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Background: This study aimed to investigate the characteristics of frequent attenders (FAs) among older patients in Shanghai, China, and explore the associated factors. Methods: This cross-sectional study was conducted in six community health service centers in Shanghai, China, from August to December 2018 based on stratified sampling. On the basis of our preliminary study, FAs were defined as those attending at least four consultations in a month. A self-administered questionnaire was used to collect the clinicodemographic data of the participants. Social support, pain severity, depression, and anxiety were evaluated using the Social Support Revalued Scale, six-point Behavioral Rating Scale, Patient Health Questionnaire–9, and Generalized Anxiety Disorder Scale, respectively. Results: This study included 619 patients aged > 60 years. Among these patients, 155 (25%) were FAs to a community health service center, 366 (59.1%) had 1 or 2 chronic diseases, 179 (28.9%) had ≥3 chronic diseases, 313 (50.4%) opted for a family doctor service, and 537 (86.8%) chose a community health service center for the first consultation. The following were identified as independent risk factors for frequent attendance: widowed status, unmarried status, the presence of > 3 chronic diseases, first consultation at a community health service center, high medical expenses, frequent attendance of the spouses, long-term medication, the use of both traditional Chinese and Western medicine services, and depression. Conclusions: This study summarizes the characteristics of older FAs to community health service centers in China and identifies 10 risk factors significantly associated with frequent attendance. [ABSTRACT FROM AUTHOR]

Background: Rural residents with chronic conditions have a stronger need for health services, which should make using family doctor contract services a priority. This study aimed to evaluate the rate of willingness among rural residents with chronic conditions to contract with family doctors and examine its determinants. Methods: A cross-sectional study was conducted from May, 2018 to June, 2018 in Shandong Province in China. A total of 769 rural unsigned residents with chronic conditions were included in the analysis. Using the Andersen model as the theoretical framework, logistic regression models were chosen to analyse the factors associated with willingness to contract with family doctors. Results: This study found that the rate of willingness to contract with family doctors among chronic patients in rural Shandong was 46.7%. A higher willingness was observed in those living a further distance from the village clinic (more than 600 m: OR = 1.85, 95%CI =1.17–2.93), having received publicity for family doctor contract services (OR = 1.71, 95% CI = 1.06–2.76), reporting need for utilizing a chronic disease management program (OR = 3.36, 95% CI = 2.20–5.23), and reporting need for higher medical insurance reimbursement (OR = 1.91, 95% CI = 1.28–2.83). Conclusions: The prevalence of contract willingness was relatively low among unsigned rural residents with chronic conditions in rural Shandong, China. The need factors were powerful factors affecting their willingness to contract with family doctors. The government should therefore strengthen targeted publicity and education to rural residents with chronic conditions and provide targeted healthcare services, such as chronic disease management programs and medical services with higher reimbursement rates, to promote their willingness to contract with family doctors. [ABSTRACT FROM AUTHOR]

Background: Adequate health literacy (HL) levels contribute to good health outcomes and successful disease self-management in patients with chronic disease. Hence, it is essential that family doctors recognize patients with inadequate HL in need of additional support. This study had two aims: (1) to assess and compare patient self-reported versus family doctor-rated HL estimates, and (2) to explore associations between patient-reported HL, self-efficacy and chronic diseases. Methods: Participants in this cross-sectional survey were recruited through general practices in North Rhine-Westphalia, Germany. Patient self-reported HL was measured using the European Health Literacy Survey-16. Family doctor-rated HL was measured with an adapted version of this instrument. Using crosstabulations patient-reported and family doctor-rated HL estimates were compared for 346 patient-family doctor pairs. Associations between HL, self-efficacy and chronic disease were investigated using regression analyses. Results: Patient-reported and family doctor-rated HL estimates were concordant in 38% of all cases. On average family doctors rated their patients' HL lower than patients rated their own HL. The lower average family doctor ratings were more pronounced when patients were older, male and had more than one chronic disease. Female family doctors rated HL of male patients lower than their male colleagues. Patient reported HL had a significant positive association with self-efficacy. Mediation analysis provided support that self-efficacy acts as mediator between HL and the number of chronic diseases. Conclusions: Our study findings indicate a significant discrepancy between patients' self-reported HL and externally rated HL by family doctors. A more systematic utilization of HL screeners might help reduce this discrepancy. At the same time, consideration should be given to enhancing communication training for family doctors and addressing critical HL skills in patient education. [ABSTRACT FROM AUTHOR]

Background: Multimorbid patients may experience a high burden of treatment. This has a negative impact on treatment adherence, health outcomes and health care costs. The objective of our study was to identify factors associated with the self-perceived burden of treatment of multimorbid patients in primary care and to compare them with factors associated with GPs assessment of this burden. Method: A cross sectional study in general practices, 100 GPs in Switzerland and up to 10 multimorbid patients per GP. Patients reported their self-perceived burden of treatment using the Treatment Burden Questionnaire (TBQ, possible score 0–150), whereas GPs evaluated the burden of treatment on a Visual Analog Scale (VAS) from 1 to 9. The study explored medical, social and psychological factors associated with burden of treatment, such as number and type of chronic conditions and drugs, severity of chronic conditions (CIRS score), age, quality of life, deprivation, health literacy. Results: The GPs included 888 multimorbid patients. The overall median TBQ was 20 and the median VAS was 4. Both patients' and GPs' assessment of the burden of treatment were inversely associated with patients' age and quality of life. In addition, patients' assessment of their burden of treatment was associated with a higher deprivation score and lower health literacy, and with having diabetes or atrial fibrillation, whereas GPs' assessment of this burden was associated with the patient having a greater number of chronic conditions and drugs, and a higher CIRS score. Conclusion: Both from patients' and GPs' perspectives TB appears to be higher in younger patients. Whereas for patients the burden of treatment is associated with socio-economic and psychological factors, GPs' assessments of this burden are associated with medical factors. Including socio-economic and psychological factors on patients' self-perception is likely to improve GPs' assessments of their patients' burden of treatment thus favoring patient-centered care. [ABSTRACT FROM AUTHOR]

Background: Chronic diseases, primarily cardiovascular disease, respiratory disease, diabetes and cancer, are the leading cause of death and disability worldwide. In sub-Saharan Africa (SSA), where communicable disease prevalence still outweighs that of non-communicable disease (NCDs), rates of NCDs are rapidly rising and evidence for primary healthcare approaches for these emerging NCDs is needed. Methods: A systematic review and evidence synthesis of primary care approaches for chronic disease in SSA. Quantitative and qualitative primary research studies were included that focused on priority NCDs interventions. The method used was best-fit framework synthesis. Results: Three conceptual models of care for NCDs in low- and middle-income countries were identified and used to develop an a priori framework for the synthesis. The literature search for relevant primary research studies generated 3759 unique citations of which 12 satisfied the inclusion criteria. Eleven studies were quantitative and one used mixed methods. Three higher-level themes of screening, prevention and management of disease were derived. This synthesis permitted the development of a new evidence-based conceptual model of care for priority NCDs in SSA. Conclusions: For this review there was a near-consensus that passive rather than active case-finding approaches are suitable in resource-poor settings. Modifying risk factors among existing patients through advice on diet and lifestyle was a common element of healthcare approaches. The priorities for disease management in primary care were identified as: availability of essential diagnostic tools and medications at local primary healthcare clinics and the use of standardized protocols for diagnosis, treatment, monitoring and referral to specialist care. [ABSTRACT FROM AUTHOR]

Background: Life and healthcare demand work from patients, more so from patients living with multimorbidity. Patients must respond by mobilizing available abilities and resources, their so-called capacity. We sought to summarize accounts of challenges that reduce patient capacity to access or use healthcare or to enact self-care while carrying out their lives. Methods: We conducted a systematic review and synthesis of the qualitative literature published since 2000 identifying from MEDLINE, EMBASE, Psychinfo, and CINAHL and retrieving selected abstracts for full text assessment for inclusion. After assessing their methodological rigor, we coded their results using a thematic synthesis approach. Results: The 110 reports selected, when synthesized, showed that patient capacity is an accomplishment of interaction with (1) the process of rewriting their biographies and making meaningful lives in the face of chronic condition(s); (2) the mobilization of resources; (3) healthcare and self-care tasks, particularly, the cognitive, emotional, and experiential results of accomplishing these tasks despite competing priorities; (4) their social networks; and (5) their environment, particularly when they encountered kindness or empathy about their condition and a feasible treatment plan. Conclusion: Patient capacity is a complex and dynamic construct that exceeds "resources" alone. Additional work needs to translate this emerging theory into useful practice for which we propose a clinical mnemonic (BREWS) and the ICAN Discussion Aid. [ABSTRACT FROM AUTHOR]

Background: A rising number of people with chronic conditions is offered interventions to enhance self-management. The responsiveness of individuals to these interventions depends on patient characteristics. We aimed to develop and validate a tool to facilitate personalised counselling and support for self-management in patients with chronic diseases in primary care. Methods: We drafted a prototype of the tool for Self-Management Screening (SeMaS), comprising 27 questions that were mainly derived from validated questionnaires. To reach high content validity, we performed a literature review and held focus groups with patients and healthcare professionals as input for the tool. The characteristics self-efficacy, locus of control, depression, anxiety, coping, social support, and perceived burden of disease were incorporated into the tool. Three items were added to guide the type of support or intervention, being computer skills, functioning in groups, and willingness to perform self-monitoring. Subsequently, the construct and criterion validity of the tool were investigated in a sample of 204 chronic patients from two primary care practices. Patients filled in the SeMaS and a set of validated questionnaires for evaluation of SeMaS. The Patient Activation Measure (PAM-13), a generic instrument to measure patient health activation, was used to test the convergent construct validity. Results: Patients had a mean age of 66.8 years and 46.6 % was female. 5.9 % did not experience any barrier to self-management, 28.9 % experienced one minor or major barrier, and 30.4 % two minor or major barriers. Compared to the criterion measures, the positive predictive value of the SeMaS characteristics ranged from 41.5 to 77.8 % and the negative predictive value ranged from 53.3 to 99.4 %. Crohnbach's alpha for internal consistency ranged from 0.56 to 0.87, except for locus of control (α = 0.02). The regression model with PAM-13 as a dependent variable showed that the SeMaS explained 31.7 % (r2 = 0.317) of the variance in the PAM-13 score. Conclusions: SeMaS is a short validated tool that can signal potential barriers for self-management that need to be addressed in the dialogue with the patient. As such it can be used to facilitate personalised counselling and support to enhance self-management in patients with chronic conditions in primary care. [ABSTRACT FROM AUTHOR]

Background: Although widespread problems in patient-professional interaction and insufficient support of patients' selfmanagement abilities have been recognized, research investigating the relationships among care quality, productive interaction, and self-management abilities to maintain overall well-being is lacking. Furthermore, studies have revealed differences in these characteristics among certain groups (e.g., less-educated and older patients). This longitudinal study thus aimed to identify relationships among background characteristics, quality of care, productivity of patient-professional interaction, and self-management abilities to maintain overall well-being in chronically ill patients participating in 18 Dutch disease management programs. Methods: This longitudinal study included patients participating in 18 Dutch disease management programs. Surveys were administered in 2011 (T1; n = 2191 (out of 4693), 47 % response rate) and 2012 (T2: n = 1722 (out of 4350), 40 % response rate). A total of 1279 patients completed questionnaires at both timepoints (T1 and T2) (27 % response rate). Self-management abilities to maintain well-being were measured using the short (18-item) version of the Self- Management Ability Scale (SMAS-S), patients' perceptions of the productivity of interactions with health care professionals were assessed with the relational coordination instrument and the short (11-item) version of the Patient Assessment of Chronic Illness Care (PACIC-S) was used to assess patients' perceptions of the quality of chronic care delivery. Results: Perceived and objective quality of care and the productivity of patient-professional interaction were found to be related to patients' self-management abilities to maintain overall well-being. These abilities were related negatively to and significantly predicted by low educational level, single status, and older age, despite the mediating role of productive interaction in their relationship with patients' perceptions of care quality. Conclusions: These findings suggest that patient-professional interaction is not yet sufficiently productive to successfully protect against the deterioration of self-management abilities in some groups of chronically ill patients, although such interaction and high-quality care are important factors in such protection. Improvement of the quality of chronic care delivery should thus always be accompanied by investment in high-quality communication and patient- professional relationships. [ABSTRACT FROM AUTHOR]

Background: The increasing prevalence of chronic disease faced by both developed and developing countries is of considerable concern to a number of international organisations. Many of the interventions to address this concern within primary healthcare settings are based on the chronic care model (CCM). The implementation of complex interventions such as CCMs requires careful consideration and planning. Success depends on a number of factors at the healthcare provider, team, organisation and system levels. Methods: The aim of this systematic review was to systematically examine the scientific literature in order to understand the facilitators and barriers to implementing CCMs within a primary healthcare setting. This review focused on both quantitative and qualitative studies which included patients with chronic disease (cardiovascular disease, chronic kidney disease, chronic respiratory disease, type 2 diabetes mellitus, depression and HIV/AIDS) receiving care in primary healthcare settings, as well as primary healthcare providers such as doctors, nurses and administrators. Papers were limited to those published in English between 1998 and 2013. Results: The search returned 3492 articles. The majority of these studies were subsequently excluded based on their title or abstract because they clearly did not meet the inclusion criteria for this review. A total of 226 full text articles were obtained and a further 188 were excluded as they did not meet the criteria. Thirty eight published peer-reviewed articles were ultimately included in this review. Five primary themes emerged. In addition to ensuring appropriate resources to support implementation and sustainability, the acceptability of the intervention for both patients and healthcare providers contributed to the success of the intervention. There was also a need to prepare healthcare providers for the implementation of a CCM, and to support patients as the way in which they receive care changes. Conclusion: This systematic review demonstrated the importance of considering human factors including the influence that different stakeholders have on the success or otherwise of the implementing a CCM. [ABSTRACT FROM AUTHOR]

Background Practice accreditation is widely used to assess and improve quality of healthcare providers. Little is known about its effectiveness, particularly in primary care. In this study we examined the effect of accreditation on quality of care regarding diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). Methods A comparative observational study with two cohorts was performed. We included 138 Dutch family practices that participated in the national accreditation program for primary care. A first cohort of 69 practices was measured at start and completion of a 3-year accreditation program. A second cohort of 69 practices was included and measured simultaneously with the final measurement of the first cohort. In separate multilevel regression analyses, we compared both within-group changes in the first cohort and between-groups differences at follow-up (first cohort) and start (second cohort). Outcome measures consisted of 24 systematically developed indicators of quality of care in targeted chronic diseases. Results In the within-group comparison, we found improvements on 6 indicators related to diabetes (feet examination, cholesterol measurement, lipid lowering medication prescription) and COPD (spirometry performance, stop smoking advice). In the between-groups comparison we found that first cohort practices performed better on 4 indicators related to diabetes (cholesterol outcome) and CVD (blood pressure outcome, smoke status registration, glucose measurement). Conclusions Improvements of the quality of primary care for patients with chronic diseases were found, but few could be attributed to the accreditation program. Further development of accreditation is needed to enhance its effectiveness on chronic disease management. [ABSTRACT FROM AUTHOR]

Background: The importance of proactive chronic care has become increasingly evident. Yet, it is unknown whether the use of general practice (GP) during daytime may affect the use of Out-of-Hours (OOH) Primary Care Service for people with chronic disease. We aimed to analyse the association between use of daytime general practice (GP) and use of OOH services for heart disease, lung disease, diabetes, psychiatric disease, or cancer. In particular, we intended to study the association between OOH contacts due to chronic disease exacerbation and recent use of daytime GP. Methods: Data comprised a random sample of contacts to the OOH services ('LV-KOS2011'). Included patients were categorised into the following chronic diseases: heart disease, lung disease, diabetes, psychiatric disease, or cancer. Information on face-to-face contacts to daytime GP was obtained from the Danish National Health Insurance Service Registry and information about exacerbation or new episodes from the LVKOS2011 survey. Associations between number of regular daytime consultations and annual follow-up consultations during one, three, six, and 12 months prior to index contacts, and outcomes of interest were estimated by using logistic regression. Results: In total, 11,897 patients aged ≥ 18 years were included. Of these, 2,665 patients (22.4%) were identified with one of the five selected chronic diseases; 673 patients (5.7%) had two or more. A higher odds ratio (OR) for exacerbation as reason for encounter (RFE) at the index contact was observed among patients with psychiatric disease (OR = 2.15) and cancer (OR = 2.17) than among other patients for ≥2 daytime recent contacts. When receiving an annual follow-up, exacerbation OR at index contact lowered for patients with lung disease (OR = 0.68), psychiatric disease (OR = 0.42), or ≥2 diseases (OR = 0.61). Conclusion: Recent and frequent use of daytime GP for patients with the selected chronic diseases was associated with contacts to the OOH services due to exacerbation. These findings indicate that the most severely chronically ill patients tend to make more use of general practice. The provision of an annual follow-up daytime GP consultation may indicate a lower risk of contacting OOH due to exacerbation. [ABSTRACT FROM AUTHOR]

Background: International and national bodies promote interdisciplinary care in the management of people with chronic conditions. We examine one facilitative factor in this team-based approach - the co-location of non-physician disciplines within the primary care practice. Methods: We used survey data from 330 General Practices in Ontario, Canada and New Zealand, as a part of a multinational study using The Quality and Costs of Primary Care in Europe (QUALICOPC) surveys. Logistic and linear multivariable regression models were employed to examine the association between the number of disciplines working within the practice, and the capacity of the practice to offer specialized and preventive care for patients with chronic conditions. Results: We found that as the number of non-physicians increased, so did the availability of special sessions/clinics for patients with diabetes (odds ratio 1.43, 1.25-1.65), hypertension (1.20, 1.03-1.39), and the elderly (1.22, 1.05-1.42). Co-location was also associated with the provision of disease management programs for chronic obstructive pulmonary disease, diabetes, and asthma; the equipment available in the centre; and the extent of nursing services. Conclusions: The care of people with chronic disease is the 'challenge of the century'. Co-location of practitioners may improve access to services and equipment that aid chronic disease management. [ABSTRACT FROM AUTHOR]

Background: Adults with chronic disease are the most frequent users of the primary healthcare system. In Manitoba, patients are allowed to seek ambulatory (outpatient) care from the provider of their choosing (primary care physician or specialist), with referrals to specialists preferred but not always required. Some patients receive their routine care from specialists. We conducted this study to determine the patterns by which adults with chronic disease access ambulatory care as a prelude to exploring the impact these patterns may have on the quality of care received. Methods: Physician claims for all visits between 2007/8-2009/10 were extracted from the Data Repository at the Manitoba Centre for Health Policy. Patients included in the analysis made at least four ambulatory visits to a primary care physician or specialist within the study period, and met the definition criteria for at least one of six chronic diseases: diabetes mellitus; congestive heart failure; mood disorders; ischemic heart disease; total respiratory morbidity; and/or hypertension. Patients were "assigned" to the physician they visited most regularly. Physician visit patterns were assessed by dividing visits into nine visit types based on the type of physician patients visited (assigned primary care physician, other primary care physician, or specialist) and whether or not they received a referral. Results: 347,606 patients with 7,662,411 physician visits were included in the analysis. Most visits were to the patients' assigned primary care physician. About 50% of the visits to specialists were by referral from the assigned primary care physician. However, 26-29% of all visits to a primary care physician were not to the assigned primary care physician, and non-assigned physicians were more likely to refer patients to specialists than assigned primary care physicians. Conclusion: The findings suggest that the current primary care system in Manitoba may not adequately support coordination of ambulatory care. Ambulatory visits to a primary care provider who is not the patient's regular provider may represent a lost opportunity for coordination and continuity of care, and may affect the quality of care patients receive. Primary care renewal initiatives in this province should address this challenge to service provision. [ABSTRACT FROM AUTHOR]

Background The Danish health care sector is reorganising based on disease management programmes designed to secure integrated and high quality chronic care across hospitals, general practitioners and municipalities. The disease management programmes assign a central role to general practice, and in the Capital Region of Denmark a facilitator-based intervention was undertaken to support the implementation of the programmes in general practice. The purpose of the study was to assess the effectiveness of this semi-tailored facilitator-based intervention. Method The study was a stepped-wedge, randomised, controlled trial among general practices in the Capital Region of Denmark. The intervention group was offered three one-hour visits by a facilitator. The intervention was semi-tailored to the perceived needs as defined by each general practice, and the practices could choose from a list of possible topics. The control group was a delayed intervention group. The primary outcome was change in the number of annual chronic disease check-ups. Secondary outcomes were: changes in the number of annual check-ups for type 2 diabetes (DM2) and chronic obstructive pulmonary disease (COPD), changes in the number of spirometry tests, changes in the use of ICPC diagnosis coding and patient stratification, sign-up for a software program for patient overview, and reduction in number of practices with few annual chronic disease check-ups. Results We randomised 189 general practices: 96 practices were allocated to the intervention group and 93 to the delayed intervention group. For the primary outcome, 94 and 89 practices were analysed. Almost every outcome improved from baseline to follow-up in both allocation groups. At follow-up there was no difference between allocation groups for the primary outcome (p = 0.1639). However, some secondary outcomes favoured the intervention: a higher reported use of ICPC diagnosis coding for DM2 and COPD (p = 0.0050, p = 0.0243 respectively), stratification for COPD (p = 0.0185) and a faster initial sign-up rate for the software program. Conclusion The mixed results from this study indicate that a semi-tailored facilitator-based intervention of relatively low intensity is unlikely to add substantially to the implementation of disease management programmes for DM2 and COPD in a context marked by important concurrent initiatives (including financial incentives and mandatory registry participation) aimed at moving all practices towards changes in chronic care. [ABSTRACT FROM AUTHOR]

Background: Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens. Methods: This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology. Results : The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives--re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices. Conclusions: The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare. [ABSTRACT FROM AUTHOR]

Background: The number of cancer patients and the number of patients surviving initial treatments is expected to rise. Traditionally, follow-up monitoring takes place in secondary care. The contribution of general practice is less visible and not clearly defined. This study aimed to compare healthcare use in general practice of patients with cancer during the follow-up phase compared with patients without cancer. We also examined the influence of comorbid conditions on healthcare utilisation by these patients in general practice. Methods: We compared health care use of N=8,703 cancer patients with an age and gender-matched control group of patients without cancer from the same practice. Data originate from the Netherlands Information Network of General Practice (LINH), a representative network consisting of 92 general practices with 350,000 enlisted patients. Health care utilisation was assessed using data on contacts with general practice, prescription and referral rates recorded between 1/1/2001 and 31/12/2007. The existence of additional comorbid chronic conditions (ICPC coded) was taken into account. Results: Compared to matched controls, cancer patients had more contacts with their GP-practice (19.5 vs. 11.9, p<.01), more consultations with the GP (3.5 vs. 2.7, p<.01), more home visits (1.6 vs. 0.4, p<.01) and they got more medicines prescribed (18.7 vs. 11.6, p<.01) during the follow-up phase. Cancer patients more often had a chronic condition than their matched controls (52% vs. 44%, p<.01). Having a chronic condition increased health care use for both patients with and without cancer. Cancer patients with a comorbid condition had the highest health care use. Conclusion: We found that cancer patients in the follow-up phase consulted general practice more often and suffered more often from comorbid chronic conditions, compared to patients without cancer. It is expected that the number of cancer patients will rise in the years to come and that primary health care professionals will be more involved in follow-up care. Care for comorbid chronic conditions, communication between specialists and GPs, and coordination of tasks then need special attention. [ABSTRACT FROM AUTHOR]

Background: The prevalence and impact of long term conditions continues to rise. Care planning for people with long term conditions has been a policy priority in England for chronic disease management. However, it is not clear how care planning is currently understood, translated and implemented in primary care. This study explores experience of care planning in patients with long term conditions in three areas in England. Methods: We conducted semi-structured interviews with 23 predominantly elderly patients with multiple long term conditions. The interviews were designed to explore variations in and emergent experiences of care planning. Qualitative analysis of interview transcripts involved reflexively coding and re-coding data into categories and themes. Results: No participants reported experiencing explicit care planning discussions or receiving written documentation setting out a negotiated care plan and they were unfamiliar with the term 'care planning'. However, most described some components of care planning which occurred over a number of contacts with health care professionals which we term"reactive" care planning. Here, key elements of care planning including goal setting and action planning were rare. Additionally, poor continuity and coordination of care, lack of time in consultations, and patient concerns about what was legitimate to discuss with the doctor were described. Conclusions: Amongst this population, elements of care planning were present in their accounts, but a structured, comprehensive process and consequent written record (as outlined in English Department of Health policy) was not evident. Further research needs to explore the advantages and disadvantages of different approaches to care planning for different patient groups. [ABSTRACT FROM AUTHOR]

Background: About 30% of the Danish population has one or more chronic conditions, and general practitioners (GPs) play a key role in effective chronic care management. However, little is known about these encounters in general practice. The aim was to describe the frequency of patients with one or more chronic conditions in general practice and how these consultations were experienced by the GPs. Methods: All GPs in the Central Denmark Region were invited to register all contacts during one day in the 12- month study period from December; 404 (46%) accepted. For each patient contact, the GPs were asked to fill in a one-page registration form covering information on chronic disease, reason for encounter, diagnosis, number of additional psychosocial problems raised by the patient during the consultation, time consumption, experienced burden of the consultation, referral to specialized care, and whether a nurse could have substituted the GP. Patients were categorized according to the number of chronic conditions (none, one, two, three or more) and the categories compared with regard to the GP-experienced burden of the contacts. Moreover, we examined which chronic conditions posed the the greatest challenge to the GPs. Results: Patients aged 40 years or more had a total of 8,236 contacts. Among these patients 2,849 (34.6%; 95% CI 33.6-35.6) had one and 2,596 (31.5%; CI 30.5-32.5) had more than one chronic disease. The time consumption and the burden of their contacts tended to rise with the number of chronic conditions. Being present in 22.9% (CI 21.6- 24.3) of all face-to-face contacts, hypertension was the most common chronic condition. The burden of the contacts was experienced as particularly heavy for patients with depression and dementia due to more additional psychosocial problems and the time consumption. Conclusion: General practitioners considered consultations with multimorbid patients demanding and not easily delegated to nurses. As the number of patients with chronic conditions and multimorbidity is increasing, GPs can be expected to face a heavier workload in the future. [ABSTRACT FROM AUTHOR]

The article offers information on a study related to the evaluation of patient and practice engagement in chronic illness care in a primary care setting. The purpose of this study was to determine whether patients who receive a multi-component rehabilitation intervention, including online monitoring of function with feedback and self-management workshops, showed less functional decline than case matched controls who did not receive this intervention.

The article offers information on a study related to the treatment of chronically ill patients. In a qualitative explorative study design, researchers held semi-structured interviews with stakeholders, face-to-face or by telephone. Data were analyzed using content analysis. It is mentioned that thirty representatives of Dutch patients with chronic illnesses, primary care professionals, policy makers, health inspectorate, health insurers, educational institutes and researchers were interviewed.

Background: General practitioners (GPs) are responsible for managing chronic care in the growing population of patients with comorbid chronic conditions and cancer. Studies have shown, however, that cancer patients are less likely to receive appropriate chronic care compared to patients without cancer. Patients say that how GPs engage in the care of comorbidities influences their own priority of these conditions. No studies have explored GPs' attitudes to and prioritization of chronic care in patients who have completed primary cancer treatment. This study aims to explore GPs' experiences, prioritization of, and perspectives on treatment and follow-up of patients with cancer and comorbidity. Methods: Semi-structured interviews were conducted during 2016 with 13 GPs in Region Zealand in Denmark. We used Systematic Text Condensation in the analysis. Results: All participating GPs said that chronic care in patients with a history of cancer was a high priority, and due to a clear structure in their practice, they experienced that few patients were lost to follow-up. Two different approaches to chronic care consultations were identified: one group of GPs described them as imitating outpatient clinics, where the GP sets the agenda and focuses on the chronic condition. The other group described an approach that was more attuned to the patient's agenda, which could mean that chronic care consultations served as an "alibi" for the patients to disclose other matters of concern. Both groups of GPs said that chronic care consultations for these patients supported normalcy, but in different ways. Some GPs said that offering future appointments in the chronic care process gave patients hope and a sense of normalcy. Other GPs strove for normalcy by focusing exclusively on the chronic condition and dealing with cancer as cured. Conclusions: The participating GPs gave a high priority to chronic care in patients with a history of cancer. Some GPs, however, followed a rigorous agenda. GPs should be aware that a very focused and biomedical approach to chronic care might increase fragmentation of care and collide with a holistic and patient-centered approach. It could also affect GPs' self-perception of their role and the core values of general practice. [ABSTRACT FROM AUTHOR]

Background: Shared medical appointments (SMAs), or group visits, are a healthcare delivery method with the potential to improve chronic disease management and preventive care. In this review, we sought to better understand opportunities, barriers, and limitations to SMAs based on patient experience in the primary care context. Methods: An experienced biomedical librarian conducted literature searches of PubMed, Cochrane Library, PsycINFO, CINAHL, Web of Science, ClinicalTrials.gov, and SSRN for peer-reviewed publications published 1997 or after. We searched grey literature, nonempirical reports, social science publications, and citations from published systematic reviews. The search yielded 1359 papers, including qualitative, quantitative, and mixed method studies. Categorization of the extracted data informed a thematic synthesis. We did not perform a formal meta-analysis. Results: Screening and quality assessment yielded 13 quantitative controlled trials, 11 qualitative papers, and two mixed methods studies that met inclusion criteria. We identified three consistent models of care: cooperative health care clinic (five articles), shared medical appointment / group visit (10 articles) and group prenatal care / CenteringPregnancy® (11 articles). Conclusions: SMAs in a variety of formats are increasingly employed in primary care settings, with no singular gold standard. Accepting and implementing this nontraditional approach by both patients and clinicians can yield measurable improvements in patient trust, patient perception of quality of care and quality of life, and relevant biophysical measurements of clinical parameters. Further refinement of this healthcare delivery model will be best driven by standardizing measures of patient satisfaction and clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Patient portal secure messaging (asynchronous electronic communication between physicians and their established patients) allows patients to manage their care through asynchronous, direct communication with their providers. This type of engagement with health information technology could have important benefits for patients with chronic conditions, and a more thorough understanding of the use and barriers of secure messaging among this population is needed. The objective of this study was to explore how experienced portal users engage with secure messaging to manage their chronic conditions. Methods: Three focus groups were conducted with 17 total patients who self-reported a cardiopulmonary condition. Participants were asked questions about their experience with patient portal secure messaging. Focus group transcripts were coded through inductive and deductive methods to reveal common themes. Results: Patients' motivation for using messaging included the speed and ease of such communication and direct access to a physician. Messaging was used by patients as an extension of the office visit and supported coordination of care among providers as well as patient collaboration with family members or caretakers. Patients identified challenges to using messaging, including technological barriers, worry about uncompensated physician time spent responding to messages, and confusion about what constitutes an appropriate 'non-urgent' message. Conclusions: This study highlights the potential of patient portal messaging as a tool for care coordination to enhance chronic disease self-management. However, uncertainty about the appropriate use of portal messaging persists even among experienced users. Additional patient training in the proper use of secure messaging and its benefits for disease self-management may help to resolve these concerns. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic conditions must mobilize capacity to access and use healthcare and enact self-care. In order for clinicians to create feasible treatment plans with patients, they must appreciate the limits and possibilities of patient capacity. This study seeks to characterize the amount, nature, and comprehensiveness of the information about patient capacity documented in the medical record. Methods: In this mixed-methods study, we extracted notes about 6 capacity domains from the medical records of 100 patients receiving care from 15 primary care clinicians at a single practice. Using a generalized linear model to account for repeated measures across multiple encounters, we calculated the rate of documented domains per encounter per patient adjusted for appointment type and number. Following quantitative analyses, we purposefully selected records to conduct inductive content analysis. Results: After adjusting for number of appointments and appointment type, primary care notes contained the most mentions of capacity. Physical capacity was most noted, followed by personal, emotional, social, financial, and environmental. Qualitatively, we found three documentation patterns: patients with broad capacity notes, patients with predominantly physical domain capacity notes, and patients with capacity notes mostly in domains other than physical. Records contained almost no mention of patients' environmental or financial capacity, or of how they coped with capacity limitations. Rarely, did notes ever mention how well patients interacted with their social network or what support they provided to the patient in managing their health. Conclusion: Medical records scarcely document patient capacity. This may impair the ability of clinicians to determine how patients can handle patient work, at what point patient capacity might become overwhelmed leading to poor adherence and health outcomes, and how best to craft feasible treatment programs that patients can implement with high fidelity. [ABSTRACT FROM AUTHOR]

Background: Patient self-management support is recognised as a key component of chronic care. Education and training for health professionals has been shown in the literature to be associated with better uptake, implementation and effectiveness of self-management programs, however, there is no clear evidence regarding whether this training results in improved health outcomes for patients with chronic conditions. Methods: A systematic review was undertaken using the PRISMA guidelines using the Cochrane Library, PubMEd, ERIC, EMBASE, CINAHL, PsycINFO, Web searches, Hand searches and Bibliographies. Articles published from inception to September 1st, 2013 were included. Systematic reviews, Meta-analysis, Randomized controlled trials (RCTs), Controlled clinical trials, Interrupted time series and Controlled before and after studies, which reported on primary care health professionals' continuing education or evidence-based medicine/education on patient self-management for any chronic condition, were included. A minimum of two reviewers participated independently at each stage of review. Results: From 7533 abstracts found, only two papers provided evidence on the effectiveness of self-management education for primary healthcare professionals in terms of measured outcomes in patients. These two articles show improvement in patient outcomes for chronic back pain and diabetes based on RCTs. The educational interventions with health professionals spanned a range of techniques and modalities but both RCTs included a motivational interviewing component. Conclusions: Before and up to 2 years after the incorporation of patient empowerment for self-management into the WONCA Europe definition of general practice, there was a scarcity of high quality evidence showing improved outcomes for patients as a result of educating health professionals in patient self-management of chronic conditions. [ABSTRACT FROM AUTHOR]

Background: Adolescents with chronic health conditions and/or disabilities (CHC/D’s) often face challenges when transitioning to adult care, which leads to a higher risk of morbidity and mortality. Although it is recommended that establishing the medical home and family physician (FP) attachment prior to transfer will improve health outcomes, there is little evidence or policy surrounding the role of the FP during this transition. This study explores the described use of health services by adolescents with CHC/D’s, as well as the adolescent’s and caregiver’s perceptions of their FP. Methods: Participants were recruited from the British Columbia Children’s Hospital, Canada and a multi-method phased approach was used. In Phase 1, 84 adolescent and caregiver pairs completed questionnaires asking what medical services they accessed for specific health needs. In Phase 2, another cohort of 21 adolescent and caregiver pairs completed the same questionnaires and were interviewed regarding their perception of their FP. Results: 96% (n = 81) of adolescents with CHC/D’s in phase 1 had a FP. Thirty four percent (n = 34) of adolescents had not seen their FP in the last 6 months. While adolescents with CHC/D mostly accessed their FP for primary health issues, they frequently also accessed specialists for prescription refills (50%, n = 51), mental health (29%, n = 30) and sexual health (16%, n = 16). While most adolescent/caregiver participants reported positive communication and trust in their FP, some had a poor understanding of the FP’s role in coordinating care. Conclusion: As many adolescents with CHC/D may see their FP infrequently and may not clearly understand their role, opportunities exist for strengthening primary care home attachment as well as adolescent and caregiver literacy around the potential contribution of the FP during and after transfer to adult services. Responsibility for improving care coordination for this population should be ideally shared between FPs and pediatric specialists. [ABSTRACT FROM AUTHOR]

Background: Practice facilitation is increasingly used to support guideline implementation and practice development in primary care and there is a need to explore how this implementation approach works in real-life settings. We focus on a facilitation intervention from the perspective of the visited practices to gain a more detailed understanding of how peer facilitation influenced practices and how they valued the facilitation. Methods: The facilitation intervention was conducted in general practice in the Capital Region of Denmark with the purpose of supporting the implementation of chronic disease management programmes. We carried out a qualitative study, where we observed 30 facilitation visits in 13 practice settings and interviewed the visited practices after their first and last visits. We then performed a thematic analysis. Results: Most of the respondents reported that facilitation visits had increased their knowledge and skills as well as their motivation and confidence to change. These positive influences were ascribed to a) the facilitation approach b) the credibility and know-how associated with the facilitators' being peers c) the recurring visits providing protected time and invoking a sense of commitment. Despite these positive influences, both the facilitation and the change process were impeded by several challenges, e.g. competing priorities, heavy workload, problems with information technology and in some cases inadequate facilitation. Conclusion: Practice facilitation is a multifaceted, interactive approach that may affect participants in several ways. It is important to attune the expectations of all the involved actors through elaborate discussions of needs, capabilities, wishes, and approaches, and to adapt facilitation interventions according to an analysis of influential contextual conditions and change opportunities. [ABSTRACT FROM AUTHOR]