Integrated healthcare for chronically ill. Reflections on the gap between science and practice and how to bridge the gap

Vlegel-Brouwer, Wilma van der

doi:10.5334/ijic.1079

Cited by 15 publications

(13 citation statements)

References 24 publications

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“…Ein gelungenes Selbstmanagement ist notwendig, um die Beschwerden von Lipödem-Patientinnen langfristig zu verringern. Die Studienlage zum Selbstmanagement ist sehr konsistent: Bei Patien-ten mit chronischen Erkrankungen [107,108] führt ein gutes Selbstmanagement zu einer Verbesserung des Gesundheitszustands, des Funktionierens im Alltag und einer höheren Lebensqualität. Inzwischen sehen wir regelmäßig Lipödem-Patientinnen, die ihre Beschwerden durch gelungene Selbstmanagementstrategien auch über einen längeren Zeitraum deutlich reduzieren konnten, viele beschreiben sich sogar als beschwerdefrei.…”

Section: Selbstmanagementunclassified

Lipoedema – myths and facts, Part 5

Bertsch¹,

Erbacher²,

Corda³

et al. 2020

Phlebologie

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The four previous articles in this series addressed the myths and facts surrounding lipoedema. We have shown that there is no scientific evidence at all for the key statements made about lipoedema – which are published time and time again. The main result of this “misunderstanding” of lipoedema is a therapeutic concept that misses the mark. The patient’s real problems are overlooked.The national and especially the international response to the series, which can be read in both German and English, has been immense and has exceeded all our expectations. The numerous reactions to our articles make it clear that in other countries, too, the fallacies regarding lipoedema have led to an increasing discrepancy between the experience of healthcare workers and the perspective of patients and self-help groups, based on misinformation mostly generated by the medical profession.Parts 1 to 4 in this series of articles on the myths surrounding lipoedema have made it clear that we have to radically change the view of lipoedema that has been held for decades. Changing our perspective means getting away from the idea of “oedema in lipoedema” – and hence away from the dogma that decongestion is absolutely necessary – and towards the actual problems faced by our patients with lipoedema. Such a paradigm shift in a disease that has been described in the same way for decades cannot be left to individuals but must be put on a much broader footing. For this reason, the lead author of this series of articles invited renowned lipoedema experts from various European countries to discussions on the subject. Experts from seven different countries took part in the two European Lipoedema Forums, with the goal of establishing a consensus. The consensus reflects the experts’ shared view on the disease, having scrutinized the available literature, and having taken into account the many years of clinical practice with this particular patient group. Appropriate to the clinical complexity of lipoedema, participants from different specialties provided an interdisciplinary approach. Nearly all of the participants in the European Lipoedema Forum had already published work on lipoedema, had been involved in drawing up their national lipoedema guidelines, or were on the executive board of their respective specialty society.In this fifth and final part of our series on lipoedema, we will summarise the relevant findings of this consensus, emphasising the treatment of lipoedema as we now recommend it. As the next step, the actual consensus paper “European Best Practice of Lipoedema” will be issued as an international publication.Instead of looking at the treatment of oedema, the consensus paper will focus on treatment of the soft tissue pain, as well as the psychological vulnerability of patients with lipoedema. The relationship between pain perception and the patient’s mental health is recognised and dealt with specifically. The consensus also addresses the problem of self-acceptance, and this plays a prominent role in the new therapeutic concept. The treatment of obesity provides a further pillar of treatment. Obesity is recognised as being the most common comorbid condition by far and an important trigger of lipoedema. Bariatric surgery should therefore also be considered for patients with lipoedema who are morbidly obese. The expert group upgraded the importance of compression therapy and appropriate physical activity, as the demonstrated anti-inflammatory effects directly improve the patients’ symptoms. Patients will be provided with tools for personalised self-management in order to sustain sucessful treatment. Should conservative therapy fail to improve the symptoms, liposuction may be considered in strictly defined circumstances.The change in the view of lipoedema that we describe here brings the patients’ actual symptoms to the forefront. This approach allows us to focus on more comprehensive treatment that is not only more effective but also more sustainable than focusing on the removal of non-existent oedema.

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Section: Selbstmanagementunclassified

Lipoedema – myths and facts, Part 5

Bertsch¹,

Erbacher²,

Corda³

et al. 2020

Phlebologie

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“…This finding also highlights the need for greater integration of clinical programs with public and population health strategies. Others have also reflected on a lack of attention to the population and community-oriented elements of the E/CCM [ 1 ]. The impacts of some of the elements that may greatly affect disease, health, and quality of life (including patient support, system design, clinical decision support and clinical information systems) can be difficult to evaluate or measure, but may be of considerable importance to the overall success of E/CCM programs [ 1 ].…”

Section: Discussionmentioning

confidence: 99%

“…Health care systems are frequently challenged by issues of access, continuity, fragmentation and quality of care in addressing the needs of older persons with chronic illness [ 1 ]. Wagner and colleagues [ 2 ] developed the Chronic Care Model (CCM) as a framework for the development of more comprehensive and integrated chronic care.…”

Section: Introductionmentioning

confidence: 99%

Measured outcomes of chronic care programs for older adults: a systematic review

et al. 2015

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BackgroundWagner’s Chronic Care Model (CCM), as well as the expanded version (ECCM) developed by Barr and colleagues, have been widely adopted as frameworks for prevention and management of chronic disease. Given the high prevalence of chronic illness in older persons, these frameworks can play a valuable role in reorienting the health care system to better serve the needs of seniors. We aimed to identify and assess the measured goals of E/CCM interventions in older populations. In particular, our objective was to determine the extent to which published E/CCM initiatives were evaluated based on population, community, system and individual-level outcomes (including clinical, functional and quality of life measures).MethodsWe conducted a systematic search of the Science Citation Index Web of Knowledge search tool to gather articles published between January 2003 and July 2014. We included published CCM interventions that cited at least one of the fundamental papers that introduced and described the CCM and ECCM. Studies retained for review reported evaluations of senior-focused E/CCM initiatives in community-based settings, with the topic of “older adults” OR senior* OR elder* OR geriatric OR aged. The resulting 619 published articles were independently reviewed for inclusion by two researchers. We excluded the following: systematic reviews, meta-analyses, descriptions of proposed programs, and studies whose populations did not focus on seniors.ResultsWe identified 14 articles that met inclusion criteria. Studies used a wide range of measures, with little consensus between studies. All of the included studies used the original CCM. While a range of system-level and individual patient outcomes have been used to evaluate CCM interventions, no studies employed measures of population or community health outcomes.ConclusionsFuture efforts to test E/CCM interventions with seniors would be aided by more consistent outcome measures, greater attention to outcomes for the caregivers of older persons with chronic illness, and a greater focus on population and community impacts.

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“…We used gap analysis to understand the discrepancy between current and best practice [27] using three indices: the gap index, the overlap index and the over-provision index.…”

Section: Methodsmentioning

confidence: 99%

Coordination of care in the Chinese health care systems: a gap analysis of service delivery from a provider perspective

Wang

Birch

Zhu

et al. 2016

BMC Health Serv Res

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BackgroundIncreases in health care utilization and costs, resulting from the rising prevalence of chronic conditions related to the aging population, is exacerbated by a high level of fragmentation that characterizes health care systems in China. There have been several pilot studies in China, aimed at system-level care coordination and its impact on the full integration of health care system, but little is known about their practical effects. Huangzhong County is one of the pilot study sites that introduced organizational integration (a dimension of integrated care) among health care institutions as a means to improve system-level care coordination. The purposes of this study are to examine the effect of organizational integration on system-level care coordination and to identify factors influencing care coordination and hence full integration of county health care systems in rural China.MethodsWe chose Huangzhong and Hualong counties in Qinghai province as study sites, with only Huangzhong having implemented organizational integration. A mixed methods approach was used based on (1) document analysis and expert consultation to develop Best Practice intervention packages; (2) doctor questionnaires, identifying care coordination from the perspective of service provision. We measured service provision with gap index, overlap index and over-provision index, by comparing observed performance with Best Practice; (3) semi-structured interviews with Chiefs of Medicine in each institution to identify barriers to system-level care coordination.ResultsTwenty-nine institutions (11 at county-level, 6 at township-level and 12 at village-level) were selected producing surveys with a total of 19 schizophrenia doctors, 23 diabetes doctors and 29 Chiefs of Medicine. There were more care discontinuities for both diabetes and schizophrenia in Huangzhong than in Hualong. Overall, all three index scores (measuring service gaps, overlaps and over-provision) showed similar tendencies for the two conditions. The gap indices of schizophrenia (> 5.10) were bigger for diabetes (< 2.60) in both counties. The over-provision indices of schizophrenia (> 3.25) were bigger than diabetes (< 1.80) in both counties. Overlap indices for the two conditions exceeded justified overlaps, especially for diabetes. Gap index scores for schizophrenia interventions at the township-level and over-provision index scores for diabetes interventions at both village- and township-level showed big differences between the two counties. Insufficient medical staff with appropriate competencies, lack of motivation for care coordination and related supportive policies as well as unconnected information system were identified as barriers to system-level care coordination in both counties.ConclusionFindings demonstrate that organizational integration in Huangzhong has not achieved a higher level of care coordination at this stage. System-level care coordination is most problematic at village-level institutions in Hualong, but at county-level institutions in Huangzhong. Th...

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Integrated healthcare for chronically ill. Reflections on the gap between science and practice and how to bridge the gap

Cited by 15 publications

References 24 publications

Lipoedema – myths and facts, Part 5

Lipoedema – myths and facts, Part 5

Measured outcomes of chronic care programs for older adults: a systematic review

Coordination of care in the Chinese health care systems: a gap analysis of service delivery from a provider perspective

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