Background: In 2008, the English Department of Health appointed 16 'Integrated Care Pilots' which used a range of approaches to provide better integrated care. We report qualitative analyses from a three-year multi-method evaluation to identify barriers and facilitators to successful integration of care.
Social relationships are an important aspect of a person's social environment that can protect against a wide range of chronic conditions and facilitate recovery from disease. Social relationships have also been linked to dietary behaviour which may be an important pathway through which social circumstances exert their influence on health. Yet, questions remain about which structural aspects of social relationships most affect healthful dietary behaviours and whether different structural components interact to produce a combined effect. Using data from adults (≥50 years) in the European Prospective Investigation of Cancer-Norfolk study (1996–2002), we examined marital status, living arrangement and social isolation in relation to scores for variety of fruit and vegetable intake as a marker of diet quality associated with adverse health outcomes. Data were analysed with multivariable linear regression models for gender-specific and interaction associations. We found that being single or widowed was associated with a lower variety score, particularly vegetable variety, and associations were enhanced when combined with male gender, living alone or infrequent friend contact. Lower variety scores for lone-living were also observed, especially for men. Infrequent friend contact interacted with living arrangement to amplify negative associations of lone-living with variety, with statistically significant differences in contact frequency for vegetable variety. Lower levels of friend contact were associated with reduced variety of fruits and vegetables in a graded trend for both genders; the trend was more pronounced among men. Family contact appeared to have limited association with vegetable variety in men; among women, weekly contact was significantly and positively associated with vegetable variety compared to daily family contact. Results highlight the importance of considering living arrangement and/or frequency of social contact when assessing whether widowed, single or lone-living older adults are at risk of lower fruit and vegetable variety.
Background Public involvement in health-care policy has been advocated as a means to enhance health system responsiveness, yet evidence for its impact has been difficult to ascertain.
BackgroundSelf-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice.MethodsWe conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals’ views on the implementation of self-management support in practice.ResultsSelf-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients’ medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture.ConclusionsAlthough collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes.
ObjectivesThe UK government has noted the public health importance of food prices and the affordability of a healthy diet. Yet, methods for tracking change over time have not been established. We aimed to investigate the prices of more and less healthy foods over time using existing government data on national food prices and nutrition content.MethodsWe linked economic data for 94 foods and beverages in the UK Consumer Price Index to food and nutrient data from the UK Department of Health's National Diet and Nutrition Survey, producing a novel dataset across the period 2002–2012. Each item was assigned to a food group and also categorised as either “more healthy” or “less healthy” using a nutrient profiling model developed by the Food Standards Agency. We tested statistical significance using a t-test and repeated measures ANOVA.ResultsThe mean (standard deviation) 2012 price/1000 kcal was £2.50 (0.29) for less healthy items and £7.49 (1.27) for more healthy items. The ANOVA results confirmed that all prices had risen over the period 2002–2012, but more healthy items rose faster than less healthy ones in absolute terms:£0.17 compared to £0.07/1000 kcal per year on average for more and less healthy items, respectively (p<0.001).ConclusionsSince 2002, more healthy foods and beverages have been consistently more expensive than less healthy ones, with a growing gap between them. This trend is likely to make healthier diets less affordable over time, which may have implications for individual food security and population health, and it may exacerbate social inequalities in health. The novel data linkage employed here could be used as the basis for routine food price monitoring to inform public health policy.
The growing recognition of care fragmentation is causing many countries to explore new approaches to healthcare delivery that can bridge the boundaries between professions, providers and institutions and so better support the rising number of people with chronic health problems. This paper examines the role of the regulatory, funding and organisational context for the development and implementation of approaches to chronic care, using examples from Austria, Germany and the Netherlands. We find that the three countries have implemented a range of policies and approaches to achieve better coordination within and across the primary and secondary care interface and so better meet the needs of patients with chronic conditions. This has involved changes to the regulatory framework to support more coordinated approaches to care (Austria, Germany), coupled with financial incentives (Austria, Germany) or changes in payment systems (the Netherlands). What is common to the three countries is the comparative 'novelty' of policies and approaches aimed at fostering coordinated care; however, the evidence of their impact remains unclear.
BackgroundDiet is a key modifiable risk factor for multiple chronic conditions, including type 2 diabetes (T2D). Consuming a range of foods from the five major food groups is advocated as critical to healthy eating, but the association of diversity across major food groups with T2D is not clear and the relationship of within-food-group diversity is unknown. In addition, there is a growing price gap between more and less healthy foods, which may limit the uptake of varied diets. The current study had two aims: first, to examine the association of reported diversity of intake of food groups as well as their subtypes with risk of developing T2D, and second, to estimate the monetary cost associated with dietary diversity.Methods and FindingsA prospective study of 23,238 participants in the population-based EPIC-Norfolk cohort completed a baseline Food Frequency Questionnaire in 1993–1997 and were followed up for a median of 10 y. We derived a total diet diversity score and additional scores for diversity within each food group (dairy products, fruits, vegetables, meat and alternatives, and grains). We used multivariable Cox regression analyses for incident diabetes (892 new cases), and multivariable linear regression for diet cost. Greater total diet diversity was associated with 30% lower risk of developing T2D (Hazard ratio [HR] 0.70 [95% CI 0.51 to 0.95]) comparing diets comprising all five food groups to those with three or fewer, adjusting for confounders including obesity and socioeconomic status. In analyses of diversity within each food group, greater diversity in dairy products (HR 0.61 [0.45 to 0.81]), fruits (HR 0.69 [0.52 to 0.90]), and vegetables (HR 0.67 [0.52 to 0.87]) were each associated with lower incident diabetes. The cost of consuming a diet covering all 5 food groups was 18% higher (£4.15/day [4.14 to 4.16]) than one comprising three or fewer groups. Key limitations are the self-reported dietary data and the binary scoring approach whereby some food groups contained both healthy and less healthy food items.ConclusionsA diet characterized by regular consumption of all five food groups and by greater variety of dairy, fruit, and vegetable subtypes, appears important for a reduced risk of diabetes. However, such a diet is more expensive. Public health efforts to prevent diabetes should include food price policies to promote healthier, more varied diets.
Introduction: In 2009, the English Department of Health appointed 16 integrated care pilots which aimed to provide better integrated care. We report the quantitative results from a multi-method evaluation of six of the demonstration projects which used risk profiling tools to identify older people at risk of emergency hospital admission, combined with intensive case management for people identified as at risk. The interventions focused mainly on delivery system redesign and improved clinical information systems, two key elements of Wagner's Chronic Care Model.
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