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Australian Journal of Primary Health Australian Journal of Primary Health Society
The issues influencing community health services and primary health care
REVIEW (Open Access)

Systematic review of integrated models of health care delivered at the primary–secondary interface: how effective is it and what determines effectiveness?

Geoffrey K. Mitchell A , Letitia Burridge B D , Jianzhen Zhang B , Maria Donald B , Ian A. Scott C , Jared Dart A and Claire L. Jackson B
+ Author Affiliations
- Author Affiliations

A School of Medicine, The University of Queensland, Ipswich Campus, Salisbury Road, Ipswich, Qld 4305, Australia.

B Discipline of General Practice, School of Medicine, The University of Queensland, Level 8, Health Sciences Building, Building 16/910, Royal Brisbane & Women’s Hospitals, Herston Road, Herston, Qld 4006, Australia.

C Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Qld 4102, Australia.

D Corresponding author. Email: l.burridge@uq.edu.au

Australian Journal of Primary Health 21(4) 391-408 https://doi.org/10.1071/PY14172
Submitted: 23 June 2014  Accepted: 11 April 2015   Published: 2 September 2015

Journal Compilation © La Trobe University 2015

Abstract

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary–secondary care. Six elements were identified that were common to these models of integrated primary–secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary–secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.


References

Askew DA, Jackson C, Ware R, Russell A (2010) Protocol and baseline data from The Inala Chronic Disease Management Service evaluation study: a health services intervention study for diabetes care. BMC Health Services Research 10, 134
Protocol and baseline data from The Inala Chronic Disease Management Service evaluation study: a health services intervention study for diabetes care.Crossref | GoogleScholarGoogle Scholar | 20492731PubMed |

Australian Government Department of Health and Ageing (2009) Building a 21st century primary health care system: a draft of Australia’s first national primary health care strategy. Commonwealth of Australia, Canberra.

Australian Government National Health and Hospitals Reform Commission (2009) A healthier future for all Australians final report. Commonwealth of Australia, Canberra.

Australian Institute of Health and Welfare (AIHW) (2012) ‘Risk factors contributing to chronic disease.’ (AIHW: Canberra)

Borgermans L, Goderis G, Van Den Broeke C, Verbeke G, Carbonez A, Ivanova A, Mathieu C, Aertgeerts B, Heyrman J, Grol R (2009) Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project. BMC Health Services Research 9, 179
Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project.Crossref | GoogleScholarGoogle Scholar | 19811624PubMed |

Boyd CM, Darer J, Boult C, Fried L, Boult L, Wu A (2005) Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. Journal of the American Medical Association 294, 716–724.
Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD2MXns1OhsL0%3D&md5=0761460b8cbdb0be44a91f668b8936ecCAS | 16091574PubMed |

Coast J, Noble S, Noble A, Horrocks S, Asim O, Peters T, Salisbury C (2005) Economic evaluation of a general practitioner with special interests led dermatology service in primary care. British Medical Journal 331, 1444–1449.
Economic evaluation of a general practitioner with special interests led dermatology service in primary care.Crossref | GoogleScholarGoogle Scholar | 16339217PubMed |

Doughty RN, Wright S, Pearl A, Walsh H, Muncaster S, Whalley G, Gamble G, Sharpe N (2002) Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study. European Heart Journal 23, 139–146.
Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD38%2FmtVOquw%3D%3D&md5=62df8962a2aa51b7370356dca92cb170CAS | 11785996PubMed |

Eliasoph H, Monaghan B, Beaudoin R, Cushman R, DuBois-Wing G, Emery M, Fenn W, Hanmer S, Huras P, Lowi-Young M, Mandy P, Trimnell J, Switzer G, Woolgar T, Butler J (2007) We are all in this together: integrated health service plans in Ontario. Healthcare Quarterly 10, 82–87.
We are all in this together: integrated health service plans in Ontario.Crossref | GoogleScholarGoogle Scholar | 18271108PubMed |

Germov J (2005) Theorising health: major theoretical perspectives in health sociology. In ‘Second opinion: an introduction to health sociology’., 3rd edn. ( Ed. J Germov) pp. 28–50. (Oxford University Press: Melbourne, Australia)

Goderis G, Borgermans L, Grol R, Van Den Broeke C, Boland B, Verbeke G, Carbonez A, Mathieu C, Heyrman J (2010) Start improving the quality of care for people with type 2 diabetes through a general practice support program: a cluster randomized trial. Diabetes Research and Clinical Practice 88, 56–64.
Start improving the quality of care for people with type 2 diabetes through a general practice support program: a cluster randomized trial.Crossref | GoogleScholarGoogle Scholar | 20047770PubMed |

Goodwin N, Smith J, Davies A, Perry C, Rosen R, Dixon A, Dixon J, Ham C (2012) Integrated care for patients and populations: improving outcomes by working together. A report to the Department of Health and the NHS Future Forum. The King’s Fund, London.

Gröne O, Garcia-Barbero M (2001) Integrated care: a position paper of the WHO European Office for Integrated Health Care Services. International Journal of Integrated Care 1, e21

Gruen RL, Weeramanthri TS, Knight SE, Bailie RS (2004) Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database of Systematic Reviews 4, CD003798

Higgins J, Green S (2011). ‘Cochrane handbook for systematic reviews of interventions.’ Version 5.1.0 [updated March 2011]. (The Cochrane Collaboration: London UK) Available at www.cochrane-handbook.org [Verified 17 November 2014]

Jackson C, Tsai J, Brown C, Askew D, Russell A (2010) GPs with special interests: impacting on complex diabetes care. Australian Family Physician 39, 972–974.

Kirsh S, Watts S, Pascuzzi K, O’Day M, Davidson D, Strauss G, O’Kern E, Aron D (2007) Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Quality & Safety in Health Care 16, 349–353.
Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk.Crossref | GoogleScholarGoogle Scholar |

Martínez-González N, Berchtold P, Ullman K, Busato A, Egger M (2014) Integrated care programmes for adults with chronic conditions: a meta-review. International Journal for Quality in Health Care 26, 561–570.
Integrated care programmes for adults with chronic conditions: a meta-review.Crossref | GoogleScholarGoogle Scholar | 25108537PubMed |

Ministry of Health (2011) ‘Better, sooner, more convenient health care in the community.’ (Ministry of Health: Wellington, New Zealand)

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred Reporting Items for Systematic Reviews and Meta-Analysis: the PRISMA statement. PLoS Med 6, e100097
Preferred Reporting Items for Systematic Reviews and Meta-Analysis: the PRISMA statement.Crossref | GoogleScholarGoogle Scholar |

Nocon A, Rhodes P, Wright J, Eastham J, Williams D, Harrison S, Young R (2004) Specialist general practitioners and diabetes clinics in primary care: a qualitative and descriptive evaluation. Diabetic Medicine 21, 32–38.
Specialist general practitioners and diabetes clinics in primary care: a qualitative and descriptive evaluation.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2c%2FmsVWgtQ%3D%3D&md5=e3c6d1ab8288f1f2be18088aa4f06f83CAS | 14706051PubMed |

Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R (2005) Integrated care programmes for chronically ill patients: a review of systematic reviews. International Journal for Quality in Health Care 17, 141–146.
Integrated care programmes for chronically ill patients: a review of systematic reviews.Crossref | GoogleScholarGoogle Scholar | 15665066PubMed |

Pearl A, Wright S, Gamble G, Muncaster S, Walsh H, Sharpe N, Doughty R (2003) The effect of an integrated care approach for heart failure on general practice. Family Practice 20, 642–645.
The effect of an integrated care approach for heart failure on general practice.Crossref | GoogleScholarGoogle Scholar | 14701886PubMed |

Popay J, Petticrew M, Britten N, Sowden A, Roberts H, Arai L, Rogers M (2006) ‘Guidance on the conduct of narrative synthesis in systematic reviews.’ (Institute for Health Research: Lancaster)

Rea H, McAuley S, Stewart A, Lamont C, Roseman P, Didsbury P (2004) A chronic disease management programme can reduce days in hospital for patients with chronic obstructive pulmonary disease. Internal Medicine Journal 34, 608–614.
A chronic disease management programme can reduce days in hospital for patients with chronic obstructive pulmonary disease.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2crnsVCruw%3D%3D&md5=5d6b05f6c405686f11c80db24951efe9CAS | 15546454PubMed |

Salisbury C, Noble A, Horrocks S, Crosby Z, Harrison V, Coast J, de Berker D, Peters T (2005) Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial. British Medical Journal 331, 1441–1446.
Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial.Crossref | GoogleScholarGoogle Scholar | 16332728PubMed |

Sheridan N, Kenealy T, Parsons M, Rea H (2009) Health reality show: regular celebrities, high stakes, new game—a model for managing complex primary health care. The New Zealand Medical Journal 122, 31–42.

Simmons D (2003) Impact of an integrated approach to diabetes care at the Rumbalara Aboriginal Health Service. Internal Medicine Journal 33, 581–585.
Impact of an integrated approach to diabetes care at the Rumbalara Aboriginal Health Service.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3srns12ltA%3D%3D&md5=2e2d42bb772a4d0c83ee8e32e77e9e07CAS | 14656232PubMed |

Singh D (2005). ‘Transforming chronic care: evidence about improving care for people with long-term conditions.’ (University of Birmingham Health Services Management Centre: Birmingham)

Smink AJ, Dekker J, Vliet Vlieland T, Swierstra B, Kortland J, Bijlsma J, Teerenstra S, Voorn T, Bierma-Zeinstra S, Schers H, van den Ende C (2014) Health care use of patients with osteoarthritis of the hip or knee after implementation of a stepped-care strategy: an observational study. Arthritis Care and Research 66, 817–827.
Health care use of patients with osteoarthritis of the hip or knee after implementation of a stepped-care strategy: an observational study.Crossref | GoogleScholarGoogle Scholar | 25200737PubMed |

Smith S, Bury G, O’Leary M, Shannon W, Tynan A, Staines A, Thompson C (2004) The North Dublin randomized controlled trial of structured diabetes shared care. Family Practice 21, 39–45.
The North Dublin randomized controlled trial of structured diabetes shared care.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2c%2FlvVOgtQ%3D%3D&md5=bb459b0102f20b54e3846171dc40353cCAS | 14760042PubMed |

Smith SM, Allwright S, O’Dowd T (2007) Effectiveness of shared care across the interface between primary and speciality care in chronic disease management. Cochrane Database of Systematic Reviews 3, CD004910

Tieman J, Mitchell G, Shelby-James T, Currow D, Fazekas B, O’Doherty L, Hegarty M, Eriksson L, Brown R, Reid-Orr D (2007) Integration, coordination and multidisciplinary care: what can these approaches offer to Australian primary health care? Australian Journal of Primary Health 13, 56–65.
Integration, coordination and multidisciplinary care: what can these approaches offer to Australian primary health care?Crossref | GoogleScholarGoogle Scholar |

Von Korff M, Tiemens B (2000) Individualized stepped care of chronic illness. The Western Journal of Medicine 172, 133–137.
Individualized stepped care of chronic illness.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c7lslOlug%3D%3D&md5=bca0fc2a6b366d2b39d82be197e38af8CAS | 10693379PubMed |