Out of Context

Wyatt, Kirk D; Stuart, Louise; Brito, Juan P.; Leon, Barbara Carranza; Domecq, Juan Pablo; Prutsky, Gabriela; Egginton, Jason S.; Calvin, Andrew D.; Shah, Nilay D.; Murad, M. Hassan; Montori, Víctor M.

doi:10.1097/mlr.0b013e3182a51b3d

Cited by 91 publications

(49 citation statements)

References 6 publications

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“…While we found that the timing of the measurements relative to the baseline and 6-month benchmarks varied considerably and fell outside a 1–2-week window for some clients, this was due in part to the use of existing client records to obtain these measures (e.g., participants did not provide bloodwork specifically for this study). The overriding concern with this measure was the evidence indicating its poor connection with patient-relevant issues [26]. …”

Section: Resultsmentioning

confidence: 99%

“…This measure appeared more promising, in that participants in our study did not experience difficulty interpreting the SF-12 questions, the summary scores generated from the SF-12 instrument (PCS and MCS) represent well-validated measures of HRQoL, published norms exist for comparison with the Canadian general population, and the PCS score captures physical functional ability which appears to be an important outcome for patients [26]. A recent systematic review found that the PCS was frequently used as a primary outcome in the evaluation of interventions similar to ours for adults with chronic or long-term health conditions [13].…”

Section: Resultsmentioning

confidence: 99%

“…Similarly, the evidence-based guidelines derived from these studies adopt a single disease focus and fail to consider the management of T2DM within the context of MCC and fail to use patient-relevant outcomes (e.g., improving function or symptom burden instead of lowering HbA1C levels) [26–28]. Although prior studies have explored a variety of outcomes, most recommend further research regarding which outcomes can best assess the effectiveness of self-management interventions.…”

Section: Introductionmentioning

confidence: 99%

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The Aging, Community and Health Research Unit—Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: a feasibility study

Markle‐Reid

Ploeg

Fisher

et al. 2016

Pilot Feasibility Stud

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BackgroundFew studies have examined the effectiveness of community-based self-management interventions in older adults with type 2 diabetes mellitus (T2DM) and multiple chronic conditions (MCC). The objectives of this study were to examine the feasibility of implementation in practice (primary) and the feasibility of study methods and potential effectiveness (secondary) of the Aging, Community and Health—Community Partnership Program, a new 6-month interprofessional, nurse-led program to promote diabetes self-management in older adults (>65 years) with T2DM and MCC.MethodsThis study used a prospective one-group pre-test/post-test design. Participants were recruited from a specialized diabetes clinic. They received a median of three in-home/clinic visits by certified diabetes educators (CDEs) and attended a median of three group wellness sessions provided by the CDEs in partnership with a community-based seniors’ association. The primary outcome was the feasibility of the program (acceptability, fidelity, implementation barriers/facilitators). Secondary outcomes included the feasibility of the study methods (recruitment/retention rates and procedures, eligibility criteria, data collection and analysis methods) and potential effectiveness of the program based on 6-month changes in self-reported outcomes including self-management behavior (diet, exercise, self-monitoring), health status (quality of life, mental health), and costs of service use. Analysis of feasibility outcomes was primarily based on descriptive statistics. The potential effectiveness of the program was explored using different tests, with the results expressed using descriptive statistics and effect estimates (95 % confidence intervals).ResultsIn total, 45 (88 %) of 51 eligible persons consented to participate. Of these, 37 (82 %) completed the 6-month follow-up. Participants and providers viewed the program as acceptable and feasible. Participants had a higher SF-12 physical component summary score at 6 months compared with baseline (mean score difference 3.0, 95 % CI 0.2–5.8). Median costs for diabetes care increased over 6 months (reflecting inclusion of program costs), while other service costs either decreased or remained unchanged.ConclusionsThis study offers preliminary evidence that the program was feasible to deliver and acceptable to participants and providers. Initial results suggest that the program may improve physical functioning. A randomized controlled trial is feasible, with some adaptations to the program and study methods that were identified from this feasibility study.Trial registrationClinicaltrials.gov identifier: NCT01880476 Electronic supplementary materialThe online version of this article (doi:10.1186/s40814-016-0063-1) contains supplementary material, which is available to authorized users.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The Aging, Community and Health Research Unit—Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: a feasibility study

Markle‐Reid

Ploeg

Fisher

et al. 2016

Pilot Feasibility Stud

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“…Key in all of these approaches is optimising care by carefully tailoring treatment to the context and preferences of the individual (older) patient with multimorbidity. However, systematic reviews suggest that these principles are generally poorly applied in guidelines for this group [25–28]. One review looked at primary CVD prevention in older people specifically, and showed that only a handful of clinical practice guidelines adequately addressed evidence about potential benefits and harms of CVD prevention in older people or how to tailor CVD management to multimorbidity and limited life expectancy [25].…”

Section: Introductionmentioning

confidence: 99%

General Practitioners’ Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

et al. 2017

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BackgroundPrimary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs’ decision making about primary CVD prevention in patients aged 75 years and older.Method25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used.ResultsAnalysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear.ConclusionOlder patients receive different care depending on their GP’s perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.

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“…[12][13][14] These patterns may be due to broadened definitions of disease, misapplied diagnostic criteria, defensive medicine, blindness to comorbid and social contexts, or inaccurate estimation of harms and benefits by clinicians or patients. 13,[15][16][17][18] Personalised or precision medicine paradigms, depending on their application, may further this trend by driving additional diagnostic or genomic testing in the search for targeted treatments.…”

Section: Overmedicalisationmentioning

confidence: 99%

Attaining minimally disruptive medicine: context, challenges and a roadmap for implementation

Shippee¹,

Allen²,

Leppin³

et al. 2015

J R Coll Physicians Edin

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In this second of two papers on minimally disruptive medicine, we use the language of patient workload and patient capacity from the Cumulative Complexity Model to accomplish three tasks. First, we outline the current context in healthcare, comprised of contrasting problems: some people lack access to care and others receive too much care in an overmedicalised system, both of which reflect imbalances between patients' workloads and their capacity. Second, we identify and address five tensions and challenges between minimally disruptive medicine, the existing context, and other approaches to accessible and patientcentred care such as evidence-based medicine and greater patient engagement. Third, we outline a roadmap of three strategies toward implementing minimally disruptive medicine in practice, including large-scale paradigm shifts, mid-level addons to existing reform efforts, and a modular strategy using an existing 'toolkit' that is more limited in scope, but can fit into existing healthcare systems.KeywordS Cumulative Complexity Model, evidence-based medicine, overmedicalisation, minimally disruptive medicine, multimorbidity, patient engagement declArAtIon of IntereStS No conflict of interest declared.

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Out of Context

Abstract: Extant clinical practice guidelines for one chronic disease sometimes consider the context of the patient with that disease, but only do so narrowly. Guideline panels must remove their contextual blinders if they want to practically guide the care of patients with MCC.

Cited by 91 publications

References 6 publications

The Aging, Community and Health Research Unit—Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: a feasibility study

The Aging, Community and Health Research Unit—Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: a feasibility study

General Practitioners’ Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

Attaining minimally disruptive medicine: context, challenges and a roadmap for implementation

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