for people classified as Frequent Caller; call volume; and results of any audit or evaluation. Method We conducted a national survey of current practice in ambulance services in relation to the management of people who call the emergency ambulance service frequently using a structured questionnaire for completion by email and telephone interview. We analysed responses using a descriptive and thematic approach. Results Twelve of 13 UK ambulance services responded. Most services used nationally agreed definitions for ‘Frequent Caller’, with 600–900 people meeting this classification each month. Service-wide policies were in place, with local variations. Models of care varied from within-service care where calls are flagged in the call centre; contact made with callers; and their General Practitioner (GP) with an aim of discouraging further calls, to case management through cross-service, multi-disciplinary team meetings aiming to resolve callers’ needs. Although data were available related to volume of calls and number of callers meeting the threshold for definition as Frequent Caller, no formal audits or evaluations were reported. Conclusions Ambulance services are under pressure to meet challenging response times for high acuity patients. Tensions are apparent in the provision of care to patients who have complex needs and call frequently. Multi-disciplinary case management approaches may help to provide appropriate care, and reduce demand on emergency services. However, there is currently inadequate evidence to inform commissioning, policy or practice development

A Preliminary Mixed-Method Investigation of Trust and Hidden Signals in Medical Consultations.

Background Several factors influence patients' trust, and trust influences the doctor-patient relationship. Recent literature has investigated the quality of the personal relationship and its dynamics by considering the role of communication and the elements that influence trust giving in the frame of general practitioner (GP) consultations. Objective We analysed certain aspects of the interaction between patients and GPs to understand trust formation and maintenance by focusing on communication channels. The impact of socio-demographic variables in trust relationships was also evaluated. Method A cross-sectional design using concurrent mixed qualitative and quantitative research methods was employed. One hundred adults were involved in a semi-structured interview composed of both qualitative and quantitative items for descriptive and exploratory purposes. The study was conducted in six community-based departments adjacent to primary care clinics in Trento, Italy. Results The findings revealed that patients trusted their GP to a high extent by relying on simple signals that were based on the quality of the one-to-one communication and on behavioural and relational patterns. Patients inferred the ability of their GP by adopting simple heuristics based mainly on the so-called social \u201chonest signals\u201d rather than on content-dependent features. Furthermore, socio-demographic variables affected trust: less literate and elderly people tended to trust more. Conclusions This study is unique in attempting to explore the role of simple signals in trust relationships within medical consultation: people shape trust and give meaning to their relationships through a powerful channel of communication that orbits not around words but around social relations. The findings have implications for both clinicians and researchers. For doctors, these results suggest a way of thinking about encounters with patients. For researchers, the findings underline the importance of analysing some new key factors around trust for future investigations in medical practice and education

Inactivation of the FLCN Tumor Suppressor Gene Induces TFE3 Transcriptional Activity by Increasing Its Nuclear Localization

Germline mutations in a tumor suppressor gene FLCN lead to development of fibrofolliculomas, lung cysts and renal cell carcinoma (RCC) in Birt-Hogg-Dubé syndrome. TFE3 is a member of the MiTF/TFE transcription factor family and Xp11.2 translocations found in sporadic RCC involving TFE3 result in gene fusions and overexpression of chimeric fusion proteins that retain the C-terminal DNA binding domain of TFE3. We found that GPNMB expression, which is regulated by MiTF, was greatly elevated in renal cancer cells harboring either TFE3 translocations or FLCN inactivation. Since TFE3 is implicated in RCC, we hypothesized that elevated GPNMB expression was due to increased TFE3 activity resulting from the inactivation of FLCN.TFE3 knockdown reduced GPNMB expression in renal cancer cells harboring either TFE3 translocations or FLCN inactivation. Moreover, FLCN knockdown induced GPNMB expression in FLCN-restored renal cancer cells. Conversely, wildtype FLCN suppressed GPNMB expression in FLCN-null cells. FLCN inactivation was correlated with increased TFE3 transcriptional activity accompanied by its nuclear localization as revealed by elevated GPNMB mRNA and protein expression, and predominantly nuclear immunostaining of TFE3 in renal cancer cells, mouse embryo fibroblast cells, mouse kidneys and mouse and human renal tumors. Nuclear localization of TFE3 was associated with TFE3 post-translational modifications including decreased phosphorylation.Increased TFE3 activity is a downstream event induced by FLCN inactivation and is likely to be important for renal tumor development. This study provides an important novel mechanism for induction of TFE3 activity in addition to TFE3 overexpression resulting from Xp11.2 translocations, suggesting that TFE3 may be more broadly involved in tumorigenesis

Development of a primary care-based complex care management intervention for chronically ill patients at high risk for hospitalization: a study protocol

Background: Complex care management is seen as an approach to face the challenges of an ageing society with increasing numbers of patients with complex care needs. The Medical Research Council in the United Kingdom has proposed a framework for the development and evaluation of complex interventions that will be used to develop and evaluate a primary care-based complex care management program for chronically ill patients at high risk for future hospitalization in Germany. Methods and design: We present a multi-method procedure to develop a complex care management program to implement interventions aimed at reducing potentially avoidable hospitalizations for primary care patients with type 2 diabetes mellitus, chronic obstructive pulmonary disease, or chronic heart failure and a high likelihood of hospitalization. The procedure will start with reflection about underlying precipitating factors of hospitalizations and how they may be targeted by the planned intervention (pre-clinical phase). An intervention model will then be developed (phase I) based on theory, literature, and exploratory studies (phase II). Exploratory studies are planned that entail the recruitment of 200 patients from 10 general practices. Eligible patients will be identified using two ways of 'case finding': software based predictive modelling and physicians' proposal of patients based on clinical experience. The resulting subpopulations will be compared regarding healthcare utilization, care needs and resources using insurance claims data, a patient survey, and chart review. Qualitative studies with healthcare professionals and patients will be undertaken to identify potential barriers and enablers for optimal performance of the complex care management program. Discussion: This multi-method procedure will support the development of a primary care-based care management program enabling the implementation of interventions that will potentially reduce avoidable hospitalizations