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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

1021 — Care Coordination: In Search of the Active Ingredients of Interventions Reported in Systematic Reviews

Smith-Spangler CM, and Sundaram V, VA Palo Alto Healthcare System; Albin L, and McDonald KM, Stanford University; Owens DK, VA Palo Alto Healthcare System;

Improved coordination of care is a national priority and while many coordination interventions have been shown to be effective, the “active ingredients” of these interventions are not well understood. Our aim was to identify the “active ingredients” associated with effective care coordination interventions.

We systematically searched MEDLINE and other sources (indexed 6/2006-9/2011) for systematic reviews examining the active ingredients of care coordination interventions, assessed quality, abstracted results, and critically reviewed the evidence for each component. The search was an update of a 2007 AHRQ evidence report.

We identified 1,418 potentially relevant articles and 31 systematic reviews published since 6/2006 met our criteria for inclusion. Eleven reviews used quantitative methods (meta-regression or subgroup analysis). Reviews generally focused on one disease population and were of high quality. Consistent evidence from diverse chronic disease populations (diabetes, multiple sclerosis, stroke, depression, congestive heart failure, COPD) suggested that multidisciplinary teams that included the primary care physician and a specialized provider resulted in small improvements in patient outcomes (e.g. HgbA1c, pain, rehospitalization). Interventions that 1) improved communication within the team; 2) provided scheduled feedback to the primary care doctor; 3) recruited patients by systematic identification; or 4) enhanced continuity were more likely to be effective than interventions without these components. Interventions that relied on 1) stand alone nurse management, 2) patient education, or 3) provider education on guidelines were generally not effective. However, conclusions are limited as primary studies were subject to bias, components were poorly described, effect sizes were significantly heterogeneous, and evidence of publication bias was frequently identified. Only one review identified economic outcomes. Two reviews that examined patient characteristics found that care coordination interventions were not necessarily more effective with increased disease severity.

Multidisciplinary teams that involve the primary care doctor and specialists and change practice patterns may improve outcomes. Little is known about the impact of these interventions on total healthcare costs and whether these interventions are cost-effective, especially in less ill populations.

Future interventions should examine best strategies to enhance communication between providers and evaluate the impact of interventions on total healthcare costs.

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