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1.  Evaluation of a Chronic Disease Management System for the Treatment and Management of Diabetes in Primary Health Care Practices in Ontario 
Background
Computerized chronic disease management systems (CDMSs), when aligned with clinical practice guidelines, have the potential to effectively impact diabetes care.
Objective
The objective was to measure the difference between optimal diabetes care and actual diabetes care before and after the introduction of a computerized CDMS.
Methods
This 1-year, prospective, observational, pre/post study evaluated the use of a CDMS with a diabetes patient registry and tracker in family practices using patient enrolment models. Aggregate practice-level data from all rostered diabetes patients were analyzed. The primary outcome measure was the change in proportion of patients with up-to-date “ABC” monitoring frequency (i.e., hemoglobin A1c, blood pressure, and cholesterol). Changes in the frequency of other practice care and treatment elements (e.g., retinopathy screening) were also determined. Usability and satisfaction with the CDMS were measured.
Results
Nine sites, 38 health care providers, and 2,320 diabetes patients were included. The proportion of patients with up-to-date ABC (12%), hemoglobin A1c (45%), and cholesterol (38%) monitoring did not change over the duration of the study. The proportion of patients with up-to-date blood pressure monitoring improved, from 16% to 20%. Data on foot examinations, retinopathy screening, use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and documentation of self-management goals were not available or not up to date at baseline for 98% of patients.
By the end of the study, attitudes of health care providers were more negative on the Training, Usefulness, Daily Practice, and Support from the Service Provider domains of the CDMS, but more positive on the Learning, Using, Practice Planning, CDMS, and Satisfaction domains.
Limitations
Few practitioners used the CDMS, so it was difficult to draw conclusions about its efficacy. Simply giving health care providers a potentially useful technology will not ensure its use.
Conclusions
This real-world evaluation of a web-based CDMS for diabetes failed to impact physician practice due to limited use of the system.
Plain Language Summary
Patients and health care providers need timely access to information to ensure proper diabetes care. This study looked at whether a computer-based system at the doctor’s office could improve diabetes management. However, few clinics and health care providers used the system, so no improvement in diabetes care was seen.
PMCID: PMC3991329  PMID: 24748911
2.  The Appropriate Use of Neuroimaging in the Diagnostic Work-Up of Dementia 
Background
Diagnosis of dementia is challenging and requires both ruling out potentially treatable underlying causes and ruling in a diagnosis of dementia subtype to manage patients and suitably plan for the future.
Objectives
This analysis sought to determine the appropriate use of neuroimaging during the diagnostic work-up of dementia, including indications for neuroimaging and comparative accuracy of alternative technologies.
Data Sources
A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published between 2000 and 2013.
Review Methods
Data on diagnostic accuracy and impact on clinical decision making were abstracted from included studies. Quality of evidence was assessed using GRADE.
Results
The search yielded 5,374 citations and 15 studies were included. Approximately 10% of dementia cases are potentially treatable, though less than 1% reverse partially or fully. Neither prediction rules nor clinical indications reliably select the subset of patients who will likely benefit from neuroimaging. Clinical utility is highest in ambiguous cases or where dementia may be mixed, and lowest for clinically diagnosed Alzheimer disease or clinically excluded vascular dementia. There is a lack of evidence that MRI is superior to CT in detecting a vascular component to dementia. Accuracy of structural imaging is moderate to high for discriminating different types of dementia.
Limitations
There was significant heterogeneity in estimates of diagnostic accuracy, which often prohibited a statistical summary of findings. The quality of data reported by studies prohibited calculation of likelihood ratios in the present analysis. No studies from primary care were found; thus, generalizability beyond tertiary care settings may be limited.
Conclusions
A diagnosis of reversible dementia is rare. Imaging has the most clinical utility in cases where there is potentially mixed dementia or ambiguity as to the type of dementia despite prolonged follow-up (e.g., 2 years or more). Both CT and MRI are useful for detecting a vascular component of dementia.
Plain Language Summary
Dementia is a devastating condition of memory loss and behaviour change that affects many Canadians, especially older adults. Diagnosis is complex because symptoms can be caused by different brain diseases, such as Alzheimer disease, and in some cases by other causes such a tumour or cerebrovascular disease. Although dementia rarely improves much, an accurate diagnosis is important because it determines the treatment a patient should receive and helps patients and families understand what the future holds.
Brain imaging, using computed tomography (CT) or magnetic resonance imaging (MRI) scans, may help in the diagnosis by allowing doctors to see changes in brain structure or function that explain the dementia. Unfortunately, it is not well understood which patients will most likely benefit from a brain scan and which type of scan works best to diagnose dementia. This study reviewed the published evidence about these questions.
The study found that relying on specific symptoms to decide who should have a brain scan, rather than imaging all dementia patients, is unreliable and can miss some potentially treatable conditions. The study also found that scans have most value when doctors are uncertain as to the type of dementia despite monitoring the patient for a while (e.g., 2 years) or when the patient may have a combination of dementia types. Brain scans are often less helpful in the diagnosis of Alzheimer disease, and doctors can often use clinical assessment to rule out vascular dementia (another common type of dementia, related to cerebrovascular disease). The evidence also shows that MRI is not better than CT in detecting vascular dementia as a contributing cause. For Alzheimer disease, Creutzfeldt-Jakob disease, and clinically ambiguous dementias, both CT and MRI are highly accurate in correctly ruling out these diagnoses, but both types of scans have only low to moderate ability to correctly identify patients with any of these conditions. Importantly, the quality of the evidence available for this study was limited by considerable differences in research and analysis methods.
PMCID: PMC3937983  PMID: 24592296
3.  The Appropriate Use of Neuroimaging in the Diagnostic Work-Up of Dementia 
Background
Structural brain imaging is often performed to establish the underlying causes of dementia. However, recommendations differ as to who should receive neuroimaging and whether computed tomography (CT) or magnetic resonance imaging (MRI) should be used.
Objectives
This study aimed to determine the cost-effectiveness in Ontario of offering structural imaging to all patients with mild to moderate dementia compared with offering it selectively according to guidelines from the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCC). We compared the cost-effectiveness of CT and MRI as first-line strategies.
Methods
We performed a systematic literature search (2000 to 2013) to identify cost-effectiveness studies of clinical prediction rules and structural imaging modalities. Studies were assessed for quality and applicability to Ontario. We also developed a model to evaluate the cost-effectiveness of clinical guidelines (image all versus according to CCC) and modalities (CT versus MRI). Transition probabilities, utilities, and costs were obtained from published literature or expert opinion. Results were expressed in terms of costs and quality adjusted life years (QALYs).
Results
No relevant cost-effectiveness analyses were identified in the published literature. According to the base-case results of our model, the most effective and cost-effective strategy is to image patients who meet CCC criteria with CT and to follow-up with MRI for suspected cases of space-occupying lesions (SOL). However, the results were sensitive to the specificity of MRI for detecting vascular causes of dementia. At a specificity of 64%, the most cost-effective strategy is CCC followed by MRI.
Limitations
Studies used to estimate diagnostic accuracy were limited by a lack of a gold standard test for establishing the cause of dementia. The model does not include costs to patients and their families, nor does it account for patient preferences about diagnostic information.
Conclusions
Given the relative prevalence of vascular dementia and SOLs, and the improvement in QALYs associated with treatment, the strategy with the greatest combined sensitivity (CCC with CT followed by MRI for patients with SOLs) results in the greatest number of QALYs and is the least costly. Due to limitations in the clinical data and challenges in the interpretation of this evidence, the model should be considered a framework for assessing uncertainty in the evidence base rather than providing definitive answers to the research questions.
Plain Language Summary
There is wide debate about whether or not brain scans should routinely be used to assess patients with mild to moderate dementia. Proponents say that imaging is important to detect or rule out possible underlying causes of dementia, such as silent strokes and tumours. Opponents call for a more selective approach, considering the need for clinical judgement and the cost of the technology. Using data from published research, a model was developed to study the cost-effectiveness of different approaches to brain imaging for a hypothetical group of patients with dementia. The model compared 2 strategies: imaging all patients and imaging selectively based on clinical practice guidelines from the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCC). It also compared 2 types of technology: computed tomography (CT) and magnetic resonance imaging (MRI).
The results of the model depended on the accuracy of CT and MRI in diagnosing dementia caused by vascular disease. Unfortunately, because there is no “gold standard” approach to diagnosing dementia, interpreting the published research is challenging. Based on current evidence, in which diagnostic strategies are assessed using a mix of methods, the model showed that the most effective and least costly strategy is to image selectively according to the CCC guidelines, using CT first and then MRI as a follow-up for patients suspected of having space-occupying lesions such as tumours. However, if we assumed that MRI plus clinical assessment is the gold standard, then imaging all patients with MRI is the most cost-effective strategy, despite the higher cost of this technology.
The model did not take into account the value that physicians, patients, and families place on having diagnostic information, even if effective treatment does not yet exist. The model was not able to answer the specific research questions with confidence, but it provides a framework for identifying areas where more research is needed to support decision-making in the diagnosis of dementia.
PMCID: PMC3937984  PMID: 24592297
4.  Vitamin B12 Intramuscular Injections Versus Oral Supplements 
Background
Vitamin B12 deficiency can lead to adverse health effects such as anemia and, in some cases, permanent neurologic damage. In Canada, patients with vitamin B12 deficiency are typically given intramuscular injections, which incur considerable cost and inconvenience. The clinical evidence-based analysis has found that oral supplementation is as effective as intramuscular injections.
Objectives
This economic analysis aimed to estimate the cost savings of switching from intramuscular injections to high-dose oral supplements for patients aged 18 years and older with confirmed vitamin B12 deficiency.
Data Sources
Population-based administrative databases for Ontario were used to identify patients receiving vitamin B12 intramuscular injections in any fiscal year between 2006 and 2011. The Ontario Drug Benefit (ODB) database was used to identify patients who were prescribed vitamin B12 injections, and the Ontario Health Insurance Plan database was used to identify all physician claims for intramuscular injections as well as laboratory tests assessing vitamin B12 levels. The Registered Physicians Database was used to identify the type of physician; the analysis was restricted to family physicians and internists.
Review Methods
Two cohorts of patients were identified. For cohort 1, the ODB database was used to identify patients who were prescribed vitamin B12 injections. Those covered under the ODB are 65 years of age or older and are economically deprived. A second cohort was created to capture those 18 to 64 years of age receiving injections. Cohort 2 consisted of patients (not in cohort 1) who received 6 or more intramuscular injections within 1 year and had a laboratory test 2 months before the intramuscular injection claim. Physician experts were consulted to estimate the resources and costs of converting patients to oral supplements. The Ministry of Health and Long-Term Care perspective was taken, and all costs are expressed in 2013 Canadian dollars.
Results
The budget impact analysis demonstrated costs of $2.8 million to the Ministry of Health and Long-Term Care in the first year of conversion; however, in subsequent years there are savings of $4.2 million per year. The cumulative 5-year budget impact demonstrates savings of $14.2 million to the health care system.
Limitations
This analysis represents the cost of conversion for those currently receiving intramuscular injections. There are no conversion costs for those who are prescribed oral supplements as an initial therapy, and so the savings could be even greater than reported. As well, an underlying assumption of this analysis is that patients will comply with oral supplementation.
Conclusions
Over 5 years, there are savings of $14.2 million to the health care system from switching to vitamin B12 oral supplements.
Plain Language Summary
Vitamin B12 deficiency has long been thought to be associated with dementia and other neurocognitive disorders. In a separate report, Health Quality Ontario (HQO) reviewed the published research on this issue and found only weak evidence that vitamin B12 deficiency is associated with the onset of dementia. That review also found moderate evidence that treatment with vitamin B12 does not improve dementia and that oral supplements are as effective as injections of vitamin B12.
In 2010, more than 2.9 million serum vitamin B12 tests were performed in Ontario at a cost of $40 million. Each year, approximately 110,000 residents receive vitamin B12 injections to boost their levels of vitamin B12. HQO commissioned an economic analysis to estimate the cost savings of switching from vitamin B12 injections to high-dose oral supplements for patients aged 18 years and older with confirmed B12 deficiency. This study concluded that the Ontario health care system could save $14.5 million in 5 years by switching to oral supplements, assuming that patients took the oral supplements as required.
PMCID: PMC3874775  PMID: 24379898
5.  Vitamin B12 and Cognitive Function 
Background
More than 2.9 million serum vitamin B12 tests were performed in 2010 in Ontario at a cost of $40 million. Vitamin B12 deficiency has been associated with a few neurocognitive disorders.
Objective
To determine the clinical utility of B12 testing in patients with suspected dementia or cognitive decline.
Methods
Three questions were addressed:
Is there an association between vitamin B12 deficiency and the onset of dementia or cognitive decline?
Does treatment with vitamin B12 supplementation improve cognitive function in patients with dementia or cognitive decline and vitamin B12 deficiency?
What is the effectiveness of oral versus parenteral vitamin B12 supplementation in those with confirmed vitamin B12 deficiency?
A literature search was performed using MEDLINE, Embase, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the Centre for Reviews and Dissemination database, from January 2002 until August 2012.
Results
Eighteen studies (7 systematic reviews and 11 observational studies) were identified to address the question of the association between B12 and the onset of dementia. Four systematic reviews were identified to address the question of the treatment of B12 on cognitive function. Finally, 3 randomized controlled trials were identified that compared oral B12 to intramuscular B12.
Conclusions
Based on very low quality evidence, there does appear to be an association between elevated plasma homocysteine levels (a by-product of B vitamins) and the onset of dementia.
Based on moderate quality evidence, but with less than optimal duration of follow-up, treatment with B12 supplementation does not appreciably change cognitive function.
Based on low to moderate quality of evidence, treatment with vitamin B12 and folate in patients with mild cognitive impairment seems to slow the rate of brain atrophy.
Based on moderate quality evidence, oral vitamin B12 is as effective as parenteral vitamin B12 in patients with confirmed B12 deficiency.
Plain Language Summary
Low levels of vitamin B12 have been associated with neurocognitive disorders. This evidence-based analysis assessed the usefulness of serum vitamin B12 testing as it relates to brain function. This review found very low quality evidence that suggests a connection between high plasma homocysteine levels (a by-product of B vitamin metabolism in the body) and the onset of dementia. Moderate quality of evidence indicates treatment with vitamin B12 does not improve brain function. Moderate quality of evidence also indicates treatment using oral vitamin B12 supplements is as effective as injections of vitamin B12.
PMCID: PMC3874776  PMID: 24379897
6.  Electrical Stimulation for Drug-Resistant Epilepsy 
Objective
The objective of this analysis was to evaluate the effectiveness of deep brain stimulation (DBS) and vagus nerve stimulation (VNS) for the treatment of drug-resistant epilepsy in adults and children.
Data Sources
A literature search was performed using MEDLINE, EMBASE, the Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published from January 2007 until December 2012.
Review Methods
Systematic reviews, meta-analyses, randomized controlled trials (RCTs), and observational studies (in the absence of RCTs) of adults or children were included. DBS studies were included if they specified that the anterior nucleus of thalamus was the area of the brain stimulated. Outcomes of interest were seizure frequency, health resource utilization, and safety. A cost analysis was also performed.
Results
The search identified 6 studies that assessed changes in seizure frequency after electrical stimulation: 1 RCT on DBS in adults, 4 RCTs on VNS in adults, and 1 RCT on VNS in children. The studies of DBS and VNS in adults found significantly improved rates of seizure frequency, but the study of VNS in children did not find a significant difference in seizure frequency between the high and low stimulation groups.
Significant reductions in hospitalizations and emergency department visits were found for adults and children who received VNS. No studies addressed the use of health resources for patients undergoing DBS. Five studies reported on adverse events, which ranged from serious to transient for both procedures in adults and were mostly transient in the 1 study of VNS in children.
Limitations
We found no evidence on DBS in children or on health care use related to DBS. The measurement of seizure frequency is self-reported and is therefore subject to bias and issues of compliance.
Conclusions
Based on evidence of low to moderate quality, both DBS and VNS seemed to reduce seizure frequency in adults. In children, VNS did not appear to be as effective at reducing seizure frequency, but children had significantly fewer hospitalizations and ED visits after VNS implantation. Despite the considerable risks associated with these invasive procedures, long-term adverse events appear to be limited.
Plain Language Summary
Electrical stimulation of specific areas of the brain is a procedure used to control epileptic seizures when more conventional treatments are not working. Most adults and children with epilepsy are able to control their seizures with medication, but for some patients, drugs are not effective and surgery to remove the part of the brain where the seizures start is not an appropriate option. This study looked at the research available on the effectiveness, safety, and cost of two types of electrical stimulation devices currently licensed for treatment of epilepsy for adults and children in Canada: vagus nerve stimulation (VNS) and deep brain stimulation (DBS).
Both approaches appear to be effective at reducing the frequency of seizures in adults. However, the evidence on DBS is limited to a single study with adults; we found no studies of DBS with children. Studies on VNS showed that both adults and children had fewer hospitalizations and emergency department visits after the procedure. Both procedures carry serious risks, but several longer-term studies have found that adverse events appear to be limited.
The cost of VNS, including the process of assessing whether or not patients are good candidates for the procedure, is estimated to be about $40,000 per person (and higher for DBS because the device is more expensive and the operating time is longer). Of the 70,000 people in Ontario with epilepsy, about 1,400 (300 children and 1,110 adults) may be candidates for VNS to reduce their seizures.
PMCID: PMC3817921  PMID: 24228081
7.  Cost-effectiveness of the Carbon-13 Urea Breath Test for the Detection of Helicobacter Pylori 
Objectives
This analysis aimed to evaluate the cost-effectiveness of various testing strategies for Helicobacter pylori in patients with uninvestigated dyspepsia and to calculate the budgetary impact of these tests for the province of Ontario.
Data Sources
Data on the sensitivity and specificity were obtained from the clinical evidence-based analysis. Resource items were obtained from expert opinion, and costs were applied on the basis of published sources as well as expert opinion.
Review Methods
A decision analytic model was constructed to compare the costs and outcomes (false-positive results, false-negative results, and misdiagnoses avoided) of the carbon-13 (13C) urea breath test (UBT), enzyme-linked immunosorbent assay (ELISA) serology test, and a 2-step strategy of an ELISA serology test and a confirmatory 13C UBT based on the sensitivity and specificity of the tests and prevalence estimates.
Results
The 2-step strategy is more costly and more effective than the ELISA serology test and results in $210 per misdiagnosis case avoided. The 13C UBT is dominated by the 2-step strategy, i.e., it is more costly and less effective. The budget impact analysis indicates that it will cost $7.9 million more to test a volume of 129,307 patients with the 13C UBT than with ELISA serology, and $4.7 million more to test these patients with the 2-step strategy.
Limitations
The clinical studies that were pooled varied in the technique used to perform the breath test and in reference standards used to make comparisons with the breath test. However, these parameters were varied in a sensitivity analysis. The economic model was designed to consider intermediate outcomes only (i.e., misdiagnosed cases) and was not a complete model with final patient outcomes (e.g., quality-adjusted life years).
Conclusions
Results indicate that the 2-step strategy could be economically attractive for the testing of H. pylori. However, testing with the 2-step strategy will cost the Ministry of Health and Long-Term Care $4.7 million more than with the ELISA serology test.
PMCID: PMC3817923  PMID: 24228083
8.  Carbon-13 Urea Breath Test for Helicobacter Pylori Infection in Patients with Uninvestigated Ulcer-Like Dyspepsia 
Background
Dyspepsia is a condition defined by chronic pain or discomfort in the upper gastrointestinal tract that can be caused by Helicobacter pylori. The carbon-13 urea breath test (13C UBT) is a non-invasive test to detect H. pylori.
Objectives
We aimed to determine the diagnostic accuracy and clinical utility of the 13C UBT in adult patients with ulcer-like dyspepsia who have no alarm features.
Data Sources
A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published between 2003 and 2012.
Review Methods
We abstracted the sensitivity and specificity, which were calculated against a composite reference standard. Summary estimates were obtained using bivariate random effects regression analysis.
Results
From 19 diagnostic studies, the 13C UBT summary estimates were 98.1% (95% confidence interval [CI], 96.3–99.0) for sensitivity and 95.1% (95% CI, 90.3–97.6) for specificity. In 6 studies that compared the 13C UBT with serology, the 113C UBT sensitivity was 95.0% (95% CI, 90.1–97.5) and specificity was 91.6 % (95% CI, 81.3–96.4). The sensitivity and specificity for serology were 92.9% (95% CI, 82.6–97.3) and 71.1% (95% CI, 63.8–77.5), respectively. In 1 RCT, symptom resolution, medication use, and physician visits were similar among the 13C UBT, serology, gastroscopy, or empirical treatment arms. However, patients tested with 13C UBT reported higher dyspepsia-specific quality of life scores.
Limitations
Processing of the 13C UBT results can vary according to many factors. Further, the studies showed significant heterogeneity and used different composite reference standards.
Conclusions
The 13C UBT is an accurate test with high sensitivity and specificity. Compared with serology, it has higher specificity. There is a paucity of data on the 13C UBT beyond test accuracy.
Plain Language Summary
Breath test for detecting bacteria in patients with ulcer-like symptoms
Dyspepsia is a condition that causes long-term pain or discomfort in the upper abdomen. Symptoms can include heartburn, burping, bloating, nausea, or slow digestion. Dyspepsia can be caused by a bacterium that also causes ulcers and stomach cancer. Half of the world’s people are believed to be infected with these bacteria. A test has been developed to detect the bacteria in a breath sample. Our review determined the accuracy of this breath test in adults with ulcer-like symptoms.
From 19 studies, the breath test correctly identified 98% of patients with the bacteria and 95% of patients without the bacteria, as determined by a reference standard. Six studies compared the breath test to a blood test that is currently used. Both the breath and blood tests performed well in correctly identifying patients with the bacteria. However, the blood test was incorrectly positive in 20 more patients who did not have the bacteria according to the breath test. This means that more patients would have received unnecessary treatment.
Thus, the breath test is an accurate test to detect the bacteria in adult patients who have ulcer-like symptoms. But the many differences among the studies in our review included several steps taken to perform the breath test and the reference standards used to compare a blood test with the breath test.
PMCID: PMC3818027  PMID: 24228082
9.  Hysteroscopic Tubal Sterilization 
Background
Hysteroscopic sterilization is a minimally invasive alternative to laparoscopic tubal ligation for women who want permanent contraception. In contrast to the laparoscopic technique, a hysteroscope is used to pass permanent microinserts through the cervix and place them in the fallopian tubes. This procedure does not require local or general anesthesia and can be performed in an office setting.
Objectives
The objective of this analysis was to determine, based on published literature, the cost-effectiveness of hysteroscopic tubal sterilization (HS) compared with laparoscopic tubal ligation (LS) for permanent female sterilization.
Data Sources
A systematic literature search was conducted for studies published between January 1, 2008, and December 11, 2012.
Review Methods
Potentially relevant studies were identified based on the title and abstract. Cost-utility analyses (studies that report outcomes in terms of costs and quality-adjusted life-years) were prioritized for inclusion. When not available, cost-effectiveness, cost-benefit, and cost-consequence analyses were considered. Costing studies were considered in the absence of all other analyses.
Results
A total of 33 abstracts were identified. Three cost analyses were included. A retrospective chart review from Canada found that HS was $111 less costly than LS; a prospective activity-based cost management study from Italy reported that it was €337 less costly than LS; and the results of an American decision model showed that HS was $1,178 less costly than LS.
Limitations
All studies had limited applicability to the Ontario health care system due to differences in setting, resource use, and costs.
Conclusions
Three cost analyses found that, although the HS procedure was more expensive due to the cost of the microinserts, HS was less costly than LS overall due to the shorter recovery time required.
Plain Language Summary
Hysteroscopic sterilization is a minimally invasive alternative to conventional tubal ligation for women who want a permanent method of contraception. Both approaches involve closing off the fallopian tubes, preventing the egg from moving down the tube and the sperm from reaching the egg. Tubal ligation is a surgical procedure to tie or seal the fallopian tubes, and it usually requires general anesthesia. In contrast, hysteroscopic tubal sterilization can be performed in 10 minutes in an office setting without general or even local anesthesia. A tiny device called a microinsert is inserted into each fallopian tube through the vagina, cervix, and uterus without surgery. An instrument called a hysteroscope allows the doctor to see inside the body for the procedure. Once the microinserts are in place, scar tissue forms around them and blocks the fallopian tubes.
Health Quality Ontario commissioned a systematic review of published economic literature to determine whether hysteroscopic sterilization is cost-effective compared to tubal ligation. This review did not find any studies that reported results in terms of both costs and effectiveness or costs and quality-adjusted life-years. We did find 3 costing studies and included them in our review. All of these studies found that when hysteroscopic sterilization was performed as an outpatient procedure, it was less expensive than tubal ligation due to a shorter recovery time. However, none of the studies apply directly to Ontario because of differences in our health care system compared to those in the studies.
PMCID: PMC3819110  PMID: 24228085
10.  Hysteroscopic Tubal Sterilization 
Background
Hysteroscopic tubal sterilization is a minimally invasive alternative to laparoscopic tubal ligation for women who want permanent contraception. The procedures involves non-surgical placement of permanent microinserts into both fallopian tubes. Patients must use alternative contraception for at least 3 months postprocedure until tubal occlusion is confirmed. Compared to tubal ligation, potential advantages of the hysteroscopic procedure are that it can be performed in 10 minutes in an office setting without the use of general or even local anesthesia.
Objective
The objective of this analysis was to determine the effectiveness and safety of hysteroscopic tubal sterilization compared with tubal ligation for permanent female sterilization.
Data Sources
A standard systematic literature search was conducted for studies published from January 1, 2008, until December 11, 2012.
Review Methods
Observational studies, randomized controlled trials (RCTs), systematic reviews and meta-analyses with 1 month or more of follow-up were examined. Outcomes included failure/pregnancy rates, adverse events, and patient satisfaction.
Results
No RCTs were identified. Two systematic reviews covered 22 observational studies of hysteroscopic sterilization. Only 1 (N = 93) of these 22 studies compared hysteroscopic sterilization to laparoscopic tubal ligation. Two other noncomparative case series not included in the systematic reviews were also identified. In the absence of comparative studies, data on tubal ligation were derived for this analysis from the CREST study, a large, multicentre, prospective, noncomparative observational study in the United States (GRADE low). Overall, hysteroscopic sterilization is associated with lower pregnancy rates and lower complication rates compared to tubal ligation. No deaths have been reported for hysteroscopic sterilization.
Limitations
A lack of long-term follow-up for hysteroscopic sterilization and a paucity of studies that directly compare the two procedures limit this assessment. In addition, optimal placement of the microinsert at the time of hysteroscopy varied among studies.
Conclusions
Hysteroscopic sterilization is associated with:
lower pregnancy rates compared to tubal ligation (GRADE very low)
lower complication rates compared to tubal ligation (GRADE very low)
no significant improvement in patient satisfaction compared to tubal ligation (GRADE very low)
Plain Language Summary
Hysteroscopic tubal sterilization is a minimally invasive alternative to conventional tubal ligation for women who want a permanent method of contraception. Both approaches involve closing off the fallopian tubes, preventing the egg from moving down the tube and the sperm from reaching the egg.
Tubal ligation is a surgical procedure to tie or seal the fallopian tubes, and it usually requires general anesthesia. In contrast, hysteroscopic tubal sterilization can be performed in 10 minutes in an office setting without general or even local anesthesia. A tiny device called a microinsert is inserted into each fallopian tube through the vagina, cervix, and uterus without surgery. An instrument called a hysteroscope allows the doctor to see inside the body for the procedure. Once the microinserts are in place, scar tissue forms around them and blocks the fallopian tubes.
Health Quality Ontario conducted a review of the effectiveness and safety of hysteroscopic tubal sterilization compared to tubal ligation.
This review indicates that hysteroscopic tubal sterilization is associated with:
lower pregnancy rates compared to tubal ligation
lower complication rates compared to tubal ligation
no significant improvement in patient satisfaction compared to tubal ligation
However, we found a number of limitations to the studies available on hysteroscopic tubal sterilization. Among other concerns, most studies did not include long-term follow-up and only 1 study directly compared hysteroscopic tubal sterilization to tubal ligation.
PMCID: PMC3819111  PMID: 24228084
11.  Impact of Advanced (Open) Access Scheduling on Patients With Chronic Diseases 
Background
The goal of advanced access scheduling is to eliminate wait times for physician visits by ensuring access to same-day appointments, regardless of urgency or health care need. The intent is to reduce delays in access, leading to improvements in clinical care and patient satisfaction, and reductions in the use of urgent care.
Objective
To evaluate whether implementation of an advanced access scheduling system reduced other types of health service utilization and/or improved clinical measures and patient satisfaction among adults with chronic diseases.
Data Sources and Review Methods
A literature search was performed on January 29, 2012, for studies published from 1946 (OVID) or 1980 (EMBASE) to January 29, 2012. Systematic reviews, randomized controlled trials, and observational studies were eligible if they evaluated advanced access implementation in adults with chronic diseases and reported health resource utilization, patient outcomes, or patient satisfaction. Results were summarized descriptively.
Results
One systematic review in a primary care population and 4 observational studies (5 papers) in chronic disease and/or geriatric populations were identified. The systematic review concluded that advanced access did not improve clinical outcomes, but there was no evidence of harm. Findings from the observational studies in chronic disease populations were consistent with those of the systematic review. Advanced access implementation was not consistently associated with changes in clinical outcomes, patient satisfaction, or health service utilization.
Limitations
All studies were retrospective: 3 studies (4 papers) included historical controls only, and 1 included contemporaneous controls. Findings were inconsistent across studies for a number of outcomes.
Conclusions
Based on low to very low quality evidence, advanced access did not have a statistically (or clinically) significant impact on health service utilization among patients with diabetes and/or coronary artery disease (CAD). Very low quality evidence showed a significant reduction in the proportion of patients with diabetes and CAD admitted to hospital whose length of stay was greater than 3 days. Evidence was inconsistent for changes in clinical outcomes for patients with diabetes or CAD. Very low quality evidence showed no increase in patient satisfaction with an advanced access scheduling system.
Plain Language Summary
Timeliness of health care access—reducing wait times and delays for those receiving and providing care—is a key measure of health system quality. However, in international comparison studies, Canada ranked either last or next to last when it came to timely access to regular doctors. Efforts in Ontario to address delays in access have included the implementation of the Advanced Access and Efficiency for Primary Care initiative through the Quality Improvement and Innovation Partnership, later incorporated into Health Quality Ontario.
Advanced access is a physician appointment scheduling system that aims to eliminate wait times for physician visits and ensure same-day access for all patients, regardless of urgency or health care need. While it can generally be agreed that timely access to health care is necessary for all patients, same-day access may not always be required. Indeed, advanced access may adversely affect the care of patients with chronic diseases if clinics implement strict same-day appointment rules and patients cannot pre-book follow-up appointments. This review evaluated the effect of advanced access scheduling on clinical outcomes, patient satisfaction, and health service utilization in patients with selected chronic diseases, as part of the Optimizing Chronic Disease Management in the Outpatient (Community) Setting mega-analysis.
In patients with diabetes or coronary artery disease, advanced access implementation had little or no impact on acute health care use (hospitalizations, emergency department visits, and/or urgent care visits) and had inconsistent effects on clinical outcomes (blood glucose, low-density lipoprotein [LDL] cholesterol, and blood pressure). Two studies reported reduced monitoring of patients with chronic diseases after implementation of advanced access. Another study reported improved patient management (regular blood glucose and cholesterol testing) after advanced access implementation, but this was attributed to improved provider continuity rather than to reduced appointment wait times. There was no increase in patient satisfaction with the advanced access scheduling system. The quality of the evidence ranged from low to very low.
PMCID: PMC3796762  PMID: 24133569
12.  Screening and Management of Depression for Adults With Chronic Diseases 
Background
Depression is the leading cause of disability and the fourth leading contributor to the global burden of disease. In Canada, the 1-year prevalence of major depressive disorder was approximately 6% in Canadians 18 and older. A large prospective Canadian study reported an increased risk of developing depression in people with chronic diseases compared with those without such diseases.
Objectives
To systematically review the literature regarding the effectiveness of screening for depression and/or anxiety in adults with chronic diseases in the community setting.
To conduct a non-systematic, post-hoc analysis to evaluate whether a screen-and-treat strategy for depression is associated with an improvement in chronic disease outcomes.
Data Sources
A literature search was performed on January 29, 2012, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, OVID PsycINFO, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published from January 1, 2002 until January 29, 2012.
Review Methods
No citations were identified for the first objective. For the second, systematic reviews and randomized controlled trials that compared depression management for adults with chronic disease with usual care/placebo were included. Where possible, the results of randomized controlled trials were pooled using a random-effects model.
Results
Eight primary randomized controlled trials and 1 systematic review were included in the post-hoc analysis (objective 2)—1 in people with diabetes, 2 in people with heart failure, and 5 in people with coronary artery disease. Across all studies, there was no evidence that managing depression improved chronic disease outcomes. The quality of evidence (GRADE) ranged from low to moderate. Some of the study results (specifically in coronary artery disease populations) were suggestive of benefit, but the differences were not significant.
Limitations
The included studies varied in duration of treatment and follow-up, as well as in included forms of depression. In most of the trials, the authors noted a significant placebo response rate that could be attributed to spontaneous resolution of depression or mild disease. In some studies, placebo groups may have had access to care as a result of screening, since it would be unethical to withhold all care.
Conclusions
There was no evidence to suggest that a screen-and-treat strategy for depression among adults with chronic diseases resulted in improved chronic disease outcomes.
Plain Language Summary
People with chronic diseases are more likely to have depression than people without chronic diseases. This is a problem because depression may make the chronic disease worse or affect how a person manages it. Discovering depression earlier may make it easier for people to cope with their condition, leading to better health and quality of life. We reviewed studies that looked at screening and treating for depression in people with chronic diseases. In people with diabetes, treatment of depression did not affect clinical measures of diabetes management. In people with heart failure and coronary artery disease, treatment of depression did not improve heart failure management or reduce rates of heart attacks or death. At present, there is no evidence that screening and treating for depression improves the symptoms of chronic diseases or lead to use of fewer health care services.
PMCID: PMC3797467  PMID: 24133570
14.  In-Home Care for Optimizing Chronic Disease Management in the Community 
Background
The emerging attention on in-home care in Canada assumes that chronic disease management will be optimized if it takes place in the community as opposed to the health care setting. Both the patient and the health care system will benefit, the latter in terms of cost savings.
Objectives
To compare the effectiveness of care delivered in the home (i.e., in-home care) with no home care or with usual care/care received outside of the home (e.g., health care setting).
Data Sources
A literature search was performed on January 25, 2012, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published from January 1, 2006, until January 25, 2012.
Review Methods
An evidence-based analysis examined whether there is a difference in mortality, hospital utilization, health-related quality of life (HRQOL), functional status, and disease-specific clinical measures for in-home care compared with no home care for heart failure, atrial fibrillation, coronary artery disease, stroke, chronic obstructive pulmonary disease, diabetes, chronic wounds, and chronic disease / multimorbidity. Data was abstracted and analyzed in a pooled analysis using Review Manager. When needed, subgroup analysis was performed to address heterogeneity. The quality of evidence was assessed by GRADE.
Results
The systematic literature search identified 1,277 citations from which 12 randomized controlled trials met the study criteria. Based on these, a 12% reduced risk for in-home care was shown for the outcome measure of combined events including all-cause mortality and hospitalizations (relative risk [RR]: 0.88; 95% CI: 0.80–0.97). Patients receiving in-home care had an average of 1 less unplanned hospitalization (mean difference [MD]: –1.03; 95% CI: –1.53 to –0.53) and an average of 1 less emergency department (ED) visit (MD: –1.32; 95% CI: –1.87 to –0.77). A beneficial effect of in-home care was also shown on activities of daily living (MD: –0.14; 95% CI: –0.27 to –0.01), including less difficulty dressing above the waist or below the waist, grooming, bathing/showering, toileting, and feeding. These results were based on moderate quality of evidence. Additional beneficial effects of in-home care were shown for HRQOL although this was based on low quality of evidence.
Limitations
Different characterization of outcome measures across studies prevented the inclusion of all eligible studies for analysis.
Conclusions
In summary, education-based in-home care is effective at improving outcomes of patients with a range of heart disease severity when delivered by nurses during a single home visit or on an ongoing basis. In-home visits by occupational therapists and physical therapists targeting modification of tasks and the home environment improved functional activities for community-living adults with chronic disease.
Plain Language Summary
It is assumed that patients with chronic disease will benefit if they are living at home and being looked after at home or in the community. In addition, there may be cost savings to the health care system when care is provided in the community or in the home instead of in hospitals and other health care settings.
This evidence-based analysis examined whether in-home care given by different health care professionals improved patient and health system outcomes. Patients included those with heart failure, atrial fibrillation, coronary artery disease, stroke, chronic obstructive pulmonary disease, diabetes, chronic wounds, and with more than one chronic disease. The results show that in-home care delivered by nurses has a beneficial effect on patients’ health outcomes. Patient mortality and/or patient hospitalization were reduced. In-home care also improved patients’ activities of daily living when delivered by occupational therapists and physical therapists. In addition, the results showed that in-home care delivered by nurses has a beneficial effect on health system outcomes, reducing the number of unplanned hospitalizations and emergency department visits.
PMCID: PMC3804052  PMID: 24167539
15.  Discharge Planning in Chronic Conditions 
Background
Chronically ill people experience frequent changes in health status accompanied by multiple transitions between care settings and care providers. Discharge planning provides support services, follow-up activities, and other interventions that span pre-hospital discharge to post-hospital settings.
Objective
To determine if discharge planning is effective at reducing health resource utilization and improving patient outcomes compared with standard care alone.
Data Sources
A standard systematic literature search was conducted for studies published from January 1, 2004, until December 13, 2011.
Review Methods
Reports, randomized controlled trials, systematic reviews, and meta-analyses with 1 month or more of follow-up and limited to specified chronic conditions were examined. Outcomes included mortality/survival, readmissions and emergency department (ED) visits, hospital length of stay (LOS), health-related quality of life (HRQOL), and patient satisfaction.
Results
One meta-analysis compared individualized discharge planning to usual care and found a significant reduction in readmissions favouring individualized discharge planning.
A second meta-analysis compared comprehensive discharge planning with postdischarge support to usual care. There was a significant reduction in readmissions favouring discharge planning with postdischarge support. However, there was significant statistical heterogeneity.
For both meta-analyses there was a nonsignificant reduction in mortality between the study arms.
Limitations
There was difficulty in distinguishing the relative contribution of each element within the terms “discharge planning” and “postdischarge support.” For most studies, “usual care” was not explicitly described.
Conclusions
Compared with usual care, there was moderate quality evidence that individualized discharge planning is more effective at reducing readmissions or hospital LOS but not mortality, and very low quality evidence that it is more effective at improving HRQOL or patient satisfaction.
Compared with usual care, there was low quality evidence that the discharge planning plus postdischarge support is more effective at reducing readmissions but not more effective at reducing hospital LOS or mortality. There was very low quality evidence that it is more effective at improving HRQOL or patient satisfaction.
Plain Language Summary
Chronically ill people experience frequent changes in their health status and multiple transitions between care settings and care providers (e.g., hospital to home). Discharge planning provides support services, follow-up activities and other interventions that span pre-hospital discharge to post-hospital settings.
A review of the effects of different discharge plans was conducted. After searching for relevant studies, 11 studies were found that compared discharge planning with routine discharge care.
This review indicates that:
Individualized discharge planning reduces initial hospital length of stay and subsequent readmission to hospital but does not reduce mortality. The effect on health-related quality of life (HRQOL) or patient satisfaction is uncertain.
Discharge planning plus postdischarge support reduces readmissions but does not reduce the initial hospital length of stay or mortality after discharge. The effect on HRQOL or patient satisfaction is uncertain.
PMCID: PMC3804053  PMID: 24167538
16.  Continuity of Care to Optimize Chronic Disease Management in the Community Setting 
Background
This evidence-based analysis reviews relational and management continuity of care. Relational continuity refers to the duration and quality of the relationship between the care provider and the patient. Management continuity ensures that patients receive coherent, complementary, and timely care. There are 4 components of continuity of care: duration, density, dispersion, and sequence.
Objective
The objective of this evidence-based analysis was to determine if continuity of care is associated with decreased health resource utilization, improved patient outcomes, and patient satisfaction.
Data Sources
MEDLINE, EMBASE, CINAHL, the Cochrane Library, and the Centre for Reviews and Dissemination database were searched for studies on continuity of care and chronic disease published from January 2002 until December 2011.
Review Methods
Systematic reviews, randomized controlled trials, and observational studies were eligible if they assessed continuity of care in adults and reported health resource utilization, patient outcomes, or patient satisfaction.
Results
Eight systematic reviews and 13 observational studies were identified. The reviews concluded that there is an association between continuity of care and outcomes; however, the literature base is weak. The observational studies found that higher continuity of care was frequently associated with fewer hospitalizations and emergency department visits. Three systematic reviews reported that higher continuity of care is associated with improved patient satisfaction, especially among patients with chronic conditions.
Limitations
Most of the studies were retrospective cross-sectional studies of large administrative databases. The databases do not capture information on trust and confidence in the provider, which is a critical component of relational continuity of care. The definitions for the selection of patients from the databases varied across studies.
Conclusions
There is low quality evidence that:
Higher continuity of care is associated with decreased health service utilization.
There is insufficient evidence on the relationship of continuity of care with disease-specific outcomes.
There is an association between high continuity of care and patient satisfaction, particularly among patients with chronic diseases.
Plain Language Summary
There are 3 broad categories of continuity of care: informational, management and relational. Relational continuity is the main focus of this review. Relational continuity refers to the ongoing relationship between the care provider and the patient. This review identified several observational studies that assessed continuity of care through the use of validated indices. All of the studies identified demonstrated that higher continuity was associated with either reduced hospitalization rates or reduced emergency department visits. The limitations of this review are that the primary data source was from retrospective studies of administrative data and that all of the studies were focused on physician continuity with a patient—no studies were identified which assessed continuity with other providers such as nurses, social workers or other allied health professionals.
PMCID: PMC3806147  PMID: 24167540
17.  Specialized Nursing Practice for Chronic Disease Management in the Primary Care Setting 
Background
In response to the increasing demand for better chronic disease management and improved health care efficiency in Ontario, nursing roles have expanded in the primary health care setting.
Objectives
To determine the effectiveness of specialized nurses who have a clinical role in patient care in optimizing chronic disease management among adults in the primary health care setting.
Data Sources and Review Methods
A literature search was performed using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database. Results were limited to randomized controlled trials and systematic reviews and were divided into 2 models: Model 1 (nurse alone versus physician alone) and Model 2 (nurse and physician versus physician alone). Effectiveness was determined by comparable outcomes between groups in Model 1, or improved outcomes or efficiency in Model 2.
Results
Six studies were included. In Model 1, there were no significant differences in health resource use, disease-specific measures, quality of life, or patient satisfaction. In Model 2, there was a reduction in hospitalizations and improved management of blood pressure and lipids among patients with coronary artery disease. Among patients with diabetes, there was a reduction in hemoglobin A1c but no difference in other disease-specific measures. There was a trend toward improved process measures, including medication prescribing and clinical assessments. Results related to quality of life were inconsistent, but patient satisfaction with the nurse-physician team was improved. Overall, there were more and longer visits to the nurse, and physician workload did not change.
Limitations
There was heterogeneity across patient populations, and in the titles, roles, and scope of practice of the specialized nurses.
Conclusions
Specialized nurses with an autonomous role in patient care had comparable outcomes to physicians alone (Model 1) based on moderate quality evidence, with consistent results among a subgroup analysis of patients with diabetes based on low quality evidence. Model 2 showed an overall improvement in appropriate process measures, disease-specific measures, and patient satisfaction based on low to moderate quality evidence. There was low quality evidence that nurses working under Model 2 may reduce hospitalizations for patients with coronary artery disease. The specific role of the nurse in supplementing or substituting physician care was unclear, making it difficult to determine the impact on efficiency.
Plain Language Summary
Nurses with additional skills, training, or scope of practice may help improve the primary care of patients with chronic diseases. This review found that specialized nurses working on their own could achieve health outcomes that were similar to those of doctors. It also found that specialized nurses who worked with doctors could reduce hospital visits and improve certain patient outcomes related to diabetes, coronary artery disease, or heart failure. Patients who had nurse-led care were more satisfied and tended to receive more tests and medications. It is unclear whether specialized nurses improve quality of life or doctor workload.
PMCID: PMC3814805  PMID: 24194798
18.  Electronic Tools for Health Information Exchange 
Background
As patients experience transitions in care, there is a need to share information between care providers in an accurate and timely manner. With the push towards electronic medical records and other electronic tools (eTools) (and away from paper-based health records) for health information exchange, there remains uncertainty around the impact of eTools as a form of communication.
Objective
To examine the impact of eTools for health information exchange in the context of care coordination for individuals with chronic disease in the community.
Data Sources
A literature search was performed on April 26, 2012, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published until April 26, 2012 (no start date limit was applied).
Review Methods
A systematic literature search was conducted, and meta-analysis conducted where appropriate. Outcomes of interest fell into 4 categories: health services utilization, disease-specific clinical outcomes, process-of-care indicators, and measures of efficiency. The quality of the evidence was assessed individually for each outcome. Expert panels were assembled for stakeholder engagement and contextualization.
Results
Eleven articles were identified (4 randomized controlled trials and 7 observational studies). There was moderate quality evidence of a reduction in hospitalizations, hospital length of stay, and emergency department visits following the implementation of an electronically generated laboratory report with recommendations based on clinical guidelines. The evidence showed no difference in disease-specific outcomes; there was no evidence of a positive impact on process-of-care indicators or measures of efficiency.
Limitations
A limited body of research specifically examined eTools for health information exchange in the population and setting of interest. This evidence included a combination of study designs and was further limited by heterogeneity in individual technologies and settings in which they were implemented.
Conclusions
There is evidence that the right eTools in the right environment and context can significantly impact health services utilization. However, the findings from this evidence-based analysis raise doubts about the ability of eTools with care-coordination capabilities to independently improve the quality of outpatient care. While eTools may be able to support and sustain processes, inefficiencies embedded in the health care system may require more than automation alone to resolve.
Plain Language Summary
Patients with chronic diseases often work with many different health care providers. To ensure smooth transitions from one setting to the next, health care providers must share information and coordinate care effectively. Electronic medical records (eTools) are being used more and more to coordinate patient care, but it is not yet known whether they are more effective than paper-based health records. In this analysis, we reviewed the evidence for the use of eTools to exchange information and coordinate care for people with chronic diseases in the community. There was some evidence that eTools reduced the number of hospital and emergency department visits, as well as patients' length of stay in the hospital, but there was no evidence that eTools improved the overall quality of patient care.
PMCID: PMC3814806  PMID: 24194799
19.  Self-Management Support Interventions for Persons With Chronic Disease 
Background
Self-management support interventions such as the Stanford Chronic Disease Self-Management Program (CDSMP) are becoming more widespread in attempt to help individuals better self-manage chronic disease.
Objective
To systematically assess the clinical effectiveness of self-management support interventions for persons with chronic diseases.
Data Sources
A literature search was performed on January 15, 2012, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published between January 1, 2000, and January 15, 2012. A January 1, 2000, start date was used because the concept of non-disease-specific/general chronic disease self-management was first published only in 1999. Reference lists were examined for any additional relevant studies not identified through the search.
Review Methods
Randomized controlled trials (RCTs) comparing self-management support interventions for general chronic disease against usual care were included for analysis. Results of RCTs were pooled using a random-effects model with standardized mean difference as the summary statistic.
Results
Ten primary RCTs met the inclusion criteria (n = 6,074). Nine of these evaluated the Stanford CDSMP across various populations; results, therefore, focus on the CDSMP.
Health status outcomes: There was a small, statistically significant improvement in favour of CDSMP across most health status measures, including pain, disability, fatigue, depression, health distress, and self-rated health (GRADE quality low). There was no significant difference between modalities for dyspnea (GRADE quality very low). There was significant improvement in health-related quality of life according to the EuroQol 5-D in favour of CDSMP, but inconsistent findings across other quality-of-life measures.
Healthy behaviour outcomes: There was a small, statistically significant improvement in favour of CDSMP across all healthy behaviours, including aerobic exercise, cognitive symptom management, and communication with health care professionals (GRADE quality low).
Self-efficacy: There was a small, statistically significant improvement in self-efficacy in favour of CDSMP (GRADE quality low).
Health care utilization outcomes: There were no statistically significant differences between modalities with respect to visits with general practitioners, visits to the emergency department, days in hospital, or hospitalizations (GRADE quality very low).
All results were measured over the short term (median 6 months of follow-up).
Limitations
Trials generally did not appropriately report data according to intention-to-treat principles. Results therefore reflect “available case analyses,” including only those participants whose outcome status was recorded. For this reason, there is high uncertainty around point estimates.
Conclusions
The Stanford CDSMP led to statistically significant, albeit clinically minimal, short-term improvements across a number of health status measures (including some measures of health-related quality of life), healthy behaviours, and self-efficacy compared to usual care. However, there was no evidence to suggest that the CDSMP improved health care utilization. More research is needed to explore longer-term outcomes, the impact of self-management on clinical outcomes, and to better identify responders and non-responders.
Plain Language Summary
Self-management support interventions are becoming more common as a structured way of helping patients learn to better manage their chronic disease. To assess the effects of these support interventions, we looked at the results of 10 studies involving a total of 6,074 people with various chronic diseases, such as arthritis and chronic pain, chronic respiratory diseases, depression, diabetes, heart disease, and stroke. Most trials focused on a program called the Stanford Chronic Disease Self-Management Program (CDSMP). When compared to usual care, the CDSMP led to modest, short-term improvements in pain, disability, fatigue, depression, health distress, self-rated health, and health-related quality of life, but it is not possible to say whether these changes were clinically important. The CDSMP also increased how often people undertook aerobic exercise, how often they practiced stress/pain reduction techniques, and how often they communicated with their health care practitioners. The CDSMP did not reduce the number of primary care doctor visits, emergency department visits, the number of days in hospital, or the number of times people were hospitalized. In general, there was high uncertainty around the quality of the evidence, and more research is needed to better understand the effect of self-management support on long-term outcomes and on important clinical outcomes, as well as to better identify who could benefit most from self-management support interventions like the CDSMP.
PMCID: PMC3814807  PMID: 24194800
20.  Health Technologies for the Improvement of Chronic Disease Management 
Background
As part of ongoing efforts to improve the Ontario health care system, a mega-analysis examining the optimization of chronic disease management in the community was conducted by Evidence Development and Standards, Health Quality Ontario (previously known as the Medical Advisory Secretariat [MAS]).
Objective
The purpose of this report was to identify health technologies previously evaluated by MAS that may be leveraged in efforts to optimize chronic disease management in the community.
Data Sources
The Ontario Health Technology Assessment Series and field evaluations conducted by MAS and its partners between January 1, 2006, and December 31, 2011.
Review Methods
Technologies related to at least 1 of 7 disease areas of interest (type 2 diabetes, coronary artery disease, atrial fibrillation, chronic obstructive pulmonary disease, congestive heart failure, stroke, and chronic wounds) or that may greatly impact health services utilization were reviewed. Only technologies with a moderate to high quality of evidence and associated with a clinically or statistically significant improvement in disease management were included. Technologies related to other topics in the mega-analysis on chronic disease management were excluded. Evidence-based analyses were reviewed, and outcomes of interest were extracted. Outcomes of interest included hospital utilization, mortality, health-related quality of life, disease-specific measures, and economic analysis measures.
Results
Eleven analyses were included and summarized. Technologies fell into 3 categories: those with evidence for the cure of chronic disease, those with evidence for the prevention of chronic disease, and those with evidence for the management of chronic disease.
Conclusions
The impact on patient outcomes and hospitalization rates of new health technologies in chronic disease management is often overlooked. This analysis demonstrates that health technologies can reduce the burden of illness; improve patient outcomes; reduce resource utilization intensity; be cost-effective; and be a viable contributing factor to chronic disease management in the community.
Plain Language Summary
People with chronic diseases rely on the health care system to help manage their illness. Hospital use can be costly, so community-based alternatives are often preferred. Research published in the Ontario Health Technology Assessment Series between 2006 and 2011 was reviewed to identify health technologies that have been effective or cost-effective in helping to manage chronic disease in the community. All technologies identified led to better patient outcomes and less use of health services. Most were also cost-effective. Two technologies that can cure chronic disease and 1 that can prevent chronic disease were found. Eight technologies that can help manage chronic disease were also found. Health technologies should be considered an important part of chronic disease management in the community.
PMCID: PMC3817826  PMID: 24228075
21.  Patient Experiences of Depression and Anxiety with Chronic Disease 
Background
Depression and anxiety are highly prevalent in patients with chronic disease, but remain undertreated despite significant negative consequences on patient health. A number of clinical groups have developed recommendations for depression screening practices in the chronic disease population.
Objectives
The objective of this analysis was to review empirical qualitative research on the experiences of patients with chronic disease (e.g., COPD, diabetes, heart disease, stroke) and comorbid depression or anxiety, and to highlight the implications of the screening and management of anxiety and/or depression on chronic disease outcomes.
Review Methods
We performed literature searches for studies published from January 2002 to May 2012. We applied a qualitative mega-filter to nine condition-specific search filters. Titles and abstracts were reviewed by two reviewers and, for the studies that met the eligibility criteria, full-text articles were obtained. Qualitative meta-synthesis was used to integrate findings across relevant published primary research studies. Qualitative meta-synthesis produced a synthesis of evidence that both retained the original meaning of the authors and offered a new, integrative interpretation of the phenomenon through a process of comparing and contrasting findings across studies.
Results
The findings of 20 primary qualitative studies were synthesized. Patients tended to experience their chronic conditions and anxiety or depression as either independent or inter-related (i.e., the chronic disease lead to depression/anxiety, the depression/anxiety lead to the chronic disease, or the two conditions exacerbated each other). Potential barriers to screening for depression or anxiety were also identified.
Limitations
A wider array of issues might have been captured if the analysis had focused on broader psychological responses to the chronic disease experience. However, given the objective to highlight implications for screening for anxiety or depression, the more narrow focus seemed most relevant.
Conclusions
Chronic disease and anxiety or depression can be independent or inter-related. Patients may be reluctant to acknowledge depression or anxiety as a separate condition, or may not recognize that the conditions are separate because of overlapping physical symptoms. More qualitative research is needed to specifically address screening for depression or anxiety.
Plain Language Summary
Depression is a common complication of chronic disease. It may worsen the disease, and it may also affect the self-management of the disease. Screening for depression earlier, and then treating it, may reduce distress and improve symptoms of the chronic disease, leading to better quality of life.
PMCID: PMC3817854  PMID: 24228079
22.  Experiences of Patient-Centredness With Specialized Community-Based Care 
Background
Specialized community-based care (SCBC) endeavours to help patients manage chronic diseases by formalizing the link between primary care providers and other community providers with specialized training. Many types of health care providers and community-based programs are employed in SCBC. Patient-centred care focuses on patients’ psychosocial experience of health and illness to ensure that patients’ care plans are modelled on their individual values, preferences, spirituality, and expressed needs.
Objectives
To synthesize qualitative research on patient and provider experiences of SCBC interventions and health care delivery models, using the core principles of patient-centredness.
Data Sources
This report synthesizes 29 primary qualitative studies on the topic of SCBC interventions for patients with chronic conditions. Included studies were published between 2002 and 2012, and followed adult patients in North America, Europe, Australia, and New Zealand.
Review Methods
Qualitative meta-synthesis was used to integrate findings across primary research studies.
Results
Three core themes emerged from the analysis:
patients’ health beliefs affect their participation in SCBC interventions;
patients’ experiences with community-based care differ from their experiences with hospital-based care;
patients and providers value the role of nurses differently in community-based chronic disease care.
Limitations
Qualitative research findings are not intended to generalize directly to populations, although meta-synthesis across several qualitative studies builds an increasingly robust understanding that is more likely to be transferable. The diversity of interventions that fall under SCBC and the cross-interventional focus of many of the studies mean that findings might not be generalizable to all forms of SCBC or its specific components.
Conclusions
Patients with chronic diseases who participated in SCBC interventions reported greater satisfaction when SCBC helped them better understand their diagnosis, facilitated increased socialization, provided them with a role in managing their own care, and assisted them in overcoming psychological and social barriers.
Plain Language Summary
More and more, to reduce bed shortages in hospitals, health care systems are providing programs called specialized community-based care (SCBC) to patients with chronic diseases. These SCBC programs allow patients with chronic diseases to be managed in the community by linking their family physicians with other community-based health care providers who have specialized training. This report looks at the experiences of patients and health care providers who take part in SCBC programs, focusing on psychological and social factors. This kind of lens is called patient-centred. Three themes came up in our analysis:
patients’ health beliefs affect how they take part in SCBC interventions;
patients’ experiences with care in the community differ from their experiences with care in the hospital;
patients and providers value the role of nurses differently.
The results of this analysis could help those who provide SCBC programs to better meet patients’ needs.
PMCID: PMC3817855  PMID: 24228080
23.  How Diet Modification Challenges Are Magnified in Vulnerable or Marginalized People With Diabetes and Heart Disease 
Background
Diet modification is an important part of self-management for patients with diabetes and/or heart disease (including coronary artery disease, heart failure, and atrial fibrillation). Many health care providers and community-based programs advise lifestyle and diet modification as part of care for people with these conditions. This report synthesizes qualitative information on how patients respond differently to the challenges of diet modification. Qualitative and descriptive evidence can illuminate challenges that may affect the success and equitable impact of dietary modification interventions.
Objectives
To (a) examine the diet modification challenges faced by diabetes and/or heart disease patients; and (b) compare and contrast the challenges faced by patients who are members of vulnerable and nonvulnerable groups as they change their diet in response to clinical recommendations.
Data Sources
This report synthesizes 65 primary qualitative studies on the topic of dietary modification challenges encountered by patients with diabetes and/or heart disease. Included papers were published between 2002 and 2012 and studied adult patients in North America, Europe, and Australia/New Zealand.
Review Methods
Qualitative meta-synthesis was used to integrate findings across primary research studies.
Results
Analysis identified 5 types of challenges that are common to both vulnerable and nonvulnerable patients: self-discipline, knowledge, coping with everyday stress, negotiating with family members, and managing the social significance of food. Vulnerable patients may experience additional barriers, many of which can magnify or exacerbate those common challenges.
Limitations
While qualitative insights are robust and often enlightening for understanding experiences and planning services in other settings, they are not intended to be generalizable. The findings of the studies reviewed here—and of this synthesis—do not strictly generalize to the Ontario (or any specific) population. This evidence must be interpreted and applied carefully, in light of expertise and the experiences of the relevant community.
Conclusions
Diet modification is not simply a matter of knowing what to eat and making the rational choice to change dietary practices. Rather, diet and eating practices should be considered as part of the situated lives of patients, requiring an individualized approach that is responsive to the conditions in which each patient is attempting to make a change. Common challenges include self-discipline, knowledge, coping with everyday stress, negotiating with family members, and managing the social significance of food. An individualized approach is particularly important when working with patients who have vulnerabilities.
Plain Language Summary
Health care providers often encourage people with diabetes and/or heart disease to change their diet. They advise people with diabetes to eat less sugar, starch, and fat. They advise people with heart disease to eat less fat and salt. However, many patients find it difficult to change what they eat. This report examines the challenges people may face when making such changes. It also examines the special challenges faced by people who are vulnerable due to other factors, such as poverty, lack of education, and difficulty speaking English. Five themes were common to all people who make diet changes: self-discipline, knowledge, coping with stress, negotiating with family members, and managing the social aspect of food. Members of vulnerable groups also reported other challenges, such as affording fresh fruit and vegetables or understanding English instructions. This report may help health care providers work with patients more effectively to make diet changes.
PMCID: PMC3817924  PMID: 24228077
24.  Chronic Disease Patients’ Experiences With Accessing Health Care in Rural and Remote Areas 
Background
Rurality can contribute to the vulnerability of people with chronic diseases. Qualitative research can identify a wide range of health care access issues faced by patients living in a remote or rural setting.
Objective
To systematically review and synthesize qualitative research on the advantages and disadvantages rural patients with chronic diseases face when accessing both rural and distant care.
Data Sources
This report synthesizes 12 primary qualitative studies on the topic of access to health care for rural patients with chronic disease. Included studies were published between 2002 and 2012 and followed adult patients in North America, Europe, Australia, and New Zealand.
Review Methods
Qualitative meta-synthesis was used to integrate findings across primary research studies.
Results
Three major themes were identified: geography, availability of health care professionals, and rural culture. First, geographic distance from services poses access barriers, worsened by transportation problems or weather conditions. Community supports and rurally located services can help overcome these challenges. Second, the limited availability of health care professionals (coupled with low education or lack of peer support) increases the feeling of vulnerability. When care is available locally, patients appreciate long-term relationships with individual clinicians and care personalized by familiarity with the patient as a person. Finally, patients may feel culturally marginalized in the urban health care context, especially if health literacy is low. A culture of self-reliance and community belonging in rural areas may incline patients to do without distant care and may mitigate feelings of vulnerability.
Limitations
Qualitative research findings are not intended to generalize directly to populations, although meta-synthesis across a number of qualitative studies builds an increasingly robust understanding that is more likely to be transferable. Selected studies focused on the vulnerability experiences of rural dwellers with chronic disease; findings emphasize the patient rather than the provider perspective.
Conclusions
This study corroborates previous knowledge and concerns about access issues in rural and remote areas, such as geographical distance and shortage of health care professionals and services. Unhealthy behaviours and reduced willingness to seek care increase patients’ vulnerability. Patients’ perspectives also highlight rural culture’s potential to either exacerbate or mitigate access issues.
Plain Language Summary
People who live in a rural area may feel more vulnerable—that is, more easily harmed by their health problems or experiences with the health care system. Qualitative research looks at these experiences from the patient’s point of view. We found 3 broad concerns in the studies we looked at. The first was geography: needing to travel long distances for health care can make care hard to reach, especially if transportation is difficult or the weather is bad. The second concern was availability of health professionals: rural areas often lack health care services. Patients may also feel powerless in “referral games” between rural and urban providers. People with low education or without others to help them may find navigating care more difficult. When rural services are available, patients like seeing clinicians who have known them for a long time, and like how familiar clinicians treat them as a whole person. The third concern was rural culture: patients may feel like outsiders in city hospitals or clinics. As well, in rural communities, people may share a feeling of self-reliance and community belonging. This may make them more eager to take care of themselves and each other, and less willing to seek distant care. Each of these factors can increase or decrease patient vulnerability, depending on how health services are provided.
PMCID: PMC3817950  PMID: 24228078
25.  Optimizing Chronic Disease Management Mega-Analysis 
Background
As Ontario’s population ages, chronic diseases are becoming increasingly common. There is growing interest in services and care models designed to optimize the management of chronic disease.
Objective
To evaluate the cost-effectiveness and expected budget impact of interventions in chronic disease cohorts evaluated as part of the Optimizing Chronic Disease Management mega-analysis.
Data Sources
Sector-specific costs, disease incidence, and mortality were calculated for each condition using administrative databases from the Institute for Clinical Evaluative Sciences. Intervention outcomes were based on literature identified in the evidence-based analyses. Quality-of-life and disease prevalence data were obtained from the literature.
Methods
Analyses were restricted to interventions that showed significant benefit for resource use or mortality from the evidence-based analyses. An Ontario cohort of patients with each chronic disease was constructed and followed over 5 years (2006–2011). A phase-based approach was used to estimate costs across all sectors of the health care system. Utility values identified in the literature and effect estimates for resource use and mortality obtained from the evidence-based analyses were applied to calculate incremental costs and quality-adjusted life-years (QALYs). Given uncertainty about how many patients would benefit from each intervention, a system-wide budget impact was not determined. Instead, the difference in lifetime cost between an individual-administered intervention and no intervention was presented.
Results
Of 70 potential cost-effectiveness analyses, 8 met our inclusion criteria. All were found to result in QALY gains and cost savings compared with usual care. The models were robust to the majority of sensitivity analyses undertaken, but due to structural limitations and time constraints, few sensitivity analyses were conducted. Incremental cost savings per patient who received intervention ranged between $15 per diabetic patient with specialized nursing to $10,665 per patient wth congestive heart failure receiving in-home care.
Limitations
Evidence used to inform estimates of effect was often limited to a single trial with limited generalizability across populations, interventions, and health care systems. Because of the low clinical fidelity of health administrative data sets, intermediate clinical outcomes could not be included. Cohort costs included an average of all health care costs and were not restricted to costs associated with the disease. Intervention costs were based on resource use specified in clinical trials.
Conclusions
Applying estimates of effect from the evidence-based analyses to real-world resource use resulted in cost savings for all interventions. On the basis of quality-of-life data identified in the literature, all interventions were found to result in a greater QALY gain than usual care would. Implementation of all interventions could offer significant cost reductions. However, this analysis was subject to important limitations.
Plain Language Summary
Chronic diseases are the leading cause of death and disability in Ontario. They account for a third of direct health care costs across the province. This study aims to evaluate the cost-effectiveness of health care interventions that might improve the management of chronic diseases. The evaluated interventions led to lower costs and better quality of life than usual care. Offering these options could reduce costs per patient. However, the studies used in this analysis were of medium to very low quality, and the methods had many limitations.
PMCID: PMC3819926  PMID: 24228076

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