Person-centered, interdisciplinary, outcome focused research: a nursing

perspective

Patricia M Davidson RN PhD FAAN pdavidson@jhu.edu

@nursingdean @jhunursing

Outline

• Personal reflections on my career • Heart failure as an exemplar

– Aka “How I have aged with the patients”

• Importance of advocacy and engagement

• Communication and partnerships

Person-focused care

• Accumulated knowledge of people • Provides the basis for better recognition of

health problems and needs over time • Facilitates appropriate care for these needs in

the context of other needs • Specifically focuses on the whole person

– Davidson et al. 2007; Starfield 2011;

Heart failure

• Final common pathway of many cardiac conditions

• Major source of morbidity and heart disease is the leading cause of death in the developed world

• Over 5 million Americans, 15 million Europeans and 350,000 Australians have a diagnosis of heart failure

5

William Withering

• Bolster'd with down, amid a thousand wants, Pale Dropsy rears his bloated form, and pants;

Productivity Commission Research Report 2005

Segments within the totalpopulation

Costs associated with each segment

Those with no chronic conditions

Those with one chronic condition

Those with multiple chronic conditions

People ££££

72%

21%

6%

36%

31%

33%

Source: Kaiser Permanente Northern California commercial member ship, DxCG methodology, 2001.

Chronic Illness Drives Medical Care Costs

Source: Towards Managed Care - Information Exchange Event. Dr HF Macintyre 17th September 2004, Effingham Park Hotel, Copthorne Accessed at http://www.natpact.nhs.uk/cms/363.php.

Innovative Care for Chronic Conditions FrameworkInnovative Care for Chronic Conditions Framework

Building Blocks for Action Innovative Care for Chronic Conditions: Global Report. World Health Organisation 2002.

Better Outcomes for Chronic Conditions

Positive Policy EnvironmentPositive Policy Environment• Strengthen partnerships

• Support legislative frameworks • Integrate policies

• Provide leadership and advocacy

• Promote consistent financing

• Develop & allocate human resources

LinksCommunityCommunity

• Raise Awareness and reduce stigma

• Encourage better outcomes through leadership and support

• Mobilise and co-ordinate resources

• Provide complementary services

Health CareHealth CareOrganisationOrganisation

• Promote continuity and co-ordination

• Encourage quality through leadership and incentives

• Organise and equip health care teams

• Use information systems

• Support self-management & prevention

Patients & Family

Prepared

Informed Monitored

Community

PartnersHeath CareTeam

Physiological (Sex)

Genetic Race

Knowledge, Attitudes and Beliefs

Health Literacy Health Seeking Behaviors

Social Economic Cultural Gender

Environmental Health System

Health Outcomes

Heart failure program impact on hospitalisation

0

5

10

15

20

25

30

35

40

England USA [B] USA [C] Australia [A]

Sweden [A]

New Zealand

USA [D] Scotland Sweden [B]

Recu

rren

t all

caus

e st

ay (d

ays)

per

pa

tient

CHF management program

69% @ 6 months

61% @ 6 months

39% @ 12 months

12% @ 12 months

33% @ 12 months

49% @ 12 months 24% @

6 months 27% @ 6 months

Usual post - discharge management

USA [A]

37% @ 3 months

Australia [B]

22% @ 36 months

0

5

10

15

20

25

30

35

40

England USA [B] USA [C] Australia [A]

Sweden [A]

New Zealand

USA [D] Scotland Sweden [B]

Recu

rren

t all

caus

e st

ay (d

ays)

per

pa

tient

CHF management program

69% @ 6 months

61% @ 6 months

39% @ 12 months

12% @ 12 months

33% @ 12 months

49% @ 12 months 24% @

6 months 27% @ 6 months

Usual post - discharge management

USA [A]

37% @ 3 months

Australia [B]

22% @ 36 months

45% @ 12 months

McAlister et al 2004

Clinic-based (x 7) N = 1183 Home-based (x 7) N = 950 Remote F/U (x 9) N = 1558 Singular strategy (x 4) N = 566 Total (27 Studies & 4257 pts)

0.71 (0.55 – 0.90)

0.74

(0.55 – 0.99)

0.86 (0.58 – 1.29)

1.18

(0.78 – 1.78)

0.80 (0.66 – 0.98)

0.81 (0.71 – 0.92)

0.78

(0.67 – 0.89)

1.02 (0.90 – 1.09)

0.73

(0.57 – 0.93)

0.82 (0.73 – 0.92)

0.76 (0.61 – 0.93)

0.62

(0.45 – 0.86)

0.67 (0.50 – 0.90)

0.67

(0.53 – 0.85)

0.70 (0.62 – 0.80)

All-cause mortality

All-cause readmission

CHF readmission

Meta-analysis of CHF care programs

Mc Alister et al 2006

Research to Practice

• Linking research, policy and practice

• 30 randomized, controlled trials of multidisciplinary outpatient CHF management

• e-mail survey of first authors (97% response rate)

• 13 of 15 in US; 7 of 13 did not continue or expand

• Seow et al; Isolation of Health Services Research from Practice and Policy:

The Example of Chronic Heart Failure Management; JAGS 2006; 54 (3): 535 - 540

The research cycle • It isn’t research until it’s published

(evidence)

• It isn’t research until it’s incorporated in ‘usual care’ best practice

Policy Makers

Interdisciplinary

Individuals, families and communities

What are the needs of

individuals, families and communities?

How can we address these issues and develop evidence?

Convincing people to pay for and deliver services

Krumholz HM, et. al Circulation. 2006;114:1432–1445.

I´m worried and concerned

GI symptoms bother me!

I can not bend over or exercise

My whole life is affected

Heartburn disturbs my sleep

I can not eat and drink whatever

I like

Shifting gears and changing paradigms Worsening

shortness of breath Chest Pain Dizziness

Urgent acute care Dependent

Symptom Management

Watch and wait

Measure everything just in case

Manage what you measure

• Interdisciplinary • Person-centered • Outcome focused

RESEARCH

EDUCATION

PRACTICE

POLICY

Challenge and Opportunity

–Competent –Credible –Credentialed –Committed –Communicators

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