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(Is there any) Effect of tailored practice and patient care plans (?)
Brand new practice management article in BMJ (BMJ 2009;339:b4220)
If anyone has seen similar data on large scale practice improvement and disease management initiatives, please share.
I would love to get your opinion?
The sampling and powering all seem appropriate.
Here is the intervention model:
After 18 months there were no changes in mmHg and [Chol] but here is the one very impressive finding:
RESULTS:
Although the differences in admissions may be considered small, they do seem to be clinically significant. The intervention patients were 56% (95% confidence interval 1.53% to 2.60%) less likely to be admitted than the control patients and for every 100 patients undergoing the intervention, 15 (95% confidence interval 1 to 29) fewer admissions could be expected over an 18 month period....Adjustment for multiple testing also removed the finding of a significant reduction in number of hospital admissions. The need for such adjustment for independent outcomes remains controversial.24-26
Although the differences in admissions may be considered small, they do seem to be clinically significant. The intervention patients were 56% (95% confidence interval 1.53% to 2.60%) less likely to be admitted than the control patients and for every 100 patients undergoing the intervention, 15 (95% confidence interval 1 to 29) fewer admissions could be expected over an 18 month period....Adjustment for multiple testing also removed the finding of a significant reduction in number of hospital admissions. The need for such adjustment for independent outcomes remains controversial.24-26
Here are some highlights from the discussion:
Previous systematic reviews23 of management programmes for cardiac disease have highlighted their potential to decrease the number of hospital admissions, and noted that few actually report this outcome. We are the first to report a significant difference in cardiovascular admissions. A Cochrane review in this area27 is ongoing, but the lack of detail on hospital admissions, which we report, is still lacking (B Buckley, personal communication, 2009).
..In the Republic of Ireland a recent uncontrolled evaluation of a centrally funded initiative involving secondary cardiac preventionin20%of practices nationally (the Heartwatch programme) found significant improvements in themanagement of blood pressure and cholesterolconcentrations over almost three years.9 Our data from control practices, which were not participating in Heartwatch, suggest that improvements may be occurring through changes in the population31 32 and general system rather than through specific interventions in themselves. These changesmay, for example, be occurring through increased societal and patient awareness of appropriate care, enhanced management of incident cases in hospital, or improved organisation of general practices in the management of chronic disease, particularly in prescribing.33 One study reported that improvements in the management of cardiovascular disease preceded the introduction of the new general practitioner contract in the UK, with its quality and outcomes framework, and the rate of improvement since then has remained similar.6
It may be that a ceiling effect has been reached in the secondary management of cardiovascular disease in primary care. Similar ceiling effects have been noted recently in relation to medical outcomes in patients with diabetes.34 The qualitative findings within our study (M D'Eath, personal communication, 2009) indicated that some patients found targeted changes unachievable or that their practitioners judged them to be unattainable. Consideration of this issue is important as significant resources are being given to support such interventions in the primary care management of cardiovascular disease and in the management of chronic disease generally. As resources are finite and workloads have increased, it may be that the focus of management programmes in the secondary prevention of cardiac disease in the community should be on those with additional absolute risk, such as patients with several morbidities35 36 or those who are more
disadvantaged.37
disadvantaged.37
Hope this all makes sense - I was very impressed by this article, its real-world context and the author's realistic discussions. But I would love to know what you think...
Tinkering with tweetering
Hello again:
I am tinkering with the idea of tweetering under the moniker of 'cmeadvocate.'
The goal would be simple - to keep an open and honest dialog going within the CME community.
If you have an interest, check it out. I am not sure how productive I will be and I am not sure of the value of the content (in 140 characters or fewer) but feel free to check it out.
I am tinkering with the idea of tweetering under the moniker of 'cmeadvocate.'
The goal would be simple - to keep an open and honest dialog going within the CME community.
If you have an interest, check it out. I am not sure how productive I will be and I am not sure of the value of the content (in 140 characters or fewer) but feel free to check it out.
