Article Figures & Data
Figures
- Figure 1
Flow of patients through the randomized trial.
ED = emergency department.
Tables
Characteristic Intervention Group (n = 126) Control Group (n = 121) P Valuea Age, mean (SD), y 61 (13.5) 59 (12.9) .14 Sex, male, No. (%) 58 (46.0) 44 (36.4) .12 Chronic conditions, mean (SD), No. 5.8 (2.7) 6.1 (2.7) .38 Disease burden, DBMA score, mean (SD)b 12.6 (7.9) 14.3 (9.0) .13 Married/living with a partner, No. (%) 80 (63.5) 75 (62.5) .22 Education, No. (%) .51 Not graduated from high school 52 (41.3) 45 (37.2) Graduated from high school or higher education 74 (58.7) 76 (62.8) Occupation, No. (%) .34 Work 32 (25.8) 26 (22.0) Without work 35 (28.2) 46 (39.0) Retired 57 (46.0) 46 (39.0) Annual household income, No. (%) .11 <Can$20,000 32 (26.4) 38 (31.4) Can$20,000–Can$49,999 62 (51.2) 46 (38.0) ≥Can$50,000 27 (22.3) 37 (30.6) Perception of economic situation, No. (%) .20 Comfortable 23 (18.3) 28 (23.1) Sufficient to meet their needs 73 (57.9) 57 (47.1) Poor/very poor 30 (23.8) 36 (29.8) At risk for mental health problems (HADS score ≥16)c, No. (%) 39 (31.2) 47 (38.8) .21 Low health literacy (NVS score <4),d No. (%) 84 (68.3) 80 (66.7) .79 Can$ = Canadian dollars; DBMA = Disease Burden Morbidity Assessment; HADS = Hospital Anxiety and Depression Scale; NVS = Newest Vital Sign.
↵a Difference between groups assessed with a t test.
↵b DBMA scores range from 1 to 48, with higher scores indicating greater disease burden.
↵c HADS scores range from 0 to 21, with higher scores indicating more severe anxiety and depression.
↵d NVS scores range from 0 to 6, with higher scores indicating greater health literacy.
Measure and Group Time Point AOR (95% CI)a or Cohen db P Value Baseline 6 Mo Psychological distress (K6 score ≥13)c Intervention group, No. (%) 33 (26.2) 20 (15.9) 0.43 (0.19–0.95) .04 Control group, No. (%) 35 (28.9) 31 (25.6) (reference) Activation (PAM score)d Intervention group, mean (SD) score 60.5 (15.1) 65.5 (16.8) 0.17 .43 Control group, mean (SD) score 63.0 (15.6) 65.4 (16.3) (reference) AOR = adjusted odds ratio; K6 = Psychological Distress Scale; PAM = Patient Activation Measure.
Note: Analyses based on 126 patients in intervention group, 121 patients in control group.
↵a From logistic regression analysis. Group comparison at 6 months adjusted for baseline psychological distress.
↵b From analysis of covariance (ANCOVA). Group comparison at 6 months adjusted for baseline score.
↵c K6 scores range from 0 to 24, with higher scores indicating greater psychological distress.
↵d PAM scores range from 0 to 100, with higher scores indicating greater activation. Scores can be categorized into 4 levels: Level 1 (score ≤47), may not yet believe that patient role is important; Level 2 (score 47.1–55.1), lacks confidence and knowledge to take action; Level 3 (score 55.2–66.9), beginning to take action; Level 4 (score ≥67), taking action.
Supplemental Appendix
Supplemental materials
Files in this Data Supplement:
- Supplemental data: Appendix - PDF file
The Article in Brief
Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study
Catherine Hudon , and colleagues
Background Frequent users of healthcare services with chronic disease and complex care needs often experience fragmented, uncoordinated and ineffective health care. This study evaluates the effects of a nurse-delivered case management intervention on such frequent users of primary care services, with a focus on psychological distress and patient activation.
What This Study Found The study finds that case management reduces psychological distress and creates a sense of security in patients who frequently use health services. In this randomized controlled trial of 247 patients, the intervention group (n=126) received six months of case management including evaluation of patients' needs and resources, a service plan tailored to patients' priorities, care coordination between health care and community partners, and self-management support for patients and families. Compared with usual care, the intervention reduced psychological distress (OR 0.43, 95% CI, 0.19-0.95) but had no effect on patient activation. In addition, interviews were conducted with 25 intervention group patients, six case management nurses, and nine health managers, and focus groups were held with eight patients' spouses and 21 participating family physicians. Overall, stakeholders had positive perceptions of the case management intervention. Many noticed that improved accessibility and self-management support led to a sense of security and better self-management of patients' health.
Implications
- The authors note that future research is needed to evaluate the effect of a case management intervention on the use and cost of services and to assess if a longer intervention would result in a change in self-management.
Annals Journal Club
May/Jun 2018: Case Management for Frequent Users of Medical Care
Emily C. Giesler, DO, Grant Family Medicine, and Michael E. Johansen, MD, MS, Associate Editor
The Annals of Family Medicine encourages readers to develop a learning community to improve health care and health through enhanced primary care. Participate by conducting a RADICAL journal club. RADICAL stands for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. We encourage diverse participants to think critically about important issues affecting primary care and act on those discussions.1
HOW IT WORKS
In each issue, the Annals selects an article and provides discussion tips and questions. Take a RADICAL approach to these materials and post a summary of your conversation in our online discussion. (Open the article and click on "TRACK Discussion/ Submit a comment.") Discussion questions and information are online at: http://www.AnnFamMed.org/site/AJC/.
CURRENT SELECTION
Article for Discussion
Hudon C, Chouinard M-C, Dubois M-F, et al. Case management in primary care for frequent users of health care services: a mixed methods study. Ann Fam Med. 2018;16(3):232-239..
Discussion Tips
Mixed methods studies bring together the complementary strengths of quantitative and qualitative methods and can be quite useful in evaluating complex interventions. As systems of care become more complex, mixed methods will likely be seen more in the literature as they can lead to better understanding about interventions and outcomes. This study uses mixed methods to evaluate a randomized controlled trial of case management in primary care.
Discussion Questions
- What question is asked by this study and why does it matter?
- How does this study advance beyond previous research and clinical practice on this topic?
- How strong is the study design for answering the question?
- To what degree can the findings be accounted for by:
- How patients were selected, excluded, or lost to follow-up?
- The entrance criteria for patients into the randomized controlled trial?
- Who was selected for the qualitative portion of the study and the selection process?
- How the main variables were measured?
- Who was blinded in the study?
- Length of follow-up?
- Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
- Chance?
- How the findings were interpreted?
- What are the main study findings? How do these findings compare with previous evaluations of case management?
- How do the qualitative findings influence your understanding of the quantitative findings, and vice versa?
- How comparable is the study sample to similar patients in your practice? Do you think the intervention could be implemented in your office?
- What contextual factors are important for interpreting the findings?
- How might this study change case management in your practice? Policy? Education? Research?
- What are the next steps in interpreting or applying the findings?
- What researchable questions remain?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197. http://annfammed.org/content/4/3/196.full.
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- Stakeholders perceptions of a nurse-led telehealth case management intervention in primary care for patients with complex care needs: a qualitative descriptive study
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