Integrating Primary and Secondary Care to Enhance Chronic Disease Management: A Scoping Review

Sara Murtagh; Geoff McCombe; John Broughan; Áine Carroll; Mary Casey; Áine Harrold; Thomas Dennehy; Ronan Fawsitt; Walter Cullen

doi:10.5334/ijic.5508

Figures & Tables

Flowchart illustrating the paper selection process.

Table 1

Summary of key findings from studies identified

AUTHOR, YEAR	COUNTRY	STUDY POPULATION	TITLE	STUDY DESIGN	INTERVENTION	MAIN FINDINGS
Hollingworth et al, 2017 [18]	Australia	Type 2 diabetes	Impact of a general practitioner-led integrated model of care on the cost of potentially preventable diabetes-related hospitalisations.	Non-randomised controlled trial	Special interest GP led multidisciplinary team with an endocrinologist and diabetes educator – Beacon model of care	– Estimated savings from potentially preventable hospitalisations = €79.1 million – Reduction in cost and occurrence of preventable hospital admissions – Works on a small scale, local approach.
Eggers et al, 2018 [19]	Germany	Parkinson’s disease	Patient-centred integrated healthcare improves quality of life in Parkinson’s disease patients: a randomized controlled trial	Randomised controlled trial	Community-based multidisciplinary team with PD specialist, nurse and general neurologist	– Significant improvement in QoL (PDQ-39), motor and non-motor symptoms – Cost benefit & maintenance inconclusive – Multidisciplinary expertise and nurse most innovative aspects – Improved patient empowerment in terms of disease acceptance or coping
Kruis et al, 2010 [20]	Netherlands	COPD	Sustained effects of integrated COPD management on health status and exercise capacity in primary care patients	Non-randomised controlled trial	Multidisciplinary team with two physiotherapists, respiratory nurse, physician assistant, dietician, pharmacist, supervising primary care physician and logistics manager	– Improvement in health status and exercise tolerance – Better results as a primary care base than other studies – Suggestion cost may improve from early intervention – Need for prolonged intervention. – Improved feelings of self-efficacy, control over one’s own disease state.
Kruis et al, 2014 [21]	Netherlands	COPD	Effectiveness of integrated disease management for primary care chronic obstructive pulmonary disease patients: results of cluster randomised trial.	Randomised controlled trial	General practitioners, practice nurses, and specialised physiotherapists in the intervention group received a two-day training course on incorporating integrated disease management in practice	– No significant difference in QoL, outcomes, self-management – Activity levels improved – Improvements in follow-up structure – Freedom for each team to decide the integration plan and priorities that worked best for them. Less intense but more realistic
Fortin et al, 2016 [22]	Canada	Multiple chronic diseases	Integration of chronic disease prevention and management services into primary care: a pragmatic randomized controlled trial (PR1MaC).	Randomised controlled trial	Patient centred self-management support and health education with interprofessional collaboration. Started with a preliminary clinical evaluation by a trained nurse and development of intervention plan based on the patient’s objective discipline involved.	– Modest yet beneficial effects of the intervention – Improvement in positive and active engagement in life, social integration and support – Much room for improvement, intervention too short
Zhang et al, 2015 [23]	Australia	Type 2 diabetes	Impact of an integrated model of care on potentially preventable hospitalizations for people with Type 2 diabetes mellitus	Open controlled trial	Care provided by multidisciplinary team of an endocrinologist; two/three advanced trained general practitioners, a diabetes educator, and a podiatrist, with additional allied health available on referral	– Intervention group half as likely to be hospitalised for potentially preventable db related incident – Shorter hospital stay: no evidence that the severity of conditions differed – Suggests substantial improvements in healthcare utilisation costs as well as patient outcomes
Boland et al, 2015 [24]	Netherlands	COPD	Cost-effectiveness of integrated COPD care: the RECODE cluster randomised trial	Randomised controlled trial	Multidisciplinary team using personally developed plan to redesign and integrate care process following a 2-day training course. Incorporated ICT application with patient and provider portal to measure and report process and outcomes.	– Not cost effective, higher cost and no significant difference in effects – Relatively low intensity of pragmatic intervention -teams not required to implement all elements learned during courses – Limited room for improvement due to the relatively high standard of care
Ferrone et al, 2019 [25]	Canada	COPD	The impact of integrated disease management in high-risk COPD patients in primary care.	Randomised controlled trial	Integrated disease management, self-management, and structured follow-up intervention: case management, self-management education, and skills training. Team care model, shared decision making Supported by electronic point-of-service system	– QoL improved – Significantly fewer sever exacerbations in IDM patients – Less hospitalisations (not statistically significant) – Improved COPD knowledge – Better lung function, FEV1
Busetto et al, 2015 [26]	Netherlands	Type 2 diabetes	Implementation of integrated care for diabetes mellitus type 2 by two Dutch care groups: a case study.	Embedded single case study, data collected through semi-structured interviews	Care groups, bundled payments, patient involvement, health professional’s cooperation and task substitution, evidence-based care protocols and a shared clinical information system Electronic administration and exchange of data.	– Quality of care increased effective, efficient, accessible, patient-centred, equitable and safe health care. – Insufficient integration between patient data bases, decreased earnings for some health professionals – Improved communication and cooperation – Need more attention on patient and community involvement.
Hernandez et al, 2015 [27]	Spain, Norway, Greece	Multiple chronic diseases	Integrated care services: lessons learned from the deployment of the NEXES project.	Randomised controlled trial	An Integrated Care Service with the aim of achieving target objectives aligned with a comprehensive treatment plan based on their health condition and social circumstances.	– Wellness and Rehabilitation service did not show significant positive effects in two of the sites – Positive outcomes in prevention of hospitalizations in high risk patients in Spain and Greece – The level of evidence on effectiveness raised in NEXES was uneven for the different services – Demonstrates effectiveness of IT-supported care services, with potential for cost-containment and complementariness of the deployment of integrated care services
Van der Marck et al, 2013 [28]	Netherlands	Parkinson’s disease	Integrated multidisciplinary care in Parkinson’s disease: a non-randomised, controlled trial (IMPACT)	Non-randomised controlled trial	Individually tailored assessment by a multidisciplinary team to create a comprehensive treatment plan and subsequent implementation of the plan within a network of specifically trained allied health professionals and follow up by the same team nurse.	– Small improvements in favour of the intervention. – Significant improvements in anxiety and depression, activities of daily living, non-motor symptoms and perceived general health – Quality-of-care scores were better but overall satisfaction was unchanged – Economic evaluation showed the average costs were similar in both groups
Waibel et al, 2015 [29]	Spain	COPD	The performance of integrated health care networks in continuity of care: a qualitative multiple case study of COPD patients.	Qualitative multiple case study	Case studies with joint management care which showed similarities in level of internal production of services but differences regarding the integration depth and inter-organisational relationship. The networks introduced different types of care coordination mechanisms ranged from an implemented single mechanism (shared electronic medical records, shared clinical guidelines, COPD patient registers, etc.) to a combination of mechanisms in a comprehensive programme	– Clear distribution of COPD care responsibilities – GPs followed the instructions received from the specialists and incorporated it into treatment plan But pulmonologists recorded disregarding recommendations from the other care level – High accessibility to care during exacerbations but long waiting times to non-urgent care – Continuity of care facilitated via computer – Established trusting patient–physician relationship over time
Russell et al, 2013 [30]	Australia	Type 2 diabetes	Model of care for the management of complex Type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial.	Open controlled trial	Care in the community by GPs with advanced skills, supported by an endocrinologist. Screening assessment by a diabetes nurse educator. Support from a dietician, psychologist and podiatrist as needed Developed a patient-specific management plan.	– Consistently lower HbA1c after 6 months – Blood pressure and total cholesterol initially significantly reduced but equivalent to usual care group at 12 months – The intervention group had higher proportions of patients’ clinical outcome targets – Self-efficacy improved – Glycaemic control improved with HbA1c consistently lower – 2.7 times as many patients seen per session – Intervention model delivered at approximately one fifth of the cost per visit accessibility
Russell et al, 2019 [31]	Australia	Type 2 Diabetes	Clinical outcomes of an integrated primary-secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial.	Randomised controlled trial	Beacon model of care using a multidisciplinary team including two GPs with special interests, an endocrinologist and a DNE in a community general practice. GPs took online advanced diabetes care course and attended a 1-day workshop	– More doctors’ visits and DNE appointments – Difficulty obtaining a better average HbA1c – No differences in BP or lipids – No difference to their QoL but higher satisfaction with care scores, although this difference was small – Better self-management support – Participants found clinicians collaborative, which improved engagement and motivation. – Higher number of doctor and DNE visits may reflect improved patient access and real-time follow-up
Hanan et al, 2014 [32]	Ireland	Cancer	Delivering care to oncology patients in the community: an innovative integrated approach	Robust evaluation of pilot	Community oncology nurse education programme to provide continuous professional development enabling nurses to develop and enhance their knowledge, skill and competence. The training is both theoretical and skills based. The national implementation groups comprises senior clinical oncology nurses, managers and educationalists.	– Considered successful by both the community and hospital staff – Improved QoL – Dramatic decrease in hospital attendances for clinical procedures that are now performed in the community – Increase in community nurses’ confidence and competency in providing a safe service in the patient’s home. – Communication between the hospital and community staff was strengthened by the training programme – Increased sense of autonomy
Oude et al, 2015 [33]	Netherlands	Diabetes	Effects of Government Supervision on Quality of Integrated Diabetes Care: a Cluster Randomized Controlled Trial	Cluster randomised controlled trial	Care groups of multiple health care providers, general practitioners and practice nurses provide diabetes care. Practice nurses perform check-ups. Bundled payment means paying a single fee for all medical services care	– Structures and processes of care did not improve more than usual, neither did health outcomes – Could not demonstrate an effect of the supervision program on quality of care in care groups – Explanations are no effect of the supervision program, control group improved too, limiting contrast or the effect of the program was not captured in this study design.
Browne et al, 2016 [34]	Australia	Type 2 diabetes	Building the evidence for integrated care for type 2 diabetes: a pilot study.	Pilot evaluation	IDEAS: an integrated, multidisciplinary, community-based health service Multidisciplinary team including an endocrinologist and registrar working with a diabetes nurse educator, podiatrist and community health nurse.	– No effect on diabetes-specific distress scores – Diabetes-specific self-efficacy did not change significantly over time as a result of receiving care – Participants perceived the quality of diabetes care as significantly better with a person-centred focus – No significant difference in HbA1c, trend in favour of IDEAS but did not reach significance
Yu et al, 2017 [35]	UK	Type 2 diabetes	Population-level impact of diabetes integrated care on commissioner payments for inpatient care among people with type 2 diabetes in Cambridgeshire: a postintervention cohort follow-up study.	Post intervention study	Community diabetes service with increased specialist nursing, dietetic, podiatry and medical support to primary care and patients, while linking into other diabetes specialist services	– Lower individual median inpatient payment – Successfully implemented with positive patient experience, improved practice nurse clinical confidence and early reports of clinical benefit – Failed to progress to a truly integrated services, potentially related failure to implement integrated information management
Simmons et al, 2015 [36]	UK	Diabetes	Hospitalisation among patients with diabetes associated with a Diabetes Integrated Care Initiative: a mixed methods case study.	Mixed methods case study	Three-component model involving GP, hospital and community with the intermediate service led by community-based diabetes specialist nurses Increased access to patient diabetes education, greater within-practice diabetes specialist support for primary care, increased linkage with hospital diabetes specialists	– Increase patients diagnosed with diabetes was comparable, prevalence increased during this time – No improvement in diabetes QoF targets – No significant reductions, and no differences compared with the other two areas, in hospitalisation rates for diabetes – A feeling that intervention increased barriers to direct access to hospital services rather than facilitating due to new additional layers to their care – Better level of personalised care than they had previously – Negatively affected by a lack of functioning information-sharing systems – Failure to implement information management systems probably led to communication and integration difficulties
Burridge et al, 2015 [37]	Australia	Diabetes	The work of local healthcare innovation: a qualitative study of GP-led integrated diabetes care in primary health care	Qualitative study	Community care led by GPs with advanced skills, supported by an endocrinologist and a diabetes nurse educator. Support from a dietician, psychologist and podiatrist as needed	– Intervention challenges professional norms and involves changes to traditional delivery models and renegotiation of professional roles – Success dependent on the trust of all involved and the credibility of clinicians – Findings imply a deeper, potentially resistant mindset – Highlighted the influence of macro institutional processes on micro-level professional identities and work practices
Hepworth et al, 2013 [38]	Australia	Type 2 diabetes	‘Working with the team’: an exploratory study of improved type 2 diabetes management in a new model of integrated primary/secondary care.	Interviews	A multidisciplinary team of an endocrinologist, advanced-skilled GPs, a diabetes educator and a podiatrist	– Participant reported easy to use, and more convenient than travelling to major hospitals for routine procedures – Diabetes advice readily accessible and participants felt comfortable requesting advice – Staff identified as “very supportive”, “very helpful” and providing care on a “one-to-one basis” – Improved patient understanding of diabetes and how to manage it, empowered to be active in their own health
Burridge et al, 2017 [39]	Australia	Type 2 diabetes	A qualitative follow-up study of diabetes patients’ appraisal of an integrated diabetes service in primary care	Interviews	Multidisciplinary clinics led by skilled GPs with special interest in diabetes and includes assessment screening and blood glucose stabilisation Model informed by elements of the Chronic Care Model, redesigning the delivery system and improving patients’ self-management skills – to improve care efficiency and effectiveness	– Increased convenience for patients with shorter wait times – Clinicians had the flexibility to tailor specialised information to the patients’ specific circumstances – Patients positioned as partners in care which increased engagement and self-care – Fluidity of boundaries might work best with meeting patients’ healthcare needs

Integrating Primary and Secondary Care to Enhance Chronic Disease Management: A Scoping Review

Figures & Tables

Figure 1

Table 1

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