Heterogeneity Is Not Always Noise

Davidoff, Frank

doi:10.1001/jama.2009.1845

Cited by 105 publications

(88 citation statements)

References 61 publications

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“…They need to go beyond assumptions of linear effects and do more than assess central tendency. From a traditional clinical trials perspective, contextual factors would be considered as noise, 56 as effect modifiers, or as confounding variables to be controlled or their effects made irrelevant through randomization. [57][58][59] Decontextualized research methods, however, are a major reason why their findings are not translated into practice.…”

Section: Methods For Generating the Needed New Knowledgementioning

confidence: 99%

“…65 Expanded research methods can be used to go beyond common reductionist conceptualizations to embrace new conceptual and computational models that include contextual factors. 66 Methods that take context into account can help make sense of heterogeneity 56 and of the frequent failure to replicate decontextualized studies in different settings. [67][68][69] Table 3 lists current methodological challenges relevant to research on MCC and offers suggestions for contextualized research methods.…”

Section: Methods For Generating the Needed New Knowledgementioning

confidence: 99%

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Understanding the Context of Health for Persons With Multiple Chronic Conditions: Moving From What Is the Matter to What Matters

Bayliss

Bonds

Boyd

et al. 2014

The Annals of Family Medicine

204

164

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PURPOSE An isolated focus on 1 disease at a time is insufficient to generate the scientific evidence needed to improve the health of persons living with more than 1 chronic condition. This article explores how to bring context into research efforts to improve the health of persons living with multiple chronic conditions (MCC).METHODS Forty-five experts, including persons with MCC, family and friend caregivers, researchers, policy makers, funders, and clinicians met to critically consider 4 aspects of incorporating context into research on MCC: key contextual factors, needed research, essential research methods for understanding important contextual factors, and necessary partnerships for catalyzing collaborative action in conducting and applying research.RESULTS Key contextual factors involve complementary perspectives across multiple levels: public policy, community, health care systems, family, and person, as well as the cellular and molecular levels where most research currently is focused. Needed research involves moving from a disease focus toward a person-driven, goal-directed research agenda. Relevant research methods are participatory, flexible, multilevel, quantitative and qualitative, conducive to longitudinal dynamic measurement from diverse data sources, sufficiently detailed to consider what works for whom in which situation, and generative of ongoing communities of learning, living and practice. Important partnerships for collaborative action include cooperation among members of the research enterprise, health care providers, community-based support, persons with MCC and their family and friend caregivers, policy makers, and payers, including government, public health, philanthropic organizations, and the business community.CONCLUSION Consistent attention to contextual factors is needed to enhance health research for persons with MCC. Rigorous, integrated, participatory, multimethod approaches to generate new knowledge and diverse partnerships can be used to increase the relevance of research to make health care more sustainable, safe, equitable and effective, to reduce suffering, and to improve quality of life. INTRODUCTIONM ore than 1 in 4 Americans lives with the burden of more than 1 ongoing health condition, [1][2][3] and the number of persons living with multiple chronic health conditions is growing dramatically. 2,4 Medical costs for persons with chronic illnesses account for 75% of US health care spending, 4 and more than 90% of the Medicare spending on older adults is devoted to persons suffering from multiple chronic conditions (MCC). 5 This heavy expenditure has not yielded the desired increase in quality of life for those affected. 4 A strategic framework of the Department of Health and Human Services (DHHS) 6 and multiple proposals and programs from the private sector highlight the growing concern about persons living with MCC. 261Current health care and research approaches are largely mismatched to the challenge of persons living with MCC. Both health care and research are p...

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Section: Methods For Generating the Needed New Knowledgementioning

confidence: 99%

Section: Methods For Generating the Needed New Knowledgementioning

confidence: 99%

Understanding the Context of Health for Persons With Multiple Chronic Conditions: Moving From What Is the Matter to What Matters

Bayliss

Bonds

Boyd

et al. 2014

The Annals of Family Medicine

204

164

View full text Add to dashboard Cite

show abstract

“…hence, teams both competed and readily learned from each other as change strategies were adopted across the diverse Collaborative settings 19 . The need to address ACGME competencies for accreditation purposes 17,18 -particularly practicebased learning and systems-based practice-provided an opportunity to address multiple demands on learners and academic institutions.…”

Section: Discussionmentioning

confidence: 99%

A Multi-Institutional Quality Improvement Initiative to Transform Education for Chronic Illness Care in Resident Continuity Practices

et al. 2010

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BACKGROUND: There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care. OBJECTIVE: To improve training for residents who provide chronic illness care in teaching practice settings. DESIGN: US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure ≤130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked. PARTICIPANTS: Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives. INTERVENTIONS: Teaching-practice teams-faculty, residents and staff-participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly. RESULTS: Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives. CONCLUSIONS: These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.

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“…Instead, RCTs should serve as starting points for more comprehensive evaluations that account for contextual variations and link them to population-level health outcomes. 5,[11][12][13][14][15][16][17][18] The need for new evaluation designs that account for context has long been recognized. [18][19][20][21] Yet designs to evaluate effectiveness at scale are poorly defined, usually lack control groups, and are often disregarded as unsatisfactory or inadequate.…”

Section: Challenges Of Evaluationmentioning

confidence: 99%

Evaluating large-scale health programmes at a district level in resource-limited countries

Svoronos

Mate

2011

Bull World Health Org

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Heterogeneity Is Not Always Noise

Cited by 105 publications

References 61 publications

Understanding the Context of Health for Persons With Multiple Chronic Conditions: Moving From What Is the Matter to What Matters

Understanding the Context of Health for Persons With Multiple Chronic Conditions: Moving From What Is the Matter to What Matters

A Multi-Institutional Quality Improvement Initiative to Transform Education for Chronic Illness Care in Resident Continuity Practices

Evaluating large-scale health programmes at a district level in resource-limited countries

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