Shared care across the interface between primary and specialty care in management of long term conditions

Smith, Susan M; Cousins, Gráinne; Clyne, Barbara; Allwright, Shane; O’Dowd, Tom

doi:10.1002/14651858.cd004910.pub3

Cited by 73 publications

(92 citation statements)

References 108 publications

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“…The World Health Organization recognises poor integration of primary, secondary and tertiary care results in reduced quality and inefficiency of healthcare as well as inconvenience to patients [30]. Evidence that integrated care leads to improved clinical outcomes is limited, with systematic reviews inconsistently demonstrating clinical benefits [9,31,32]. Relevant to diabetes, three randomised controlled trials of primary-secondary integrated models have been conducted, looking at: combining upskilled GPs with practice visits by a DNE [33]; interdisciplinary diabetes team case discussions [28]; and a virtual clinic including a diabetes nurse and endocrinologist [34].…”

Section: Discussionmentioning

confidence: 99%

“…Patient benefits include improved communication, clinic accessibility and satisfaction [8]. Evidence for the effectiveness of shared or integrated care for long-term conditions including diabetes is more equivocal, with trials reporting similar improvements in metabolic control when compared with conventional hospital-based specialist care [9]. Our interest, therefore, in integrated diabetes care is less about identifying models superior to the status quo and more about investigating models that deliver non-inferior clinical outcomes but offer alternative benefits such as patient satisfaction and efficiency.…”

Section: Introductionmentioning

confidence: 99%

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Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial

et al. 2018

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Aims/hypothesis The aim of the study was to determine if a Beacon model of integrated care utilising general practitioners (GPs) with special interests could achieve similar clinical outcomes to a hospital-based specialist diabetes outpatient clinic. Methods This pragmatic non-inferiority multisite randomised controlled trial assigned individuals with complex type 2 diabetes to care delivered by a Beacon clinic or to usual care delivered by a hospital outpatient department, in a 3:1 ratio. Owing to the nature of the study, researchers were only blinded during the allocation process. Eligible participants were aged 18 or over, had been referred by their usual GP to the hospital central referral hub with type 2 diabetes and had been triaged to be seen within 30 or 90 days. The intervention consisted of diabetes management in primary care by GPs with a special interest who had been upskilled in complex diabetes under the supervision of an endocrinologist. The primary outcome was HbA 1c at 12 months postrecruitment. The non-inferiority margin was 4.4 mmol/mol (0.4%). Both per-protocol and intention-to-treat analyses are reported. Results Between 27 November 2012 and 14 July 2015, 352 individuals were recruited and 305 comprised the intention-to-treat sample (71 in usual care group and 234 in the Beacon model group). The Beacon model was non-inferior to usual care for both the per-protocol (difference −0.38 mmol/mol [95% CI −4.72, 3.96]; −0.03% [95% CI −0.43, 0.36]) and the intention-to-treat (difference −1.28 mmol/mol [95% CI −5.96, 3.40]; −0.12% [95% CI −0.55, 0.31]) analyses. Non-inferiority was sustained in a sensitivity analysis at 12 months. There were no statistically or clinically significant differences in the secondary outcomes of BP, lipids or quality of life as measured by the 12 item short-form health survey (SF-12v2) and the diabetes-related quality of life (DQoL-Brief) survey. Safety indicators did not differ between groups. Participant satisfaction on the eight-item client satisfaction questionnaire (CSQ-8) was good in both groups, but scores were significantly higher in the Beacon model group than the usual care group (mean [SD] 28.4 [4.9] vs 25.6 [4.9], respectively, p < 0.001). Conclusions/interpretation In individuals with type 2 diabetes, a model of integrated care delivered in the community by GPs with a special interest can safely achieve clinical outcomes that are not inferior to those achieved with gold-standard hospitalbased specialist outpatient clinics. Individuals receiving care in the community had greater satisfaction. Further studies will determine the cost of delivering this model of care.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial

et al. 2018

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“…Uma estratégia de "bola de neve" ou snowballing, útil para revisão de tópicos onde há pouco consenso sobre terminologia e definições 41 , foi preferida a uma busca eletrônica por palavras-chave devido à polissemia da literatura sobre cuidados colaborativos 15,17 . Um pequeno número de revisões sistemáticas altamente relevantes foram identificadas a partir da base eletrônica da Biblioteca Cochrane 12,14,15,17 como ponto de partida para exame de referências, levando a identificação de mais 32 trabalhos que se encaixavam nos objetivos da revisão. Ao final 36 artigos foram lidos integralmente, dos quais 24 foram incluídos na síntese aqui apresentada (Quadro 1).…”

Section: Etapa 2: Quais Os Componentes Dos Cuidados Colaborativos E unclassified

“…Estratégias de integração com foco na colaboração entre profissionais parecem mais efetivas do que aquelas com foco em mudanças de comportamento individual 13 . Entre as primeiras, cuidados colaborativos (collaborative care) são amplamente usados para integrar saúde mental e AP, com evidências de efetividade no manejo de depressão, ansiedade e, em menor escala, psicoses e diabetes, quando comparados a cuidado usual ou consultoria de ligação 12,[14][15][16][17] . Efeitos positivos incluem melhoras em: detecção, tratamento e desfechos clínicos de transtornos mentais [15][16][17][18][19][20][21] , inclusive no longo prazo 18 ; satisfação e qualidade de vida dos usuários 14,21 ; e custo-efetividade, ainda que não reduza os custos totais da atenção 17,18,21 .…”

Section: Introductionunclassified

Componentes do apoio matricial e cuidados colaborativos em saúde mental: uma revisão narrativa

Saraiva

Zepeda

Liria

2020

Ciênc. saúde coletiva

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Resumo Cuidados colaborativos entre saúde mental e atenção primária são efetivos em melhorar desfechos de saúde. O apoio matricial tem semelhanças com cuidados colaborativos pouco exploradas na literatura. Este artigo compara os dois modelos e analisa o apoio matricial a partir de evidências sobre cuidados colaborativos. Revisão narrativa. Componentes de cada modelo (atividades e dimensões) foram identificados e comparados. Evidências sobre cuidados colaborativos informaram análise de componentes semelhantes do apoio matricial. Foram identificadas dimensões do apoio matricial – suporte educacional, cuidado especializado, regulação, cogestão – e dos cuidados colaborativos – cuidado multiprofissional, comunicação sistemática, cuidado estruturado, suporte organizacional. A principal semelhança entre os modelos está nas atividades colaborativas diretas em torno de problemas clínicos, relacionadas a efetividade em estudos sobre cuidados colaborativos. Atividades colaborativas diretas são ponto positivo do apoio matricial. Cuidado estruturado e suporte em nível organizacional devem ser encorajados. Futuros estudos devem refinar as categorias propostas e explorar seu uso para desenvolvimento do apoio matricial.

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“…During the past decades, such shared care models have been designed and tested for people with Type 2 diabetes with the purpose of providing qualified healthcare services. Focus has been on combining the disease-specific expertise of the endocrinologist [4][5][6][7][8][9] with the GP's knowledge of general health and everyday living [10]. In most interventions testing shared care models, the majority of consultations take place in general practice, all consultations in some models [4][5][6]11,12], whereas others include an annual check-up at a specialized outpatient clinic [7,8,13,14].…”

Section: Introductionmentioning

confidence: 99%

Management of people with Type 2 diabetes shared between a specialized outpatient clinic and primary health care is noninferior to management in a specialized outpatient clinic: a randomized, noninferiority trial

et al. 2019

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Aim To evaluate whether management of people with Type 2 diabetes shared between a specialized outpatient clinic and primary health care has noninferior HbA1c outcomes compared with mono‐sectorial management in a specialized outpatient clinic. Methods A randomized controlled, noninferiority study. People with moderate hyperglycaemia, hypertension and/or incipient complications were eligible for the study. All participants had annual comprehensive check‐ups at the outpatient clinic. Quarterly check‐ups were conducted by general practitioners (GPs) for the shared care group and by endocrinologists at the outpatient clinic for the control group. The primary outcome was the mean difference in HbA1c from baseline to 12 months of follow‐up. The noninferiority margin for HbA1c was 4.4 mmol/mol. Results A total of 140 people were randomized [age 65.0 ± 0.9 years, HbA1c 52 ± 0.8 mmol/mol (6.9 ± 0.1%), systolic BP 135.6 ± 1.1 mmHg; all mean ± sem]. Peripheral neuropathy was present in 68% of participants and microalbuminuria in 19%; 15% had history of a previous major cardiovascular event. Among study completers (n = 133), HbA1c increased by 2.3 mmol/mol (0.2%) in the shared care group and by 1.0 mmol/mol (0.1%) in the control group, with a between‐group difference of 1.3 mmol/mol [90% confidence interval (CI) −1.3, 3.9] (0.1%, 90% CI −0.1, 0.4). Noninferiority was confirmed in both per protocol and intention to treat analyses. Conclusion We found that our shared care programme was noninferior to specialized outpatient management in maintaining glycaemic control in this group of people with Type 2 diabetes. Shared care should be considered for the future diabetes management of Type 2 diabetes.

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Shared care across the interface between primary and specialty care in management of long term conditions

Cited by 73 publications

References 108 publications

Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial

Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial

Componentes do apoio matricial e cuidados colaborativos em saúde mental: uma revisão narrativa

Management of people with Type 2 diabetes shared between a specialized outpatient clinic and primary health care is noninferior to management in a specialized outpatient clinic: a randomized, noninferiority trial

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