FRI0512 INTEGRATED CARE NETWORK AS A BUILDING STONE FOR SUSTAINABLE AND COMPREHENSIVE CARE FOR PATIENTS WITH ARTHRALGIA

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 855.1-855
Author(s):  
E. Van Delft ◽  
K. H. Han ◽  
J. Hazes ◽  
D. Lopes Barreto ◽  
A. Weel
Keyword(s):  
Primary Care ◽  
Usual Care ◽  
Integrated Care ◽  
Usual Care Group ◽  
Inflammatory Arthritis ◽  
Care Setting ◽  
Primary Care Setting ◽  
Care Group ◽  
Care Network ◽  
The Right

Background:Western countries experience an increasing demand for care, particularly for inflammatory arthritis (IA), while the healthcare budget decreases1. The innovative value-based primary care strategy2includes integrated care networks, where primary and secondary care bundle their expertise to improve patient value by providing the right care at the right place.General practitioners (GPs) have difficulties recognising IA, leading up to only 20% IA diagnoses of all newly referred arthralgia patients. However, since IA needs to be treated as early as possible to overcome progression, it is worthwhile to analyse whether integrated care networks have an impact on patient outcomes and cost-effectiveness. Triage by a rheumatologist in a primary care setting is one of the most promising integrated care networks for efficient referrals3.Objectives:To assess the effect of triage by a rheumatologist in a primary care setting in patients suspect for inflammatory arthritis.Methods:The present study follows a cluster randomized controlled trial design. The intervention, triage by a rheumatologist in a local primary care centre, will be compared to usual care. Usual care means that patients are referred to a rheumatology outpatient clinic based on the opinion of the general practitioner.The primary outcome is the frequency of IA diagnoses assessed by a rheumatologist. Patient reported outcome measures (PROMs (EQ-5D)) and costs (work productivity (iPCQ) and healthcare utilization (iMCQ)) were determined at baseline, after three, six and twelve months. The target was to include 267 patients for each study group (power level 0.8). Since this study is still ongoing we can only show first results on the efficiency of referrals.Results:In the period between February 2017 and December 2019 a total of 543 participants were included; 275 in the usual care group and 268 in the triage group. Mean age (51.3 ± 14.6 years) and percentage of men (23.6%) were comparable between groups (page=0.139; psex=0.330).The preliminary data show that the number of referred patients in the triage group is n=28 (10.5%) (Fig. 1). 32 patients (11.9%) were not referred directly but advice was given for additional diagnostics. Since all patients in the usual care group were referred there is a decrease of at least 77.6% in referrals when rheumatologists are participating in the integrated practice units.Preliminary data on diagnosis are available for all referred patients in the triage group and for n=137 (49.8%) in the usual care group at this point. In the triage group n=18 (64.2%) of referred patients were diagnosed with IA (6.7% of the total study population). In the usual care group this was n=52 (38.0%) of the patients yet diagnosed.Conclusion:These preliminary results of an integrated care network are promising. Approximately three-quarters of all patients can be withheld from expensive outpatient care. PROMs data and cost-effectiveness analysis will give clear answers in order to provide evidence whether this integrated care network can be implemented as a standard of care.References:[1] Rijksoverheid. (2018). Bestuurlijk akkoord medisch-specialistische zorg 2019 t/m 2022.https://www.rijksoverheid.nl/.[2] Porter ME, Pabo EA, Lee TH. (2013). Redesigning Primary Care: a strategic vision to improve value by organizing around patients’ needs. Health affairs, 32(3);516-525[3] Akbari A, et al. (2008). Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev, 4,CD005471.Disclosure of Interests:None declared

scholarly journals POS0261 DIAGNOSTIC PERFORMANCE AND CLINICAL UTILITY OF TWO REFERRAL RULES FOR INFLAMMATORY ARTHRITIS

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 353.1-353
Author(s):  
E. Van Delft ◽  
D. Lopes Barreto ◽  
A. Van der Helm - van Mil ◽  
C. Alves ◽  
J. Hazes ◽  
...  
Keyword(s):  
Primary Care ◽  
Usual Care ◽  
Inflammatory Arthritis ◽  
Clinical Utility ◽  
Diagnostic Performance ◽  
Youden Index ◽  
Care Model ◽  
Net Benefit ◽  
Independent Population ◽  
The Right

Background:The Rotterdam Early Arthritis Cohort (REACH) rule [1] and Clinical Arthritis RulE (CARE) [2] are both evidence-based and easy-to-use methods developed to identify the presence of inflammatory arthritis (IA) in patients suspected by their general practitioner (GP). However, the clinical utility of both models in daily clinical practice in an independent primary care setting has not yet been established. While developed for recognizing IA, we believe that it is also important that the broader spectrum of inflammatory rheumatic diseases (IRDs) is correctly classified from primary care, to facilitate appropriate referral towards outpatient rheumatology clinics.Objectives:The primary objective was to determine the diagnostic performance and clinical utility of the REACH and CARE referral rules in identifying IA in an independent population of unselected suspected patients from primary care. Secondly we will assess the diagnostic performance and clinical utility of both models in identifying IRDs.Methods:This prospective observational diagnostic study consisted of adults newly suspected by their GP for the need of referral to the rheumatology outpatient clinic of the Maasstad Hospital in Rotterdam. Primary outcome was IA, consisting of rheumatoid arthritis, axial spondylitis and psoriatic arthritis. Secondary outcome was IRD, defined as IA plus arthritis in systemic disorders such as systemic lupus erythematosus, systemic sclerosis and morbus sjögren. Rheumatologist diagnosis was used as gold standard. To evaluate the clinical performance of the REACH and CARE referral rules in this population, diagnostic accuracy measures were investigated using the Youden index (J) [3]. Moreover, a net benefit approach [4] was used to determine clinical utility of both rules when compared to usual care.Results:This study consisted of 250 patients (22.8% male) with a mean age of 50.8 years (SD 13.9 years). In total 42 (17%) patients were diagnosed with IA and 55 (22%) with an IRD. Figure 1 presents the diagnostic performance in IA (Figure 1A) and in IRD (Figure 1B). For the primary outcome, the REACH model shows an AUC of 0.72 (95% CI 0.64-0.80) and the optimal cut-off point is indicated (J). The CARE model shows an AUC of 0.82 (95% CI 0.75-0.88) and at J there is a somewhat higher sensitivity and specificity. When taking the broader spectrum of IRDs as outcome, the AUC was 0.66 (95% CI 0.58-0.74) for the REACH and 0.76 (95% CI 0.69-0.83) for the CARE model. The net benefit analysis with either IA or IRD as outcome showed that the CARE was of the highest clinical value when compared to usual care.Conclusion:Both the REACH and CARE model showed a good diagnostic performance for detecting IA in an independent population of unselected suspected patients from primary care. Although not specifically developed to recognize the entire spectrum of IRDs, the CARE shows a good performance in doing so. When evaluating clinical utility, we see that both rules have a net benefit in recognizing IA as well as IRDs compared to usual care, however the CARE shows superiority over the REACH. By using the CARE, over half of all suspected patients can be withheld from expensive outpatient rheumatology care, implied by the high specificity of 70%. These results support the idea that incorporating these easy-to-use methods into primary care could lead to providing patients the right care at the right place and improving value based health care.References:[1]ten Brinck RM, van Dijk BT, van Steenbergen HW, le Cessie S, Numans ME. Development and validation of a clinical rule for recognition of early inflammatory arthritis. BMJ Open; 2018: 8[2]Alves, C. Improving early referral of inflammatory arthritis. In Early detection of patients at risk for rheumatoid arthritis – a challenge for primary and secondary care; 2015: 27-38 Ridderkerk, the Netherlands.[3]Fluss R, Faraggi D, Reiser B. Estimation of the Youden Index and its associated cutoff point. Biom J; 2005: 47(4): 458-472[4]Vickers AJ, Elkin EB. Decision curve analysis: a novel method for evaluating prediction models. Med Decis Making; 2006: 26(6): 565-574Disclosure of Interests:None declared

Crisis Intervention in Integrated Care

2017 ◽  
Author(s):  
Scott A. Simpson ◽  
Robert E. Feinstein
Keyword(s):  
Primary Care ◽  
Integrated Care ◽  
Crisis Intervention ◽  
Care Setting ◽  
Primary Care Setting ◽  
Care Environment ◽  
Intervention Treatment ◽  
Response To Stress ◽  
Life Stressor ◽  
Integrated Team

A crisis occurs when a life stressor overwhelms a person’s ability to cope with a problematic life situation. Crises often become evident in the primary care setting. People in crisis feel distressed and alone; they experience a psychological disorganization that affects their mood and functioning. Most patients can benefit from a brief crisis intervention treatment delivered in an integrated care environment. Behavioral health specialists can lead crisis intervention therapy with the support of the primary care provider, nurses, staff, and a consulting psychiatrist. Crisis intervention treatment includes identifying the life stressor, understanding the patient’s response to stress, assessing the patient’s social system, listing possible solutions to the crisis, and working to implement those solutions. As the crisis resolves, the integrated team provides anticipatory guidance for the patient and primary provider.

Increased Cardiovascular Disease in Patients with Inflammatory Arthritis in Primary Care: A Cross-sectional Observation: Table 1.

2009 ◽  
Vol 36 (9) ◽  
pp. 1866-1868 ◽  
Author(s):  
MIKE J.L. PETERS ◽  
MARK M.J. NIELEN ◽  
HENNIE G. RATERMAN ◽  
ROBERT A. VERHEIJ ◽  
FRANCOIS G. SCHELLEVIS ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Primary Care ◽  
Inflammatory Arthritis ◽  
Care Setting ◽  
Primary Care Setting ◽  
Conditional Logistic Regression ◽  
Regression Analyses ◽  
Cross Sectional ◽  
Cardiovascular Risk Management ◽  
And Control

Objective.To compare the prevalence of cardiovascular disease (CVD) in patients with inflammatory arthritis and control subjects registered in primary care.Methods.Conditional logistic regression analyses were used to compare the CVD prevalence in patients and controls, aged 50–75 years.Results.Overall, the CVD prevalence was 66.1 per 1000 patients in inflammatory arthritis and 37.3 per 1000 patients in controls, resulting in an odds ratio of 1.83 (95% confidence interval 1.33–2.51).Conclusion.Inflammatory arthritis patients registered in primary care are associated with an increased cardiovascular burden, which emphasizes the need for cardiovascular risk management in the primary care setting.

scholarly journals Aliskiren and losartan study in non-diabetic CKD: a comparison of patients in the clinical trial versus the usual care group

2018 ◽  
Vol 5 (1) ◽  
pp. 12
Author(s):  
Keng Thye Woo ◽  
Choong Meng Chan ◽  
Stephanie Fook Chong ◽  
Cynthia Lim ◽  
Jason Choo ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Renal Function ◽  
Usual Care ◽  
Usual Care Group ◽  
Care Setting ◽  
Care Group ◽  
Trial Group ◽  
Clinical Trial Setting ◽  
Phase Study ◽  
Trial Setting

<p class="abstract"><strong>Background:</strong> This is a comparative study of a 6 year retrospective analysis of the therapeutic efficacy and safety of Combined Aliskiren (150 mg a day) and Losartan (100 mg a day) in a Clinical Trial setting versus a Usual Care group of patients on Losartan (100 mg a day), Telmisartan (80 mg a day) and Combined Enalapril (10 mg a day) plus Losartan (100mg a day) in non-Diabetic Chronic Kidney Disease (CKD) patients. The objective of this study was to ascertain if there were any differences in the renal outcome of patients treated within a Clinical Trial setting versus a Usual Care setting. The study seeks to establish the relevance of having a Usual Care group as a comparator and whether its inclusion in the study would help to validate the findings in the Clinical Trial group</p><p class="abstract"><strong>Methods:</strong> This is a 2<sup>nd</sup> Phase follow up study three years after the initial 1<sup>st </sup>Phase study in the Clinical Trial Group. Patients in the 2<sup>nd</sup> Phase study were those who continued to have proteinuria and were treated with Losartan 100mg a day. The 2<sup>nd</sup> Phase study seeks to document the incidence of remission of proteinuria following their initial 1st Phase therapy for proteinuria compared to those in the Usual Care group where treatment remained unchanged from year 1 to end of year 6. The rates of remission of proteinuria and improvement of renal function as well as associated comorbidities between the 2 groups are compared.</p><p class="abstract"><strong>Results:</strong> Among the 154 patients in the Clinical Trial Group, 70/154 (45%) continued to have proteinuria, while 84/154 (55%) had no proteinuria (remission) compared to 41 (28%) in remission and 104 (72%) with continued proteinuria in the Usual Care group (p&lt;0.001). There were more patients with hypertension and hyperkalaemia in the Clinical Trial group compared to the Usual Care group. Seven patients were in ESRF in the Usual Care group compared to only 3 in the Clinical Trial group but this difference was not significant. More patients in the Clinical Trial group compared to the Usual Care group had improvement in eGFR at the end of the 6 years (p&lt;0.001).</p><p><strong>Conclusions: </strong>This study shows that patients in a Clinical Trial setting do better than those in the Usual Care setting as they are more likely to have improvement in renal function with remission of proteinuria. </p>

Treating Substance Use Disorders in Integrated Care Settings

2017 ◽  
Author(s):  
Patricia Pade ◽  
Laura Martin ◽  
Sophie Collins
Keyword(s):  
Primary Care ◽  
Substance Use ◽  
Integrated Care ◽  
Substance Use Disorders ◽  
Care Setting ◽  
Primary Care Setting ◽  
Primary Care Providers ◽  
Assessment Process ◽  
Care Providers ◽  
Care Environment

Addiction and substance use disorders (SUDs) are extremely prevalent and are commonly encountered in the primary care setting. The traditional separation of SUD treatment from mainstream medicine has not been an optimal model of effective patient care. Primary care providers can play a crucial role in the recognition, intervention, and treatment of SUDs. This chapter provides an overview of the assessment process, intervention strategies, and pharmacologic and nonpharmacologic treatments that can be effectively implemented in an integrated care environment or primary care setting for a variety of SUDs. The integration of SUD treatment into integrated care environments holds the promise of improving acceptability to patients, decreasing the stigmatization of SUDs, enhancing satisfaction for providers, and improving outcomes for patients.

Introduction

CNS Spectrums ◽  
2007 ◽  
Vol 12 (S13) ◽  
pp. 3-3
Author(s):  
Madhukar Trivedi
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Usual Care ◽  
Health Care System ◽  
Collaborative Care ◽  
Depressive Disorders ◽  
Care Setting ◽  
Primary Care Setting ◽  
Care Treatment ◽  
Care Models

AbstractMajor depressive disorder (MDD) is often a chronic, recurrent, and debilitating disorder with a lifetime prevalence of 16.2% and a 12-month prevalence of 6.6% in the United States. The disorder is associated with high rates of comorbidity with other psychiatric disorders and general medical illnesses, lower rates of adherence to medication regimens, and poorer outcomes for chronic physical illness. While 51.6% of cases reporting MDD received health care treatment for the illness, only 21.7% of all MDD cases received minimal guideline-level treatment. Because the overwhelming majority of patients with depressive disorders are seen annually by their primary care physicians, the opportunity to diagnose and treat patients early in the course of their illness in the primary care setting is substantial, though largely unfulfilled by our current health care system. The goal of treatment is 2-fold: early and complete remission of symptoms of depression and eventual recovery to premorbid levels of functioning in response to acute-phase treatment, and prevention of relapse during the continuation phase or recurrence during the maintenance phase. However, only 25% to 50% of patients with MDD adhere to their antidepressant regimen for the length of time recommended by depression guidelines, and nearly 50% of depressed patients referred from primary care to specialty care treatment fail to complete the referral. Patients with chronic or treatment-resistant depression often require multiple trials using an algorithm-based approach involving more than one treatment strategy. Under conditions of usual care, 40% to 44% of patients with MDD treated with antidepressants in the primary care setting show a >50% improvement in depression scores at 4-month follow-up, compared with 70% to 75% of those treated using collaborative care models. This demonstrates the importance of factors other than antidepressant medication per se for achieving treatment effectiveness. Additional research is needed to evaluate longer-term outcomes of algorithm-based, stepped, collaborative care models that incorporate patient self-management in conjunction with usual care. Furthermore, the health care system must undergo major transformation to effectively treat depression, along with other chronic illnesses. The use of evidence-based treatment algorithms are discussed and recommendations are provided for patients and physicians based on collaborative care interventions that may be useful for improving the current management of depressive disorders.

scholarly journals Creating an integrated care model for childhood obesity: a randomized pilot study utilizing telehealth in a community primary care setting

2016 ◽  
Vol 6 (6) ◽  
pp. 380-388 ◽  
Author(s):  
A. Fleischman ◽  
S. E. Hourigan ◽  
H. N. Lyon ◽  
M. G. Landry ◽  
J. Reynolds ◽  
...  
Keyword(s):  
Primary Care ◽  
Childhood Obesity ◽  
Pilot Study ◽  
Integrated Care ◽  
Care Setting ◽  
Primary Care Setting ◽  
Care Model

scholarly journals Effects of a 2-Year Primary Care Lifestyle Intervention on Cardiometabolic Risk Factors

Circulation ◽  
2021 ◽  
Vol 143 (12) ◽  
pp. 1202-1214
Author(s):  
Christoph Höchsmann ◽  
James L. Dorling ◽  
Corby K. Martin ◽  
Robert L. Newton ◽  
John W. Apolzan ◽  
...  
Keyword(s):  
Risk Factors ◽  
Primary Care ◽  
Usual Care ◽  
Usual Care Group ◽  
Cardiometabolic Risk ◽  
Density Lipoprotein ◽  
Mean Difference ◽  
Cardiometabolic Risk Factors ◽  
Lipoprotein Cholesterol ◽  
Care Group

Background: Intensive lifestyle interventions (ILIs) are the first-line approach to effectively treat obesity and manage associated cardiometabolic risk factors. Because few people have access to ILIs in academic health centers, primary care must implement similar approaches for a meaningful effect on obesity and cardiometabolic disease prevalence. To date, however, effective lifestyle-based obesity treatment in primary care is limited. We examined the effectiveness of a pragmatic ILI for weight loss delivered in primary care among a racially diverse, low-income population with obesity for improving cardiometabolic risk factors over 24 months. Methods: The PROPEL trial (Promoting Successful Weight Loss in Primary Care in Louisiana) randomly allocated 18 clinics equally to usual care or an ILI and subsequently enrolled 803 (351 usual care, 452 ILI) adults (67% Black, 84% female) with obesity from participating clinics. The usual care group continued to receive their normal primary care. The ILI group received a 24-month high-intensity lifestyle-based obesity treatment program, embedded in the clinic setting and delivered by health coaches in weekly sessions initially and monthly sessions in months 7 through 24. Results: As recently demonstrated, participants receiving the PROPEL ILI lost significantly more weight over 24 months than those receiving usual care (mean difference, −4.51% [95% CI, −5.93 to −3.10]; P <0.01). Fasting glucose decreased more in the ILI group compared with the usual care group at 12 months (mean difference, −7.1 mg/dL [95% CI, −12.0 to −2.1]; P <0.01) but not 24 months (mean difference, −0.8 mg/dL [95% CI, −6.2 to 4.6]; P =0.76). Increases in high-density lipoprotein cholesterol were greater in the ILI than in the usual care group at both time points (mean difference at 24 months, 4.6 mg/dL [95% CI, 2.9–6.3]; P <0.01). Total:high-density lipoprotein cholesterol ratio and metabolic syndrome severity ( z score) decreased more in the ILI group than in the usual care group at both time points, with significant mean differences of the change of −0.31 (95% CI, −0.47 to −0.14; P <0.01) and −0.21 (95% CI, −0.36 to −0.06; P =0.01) at 24 months, respectively. Changes in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and blood pressure did not differ significantly between groups at any time point. Conclusions: A pragmatic ILI consistent with national guidelines and delivered by trained health coaches in primary care produced clinically relevant improvements in cardiometabolic health in an underserved population over 24 months. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02561221.

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