Abstract
BackgroundMany patients now present with multimorbidity and chronicity of disease. This means that multidisciplinary management in a care continuum, integrating primary care and hospital care services, is needed to ensure high quality care.AimTo evaluate cardiovascular risk management (CVRM) via linkage of health data sources, as an example of a multidisciplinary continuum within a learning healthcare system (LHS).Design & settingIn this prospective cohort study, data were linked from the Utrecht Cardiovascular Cohort (UCC) to the Julius General Practitioners' Network (JGPN) database. UCC offers structured CVRM at referral to the University Medical Centre (UMC) Utrecht. JGPN consists of electronic health record (EHR) data from referring GPs.MethodThe cardiovascular risk factors were extracted for each patient 13 months before referral (JGPN), at UCC inclusion, and during 12 months follow-up (JGPN). The following areas were assessed: registration of risk factors; detection of risk factor(s) requiring treatment at UCC; communication of risk factors and actionable suggestions from the specialist to the GP; and change of management during follow-up.ResultsIn 52% of patients, ≥1 risk factors were registered (that is, extractable from structured fields within routine care health records) before UCC. In 12%–72% of patients, risk factor(s) existed that required (change or start of) treatment at UCC inclusion. Specialist communication included the complete risk profile in 67% of letters, but lacked actionable suggestions in 86%. In 29% of patients, at least one risk factor was registered after UCC. Change in management in GP records was seen in 21%–58% of them.ConclusionEvaluation of a multidisciplinary LHS is possible via linkage of health data sources. Efforts have to be made to improve registration in primary care, as well as communication on findings and actionable suggestions for follow-up to bridge the gap in the CVRM continuum.
Highlights
Modern medical practice takes place in the context of a growing and ageing population, which means it is characterised by multimorbidity, high-complexity diseases, and a high proportion of chronic diseases.[1,2] In order to provide high quality care, multidisciplinary collaboration and communication between all different caregivers is needed to form a care continuum.[3]
Efforts have to be made to improve registration in primary care, as well as communication on findings and actionable suggestions for follow-up to bridge the gap in the cardiovascular risk management (CVRM) continuum
How this fits in Multimorbidity, high complexity, and chronicity of disease require multidisciplinary management in a care continuum
Summary
Modern medical practice takes place in the context of a growing and ageing population, which means it is characterised by multimorbidity, high-complexity diseases, and a high proportion of chronic diseases.[1,2] In order to provide high quality care, multidisciplinary collaboration and communication between all different caregivers is needed to form a care continuum.[3] Evidence for clinical practice is derived from medical research. Many patients present with multimorbidity and chronicity of disease. This means that multidisciplinary management in a care continuum, integrating primary care and hospital care services, is needed to ensure high quality care
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