Incorporating patient preferences in the management of multiple long-term conditions: is this a role for clinical practice guidelines?

Background: Clinical practice guidelines provide an evidence-based approach to managing single chronic conditions, but their applicability to multiple conditions has been actively debated. Incorporating patient-preference recommendations and involving consumers in guideline development may enhance their applicability, but further understanding is needed. Objectives: To assess guidelines that include recommendations for comorbid conditions to determine the extent to which they incorporate patient-preference recommendations; use consumer-engagement processes during development, and, if so, whether these processes produce more patient-preference recommendations; and meet standard quality criteria, particularly in relation to stakeholder involvement. Design: A review of Australian guidelines published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. Document analysis of guidelines examined the presence of patient-preference recommendations and the consumer-engagement processes used. The Appraisal of Guidelines for Research and Evaluation instrument was used to assess guideline quality. Results: Thirteen guidelines were reviewed. Twelve included at least one core patient-preference recommendation. Ten used consumer-engagement processes, including participation in development groups (seven guidelines) and reviewing drafts (ten guidelines). More extensive consumer engagement was generally linked to greater incorporation of patient-preference recommendations. Overall quality of guidelines was mixed, particularly in relation to stakeholder involvement. Conclusions: Guidelines do incorporate some patient-preference recommendations, but more explicit acknowledgement is required. Consumer-engagement processes used during guideline development have the potential to assist in identifying patient preferences, but further research is needed. Clarification of the consumer role and investment in consumer training may strengthen these processes.Journal of Comorbidity 2015;5(1):122–13

Are care plans suitable for the management of multiple conditions?

Care plans have been part of the primary care landscape in Australia for almost two decades. With an increasing number of patients presenting with multiple chronic conditions, it is timely to consider whether care plans meet the needs of patients and clinicians.To review and benchmark existing care plan templates that include recommendations for comorbid conditions, against four key criteria: (i) patient preferences, (ii) setting priorities, (iii) identifying conflicts and synergies between conditions, and (iv) setting dates for reviewing the care plan.Document analysis of Australian care plan templates published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care.Sixteen templates were reviewed. All of the care plan templates addressed patient preference, but this was not done comprehensively. Only three templates included setting priorities. None assisted in identifying conflicts and synergies between conditions. Fifteen templates included setting a date for reviewing the care plan.Care plans are a well-used tool in primary care practice, but their current format perpetuates a single-disease approach to care, which works contrary to their intended purpose. Restructuring care plans to incorporate shared decision-making and attention to patient preferences may assist in shifting the focus back to the patient and their care needs

Increasing access to consumer health organisations among patients with chronic disease - a randomised trial of a print-based intervention

To assess whether a print-based intervention led to increased contact with consumer health organisations (CHOs) by general practice patients with chronic disease. CHOs can enhance people's capacity to manage chronic illness by providing information, education and psychosocial support. However, these organisations appear to be grossly under-utilised by patients and clinicians. A total of 276 patients completed a computer-assisted telephone interview before randomisation to an intervention (n = 141) or control (n = 135) group. The intervention consisted of mailed printed materials designed to encourage contact with a CHO relevant to the patient's main diagnosed chronic condition. Follow-up interviews were conducted 4 and 12 months later. Patients with conditions other than diabetes who received the intervention were twice as likely as those in the control group to contact a consumer health organisation during the 12-month study period: 41% versus 21% (P < 0.001). No such effect was found for diabetes patients, probably because of pre-existing high levels of contact with diabetes organisations. The intervention package received strong patient endorsement. Low-intensity interventions may be effective in improving access to CHOs for patients with chronic disease

Who Knows They Have A Treatment Plan?

Background:Guidelines for the effective care of chronic and complex conditions increasingly recommend developing treatment plans in collaboration with patients as one strategy in a coordinated approach to management. We examined the socio-demographic characteristics associated with the development of treatment plans for patients with asthma, diabetes or a cardiovascular condition to establish what proportion of patients with these conditions recalled being consulted in the plan’s preparation. Method:Serial, cross-sectional population based surveys using computer assisted telephone interviews (CATI) with 2,296 randomly selected adult participants with asthma, diabetes or a cardiovascular condition living in Queensland in 2006 and 2,203 adults with these conditions in 2008.Results:The proportion of patients with asthma, diabetes or a cardiovascular condition aware of having a treatment plan for their chronic condition increased almost two-fold between 2006 and 2008. Approximately half the respondents did not recall being asked for their input into the plan. Patients with a cardiovascular condition, older patients, and early school leavers were less likely to recall having a treatment plan. There were some variations when each condition was examined separately.Conclusion:Overall, the use of treatment plans and engagement of patients in their development remains low, particularly in those subgroups of the community who are most likely to benefit.

Investigating referral pathways from primary care to consumer health organisations

While chronic disease places an increasing burden on Australia's primary care system it is unrealistic to expect GPs to meet the range of support needs experienced by patients managing chronic conditions. Consumer health organisations (CHO) have the potential to augment clinical care by providing a variety of supportive services; however, they are underutilised by patients and GPs. This qualitative study investigates GPs' knowledge and perceptions of CHO and their contributions to chronic disease care The study involved semi-structured interviews with 10 GPs. Overall, participants demonstrated clear understanding of the role of CHO in chronic disease management, but a critical finding was the way GPs' view of their own chronic care role appears to influence referral practices. GPs operating in a traditional role were less likely to refer to CHO than those who had adopted a chronic care approach. A second key finding related to GPs' views of Diabetes Australia. All GPs identified this organisation as an important referral point, providing some reassurance that CHO can be integrated into the primary care sector. Further research is needed to determine how the 'definite advantages' associated with Diabetes Australia can be used to extend GP referral and enhance the health system's integration of other CHO

Why do people with chronic disease not contact consumer health organisations? A survey of general practice patients

Aim Consumer health organisations (CHOs) are non-profit or voluntary sector organisations that promote and represent the interests of patients and carers affected by particular conditions. The purpose of this study was to examine, among patients with chronic disease, what differentiates those who contact CHOs from those who do not and what stops people from making contact. Background CHOs can enhance people's capacity to manage chronic disease by providing information, education and psychosocial support, but are under-utilised. Little is known about barriers to access. Methods Data were from a baseline telephone survey conducted as part of a randomised trial of an intervention to improve access to CHOs. Participants constituted a consecutive sample of 276 adults with diagnosed chronic disease recruited via 18 general practitioners in Brisbane, Australia. Quantitative survey items examined participants' use and perceptions of CHOs and a single open-ended question explored barriers to CHO use. Multiple logistic regression and thematic analysis were used. Findings Overall, 39% of participants had ever contacted a CHO for their health and 28% had contacted a CHO specifically focussed on their diagnosed chronic condition. Diabetes, poorer self-reported physical health and greater health system contact were significantly associated with CHO contact. The view that 'my doctor does it all' was prevalent and, together with a belief that their health problems were 'not serious enough', was the primary reason patients did not make contact. Conclusion Attitudinal and system-related barriers limit use of CHOs by those for whom they are designed. Developing referral pathways to CHOs and promoting awareness about what they offer is needed to improve access

Supporting parents following pregnancy loss: A cross-sectional study of telephone peer supporters

Background: The death of a baby before or soon after birth can place an enormous psychological toll on parents. Parent support groups have grown in response to bereaved parents' unmet needs for support. Peer support is the hallmark of these organisations but little is known about the experiences of volunteers who provide support. This study examines the perceptions and experiences of parent support group volunteers who deliver a 24-h telephone support service for the Australian Stillbirth and Newborn Death Support (Sands) organisation in order to inform the ongoing development and sustainability of effective peer support. This parent-led organisation has delivered support to those affected by miscarriage, stillbirth and newborn death for more than 30 years

Consumer perspectives on pharmacy staff roles in providing oral health services in Australia

Australian and international findings report pharmacy staff are motivated to expand and undertake new roles in public health and expressed a strong interest in providing oral healthcare services to the community. We sought to describe consumer experiences within primary oral healthcare, and views about pharmacy staff roles and boundaries in providing oral health services as perceived by a sample of consumers living within metropolitan Australia. Sampling occurred purposively to enable diverse perspectives on the topic. Socioeconomic status, as defined by the Socio-Economic Index for Areas, was used as the primary criteria to stratify focus group recruitment. Thematic, in-depth analysis of focus group discussions was carried out. In all, 34 participants took part in six focus groups, held in metropolitan settings in Queensland, Australia. Findings show that consumers supported pharmacy staff performing non-invasive oral health services including providing oral health education and advice, reviewing medications and recommending evidence-based medications. As services became more invasive (i.e., oral screening and fluoride application), questions and concerns were raised around the appropriateness of the community pharmacy setting and the level of training of pharmacy staff to provide these services. This study identifies the need to support greater integration of oral healthcare roles by community pharmacy staff. Future innovative and collaborative research involving additional stakeholder groups are necessary to explore, develop and test the feasibility and effectiveness of pharmacy-led oral healthcare models

Intimate partner violence prevention: using interactive drama for intimate relationship education with young people in Samoa

Globally, young people experience physical, sexual and emotion abuse within their intimate relationships. There is a need to explore creative, participatory sexual and relationship education that provides spaces for critical reflection regarding gender norms and approaches within intimate relationships. This study explores an interactive theatre intervention aimed at uncovering and analysing social and cultural influences affecting experiences and approaches within intimate relationships among young people in Samoa. Focus groups were conducted with the audience before and after a public, interactive theatre production. Focus groups aimed to capture shifts in understandings and perceptions as well as overall experiences related to participating in the production. Post production, participants showed a deepened of understandings related to social and cultural factors influencing approaches and actions within intimate relationships. Participants engaged in dialogue around new possible approaches to initiating and maintaining intimate relationships free from violence. Embodied learning opportunities appeared to contribute to feelings of empowerment to try out new responses in everyday life. Study findings highlight a role for drama in intimate relationship education and advocate for the inclusion of intersectionality informed approaches that uncover diversity within a group and acknowledge interactions between individuals’ social position(s) within complex social and cultural contexts