Effectiveness of shared care across the interface between primary and specialty care in chronic disease management

 

Abstract

Background

Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than either primary or specialty care alone. It has been defined as the joint participation of primary care physicians and specialty care physicians in the planned delivery of care, informed by an enhanced information exchange over and above routine discharge and referral notices. It has the potential to offer improved quality and coordination of care delivery across the primary-specialty care interface and to improve outcomes for patients.

Objectives

To determine the effectiveness of shared-care health service interventions designed to improve the management of chronic disease across the primary-specialty care interface.

Search methods

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (and the database of studies awaiting assessment); Cochrane Central Register of Controlled Trials (CENTRAL); Database of Abstracts of Reviews of Effects (DARE); MEDLINE (from 1966); EMBASE (from 1980) and CINAHL (from 1982). We also searched the reference lists of included studies.

Selection criteria

Randomised controlled trials, controlled before and after studies and interrupted time series analyses of shared-care interventions for chronic disease management. The participants were primary care providers, specialty care providers and patients. The outcomes included physical health outcomes, mental health outcomes, and psychosocial health outcomes, treatment satisfaction, measures of care delivery including participation in services, delivery of care and prescribing of appropriate medications, and costs of shared care.

Data collection and analysis

Three review authors independently assessed studies for eligibility, extracted data and assessed study quality.

Main results

Twenty studies of shared care interventions for chronic disease management were identified, 19 of which were randomised controlled trials. The majority of studies examined complex multifaceted interventions and were of relatively short duration. The results were mixed. Overall there were no consistent improvements in physical or mental health outcomes, psychosocial outcomes, psychosocial measures including measures of disability and functioning, hospital admissions, default or participation rates, recording of risk factors and satisfaction with treatment. However, there were clear improvements in prescribing in the studies that considered this outcome. The methodological quality of studies varied considerably with only a minority of studies of high-quality design. Cost data were limited and difficult to interpret across studies.

Authors' conclusions

This review indicates that there is, at present, insufficient evidence to demonstrate significant benefits from shared care apart from improved prescribing. Methodological shortcomings, particularly inadequate length of follow-up, may partially account for this lack of evidence. This review indicates that there is no evidence to support the widespread introduction of shared care services at present. Future shared-care interventions should only be developed within research settings and with account taken of the complexity of such interventions and the need to carry out longer studies to test the effectiveness and sustainability of shared care over time.

 

Plain language summary

Effectiveness of shared care across the interface between primary and specialty care in chronic disease management

Shared care across the primary-specialty interface has been defined as the joint participation of primary care physicians and specialty care physicians in the planned delivery of care, informed by an enhanced information exchange, over and above routine discharge and referral notices. As such it has the potential to improve the management of chronic diseases and lead to better outcomes than either primary or specialty care on their own. This review examines the effectiveness of shared care for a range of chronic conditions in a variety of healthcare settings. Shared care interventions identified were complex and multifaceted. Results were varied and many of the studies were of poor quality. Shared care had a clear effect on improving prescribing but the pattern of results was mixed for all other outcomes. There is a need to improve the design and quality of studies examining such interventions in order to determine which components, if any, are effective, to assess issues such as sustainability of shared care and to determine settings and patient groups in which shared care may be most effective.

 

摘要

背景

共同照護透過基層與專科照護平台對於慢性疾病管理的效果

共同照護已用於管理許多的慢性疾病並假設其比基層或專科照護提供更好的照護。它被定義為基層照護醫師與專科照護醫師共同參與有計畫的照護提供，加強資訊交流的通知，超出常規的出院與轉介通知。它透過基層與專科照護的平台提供改善品質與照護提供合作與改善病患結果的可能性。

目標

確定透過基層與專科照護平台來改善慢性疾病之共同照護健康服務介入措施的效果。

搜尋策略

我們檢索 the Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (與研究有待評估的資料庫)；Cochrane Central Register of Controlled Trials (CENTRAL)；Database of Abstracts of Reviews of Effects (DARE)；MEDLINE (from 1966)；EMBASE (自1980年起) and CINAHL (自1982年起)。我們也檢索納入研究的參考文獻。

選擇標準

用於慢性疾病管理之共同照護介入措施的隨機對照試驗，前後對照研究與間斷時間序列分析。研究對象為基層照護提供者，專科照護提供者與病患。結果包括身體健康結果，心理健康結果，與心理社會健康結果，治療滿意度，照護提供的測量包括參與服務與調劑適當藥物，與共同照護的成本。

資料收集與分析

三篇回顧作者分別評估研究的合格性，摘錄資料並評估研究品質。

主要結論

確定20篇有關共同照護用於慢性疾病管理的研究，其中19篇為隨機對照試驗。大部分的研究評估複雜多面向的介入措施且研究期間相對較短。研究結果為混合的。整體來說，在身體或心理健康結果，心理社會結果，心理社會的測量包括失能與功能測量，住院，不參與或參與率，紀錄風險因素與治療滿意度等結果的改善沒有一致性。然而，在有考量藥物調劑結果的研究中顯示，在調劑方面有明顯的改善。研究的方法學品質差異很大，只有少數研究具有高品質的研究設計。成本的資料有限且不易解釋。

作者結論

這篇回顧指出，目前沒有足夠的證據可以證明共同照護的顯著效益，除了調劑的改善以外。方法學的缺點，尤其是追蹤的時間不夠長，也許可以解釋為缺乏證據的原因。這篇回顧指出目前沒有證據支持普遍使用共同照護服務。未來共同照護介入措施應只在研究機構中發展並考量這種介入措施的複雜性，並需要長期進行的研究以測試共同照護隨著時間的可持續性。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

透過基層與專科平台的共同照護被定義為基層照護醫師與專科照護醫師共同參與有計畫的照護提供，加強資訊交流的通知，超出常規的出院與轉介通知。因此，它具有改善慢性疾病的管理並比基層與專科照護本身帶來更好的結果。這篇回顧評估共同照護對於各種健康照護機構中某一範圍慢性疾病的效果。確定共同照護介入措施為複雜且多面向的。研究結果不同且許多研究的方法學品質不佳。共同照護對於改善調劑具有明顯的效果，但對於其他結果的效果為混合的。需要改善評估這種介入措施之研究設計與研究品質，以確定哪個部分是有效的，評估如共同照護可持續性的問題，並確定機構與病患族群在何種共同照護下可能是最有效的。