Organisation of services for people with cardiovascular disorders in primary care: transfer to primary care or to specialist-generalist multidisciplinary teams?
TL;DR: Current research supports the idea of the management of certain chronic health conditions in primary care based on the integration of GPs and specialists into multidisciplinary teams, based on availability of reliable evidence about cost-effectiveness, health care outcomes, patient preference and incentives for GPs.
Abstract: An ageing population and high levels of multimorbidity increase rates of GP and specialist consultations. Constraints on health care funding are leading to additional pressure for the adoption of safe and cost-effective alternatives to specialist care, in some cases by shifting services to primary care. In this paper we argue, having searched for evidence on approaches to shifting care for some people with cardiovascular problems from secondary to primary care, that a collaborative, multidisciplinary approach is required to achieve high quality outcomes from cardiovascular care in the primary care setting. Simply transferring patients from specialist care to management by primary care teams is likely to lead to worse outcomes than services that involve both specialists and primary care teams together, in planned and effectively managed systems of care. The care of patients with certain chronic conditions in the community, if appropriately organised, can achieve the same health outcomes as ambulatory care by hospital specialists. However, shared care by GPs and specialists for patients with chronic heart failure after discharge from hospital can deliver better patient survival. The existing models of shared care include specialists working in an ambulatory care setting (in Central and Eastern Europe) or in hospital based outreach clinics, and cardiology care organised by GPs in the UK and Australia, which have demonstrated reductions in referral rates. Current research supports the idea of the management of certain chronic health conditions in primary care based on the integration of GPs and specialists into multidisciplinary teams, based on availability of reliable evidence about cost-effectiveness, health care outcomes, patient preference and incentives for GPs. Evaluation of such schemes is mandatory, however, to ensure that the expected benefits do materialise.
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07 May 1992
TL;DR: This chapter discusses the elements of primary care in the United States, as well as issues in primary care, including organization, financing, and access to services.
Abstract: Section I: Primary Care: Concept and Goals. 1: What is primary care?. 2: A basis for evaluating primary care. Section II: Elements of Primary Care. 3: First contact care and gatekeepers. 4: Longitudinality and managed care. 5: Comprehensiveness and benefit packages. 6: Coordination and the processes of referral. Section III: Primary Care in the United States. 7: Characteristics of practice and practitioners. 8: Organization, financing, and access to services. Section IV: Issues in Primary Care. 9: What type of physicians should provide primary care. 10: Medical records and information systems in primary care. 11: Physician-patient interactionsin primary care. 12: Quality assessment and quality improvement. 13: Community oriented primary care. Section V: Primary Care Systems. 14: Evaluation of primary care programs. 15: Cross-national comparisons of primary care. 16: A research agenda. 17: A policy agenda and epilogue
459 citations
TL;DR: Dr Starfield, in this well-written and easily readable book, objectively reviews the concept of primary care in its entirety and constructs the argument for primary care starting with a historical review.
Abstract: Primary Care: Concept, Evaluation, and Policy is a comprehensive treatise that should be obligatory reading for all physicians and for legislators planning the future of health care in the United States. Dr Starfield, in this well-written and easily readable book, objectively reviews the concept of primary care in its entirety. She constructs the argument for primary care starting with a historical review. Within the book's first chapter, the need for restructuring from a primary medical to a primary health care model is introduced. Such a change requires new focus (eg, from illness to health), new content (eg, from treatment to health promotion), new organization (eg, from specialists to generalists), and new responsibility (eg, from professional dominance to community participation). To evaluate the rationale and the success of such a change, Dr Starfield reviews the 1978 Institute of Medicine approach to assessing the success of a health care system, noting accessibility,
406 citations
TL;DR: A synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making is provided to provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities.
Abstract: Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person-specific factors (including social disadvantage and age), which represent important considerations for health service planning. Important priorities for research include economic evaluations of interventions, services, or health system approaches that can remediate the burden of multimorbidity in safe and cost-effective ways.
280 citations
05 Jul 2016
TL;DR: In this paper, the authors provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making, and highlight the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits.
Abstract: Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person-specific factors (including social disadvantage and age), which represent important considerations for health service planning. Important priorities for research include economic evaluations of interventions, services, or health system approaches that can remediate the burden of multimorbidity in safe and cost-effective ways.
Keywords: chronic disease, comorbidity, economic, complexity, cost-effectiveness, burden
153 citations
TL;DR: The examples of integrated working provide insights into problems and solutions around interorganisational and interprofessional working that will guide those planning integration in the future.
Abstract: Many national policies propose integration between primary and specialist care to improve the care of people with long-term conditions There is an increasing need to understand how to practically implement such service redesign This paper reviews the literature on the barriers to, and facilitators of, integrating primary and specialist healthcare for people with long-term conditions in the UK, with the aim of informing the development and implementation of similar initiatives in integration MEDLINE and CINAHL databases were searched and 14 articles discussing factors hindering or enabling integration were identified The factors were extracted and synthesised and key lessons were tabulated Successful integration of care requires synchronised changes on different levels, a well-resourced team, a well-defined and evidence-based service, agreed and articulated new roles and responsibilities, and a willingness among healthcare professionals to co-work and co-learn Barriers to successful implementation of integrated care include a lack of commitment across organisations, limited resources, poorly functioning information technology (IT), poor coordination of finances and care pathways, conflicting objectives, and conflict within teams The examples of integrated working provide insights into problems and solutions around interorganisational and interprofessional working that will guide those planning integration in the future
30 citations
References
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TL;DR: In this article, Anderson et al. proposed a new FAHA Chair, Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect, Alice K. Jacobs et al., this article and Biykem Bozkurt.
11,386 citations
TL;DR: The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.
Abstract: Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.
4,011 citations
"Organisation of services for people..." refers background in this paper
...During the last decade a shift of some services from secondary to primary care has tended to occur, the rationale being to make better use of health care resources [17]....
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TL;DR: The medical profession should play a central role in evaluating the evidence related to drugs, according to a report by the World Health Organization and the European Medicines Agency.
Abstract: The medical profession should play a central role in evaluating the evidence related to drugs, …
2,859 citations
TL;DR: The challenge is to organize these components into an integrated system of chronic illness care, which can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care.
Abstract: Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
2,805 citations
"Organisation of services for people..." refers background in this paper
...The existing evidence about chronic disease management in community setting A well-known example of an approach to the management of chronic health conditions outside the specialist setting is Wagner's Chronic Care module (CCM) [26], which has been applied to, among other conditions, congestive heart failure, asthma and diabetes....
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...A well-known example of an approach to the management of chronic health conditions outside the specialist setting is Wagner's Chronic Care module (CCM) [26], which has been applied to, among other conditions, congestive heart failure, asthma and diabetes....
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...Developed more than a decade ago, the CCM is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world....
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...The accumulated evidence of the CCM’s effectiveness in articles published since 2000 appears to support the CCM as an integrated framework to guide practice redesign [27]....
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...Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes....
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01 Jan 2008
TL;DR: This is the third edition of European cardiovascular disease statistics, which was the first publication to bring together all the available sources of information about the burden of CVD in Europe, including data on death and illness, treatment, the prevalence of behavioural risk factors for CVD, andThe prevalence of medical conditions associated with CVD.
Abstract: This is the third edition of European cardiovascular disease statistics. The first edition was published in 2000 when the European Union (EU) consisted of 15 Member States. After enlargement in 2004 and then again in 2007, there are now 27 Member States. Much has changed in the last seven years, but cardiovascular disease (CVD) remains the main cause of death in the EU. The European cardiovascular disease statistics was the first publication to bring together all the available sources of information about the burden of CVD in Europe, including data on death and illness, treatment, the prevalence of behavioural risk factors for CVD (smoking, diet, physical inactivity and alcohol consumption), and the prevalence of medical conditions associated with CVD (raised cholesterol, raised blood pressure, overweight and obesity, and diabetes). It has become an indispensable resource for anybody working on reducing the burden of CVD in Europe or in public health generally.
1,731 citations
"Organisation of services for people..." refers background in this paper
...In economically developed countries, cardiovascular disorders account for substantial proportions of health care expenditure [4-6]....
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