A prospective multicentre study examining the degree of utilization and factors associated with the use of disease management programs by complex cardiac outpatients.

摘要

BACKGROUND: Specialized multi-disciplinary programs for the management of people burdened with cardiovascular disease (CVD) have become increasingly important over the last decade in order to bridge the gap between primary and tertiary care and to manage individuals over the course of their disease. Research has shown that the use of disease management programs (DMPs) by patients with CVD is associated with improved outcomes. There is however a current gap in knowledge and understanding about the flow of CVD patients from hospital discharge through to the outpatient disease management system. Specifically, there is no current knowledge about how many outpatient DMPs are used by each patient, or the health system and patient level factors that may be associated with attending no programs or multiple programs where indicated.;METHODS: Study 1:: In this prospective cohort study, 2635 CVD inpatients from 11 Ontario hospitals completed a survey that assessed factors affecting DMP utilization. One year later, 1803 participants (68% retention rate) completed a mailed survey that assessed DMP use. Specifically, participants were asked if they attended one of the following programs: cardiac rehabilitation (CR), diabetes education, a HF clinic, stroke rehabilitation or a smoking cessation program. Study 2:: This study represents a secondary analysis of the larger cohort study. In-hospital, a convenience sample of474 HF inpatients completed a survey that examined factors affecting use of HF clinics. One-year later, 271 HF patients completed a mailed survey that assessed referral and use of HF clinics. Study 3: An exploratory qualitative study using semi-structured interviews was conducted with three female HF patients who reported being referred to a HF clinic but (i) did not attend the program or (ii) stopped using the program. Reasons for nonattendance were examined. The interviews were conducted by telephone and then transcribed and coded using NVivo-8 software. Data was analyzed using Qualitative Content Analysis.;RESULTS: Study 1: Sixty percent of participants reported using at least one DMP (median=1.0). Overall, 52.7% of participants reported attending cardiac rehabilitation, and among participants with a comorbid indication, 41.2% reported attending a diabetes education centre, 25.9% attended stroke rehabilitation, 12.9% used a HF clinic, and 11.7% attended a smoking cessation program. A multinomial logistic regression analysis showed that compared to no DMP use, participants that attended one or multiple programs were younger, married, diagnosed with a myocardial infarction, less likely to have had a percutaneous coronary intervention (PCI) and had higher perceptions of personal control over their heart condition. There were few differences between participants that used one versus multiple DMPs, however, having diabetes or comorbid stoke significantly increased the likelihood of multiple DMP use. Study 2: Forty-one participants (15.1%) self-reported referral, and 35 (12.9%) reported attending a HF clinic. Generalized estimating equations showed that factors related to greater program use were: having a HF clinic at the site of hospital recruitment (Odds Ratio [OR]=8.40, p=0.04), receiving a referral to other DMPs (OR=4.87, p=0.04), higher education (OR=4.61, p=0.02), lower stress (OR=0.93, p=0.03) and lower functional status (OR=0.97, p=0.03). Study 3: Themes identified from the interviews included: logistical issues, perceived program dissatisfaction, lack of-in-hospital communication, health complications, gender treatment differences, lack of program endorsement by healthcare providers and lack of perceived need.;CONCLUSIONS: Overall, 60% of CVD participants reported attending at least one DMP with 10% of the sample having used multiple programs. While this rate of utilization is encouraging, there remain some clinical, demographic, psychosocial and health system factors that may serve as attendance barriers. Moreover, the results herein revealed a gross underuse of stroke rehabilitation (26%)t HF clinics (13%)t and most notably, smoking cessation programs (12%). Given the benefits of DMP services, more research examining how equitable access can be increased is needed. Furthermore, the appropriateness and cost repercussions of multiple DMP use should be investigated.;OBJECTIVES: Study 1: (1) Describe the rates of referral and use of DMPs by CVD patients; and (2) Examine factors related to the use of no versus one versus multiple DMPs. Study 2: (1) Describe the rates of heart failure (HF) clinic referral and use; and (2) Examine patient and health system-level factors related to HF clinic use based on the Andersen's Model of Healthcare Utilization. Study 3: (1) Qualitatively explore the reasons why female patients who were referred to a HF clinic did not use or stopped using the program.