Co-located specialty care within primary care practice settings: A systematic review and meta-analysis.

BACKGROUND: Co-location of specialists in primary care has been suggested as an approach to reduce care fragmentation, inefficiency, and cost. We conducted a systematic review and meta-analysis evaluating the impact of co-located specialty care models in primary care settings. METHODS: Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus was conducted through February 2015. A manual search of the included studies' bibliographies was conducted. Randomized controlled trials (RCTs) and observational studies reporting physically co-located specialties in primary care on the following outcomes were included: patient satisfaction; provider satisfaction; health care access and utilization; clinical outcomes, and costs. RESULTS: Of 1620 articles, 22 studies met inclusion criteria, including 9 RCTs and 13 observational studies. Co-located care was observed to be associated with increased patient satisfaction (OR 2.04; 95% CI 1.04-3.98), primary care provider satisfaction (OR 6.49, 95% CI 4.28-9.85), and outpatient visits (OR 1.94; 95% CI 1.13-3.33). Co-located care was associated with reduced appointment wait time (OR 0.20, 95%CI 0.10 - 0.41). Reduced costs and improvement in quality of life and selected diabetes related outcomes were also observed. Evidence quality was limited by few studies, high risk of bias, and heterogeneity. CONCLUSIONS: Co-located specialty care in primary care settings may support the aims of high value care delivery. However, additional studies are needed to further evaluate the value of co-location of specific specialties and stronger data on impact to health outcomes and cost.

Quality Improvement Education for Health Professionals: A Systematic Review.

Effective quality improvement (QI) education should improve patient care, but many curriculum studies do not include clinical measures. The research team evaluated the prevalence of QI curricula with clinical measures and their association with several curricular features. MEDLINE, Embase, CINAHL, and ERIC were searched through December 31, 2013. Study selection and data extraction were completed by pairs of reviewers. Of 99 included studies, 11% were randomized, and 53% evaluated clinically relevant measures; 85% were from the United States. The team found that 49% targeted 2 or more health professions, 80% required a QI project, and 65% included coaching. Studies involving interprofessional learners (odds ratio [OR] = 6.55; 95% confidence interval [CI] = 2.71-15.82), QI projects (OR = 13.60; 95% CI = 2.92-63.29), or coaching (OR = 4.38; 95% CI = 1.79-10.74) were more likely to report clinical measures. A little more than half of the published QI curricula studies included clinical measures; they were more likely to include interprofessional learners, QI projects, and coaching.

The efficacy of resiliency training programs: a systematic review and meta-analysis of randomized trials.

IMPORTANCE: Poor mental health places a burden on individuals and populations. Resilient persons are able to adapt to life's challenges and maintain high quality of life and function. Finding effective strategies to bolster resilience in individuals and populations is of interest to many stakeholders. OBJECTIVES: To synthesize the evidence for resiliency training programs in improving mental health and capacity in 1) diverse adult populations and 2) persons with chronic diseases. DATA SOURCES: Electronic databases, clinical trial registries, and bibliographies. We also contacted study authors and field experts. STUDY SELECTION: Randomized trials assessing the efficacy of any program intended to enhance resilience in adults and published after 1990. No restrictions were made based on outcome measured or comparator used. DATA EXTRACTION AND SYNTHESIS: Reviewers worked independently and in duplicate to extract study characteristics and data. These were confirmed with authors. We conducted a random effects meta-analysis on available data and tested for interaction in planned subgroups. MAIN OUTCOMES: The standardized mean difference (SMD) effect of resiliency training programs on 1) resilience/hardiness, 2) quality of life/well-being, 3) self-efficacy/activation, 4) depression, 5) stress, and 6) anxiety. RESULTS: We found 25 small trials at moderate to high risk of bias. Interventions varied in format and theoretical approach. Random effects meta-analysis showed a moderate effect of generalized stress-directed programs on enhancing resilience [pooled SMD 0.37 (95% CI 0.18, 0.57) p = .0002; I2 = 41%] within 3 months of follow up. Improvement in other outcomes was favorable to the interventions and reached statistical significance after removing two studies at high risk of bias. Trauma-induced stress-directed programs significantly improved stress [-0.53 (-1.04, -0.03) p = .03; I2 = 73%] and depression [-0.51 (-0.92, -0.10) p = .04; I2 = 61%]. CONCLUSIONS: We found evidence warranting low confidence that resiliency training programs have a small to moderate effect at improving resilience and other mental health outcomes. Further study is needed to better define the resilience construct and to design interventions specific to it. REGISTRATION NUMBER: PROSPERO #CRD42014007185.

The efficacy of resilience training programs: a systematic review protocol.

BACKGROUND: Resilience has been defined as the ability of individuals to manage and adapt to stress and life challenges. Training programs that develop and/or enhance resilience may have efficacy in improving health, well-being, and quality of life. Because patients with chronic conditions must reliably self-manage their health, strategies to bolster resilience in this population may be of particular value. The objectives of this systematic review are to synthesize the evidence of resilience training program efficacy in improving outcomes related to quality of life, self-efficacy and activation, and resilience and coping ability in: 1) diverse adult populations; and 2) patients with chronic conditions. METHODS/DESIGN: We will conduct a systematic review of randomized controlled trials assessing the efficacy of any program designed to enhance resilience in adults that measure any outcome against any comparator. We will search multiple electronic databases, trial registries, bibliographies, and will contact authors and experts to identify studies. We will use systematic review software to independently and in duplicate screen reports and extract data. We will extract characteristics of the study populations, interventions, comparators, outcomes, and quality/risk of bias. Primary, patient reported outcomes will be categorized into domains of quality of life, self-efficacy, and resilience. Secondary outcomes will be considered based on findings of the review. We will attempt meta-analysis by pooling standardized mean differences and minimally important differences (MIDs), when possible. Planned trial subgroup analyses are: 1) studies of patients with chronic conditions; 2) studies with placebo controls; 3) studies with similar intervention characteristics; and 4) studies with common lengths of follow-up. DISCUSSION: This study is intended to accumulate the evidence for resilience training programs in improving quality of life, resilience, and self-efficacy for care management, particularly among adult patients with chronic conditions. Its findings will be valuable to policy-makers, funding agencies, clinicians, and patients seeking innovative and effective ways to achieve patient-centered care. TRIAL REGISTRATION: PROSPERO registration number: CRD42014007185.