Shared Care Group Research Articles

Models of shared care for the management of psychotic disorder after first diagnosis in Ontario.

To describe the provision of care for young people following first diagnosis of psychotic disorder. Retrospective cohort study using health administrative data. Ontario. People aged 14 to 35 years with a first diagnosis of nonaffective psychotic disorder in Ontario between 2005 and 2015 (N=39,449). Models of care, defined by psychosis-related service contacts with primary care physicians and psychiatrists during the 2 years after first diagnosis of psychotic disorder. During the 2-year follow-up period, 29% of the cohort received only primary care, 30% received only psychiatric care, and 32% received both primary and psychiatric care (shared care). Among the shared care group, 72% received care predominantly from psychiatrists, 20% received care predominantly from primary care physicians, and 9% received approximately equal care from psychiatry and primary care. Variation in patient and physician characteristics was observed across the different models of care. One in 3 young people with psychotic disorder received shared care during the 2-year period after first diagnosis. The findings highlight opportunities for increasing collaboration between primary care physicians and psychiatrists to enhance the quality of care for those with early psychosis.

The impact of physician subspeciality on the quality of diabetes care for people living with HIV

Management of comorbidities of people living with HIV (PLHIV) involves different care models, including providing diabetes care and HIV care by the same infectious diseases physician (IDP) ("consolidated care") or providing diabetes care by the physicians other than IDP ("shared care"). The impact of diabetes care model on PLHIV with diabetes mellitus (DM) has not been well-evaluated. A nationwide cross-sectional sample in the Taiwan National Health Insurance Research Database was used to compare the performance rates of seven guideline-recommended tests provided by the different subspecialists. Of 523 PLHIV with DM, there were 54.88% (n=287) in the consolidated care group and 45.12% (n=236) in the shared care group. More patients in the consolidated care group received the tests of lipid profile (92.33% vs. 79.24%), creatinine (Cr) (93.73% vs. 78.39%), and alanine transaminase (ALT) (91.99% vs. 75.42%), but fewer received urine protein test (35.54% vs. 51.69%) and fundoscopic examination (8.01% vs. 33.90%). The two groups did not differ in the performance rates of serum fasting glucose and HbA1c. After controlling for demographic factors and diabetic severity, the consolidated group was less likely to miss the serum tests of lipid profile (odds ratio [OR]: 0.30), Cr (OR: 0.19), and ALT (OR: 0.23), but more often missed urine protein test (OR: 1.56) and fundoscopic examination (OR: 4.97). These findings suggest the need to focus on different process indicators of diabetes cares in different care models to enhance the diabetes care for PLHIV.

Shared Care for Adults with Sickle Cell Disease: An Analysis of Care from Eight Health Systems.

Adult sickle cell disease (SCD) patients frequently transition from pediatric hematology to adult primary care. We examined healthcare utilization for adult patients with SCD with shared care between hematologists and primary care providers (PCP). We analyzed the OneFlorida Data Trust, a centralized data repository of electronic medical record (EMR) data from eight different health systems in Florida. The number of included adults with SCD was 1147. We examined frequent hospitalizations and emergency department (ED) visits by whether the patient had shared care or single specialty care alone. Most patients were seen by a PCP only (30.4%), followed by both PCP and hematologist (27.5%), neither PCP nor hematologist (23.3%), and hematologist only (18.7%). For patients with shared care versus single specialist care other than hematologist, the shared care group had a lower likelihood of frequent hospitalizations (OR 0.63; 95% CI 0.43–0.90). Similarly, when compared to care from a hematologist only, the shared care group had a lower likelihood of frequent hospitalizations (OR 0.67; 95% CI 0.47–0.95). There was no significant relationship between shared care and ED use. When patients with SCD have both a PCP and hematologist involved in their care there is a benefit in decreased hospitalizations.

Management of people with Type 2 diabetes shared between a specialized outpatient clinic and primary health care is noninferior to management in a specialized outpatient clinic: a randomized, noninferiority trial.

To evaluate whether management of people with Type 2 diabetes shared between a specialized outpatient clinic and primary health care has noninferior HbA1c outcomes compared with mono-sectorial management in a specialized outpatient clinic. A randomized controlled, noninferiority study. People with moderate hyperglycaemia, hypertension and/or incipient complications were eligible for the study. All participants had annual comprehensive check-ups at the outpatient clinic. Quarterly check-ups were conducted by general practitioners (GPs) for the shared care groupand by endocrinologists at the outpatient clinic for the control group. The primary outcome was the meandifference in HbA1c from baseline to 12 months of follow-up. The noninferiority margin for HbA1c was 4.4mmol/mol. A total of 140 people were randomized [age 65.0±0.9 years, HbA1c 52±0.8 mmol/mol (6.9±0.1%), systolic BP 135.6±1.1 mmHg; all mean±sem]. Peripheral neuropathy was present in 68% of participants and microalbuminuria in 19%; 15% had history of a previous major cardiovascular event. Among study completers (n=133), HbA1c increased by 2.3 mmol/mol (0.2%) in the shared care group and by 1.0 mmol/mol (0.1%) in the control group, with a between-group difference of 1.3 mmol/mol [90% confidence interval (CI) -1.3, 3.9] (0.1%, 90% CI -0.1, 0.4). Noninferiority was confirmed in both per protocol and intention to treat analyses. We found that our shared care programme was noninferior to specialized outpatient management in maintaining glycaemic control in this group of people with Type 2 diabetes. Shared care should be considered for the future diabetes management of Type 2 diabetes.

Sharing Post-AML Consolidation Supportive Therapy with Local Centers Reduces Patient Travel Burden without Compromising Safety and Efficacy of Care

AML (acute myeloid leukemia) is frequently treated with intensive induction and consolidation chemotherapy that often requires prolonged admissions to hospital. Our group and others demonstrated that consolidation chemotherapy for AML can be safely and effectively administered to selected patients on an ambulatory basis. However, this ambulatory care is centralized in quaternary centers, requiring some patients to travel long distances to these specialized centres. Recently, we developed a shared care model where patients receive their consolidation chemotherapy for AML at the specialized quaternary care center, but receive post-consolidation supportive care including blood checks, transfusions, and treatment for febrile neutropenia at their local hospitals. Here, we reviewed the impact of our new model of care with a focus on savings in travel time and distance.Between 2009-2013, 73 patients with AML (n=61,) or APL (n=12) received post-consolidation care after CR1 at 14 local centers in the province of Ontario. These centers were regional cancer centers staffed by oncologists and/or hematologists experienced in the management of cytopenias and febrile neutropenia. However, these centers did not provide induction or consolidation chemotherapy for AML. Patients were seen at least weekly as out-patients at these hospitals while recovering from their consolidation chemotherapy. These centers were located a median of 70 km (range: 36-190) from the quaternary centre (The Princess Margaret Cancer Centre in Toronto, Canada). The 73 patients received 137 cycles of intensive consolidation where the post-consolidation care was provided by their local centre. The local centers treated a median of 2 patients (range of 1-19 patients) during the time frame evaluated.Patients receiving shared care had a median age of 57 years (range: 21.7-78.6) and 40 (54.8%) were male. 7 (9.6%) had favourable, 42 (57.5%) had intermediate, 6 (8.2%) had poor and 18 (24.7%) had indeterminate cytogenetic profiles.Google Maps (www.google.ca/maps) was used to calculate the distance travelled and estimated travel time between the patient's home and the quaternary centre or their local centre. Use of toll roads was permitted to achieve the fastest and shortest distance. Patients in the shared care model travelled a mean distance of 99.5 km ± 57.8 (median: 87.8 range: 28.4-266 km) each way to the quaternary care centre versus 26.3 km ± 33.6 (median: 14.5 range: 0.55-211 km) each way to their local treatment centre (p <0.001 for difference in means by t-test). The estimated mean time to travel from their home to the quaternary center was 71.6 ± 38 minutes (median: 62 range: 29-170) and the estimated time to travel to their local center was 23.3 ± 21.9 minutes (median: 18 range: 2-137) (p <0.001 for difference in means by t-test). Thus, by receiving post-consolidation care locally, patients saved a mean round trip travel distance of 146.5 km ± 99.6 and 96.7 min ± 63.4 of round trip travel time per visit compared to travelling to the quaternary care centre.To assess the safety and efficacy of the shared care model, we compared the survival of the patients who received shared care to that of the other 344 patients with AML (n=297) or APL (n=47) who received consolidation chemotherapy in CR1 during the same time frame and remained at the quaternary care centre for all of their post-consolidation care. Gender, age and cytogenetic risk did not significantly differ between the shared care group and the group of patients receiving all of their care at the quaternary center (p>0.05). There was no significant difference in overall survival between the 2 groups (p value of log-rank test >0.05). 30, 60, and 90 day survival from start of consolidation chemotherapy was 98.6%, 97.2%, and 95.9% for the patients receiving shared care and 98.8%, 97.1%, and 95.3% for patients receiving all of their care at the quaternary center. Multivariate Cox proportional hazards model revealed no significant increase in hazard of death for the Shared Care patients compared to control when controlling for age, gender, AML vs. APL and cytogenetic prognosis (p value >0.05).Thus, a collaborative care delivery model utilizing partnerships with regional centres for post-consolidation care in AML reduces patient travel burden while maintaining safety and efficacy. DisclosuresNo relevant conflicts of interest to declare.

General principles of medical interconsultation for hospitalised patients

Medical interconsultation for hospitalised patients is a regular activity among internal medicine specialists. However, despite its growing impact and importance, a model that defines its characteristics, objectives and information has not been established. This study, conducted by the Shared Care and Interconsultations Group of the Spanish Society of Internal Medicine, proposes a number of general recommendations concerning the method for requesting and responding to hospital medical interconsultations, as well as a format for these interconsultations.

Principios generales de la interconsulta médica en enfermos hospitalizados

Medical interconsultation for hospitalised patients is a regular activity among internal medicine specialists. However, despite its growing impact and importance, a model that defines its characteristics, objectives and information has not been established. This study, conducted by the Shared Care and Interconsultations Group of the Spanish Society of Internal Medicine, proposes a number of general recommendations concerning the method for requesting and responding to hospital medical interconsultations, as well as a format for these interconsultations.

A randomised translational trial of lifestyle intervention using a 3-tier shared care approach on pregnancy outcomes in Chinese women with gestational diabetes mellitus but without diabetes.

BackgroundThere are no randomised controlled trials to demonstrate whether lifestyle modifications can improve pregnancy outcomes of gestational diabetes mellitus (GDM) diagnosed by the International Association of Diabetes and Pregnancy Study Group’s (IADPSG) criteria. We tested the effectiveness of lifestyle modifications implemented in a 3-tier’s shared care (SC) on pregnancy outcomes of GDM.MethodsBetween December 2010 and October 2012, we randomly assigned 700 women with IADPSG-defined GDM but without diabetes at 26.3 (interquartile range: 25.4-27.3) gestational weeks in Tianjin, China, to receive SC or usual care (UC). The SC group received individual consultations and group sessions and performed regular self-monitoring of blood glucose compared to one hospital-based education session in the UC group. The outcomes were macrosomia defined as birth weight ≥ 4.0 kg and the pregnancy-induced hypertension (PIH).ResultsWomen in the SC (n = 339) and UC (n = 361) groups delivered their infants at similar gestational weeks. Birth weight of infants in the SC group was lower than that in the UC group (3469 vs. 3371 grams, P = 0.021). The rate of macrosomia was 11.2% (38/339) in the SC group compared to 17.5% (63/361) in the UC group with relative risk (RR) of 0.64 (95% CI: 0.44-0.93). The rate of PIH was 8.0% (27/339) in the SC compared to 4.4% (16/361) in the UC with RR of 1.80 (0.99-3.28). Apgar score at 1 min < 7 was lower but preeclampsia was higher in the SC than in the UC.ConclusionsLifestyle modifications using a SC system improved pregnancy outcomes in Chinese women with GDM.Trial registrationClinicaltrials.gov; NCT01565564.Electronic supplementary materialThe online version of this article (doi:10.1186/s12967-014-0290-2) contains supplementary material, which is available to authorized users.

Shared care or nursing consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis outpatients with low disease activity—patient outcomes from a 2-year, randomised controlled trial

ObjectivesTo compare patient outcomes of three regimes of follow-up care for rheumatoid arthritis (RA) outpatients with low disease activity.MethodsRA outpatients (n=287) with Disease Activity Score (DAS28-CRP)<3.2 and Health Assessment Questionnaire<2.5...

The impact on self-efficacy of different types of follow-up care and disease status in patients with rheumatoid arthritis—A randomized trial

ObjectiveTo explore the impact from different types of outpatient care, demographic and disease related variables on self-efficacy beliefs (SE) in patients with established rheumatoid arthritis (RA) after completing an educational program. Methods287 adult RA outpatients with low disease activity and moderate physical disability from two Danish rheumatology clinics were randomized for follow-up care. 1: planned rheumatologist's consultations, 2: a shared care model without planned consultations, 3: planned nursing consultations. The participants’ SE were assessed by the Danish versions of the Rheumatoid Arthritis Self-Efficacy questionnaire (RASE) and the Arthritis Self-Efficacy Scale (ASES). Data were collected at baseline, 3 months and one-year follow up and were explored in random intercept models. ResultsFollowing an educational programme the nursing group increased or stabilized their SE during the first year compared to the medical and the shared care group. SE in the shared care group did not differ significantly from the medical group. No difference between the groups was seen in disease activity at any time. ConclusionNursing consultations provide opportunities for maintenance of the patients’ SE after patient education. Practice implicationsImplementation of nursing consultations as part of follow-up care in patients with stable RA is recommended.

A shared care system of hospital follow up reduced pain and use of healthcare resources and increased satisfaction in patients with rheumatoid arthritis

Hewlett S, Mitchell K, Haynes J , et al. Patient-initiated hospital follow-up for rheumatoid arthritis. Rheumatology2000 Sep; 39 : 990 –7 [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] QUESTION: Is a patient and general...

Can shared care deliver better outcomes for patients undergoing total hip replacement?

To assess whether shared care for patients undergoing total hip replacement delivers better outcomes compared to care as usual. Prospective, observational cohort study. Two regions in The Netherlands where different organisational health care models have been implemented: a shared care setting (experimental group) and a care as usual setting (control group). One hundred and fifteen patients undergoing total hip replacement: 56 in the experimental group and 59 in the control group. Functional health status according to the sickness impact profile, hip function, patient satisfaction and use of health care services. Two weeks before hip replacement both groups were comparable concerning patient characteristics, hip function and health status. The mean improvement of the total sickness impact profile score between two weeks before hip replacement and six months after was -1.92 in the shared care group, compared to -5.11 in care as usual group, a difference in favour of the control group (p=0.02). The mean length of hospital stay was comparable in both settings: 12.8 days in the shared care group and 13.2 days in the care as usual group. After hip replacement, compared to care as usual, patients in the shared care group received more homecare, with a higher frequency, and for a longer period of time. No differences in patient satisfaction between the two groups were found. Six months after hip replacement, the health status of patients in the care as usual group, using significantly less home care, was better than the status of patients in the shared care group. The utilisation of home care after hip replacement should be critically appraised in view of the need to stimulate patients' independence.

Can midwife-managed units improve continuity of care?

This study aimed to determine whether a midwife-managed programme could improve continuity of care over that achieved by shared care (i.e. care divided between hospital doctors, midwives and GPs). A randomized controlled trial (analysis by intention to treat) was conducted at the Glasgow Royal Maternity Hospital, which compared 648 women allocated to receive midwife-managed care and 651 allocated to receive shared care. The two main study outcomes were continuity of advice and continuity of carer. Data were collected via questions included in self-report questionnaires sent to women's homes at three time periods (response rates ranged from 63.1% to 85.3%) and a case record review. Women in the midwife-managed group reported receiving more consistent advice across all care periods. For example, during antenatal care, 51.0% of women in the midwife group reported receiving consistent advice all of the time, compared with 21.2% of women in the shared-care group (difference [diff] = 29.9%; 95% confidence interval [CI]; 24.1% to 35.6%). Overall, women in the midwife-managed group saw seven fewer care providers (midwife care mean = 10.0 [standard deviation [SD] = 6.3]; shared care mean = 17.1 [SD = 6.1], diff = -7.1; 95% CI; -8.4 to -5.8). At 7 months follow-up, 4.0% of women in the midwife group reported that they had seen too many or far too many staff during their care, compared with 28.3% of women in the shared care group (diff = -24.3%; 95% CI;-30.7% to -17.8%). These results suggest that midwife-managed care programmes can improve continuity of care.

Explication of the construct of shared care and the prevention of pressure ulcers in home health care.

The purpose of this investigation was to render a more complete understanding of subjective perceptions of pressure ulcers from the perspective of family dyads, and to study the effect of these subjective experiences on preventive behaviors and pressure ulcer outcomes. A naturalistic inquiry, combined with objective measures, was used. Twenty-one dyads participated in four in-depth interviews to explore how they mentally represented and responded to the risk of pressure ulcers. Through the process of concept development, a lay representation of pressure ulcers was developed. This process produced a new concept, identified as "shared care," that explained how the dyad's interaction influenced preventive behavior. Shared care consists of three elements: communication of symptoms, decisions about how to respond to symptoms, and appraisals of reciprocity. Two contrasting patterns of care were identified: shared and directed/discrepant. In the shared care group, 10 patients were at risk for pressure ulcers but only 4 developed ulcers. In this discrepant care group, 3 patients were at risk and 2 developed pressure ulcers. Shared care was a pattern of interaction used successfully by family members to prevent pressure ulcers in patients at risk.

As good as anyone: antenatal shared care at an inner Sydney hospital.

An exploratory survey design was used to assess satisfaction with antenatal care over a two-month period of women giving birth in an inner Sydney teaching hospital. Patients received obstetric services from private obstetricians, midwives, the hospital outpatient clinic, or 'shared care' between general practitioners and the outpatient clinic or birth centre. Insurance status and demographic information were collected across all groups. Shared care patients gave reasons why they chose that model of antenatal service. Ten per cent of women in the sample received shared care. Shared care patients were equally as satisfied as those in other modes of care in all but one factor--promptness of service (in which private obstetricians received higher ratings). They also judged shared care to have the advantages of being convenient, personal, and culturally appropriate. Significantly more patients in the shared care group were born overseas and they were less likely to hold private insurance. This paper discusses the results of the current study in the context of the Australian literature, explores some issues surrounding satisfaction research, and suggests further research arising from this work.