Network of doctors for multimorbidity and diabetes - the NOMAD intervention: protocol for feasibility trial of multidisciplinary team conferences for people with diabetes and multimorbidity.

BACKGROUND: The prevalence of diabetes and coexisting multimorbidity rises worldwide. Treatment of this patient group can be complex. Providing an evidence-based, coherent, and patient-centred treatment of patients with multimorbidity poses a challenge in healthcare systems, which are typically designed to deliver disease-specific care. We propose an intervention comprising multidisciplinary team conferences (MDTs) to address this issue. The MDT consists of medical specialists in five different specialities meeting to discuss multimorbid diabetes patients. This protocol describes a feasibility test of MDTs designed to coordinate care and improve quality of life for people with diabetes and multimorbidity. METHODS: A mixed-methods one-arm feasibility test of the MDT. Feasibility will be assessed through prospectively collected data. We will explore patient perspectives through patient-reported outcomes (PROs) and assess the feasibility of electronic questionnaires. Feasibility outcomes are recruitment, PRO completion, technical difficulties, impact of MDT, and doctor preparation time. During 17 months, up to 112 participants will be recruited. We will report results narratively and by the use of descriptive statistics. The collected data will form the basis for a future large-scale randomised trial. DISCUSSION: A multidisciplinary approach focusing on better management of diabetic patients suffering from multimorbidity may improve functional status, quality of life, and health outcomes. Multimorbidity and diabetes are highly prevalent in our healthcare system, but we lack a solid evidence-based approach to patient-centred care for these patients. This study represents the initial steps towards building such evidence. The concept can be efficiency tested in a randomised setting, if found feasible to intervention providers and receivers. If not, we will have gained experience on how to manage diabetes and multimorbidity as well as organisational aspects, which together may generate hypotheses for research on how to handle multimorbidity in the future. ADMINISTRATIVE INFORMATION: Protocol version: 01 TRIAL REGISTRATION: NCT05913726 - registration date: 21 June 2023.

Understanding Facilitators and Challenges to Care Transition in Cardiac Rehabilitation: Perspectives and Assumptions of Healthcare Professionals.

Cardiac rehabilitation is an essential part of treatment for patients with cardiovascular disease. Cardiac rehabilitation is increasingly organized outside hospital in community healthcare services. However, this transition may be challenging. The aim of this study was to examine assumptions and perspectives among healthcare professionals on how facilitators and challenges influence the transition from hospital to community healthcare services for patients in cardiac rehabilitation. The study followed the Interpretive Description methodology and data consisted of participant observations and focus group interviews. The analysis showed that despite structured guidelines aimed to support the collaboration, improvements could be made. Facilitators and challenges could occur in the collaboration between the healthcare professionals, in the collaboration with the patient, or because of the new reality for patients when diagnosed with cardiovascular disease.

The patient education strategy "learning and coping" improves adherence to cardiac rehabilitation in primary healthcare settings: a pragmatic cluster-controlled trial.

BACKGROUND: Adherence and completion of programmes in educational and physical exercise sessions is essential in cardiac rehabilitation (CR) to obtain the known benefits on morbidity, mortality, risk factors, lifestyle, and quality of life. The patient education strategy "Learning and Coping" (LC) has been reported to positively impact adherence and completion in a hospital setting. It is unknown if LC has impact on adherence in primary healthcare settings, and whether LC improves self-management. The aim of this pragmatic primary healthcare-based study was to examine whether patients attending CR based on LC had a better adherence to patient education and physical exercise, higher program completion rate, and better self-management compared to patients attending CR based on a consultation program Empowerment, Motivation and Medical Adherence (EMMA). METHOD: A pragmatic cluster-controlled trial of two types of patient education LC and EMMA including ten primary healthcare settings and 514 patients (LC, n = 266; EMMA, n = 248) diagnosed with ischaemic heart disease discharged from hospital and referred to CR between August 1, 2018 and July 31, 2019. Adherence was defined as participation in ≥ 75% of provided sessions. Completion was defined as patients attended the final interview at the end of the 12-weeks programme. Patient Activation Measure (PAM) was used to obtain information on a person's knowledge, skills and confidence for self-management. PAM questionnaire was completed at baseline and 12-weeks follow-up. Multiple and Linear regression analyses adjusted for potential confounder variables and cluster effect were performed. RESULT: Patients who followed CR based on LC had a higher adherence rate to educational and physical exercise sessions compared to patients who followed CR based on EMMA (p < 0.01). High-level of completion was found at the end of CR with no statistically significant between clusters (78.9% vs. 78.2%, p > 0.05). At 12-weeks, there was no statistical differences in PAM-score between clusters (p > 0.05). CONCLUSION: This study indicates that the LC positively impacts adherence in CR compared to EMMA. We found non-significant difference in completing CR and in patient self-management between the two types of patient education. Future studies are needed to investigate if the higher adherence rate achieved by LC in primary healthcare settings translates into better health outcomes.

Understanding healthcare providers' experiences with video recording of patient consultations.

AIM: To understand healthcare providers' experiences with video recording of patient consultations. BACKGROUND: Video recordings have been recognised to be an effective method to evaluate in situ interactions in clinical practice. The video recordings are often conducted by researchers, but active involvement of healthcare providers into the process of recording is evolving. Still, little is known of how video recordings by healthcare providers may influence daily clinical practice and potentials for direct use to guide practice development. METHODS: A qualitative design was used, conducting two focus group interviews including 12 healthcare providers representing eight different healthcare services who provide municipal cardiac rehabilitation. Interpretive description was used as the methodological framework, and symbolic interactionism served as the theoretical lens. FINDINGS: Three themes were identified reflecting healthcare providers' experiences with video recording of patient consultations: 'Concerns of compromising primary work tasks', 'Exposing professional and personal skills' and 'A new learning dimension'. Overall, the three themes represent the process of video recording own practices attached to patient consultations and the personal investment attached to the video data. Also, how the recordings may provide new insights for practice development in terms of individual and team-based performance in patient consultations. CONCLUSION: Video recordings by healthcaref providers may be a useful source to provide information and learning about patient consultation practice to use in research and supervision, keeping in mind their challenges of implementation into daily clinical practice.

Implementation of patient involvement methods in the clinical setting: A qualitative study exploring the health professional perspective.

RATIONALE, AIMS AND OBJECTIVES: Patient involvement is increasingly recognized as a key component on the international health care agenda. This attention has brought a need for developing generic and standardized open-source methods, tools, and guidelines on how to systematically implement patient involvement initiatives in the clinical setting. The large-scale project the User-involving Hospital was initiated to implement two systematic methods for patient involvement at a Danish university hospital, but the required methods can only be implemented if embraced by the health professionals. This evaluation study aimed to explore the health professional perspective on the development and implementation of shared decision making (SDM) and user-led health care. Specifically, the objectives were to identify the most crucial preconditions for success and to translate the findings into practice recommendations. METHOD: The study was based on a simple questionnaire survey and a qualitative descriptive analysis of semistructured focus group interviews with representatives of 21 multidisciplinary clinical teams (nine interviews) and 18 health professional department managers (six interviews). RESULTS: Two years after the initiation of the User-involving Hospital, 13 out of 21 developed patient involvement initiatives were fully incorporated into clinical practice. Five domains were found significant for successful development and implementation of the patient involvement methods: the patients' perspectives, composition of multidisciplinary teams, bottom-up and skill building, support from management, and information sharing with colleagues. CONCLUSIONS: The findings draw attention to several significant factors for successful implementation of large-scale patient involvement initiatives in hospitals, including the importance of having both a top-down and bottom-up approach and of active listening to the patients' perspectives. On the basis of these findings, the study outlines four recommendations incorporating the five identified key domains, which may inspire future projects on systematic development and implementation of patient-involvement initiatives based on either shared decision making or user-led health care in the clinical setting.

Systematic suicide risk assessment for patients with schizophrenia: a national population-based study.

OBJECTIVES: Systematic suicide risk assessment is recommended for patients with schizophrenia; however, little is known about the implementation of suicide risk assessment in routine clinical practice. The study aimed to determine the use of systematic suicide risk assessment at discharge and predictors of suicide attempt among hospitalized patients with schizophrenia in Denmark. METHODS: A one-year follow-up study was conducted of 9,745 patients with schizophrenia who were discharged from psychiatric wards and registered in a national population-based schizophrenia registry between 2005 and 2009. RESULTS: The proportion of patients receiving suicide risk assessment at discharge from a psychiatric ward increased from 72% (95% confidence interval [CI]=71%-74%) in 2005, when the national monitoring began, to 89% (CI=89%-90%) in 2009. Within one year after discharge, 1% of all registered patients had died by suicide and 8% had attempted suicide. One out of three patients who died by suicide had no documented suicide risk assessment before discharge. CONCLUSIONS: The use of systematic suicide risk assessment at discharge among patients with schizophrenia increased in Denmark between 2005 and 2009, in accordance with recommendations in national clinical guidelines and monitoring in a national clinical registry. Additional efforts are warranted to ensure a lower risk of suicidal behavior after hospital discharge.

Processes of in-hospital psychiatric care and subsequent criminal behaviour among patients with schizophrenia: a national population-based, follow-up study.

OBJECTIVES: It is unknown whether evidence-based, in-hospital processes of care may influence the risk of criminal behaviour among patients with schizophrenia. Our study aimed to examine the association between guideline recommended in-hospital psychiatric care and criminal behaviour among patients with schizophrenia. METHODS: Danish patients with schizophrenia (18 years or older) discharged from a psychiatric ward between January 2004 and March 2009 were identified using a national population-based schizophrenia registry (n = 10 757). Data for in-hospital care and patient characteristics were linked with data on criminal charges obtained from the Danish Crime Registry until November 2010. RESULTS: Twenty per cent (n = 2175) of patients were charged with a crime during follow-up (median = 428 days). Violent crimes accounted for 59% (n = 1282) of the criminal offences. The lowest risk of crime was found among patients receiving the most processes of in-hospital care (top quartile of received recommended care, compared with bottom quartiles, adjusted hazard ratio = 0.86, 95% CI 0.75 to 0.99). The individual processes of care associated with the lowest risk of criminal behaviour were antipsychotic treatment and staff contact with relatives. CONCLUSIONS: High-quality, in-hospital psychiatric care was associated with a lower risk of criminal behaviour after discharge among patients with schizophrenia.

Objectifs : On ne sait pas si les processus de soins à l'hôpital bas sur des données probantes peuvent influencer le risque de comportement criminel chez des patients souffrant de schizophrénie. Notre étude visait à examiner l'association entre soins psychiatriques à l'hôpital recommandés par des lignes directrices et le comportement criminel chez des patients souffrant de schizophrénie. Méthodes : Des patients danois souffrant de schizophrénie (de 18 ans et plus) et ayant reçu leur congé d'une unité psychiatrique entre janvier 2004 et mars 2009 ont été identifiés à l'aide du registre national de la schizophrénie dans la population (n = 10 757). Les données des soins à l'hôpital et des caractéristiques des patients ont été couplées avec les données sur les accusations criminelles obtenues du registre danois de la criminalité jusqu'en novembre 2010. Résultats : Vingt pour cent (n = 2175) des patients ont été accusés d'un crime durant le suivi (moyenne = 428 jours). Les crimes violents représentaient 59 % (n = 1282) des infractions criminelles. Le risque de comportement criminel le plus faible a été constaté chez les patients recevant le plus de processus de soins à l'hôpital (quartile supérieur des soins recommandés reçus, comparé aux quartiles inférieurs, rapport de risques corrigé = 0.86, IC à 95 % 0,75 à 0,99). Les processus de soins individuels associés au risque le plus faible de comportement criminel étaient le traitement par antipsychotiques et les contacts du personnel avec les membres de la famille. Conclusions : Les soins psychiatriques de grande qualité, à l'hôpital, étaient associés à un risque plus faible de comportement criminel après le congé chez des patients souffrant de schizophrénie.

Challenges in validating quality of care data in a schizophrenia registry: experience from the Danish National Indicator Project.

BACKGROUND: Improvement of quality of care for psychiatric patients is a key objective of health care systems worldwide. Consequently, there is an increasing interest in documenting quality of care; however, little is known about the validity of the available data on psychiatric care. OBJECTIVE: To assess the validity of process of care data recorded in the Danish National Indicator Project (DNIP), a national population-based registry containing quality of care data of patients diagnosed with schizophrenia in Denmark. METHODS: A random sample of 1% of patients with schizophrenia registered in the DNIP between 2004 and 2009 (111 inpatient and 85 outpatient) was identified for validation. Medical records for these patients, which were used as the gold standard, were retrieved and reviewed for information on the processes of care received. Agreement between the data in the DNIP and the medical records were assessed by computing sensitivity, specificity, and positive and negative predictive values. RESULTS: The agreement between the recorded processes of care in the DNIP and in the medical records varied substantially across the individual process of care variables. However, a collection of the processes of care demonstrated a high agreement (80% or more) between data in the DNIP and the medical records, according to all examined aspects of data validity (sensitivity, specificity, and positive and negative predictive values). The medical records contained varying levels of missing information regarding the processes of care, from 1% for antipsychotic medication prescription to 54% for psychoeducation. CONCLUSION: Current documentation practices in Danish psychiatric hospitals appear to be inconsistent and may preclude the use of psychiatric medical records as the gold standard when validating registry data.