Family Practice Vol. 20, No. 6, 642-645
© Oxford University Press 2003, all rights reserved
Article |
The effect of an integrated care approach for heart failure on general practice
Department of General Practice and Primary Health Care and a Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
Correspondence to Dr A. Pearl, Division of General Practice and Primary Health Care, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand; E-mail: a.pearl{at}auckland.ac.nz
Received 21 January 2003; Revised 20 May 2003; Accepted 14 July 2003.
Pearl A, Wright SP, Gamble GD, Muncaster S, Walsh HJ, Sharpe N and Doughty RN. The effect of an integrated care approach for heart failure on general practice. Family Practice 2003; 20: 642–645.
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Abstract |
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Background. Recent studies have investigated specific strategies for heart failure management. None has involved collaboration between primary and secondary care. Potential gains for patients may result from collaborative strategies.
Objective. To assess the effect of an integrated management approach for patients with heart failure on general practice.
Methods. The study design was a cluster randomized controlled trial of integrated primary/ secondary care compared with usual care for heart failure patients. The study took place at Auckland Hospital, New Zealand and involved 197 patients admitted with an episode of heart failure. Patients were randomized to management group or control group (who received ‘usual’ care). Management group patients received early clinical review, education sessions, a personal diary for medications and weight, and regular clinical follow-up alternating between GP and hospital clinic. Follow-up was for 12 months.
Results. Patients visited GPs frequently (median 14 visits, range 0–40), with no statistical difference between the two groups. Heart failure was the most common reason for consulting the GP. There was no relationship between GP consultations and patients' attendance at the study clinic, or hospital admissions. Management group GPs and patients expressed a high level of satisfaction.
Conclusion. GP consultation rates were not affected by the programme. Further research will determine if general practice based programmes result in further gains.
Keywords. Congestive heart failure, general practice, integrated care.
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Introduction |
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Heart failure (HF) is a major public health problem in the Western world.1 Several randomized controlled trials have shown that specific management interventions can enhance care of patients with HF.2–5 Most HF patients are cared for by primary care physicians (GPs); therefore developing multi-disciplinary strategies that include closer liaison between primary care and specialist services may improve outcomes. This trial, the Auckland Heart Failure Management Study (AHFMS),6 aimed to determine the effectiveness of an integrated management approach involving primary and secondary care in patients with HF.
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Methods |
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Primary medical care in New Zealand is provided predominantly by GPs on a part patient fee-for-service and part government subsidy. The study methods have been described elsewhere.6 The patients were those admitted to Auckland Hospital with a diagnosis of HF. Each patient was allocated to either the management or control group using a cluster randomization (GP as the unit of randomization). At discharge, patients in the control group received usual follow-up care, which was mainly in primary care. Management group patients received early clinical review, three group education sessions, patient diary, and regular follow-up alternating between GP and HF clinic. Follow-up was for 12 months, at which time all patients were invited for review. Hospital and GP records were reviewed to determine the number and reason for GP consultations and admissions during the study. Cause of death was ascertained from death certificates. Finally, surviving patients and GPs from the management group were sent an evaluation questionnaire.
Statistical analysis
The relationship between visits to HF clinic, hospital out-patients, admissions and the GP was examined with a graphical approach and also using multivariate time domain models (time series modelling procedures (STATESPACE) of SAS.7 The hypothesis was that in the week immediately before and after a study visit the chance of a GP visit was reduced. Comparison of categorical data was made using the chi-square procedure. Independent predictors of GP consultation rates were sought: firstly, predictive models were constructed with multiple regression procedures and secondly, patients were assigned to either a high GP consultation rate group (upper tertile of GP consultation rates) or a low GP consultation group and iterative logistic regression performed. All tests were two-tailed and P < 0.05 was considered significant.
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Results |
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Overall study results
The study included 197 patients (management group n = 100, control group n = 97); only one patient was lost to follow up. The groups were well matched at baseline (Table 1). Seven patients in each group were unable to attend the clinic review at 12 months. GP records were not available for one patient in the management group and five in the control group. At 12 months, 19 management group patients and 24 control group patients had died. Results already published6 showed no significant difference between the management and control groups for the combined end-point of death or hospital re-admission. There was an effect on the prevention of subsequent re-admissions (56 in the management group versus 95 in the control group, P = 0.015).
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GP participation
There were 64 GPs in the management group and 69 in the control group. Forty management group GPs (63%) and 49 control group GPs (71%) had one patient in the study. Similarly, 23% of management GPs and 17% of control GPs had two patients, and 14% and 12% respectively, had three or four patients in the study. No GP had more than four patients in the study.
GP consultations
Patients from both groups consulted GPs frequently. There was a median of 14 (range 0–40) visits during the study with no significant difference between the two groups (P = 0.85) (Table 1). HF was the most common reason for GP consultations in both management and control groups (54% and 53%, respectively) with no significant difference between the two groups (P = 0.44).
In a multiple linear regression model (stepwise) the only significant predictor of number of GP visits was total number of medications (P = 0.05). There was no temporal relationship between GP consultations and patients' attendance at the study clinic for the management group. In the week immediately before and after a HF clinic visit patients were just as likely to present to their GP as in any other week (P = 0.86). Similarly, in both management and control groups there was no relationship between GP consultations and either hospital admissions or out-patient clinic visits (P > 0.05).
Acceptability of management programme
The response rate for the evaluation questionnaire sent to the management group was 92% (59/64) for GPs and 69% (55/80) for patients. A high level of satisfaction for the shared care arrangements was expressed by 91% (52/57) of GPs and 89% (49/55) of patients. Similarly, 88% (50/57) of GPs and 84%(67/80) of patients were happy to continue with shared care and 88% (50/57) of GPs believed that their patients benefited from the programme.
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Discussion |
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In this randomized, controlled trial the management approach had no effect on GP consultation rates, nor on the timing of GP visits in relation to the HF clinic visits, despite advice to alternate visits between GP and HF clinic. Patients with HF visited their GPs often (median 14 visits per year) with HF being the most common reason for consultation.
Patients with chronic conditions such as HF, particularly those with co-morbidities, have high GP consultation rates.8 Consultation rates in this study are similar to those observed in a recent audit of 70 patients with mild to moderate HF.9 Given that a fee-for-service system operates in NZ, the high consultation rates cannot be explained by easy access. Similarly, as most visits to the GP were patient initiated, it raises the possibilities that either the patients had unmet clinical needs or that GP consultations met patient needs other than those relating to clinical management.
Currently, GPs continue to manage most patients with HF. If management programmes do not significantly alter GP consultation rates, gains may be made in HF management by working more closely with GPs and basing interventions in primary care. This would then allow the option of involving HF patients in such programmes before hospitalization. Further trials are required to assess these alternative management approaches.
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Acknowledgments |
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The study was funded by a project grant from the National Heart Foundation of New Zealand and an unrestricted educational grant from Merck Sharp Dohme (NZ) Ltd. RND was the recipient of the NZ National Heart Foundation Bank of New Zealand Senior Fellowship. We are very grateful to Jenny Koenders, research nurse, for her assistance at the start of this study.
We wish to thank the following Auckland GPs who participated in this study: Doctors Abeysekera, Addis, Antunovich, Atlas, Bailey, Baker (Robin), Baker (Robyn), Barrett, Batt, Beetham, Beer, Beltwoski, Bond, Botica, Bowden, Boyd, Broom, Budelman, Cairney, Caldwell Cameron, Cearns, Chaffey, Chan, Cheung, Collinson, Connell, Cook, Cotton, Cotton-Barker, de Lacey, Dhana, Dublessis, Farquharson, Ford, Fowler, Fox(Jonathan), Fox(Judith), Frye, Gabriel, Gardyne, Gibson, Grieve, Gulbransen, Haydon, Heath, Hefford, Hewitt, Hill, Hillman, Hoadley, Hodder, Hopcroft, Horne, Houng-Lee, Hulley, Hurly, Isted, Jansen, Jennings, Johnson, Kara, Karetai, Kidd, King, Lam, Large, Lawson, Leggat, Lello, Levenberg, Liang, Long, Lusk, MacGibbon, MacLachlan, Madgwick, Marshall, Martley, McAllister, Mok, Ng, Nola, O'Sullivan, Parbhu, Parr, Patel, Paul, Peak, Pettit, Pohl, Raj, Ramirez, Rasalingham, Robertson, Rushmer, Russell, Ryan, Sanders, Selvakumar, Settle, Short, Skinner, So, Solomon, Soysa, Strange, Stubbs, Sullivan, Svensen, Tagg, Thomas, Tseung, Twhigg, Tye, van Roekel, Vather, Vickers, Wah, Wardrope, Washer, Waterfall, Watson, Way, Weeramuni, Wernham, Wiles, Williams (A), Williams (J), Wong, Woolford, Zink.
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References |
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1 Doughty RN, Yee T, Sharpe N, MacMahon S. Hospital admissions and deaths due to congestive heart failure in New Zealand, 1988–91. NZ Med J 1995; 108: 473–475.[Medline]
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3 Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med 1998; 158: 1067–1072.
4 Rich MW, Beckham RN, Wittenberg RN, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995; 333: 1190–1195.
5 Weinberger M, Oddone EZ, Henderson WG. For the veterans affairs cooperative study group on primary care and hospital readmission. Does increased access to primary care reduce hospital admissions? N Engl J Med 1996; 334: 1441–1447.
6 Doughty RN, Wright SP, Pearl A et al. Randomised controlled trial of integrated heart failure management: the Auckland Heart Failure Management Study. Eur Heart J 2002; 23: 139–146.
7 SAS Institute Inc. SAS/ETS User's Guide, version 5 edition. Cary NC: SAS Institute Inc., 1984.
8 Schellevis FG, Van de Lisdonk EH, Van der Velden J, Hoogbergen SH, Van Eijk JT, Van Weel C. Consultation rates and incidence of intercurrent morbidity among patients with chronic disease in general practice. Br J Gen Pract 1994; 44: 259–262.[ISI][Medline]
9 Buetow SA, Coster GD. Enabling clinical governance: a primary care audit of prescribing for heart failure in central Auckland, New Zealand. Br J Clinical Governance 2001; 6: 175–182.
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