Improving Health Care for Patients with Multimorbidity: A Mixed-Methods Study to Explore the Feasibility and Process of Aligning Scheduled Outpatient Appointments through Collaboration between Medical Specialties

Cathrine Bell; Charlotte Weiling Appel; Anne Frølich; Anders Prior; Peter Vedsted

doi:10.5334/ijic.6013

Figures & Tables

Table 1

Characteristics of patients in the Multidisciplinary Outpatient Pathway from 15 August 2018 to 14 August 2019.

			N	%
Patients			102	100
Age, years	median = 71 years, IQR (63; 76)
<60			19	18.6
60–69			27	26.5
70–79			42	41.2
80–89			14	13.7
Gender, female			46	45.1
Distance to hospital, km	median = 7.7 km, IQR (3.7; 17.8)
<10			52	56.5
10–19			23	25.0
20<			17	18.5
Civil status
Living with a partner			54	52.9
Not living partner			39	38.2
Chronic diseases	median per patient = 5 diagnoses, IQR (3; 7)		491	100
Hypertension			50	10.2
Diabetes mellitus			47	9.6
Chronic obstructive pulmonary disease			45	9.2
Dyslipidaemia			38	7.7
Allergy			36	7.3
Ischemic heart disease			35	7.1
Concomitant chronic diseases¹
Hypertension – Dyslipidaemia			34	33.7
Hypertension – Diabetes mellitus			30	29.7
Chronic obstructive pulmonary disease – Hypertension			26	25.7
Well-being
Physical health, summary score SF12		mean score = 31.7	47	46.1
Mental health, summary score SF12		mean score = 46.1	47	46.1
Trajectories in outpatient clinics			239	100
Pulmonology			68	28.5
Cardiology			45	18.8
Endocrinology			58	24.3
Rheumatology			36	15.1
Nephrology			20	8.4
Other non-included outpatient clinics			12	5.0
Trajectories per patient²			239	100
2			75	73.5
3			21	20.6
4+			6	5.9
Patient assessment of chronic integrated care	mean	95% CI
Patient activation	3.3	(2.94; 3.57)	65	63.7
Delivery system design/decision support	3.6	(3.33; 3.78)	64	62.8
Goal setting	2.8	(2.58; 3.04)	65	63.7
Problem-solving/Contextual counselling	3.1	(2.81; 3.36)	62	60.8
Follow-up/Coordination	2.4	(2.14; 2.69)	63	61.8
Overall score	2.9	(2.23; 3.64)	61	59.8
Multimorbidity treatment burden	median overall score = 7.5, IQR (2.5; 15)
No burden (score 0)			9	19.6
Low burden (score <10)			17	37.0
Medium burden (score 10–22)			17	37.0
High burden (score ≥ 22)			3	6.5

[i] ¹ Most frequent among diagnoses appearing in the Danish Multimorbidity Index.

² Including non-included outpatient clinics other than the five clinics.

Numbers may not add to 100% due to missing values.

Table 2

The Multidisciplinary Outpatient Pathway (15 August 2018 – 14 August 2019).

ELIGIBILITY – ALL ASSESSED APPOINTMENTS APPEARING ON THE COORDINATORS’ LISTS	N	%
Patients	510	100.0
Appointments assessed by care managers incl. repeaters¹	2367	116.8
Unique appointments²	2027	100.0
Unique appointments/patient	median = 3	IQR (2; 5)
Unique appointments by same specialty³	1900	93.7
INTERVENTION APPLIED
Multidisciplinary outpatient pathway [Intension to treat]	131
Patients with intervention	102	20
Multidisciplinary outpatient pathway per patient	median = 1	min: max (1; 4)
Coordinated appointments	309	15.2
Coordinated appointments per patient	median = 2	IQR (2; 4)
Coordinated appointments per specialty	268	13.2
Specialty involvement	268	100
Pulmonology	86	32.1
Rheumatology	43	16.0
Cardiology	39	14.6
Endocrinology	76	28.4
Nephrology	24	9.0
Coordinated appointments by specialty per patient	median = 2	IQR (2; 3)
Healthcare professionals coordinated for conference	267	100
Nurses	70	26.2
Physicians	197	73.8
Reduction in blood sample collection	41	29.1
REASONS WHY COORDINATION WAS NOT POSSIBLE⁴
Appointments not coordinated for intervention	1718	84.8
Due to the other appointment(s)	295	14.6
Relevant healthcare professional not present	280	13.8
No available time slots/timely coordination not made	199	9.8
Appointments already coordinated	157	7.8
Work schedule not ready	135	6.7
Treatment/clinical cause	131	6.5
Other reasons, e.g. cancellation	38	1.9
TRACKING FIDELITY
Multidisciplinary outpatient pathway [Intension to treat]	131	100
Full intervention with conference held	109	83.2
Notification sent to general practice after conference	104	95.4
Declined by patient	4	3.1
Cancelation by patient/no show	6	4.6
Pathway without conference being held	12	9.2
Dictation summary for receiving specialty	88
Ready	29	33.0
Not ready	59	67.1
Patient wait time between specialties, minutes	median = 35	IQR (19; 54)

[i] ¹ Appointments may reappear on the care managers’ lists due to new combination possibilities in cross-sections.

² All possible appointments made by the coordinators, including times when the intervention was only partially received.

³ Within same specialty, patients may have had a nurse’s appointment followed by a doctor’s appointment on the same day.

⁴ Out of the 2367 appointments, documented by the care managers.

Table 3

Characteristics of healthcare professionals and patients interviewed on their experience with the Multidisciplinary Outpatient Pathway.

HEALTHCARE PROFESSIONALS¹	N = 10
Median age, years	56	(IQR, 47:58)
Gender, female	5
Specialties
Cardiology	2
Endocrinology	3
Pulmonology	2
Nephology	1
Rheumatology	2
Nurses	3
Years since nursing authorisation (median)	34	(IQR, 17:34)
Physicians	7
Years since specialty authorisation (median)	12	(IQR, 7:14)
PATIENTS²	N = 10
Median age, years	75	(IQR, 71:82)
Gender, female	2
Educational level³
>10 years	3
10–15 years	5
<15 years	2
Civil status
Living with partner	6
Living alone	4
Speciality trajectories in outpatient clinics
Cardiology	5
Endocrinology	4
Pulmonology	6
Nephology	4
Rheumatology	4

[i] ¹ Data available at autregweb.sst.dk.

² Data collected through the interviews.

³ According to UNESCO’s International Standard Classification of Education (ISCED) 2011.

IQR = interquartile range.

Improving Health Care for Patients with Multimorbidity: A Mixed-Methods Study to Explore the Feasibility and Process of Aligning Scheduled Outpatient Appointments through Collaboration between Medical Specialties

Figures & Tables

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Figure 2

Table 1

Table 2

Table 3

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