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Quality improvement in the care of patients with inflammatory bowel disease
Linköpings universitet, Institutionen för klinisk och experimentell medicin. Linköpings universitet, Hälsouniversitetet.
2012 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

A range of studies have supported the existence of a gap between what medicine could possibly deliver and what it actually does deliver. This is also true for the delivery of care to patients with inflammatory bowel disease (IBD) and several international stakeholders have called for action. The aim of this thesis was to describe, study and evaluate a quality improvement intervention (QII) in the care for patients with IBD in a population-based setting, with special reference to clinical redesign, performance measurement and patient experience.

The patient population on which this thesis is based was recruited from the gastroenterological unit at the Department of Internal Medicine, Highland Hospital, in Eksjö, Sweden. The QII was implemented through iterative improvement cycles in the early years of the 21st century. Data from yearly check-ups of patients including identification, gender, disease duration, medication, four questions about quality of life (QoL) and laboratory results were entered into a local register created as part of the QII. In addition, data on admittances to hospital were retrieved. The interactions between staff and patients as well as the elements of the delivered care were analysed by applying the model of clinical microsystems (CMS) and the Chronic Care Model (CCM). The QII was studied using a retrospective, descriptive analysis with quantitative elements. A multidimensional quality tool, the Clinical Value Compass (CVC), was applied to assess the quality of care. Later, the CVC and the quality model by Donabedian (Df) were merged to create a quality framework for IBD, which was tested on already existing data in the local IBD register. In a study of patients’ experiences of living with IBD, a content analysis was applied to interviews with 20 purposefully sampled patients.

The main components of the redesign, described as a “patient- and demand-directed care”, were: - A specialist nurse staffed the outpatient clinic full time and could offer patients who contacted the clinic an acute visit at the outpatient clinic within two days. - Yearly checkups to either the nurse or physician were offered, either as telephone calls or as traditional visits to the clinic. A letter preceded the contact and included a QoL questionnaire and instructions for laboratory testing of haemoglobin (Hb). The QII led to decreasing numbers of hospitalizations compared to national data and better access to care. The prevalence of anaemia in the population was 6% and was correlated to a risk of being admitted to hospital during the year. The analysis of the interviews showed several parallels to the experiences of people who  live with other chronic diseases than IBD. Consequences of living with IBD were associated with everyday life and the adaptations needed to restore one’s life. It was always shadowed by the person’s worry that he or she might potentially need a toilet.

The main contribution of this thesis is the overall example of how a quality improvement intervention including continuous performance measures and frameworks, as well as the study of patients’ experiences, can be applied in a local population-based setting. The understanding of the interactions between patients, staff and the healthcare system was described and analysed through the application of CMS and the CCM. As a whole, this thesis contributes to the international quest for quality improvement efforts to bridge the quality gap in the delivery of IBD care today.

Ort, förlag, år, upplaga, sidor
Linköping: Linköping University Electronic Press, 2012. , s. 30
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1324
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
URN: urn:nbn:se:liu:diva-84633ISBN: 978-91-7519-804-0 (tryckt)OAI: oai:DiVA.org:liu-84633DiVA, id: diva2:560873
Disputation
2012-11-02, Qulturum, Länssjukhuset Rybohov, Jönköping, 13:00 (Engelska)
Opponent
Handledare
Tillgänglig från: 2012-10-16 Skapad: 2012-10-16 Senast uppdaterad: 2019-12-10Bibliografiskt granskad
Delarbeten
1. Improved population-based care: Implementing patient-and demand-directed care for inflammatory bowel disease and evaluating the redesign with a population-based registry
Öppna denna publikation i ny flik eller fönster >>Improved population-based care: Implementing patient-and demand-directed care for inflammatory bowel disease and evaluating the redesign with a population-based registry
2007 (Engelska)Ingår i: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 16, nr 1, s. 38-50Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

The gastroenterology unit at the Höglands Hospital in Eksjö is responsible for the care of all 466 patients with inflammatory bowel disease (IBD) in a geographic area including approximately 115,000 inhabitants. In 2000, the frustration over an inadequate traditional outpatient clinic inspired us to redesign our outpatient unit to become more patient and demand directed. The redesign included the following: A direct telephone line for patients to a specialized nurse, available during working hours, appointments were scheduled in accordance with expected needs, and emergency appointments were available daily, traditional follow-ups of IBD patients were replaced by an annual telephone contact with a specialized nurse, the team agreed on a patient-centered value base for its work, and the redesign was monitored using clinical outcome measures reflecting 4 dimensions (see parentheses below) of the care in a "Value compass", quality of life (functional) and routine blood samples (clinical) were followed yearly and collected in a computerized IBD registry together with basic information about the patients, access and waiting lists together with patient satisfaction (satisfaction) are followed regularly, and ward utilization (financial) was registered. Our study shows that the new design offers a more efficient outpatient clinic in which waiting lists are markedly reduced although production rates remains the same. Utilization data show a significant decrease in comparison with national data, showing that the new care is economically favorable. The clinical results regarding anemia frequency in the IBD population are highly comparable with or even better than those found in the literature. We also show good results regarding quality of life where more than 88% of patients achieve set goals. In conclusion, our new patient- and demand-directed care seems to be more efficient and with clinical and quality-of-life results remaining on a high standard. ©2007Lippincott Williams & Wilkins, Inc.

Ort, förlag, år, upplaga, sidor
Lippincott Williams & Wilkins, 2007
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:liu:diva-37697 (URN)37608 (Lokalt ID)37608 (Arkivnummer)37608 (OAI)
Tillgänglig från: 2009-10-10 Skapad: 2009-10-10 Senast uppdaterad: 2018-03-19
2. Framework for assessing quality of care for inflammatory bowel disease in Sweden
Öppna denna publikation i ny flik eller fönster >>Framework for assessing quality of care for inflammatory bowel disease in Sweden
Visa övriga...
2012 (Engelska)Ingår i: World Journal of Gastroenterology, ISSN 1007-9327, E-ISSN 2219-2840, Vol. 18, nr 10, s. 1085-1092Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

AIM: To create and apply a framework for quality assessment and improvement in care for inflammatory bowel disease (IBD) patients. less thanbrgreater than less thanbrgreater thanMETHODS A framework for quality assessment and improvement was created for IBD based on two generally acknowledged quality models. The model of Donabedian (Df) offers a logistical and productive perspective and the Clinical Value Compass (CVC) model adds a management and service perspective. The framework creates a pedagogical tool to understand the balance between the dimensions of clinical care (CVC) and the components of clinical outcome (Df). The merged models create a framework of the care process dimensions as a whole, reflecting important parts of the IBD care delivery system in a local setting. Clinical and organizational quality measures were adopted from clinical experience and the literature and were integrated into the framework. Data were collected at the yearly check-up for 481 IBD patients during 2008. The application of the quality assessment framework was tested and evaluated in a local clinical IBD care setting in Jonkoping County, Sweden. less thanbrgreater than less thanbrgreater thanRESULTS: The main outcome was the presentation of how locally-selected clinical quality measures, integrated into two complementary models to develop a framework, could be instrumental in assessing the quality of care delivered to patients with IBD. The selected quality measures of the framework noted less anemia in the population than previously reported, provided information about hospitalization rates and the few surgical procedures reported, and noted good access to the clinic. less thanbrgreater than less thanbrgreater thanCONCLUSION: The applied local quality framework was feasible and useful for assessing the quality of care delivered to IBD patients in a local setting.

Ort, förlag, år, upplaga, sidor
Baishideng Publishing Group Co. Limited, 2012
Nyckelord
Quality measures, Inflammatory bowel disease, Value compass, Donabedian, Quality improvement
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:liu:diva-76615 (URN)10.3748/wjg.v18.i10.1085 (DOI)000301627900011 ()
Anmärkning

Funding Agencies|Futurum Research Council||Jonkoping County Council||Foundation for Clinical Cancer Research in Jonkoping County||VINNVARD-research program||

Tillgänglig från: 2012-04-13 Skapad: 2012-04-13 Senast uppdaterad: 2017-12-07
3. Low prevalence of anemia in inflammatory bowel disease: A population-based study in Sweden
Öppna denna publikation i ny flik eller fönster >>Low prevalence of anemia in inflammatory bowel disease: A population-based study in Sweden
2012 (Engelska)Ingår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 47, nr 8-9, s. 937-942Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Objective. Anemia is a well-known complication of inflammatory bowel disease (IBD) with a reported prevalence of 8.8-73.7%. However, knowledge is sparse about the anemia prevalence in a population-based cohort of patients affected by IBD. Materials and methods. The aim of this retrospective, descriptive, population-based study was to determine and analyze the prevalence of anemia for ambulatory (n = 485) as well as for hospitalized patients diagnosed with IBD in 2008 in the Highland Health Care District, Jonkopings County, Sweden. Results. The prevalence of anemia at the annual follow-up in the studied IBD population was 6%, 5% for patients with ulcerative colitis (UC), and 9% for those with Crohns disease (CD). There was a higher rate of anemia at the yearly check up in patients requiring inpatient care during the year. IBD patients, prescribed anti-TNF-alpha treatment, had a higher rate of anemia. Of the hospitalized UC and CD patients (n = 31), 35% and 50%, respectively, had anemia at admission and 6% and 4% had severe anemia (Hb andlt;100 g/L), respectively. Conclusions. The prevalence of anemia in this population was lower than reported previously, probably due to inclusion of all IBD patients in the area in combination with a proactive follow-up model. The prevalence of anemia in this IBD population was similar to the prevalence in the general population. This may indicate that efforts by health care professionals to prevent, identify, and treat anemia in the IBD population have been successful.

Ort, förlag, år, upplaga, sidor
Informa Healthcare, 2012
Nyckelord
anemia, annual follow-up, hospitalization, inflammatory bowel disease, population-based study quality, prevalence
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:liu:diva-82062 (URN)10.3109/00365521.2012.672590 (DOI)000308213200009 ()
Anmärkning

Funding Agencies|Futurum Research Council||Jonkoping County Council||Foundation for Clinical Cancer Research in Jonkoping County||VINNVARD||

Tillgänglig från: 2012-10-01 Skapad: 2012-09-28 Senast uppdaterad: 2017-12-07
4. Always considering the potential need for a toilet: A content analysis of 20 interviews with persons living with inflammatory bowel disease
Öppna denna publikation i ny flik eller fönster >>Always considering the potential need for a toilet: A content analysis of 20 interviews with persons living with inflammatory bowel disease
(Engelska)Manuskript (preprint) (Övrigt vetenskapligt)
Abstract [en]

Objective: Inflammatory bowel disease (IBD) is a well explored medical condition; in contrast, few studies have evaluated IBD as a chronic illness as experienced by the patient.

Method: Twenty participants were included in a purposeful sample. Interview responses were subjected to a qualitative systematic text condensation analysis.

Result: The main finding of the analysis was the description of life with chronic IBD as one where the patient is “always considering the potential need for a toilet”. This new description emerged from three main parts of the analysis: firstly, the experience of what it is like to be affected by the disease; secondly, the accompanying consequences of the illness; and thirdly, the adaptation needed to restore one’s normal life.

Conclusion: IBD shares several characteristics with other chronic illnesses. Patients pass through a series of stages including managing their disease, controlling the symptoms and consequences of the illness, and normalizing social interactions and restoring a normal life, all with the particularity of always having to consider the potential need for a toilet.

Nyckelord
Lived experience, inflammatory bowel disease, content analysis, chronic illness, qualitative
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:liu:diva-84632 (URN)
Tillgänglig från: 2012-10-16 Skapad: 2012-10-16 Senast uppdaterad: 2012-10-16Bibliografiskt granskad

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