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DEVELOPING THE SICAM-TRIAL

USING MIXED METHODS

Connie Bøttcher Berthelsen, MScN, PhD.

Clinical Nurse Specialist, Post doctoral fellow,

Orthopaedic Department

Regional Hospital of Køge, Denmark

For the EANS Summer Conference, June 4th. 2013

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PROJECT MEMBERS OF THE SICAM-TRIAL

� Project manager:� Connie Bøttcher Berthelsen,

� Project members:� Kirsten Frederiksen, MEd, PhD, Faculty of Health

Science, Aarhus University, Denmark

� Tove Lindhardt, MScN, PhD, Department of Internal Medicine, Copenhagen University Hospital, Herlev, Denmark

� Bibi Hølge-Hazelton, Associate Professor, PhD, Department of Public Health, Copenhagen University, Denmark

� Jimmie Kristensson, Associate Professor, PhD, Faculty of Medicine, Lund University, Sweden

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THE OBJECTIVES OF THE SICAM-TRIAL

To develop, implement, and evaluate a complex intervention of spouses’ involvement through case management in fast-track treatment programmes,

to increase the post-discharge functional status of older patients after total hip replacement.

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THE FOUR PHASES OF THE MRC-FRAMEWORK

Craig P, Dieppe P, Petticrew M, et al. (2008)

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THE DEVELOPMENT PHASE OF THE SICAM-TRIAL

1. An arching grounded theory of the pattern of behaviour among relatives, patients, and health professionals, when relatives are involved in older patients’ fast-track treatment programmes during hip or knee replacement.

(Developing theory)

2. Conducting a systematic review of how spouses are involved in older patients’ care through case management, focusing on intervention process and outcomes.

(Identifying the evidence base)

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BACKGROUND

� 15.000 total joint replacements a year in Denmark

� 50%of patients are above 70 years of age

� Same discharge criteria as traditional care but

systematic optimizing of care reduces length of stay

� High patient satisfaction and overall effectiveness

� Clinical pathways for daily standardises schedules

� Relatives could be an essential support

Kehlet H, Wilmore DW (2005, 2008), Hawker, GA. (2006), Ethgen, O, Bruyere, O, Reginster, JY, et al.(2007),

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BACKGROUND

� Relatives often play a substantial role as caregivers and a buffer against stress

� Improvements in patients’ stress, depression, pain,

anxiety and decrease in length of stay

Allen D 2000, Waters K, Allsopp D, Dennis, A. 2001, Craddock AE 1996 , Mitchinson AR, Kim HM, Geisser M, et al. 2008, Prouty A, Cooper M, Thomas P, et al. 2006, Theiss, MM, Ellison, MW, Murphy, VJ, et al. 2011,

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THREE GROUNDED THEORIES

� Relatives, patients, and health professionals’ pattern of behaviour, respectively, in relation to the relatives of older patients’ fast-track treatment programmes during total hip or knee replacement

� Glaserian grounded theory approach

� 67 participants included� Relatives (n=7), patients (n=16), health professionals

(n=44).

� Data was collected in two orthopaedic wards in Danish university hospitals between 2010 to 2011

Glaser BA (1978, 1998)

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THE THEORIES SHOWED

� Relatives played an important role for the patients by protecting, substituting and adapting

� Spouses was autonomous together while single patients claimed their independency

� Health professionals accepted relatives who adhered to the standard principles of the

programme and excluded those who disobeyed

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DECIDING TO MODEL AN INTERVENTION

Exploratory triangulation mixed methods

Systematic

review

Arching

grounded

theory

Complex

intervention

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CASE MANAGEMENT

”A collaborative process of assessment, planning,

facilitation and advocacy for options and services to meet an individual’s holistic needs through

communication and available resources to promote quality cost-effective outcomes”

(www.cmsa.org.au/definition.html).

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CASE MANAGEMENT

� Case management has:

� been applied with success to patients in complex settings

Björkman T, Hansson L, Sandlund M. (2002), Harvey K, Burns T, Fahy T, et al. (2002), Rosen A, Teesson M. (2001), Van Achterberg T, Stevens FCJ, Philipsen H, et al. (1996), Rosemann T, Joos, S, Szecsenyi, J, et al. (2007), Schifalacqua M, Hook M, Schmidt M, et al. (2000), Kristensson J, Ekwall AK,

Hallberg IR, et al. (2010), Gensichen J, Beyer M, Muth C, et al. (2006), Landi F, Onder G, Bernabei R, et al. (2001).

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CASE MANAGEMENT

� Case management has:

� been applied with success to patients in complex settings

� concluded effectiveness of patients quality of life,

general satisfaction, depression, functional dependency, length of stay and cost effectiveness

Björkman T, Hansson L, Sandlund M. (2002), Rosen A, Teesson M. (2001), Rosemann T, Joos, S, Szecsenyi, J, et al. (2007),Kristensson J, Ekwall AK, Hallberg IR, et al. (2010), Gensichen J, Beyer M, Muth C, et al. (2006), Landi F, Onder G, Bernabei R, et al. (2001), Bernabei R, Landi F, Carbonin PU, et al. (1998).

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CASE MANAGEMENT

� Case management has:

� been applied with success to patients in complex settings

� concluded effectiveness of patients quality of life,

general satisfaction, depression, functional dependency, length of stay and cost effectiveness

Total joint replacement trajectories evaluated to be an ideal setting for successful patient outcome

through family education

Madrid C. (1994)

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OBJECTIVES OF THE SYSTEMATIC REVIEW

� Baseline knowledge of strengths and weaknesses of case management interventions

� Identifying, appraising and synthesising literature on case management interventions for spouses

� Dissemination of intervention

� Primary outcomes

� Effect of intervention

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THE BENEFITS OF USING MIXED METHODS

� Providing a better understanding of research problem

� Model the process and outcomes relevant for older patients and their spouses in orthopaedic fast-track treatment programmes

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THANK YOU

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REFERENCES

� Allen, D. Negotiating the role of expert carers on an adult hospital ward. Sociology of Health and Illness 2000, 22.

� Bernabei R, Landi F, Carbonin PU, et al. Randomised trial of impact of model of integrated care and case management for older people living in community. British Medical Journal 1998;316:1348-1351.

� Björkman T, Hansson L, Sandlund M. Outcome of case management base don the strengths model compared to standard care. A randomised controlled trial. Social Psychiatry and Psychiatric Epidemiology 2002;37:147-152.

� Craddock, AE. Relational resources as buffers against the impact of stress: A longitudinal study of seminary students and their partners. Journal of Psychology and Theology 1996;24:38-46.

� Craig P, Dieppe P, Petticrew M, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. British Medical Journal 2008;337:a1655.

� Ethgen, O, Bruyere, O, Reginster, JY, et al. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature 3. Journal of Bone and Joint Surgery Am 2007;86-A:963-974.

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REFERENCES

� Gensichen J, Beyer M, Muth C, et al. Review: case management in primary health care improves symptoms and drug adherence in people with major depression. Psychological Medicine 2006;36:7-14.

� Glaser BG. Theoretical sensitivity. The Sociology Press, University of California, San Fransisco, 1978.

� Glaser BG. Doing grounded theory: Issues and discussions. The Sociology Press, University of California, San Fransisco, 1998.

� Hallberg IR, Kristensson J. Preventive home care of frail older people: a review of recent case management studies. International Journal of Older People Nursing 2004;13:112-120.

� Harvey K, Burns T, Fahy T, et al. The effect of intensive case management on the relatives of patients with severe mental illness. Psychiatric Services 2002;53:1580-1585.

� Hawker, GA. Who, when, and why total joint replacement surgery? The patient's perspective. Current Oppinion in Rheumatology 2006;18:526-530.

� Intagliata J. Improving the quality of community care for the chronically mentally disabled: the role of case management. Schizophrenia Bulletin 1982;8:655-674.

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REFERENCES

� Kehlet H, Wilmore DW. Fast-track surgery. British Journal of Surgery 2005; 92: 3-4.

� Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Annals of Surgery 2008; 248: 189-198.

� Kristensson J, Ekwall AK, Hallberg IR, et al. Case managers for frail older people: a randomised controlled pilot study. Scandinavian Journal of Caring Science 2010;24:755-763.

� Landi F, Onder G, Bernabei R, et al. A new model of integrated home care for the elderly: impact on hospital use. Journal of Clinical Epidemiology 2001;54:968-970.

� Madrid C. Orthopedic case management in a collaborative practice setting. Seminar for Perioperative Nursing 1994;3:13-15.

� Mitchinson AR, Kim HM, Geisser M, et al. Social connectedness and patient recovery after major operations. Journal of the American College of Surgeons 2008; 206:292-300.

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REFERENCES

� Prouty A, Cooper M, Thomas P, et al. Multidiciplinary patient education to total joint replacement surgery patients. Orthopaedic Nursing 2006;25:257-261.

� Rosemann T, Joos, S, Szecsenyi, J, et al. Case Management of Arthritis Patients in Primary Care: A Cluster-Randomized Controlled Trial. Arthritis Care and Research 2007;57:1390-1397.

� Rosen A, Teesson M. Does case management work? The evidence and the abuse of evidence-based medicine. Australian and New Zealand Journal of Psychiatry 2001;35:731-746.

� Schifalacqua M, Hook M, Schmidt M, et al. Coordinating the Care of the Chronically Ill in a World of Managed Care. Nursing Administration Quarterly 2000;24:12-20.

� Theiss, MM, Ellison, MW, Murphy, VJ, et al. The Connection Between Strong Social Support and Joint Replacement Outcomes. Orthopaedics 2011;34:357-367.

� Van Achterberg T, Stevens FCJ, Philipsen H, et al. Coordination of care: effects on the continuity and quality of care. International Journal of Nursing studies 1996;33:638-650.

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REFERENCES

� Waters, K, Allsopp, D, Dennis, A. Sources of support for older people

after discharge from hospital: 10 years on. Journal of Advanced

Nursing 2001;33:575-582.