August, 2016 - SUPPORT Summary of a systematic review | print this article |

Does interactive communication between primary care physicians and specialists improve patient outcomes?

Many health systems fail to facilitate the seamless movement and management of patients between different providers and different levels of care. Poor coordination and continuity of care can result in suboptimal patient outcomes and the inefficient utilisation of scarce healthcare resources. Interactive communication holds promise as a method to improve coordination between primary and specialty care. Interactive communication refers to planned, timely, two-way exchanges of pertinent clinical information directly between primary care and specialist physicians. Such communication may occur, for example, through face-to-face exchanges, videoconferencing, telephone, or contact by email.

 

Key messages

  • Interactive communication between primary care physicians and specialists probably leads to substantial improvements in patient outcomes.
  • Although the population samples in the included studies were patients with diabetes and psychiatric conditions in high-income countries, the consistency of effects suggests the potential of interactive communication to improve the effectiveness of primary care/specialist collaboration across other conditions and settings.
  • When assessing the transferability of these findings to low-income country settings, the availability and accessibility of specialist care in these settings should be considered as well as the technology required for interactive communication.

Background

Chronic communicable and non-communicable diseases are the leading causes of morbidity and mortality, and a major reason for the utilisation of health services in many low-income countries. The treatment of these diseases requires multiple interactions with healthcare services, often involving numerous primary care physicians and specialists over the lifetime of those affected. Proper coordination between primary and specialty care is therefore important.



About the systematic review underlying this summary

Review objectives: To assess the effects of interactive communication between collaborating primary care physicians and key specialists on outcomes for patients receiving ambulatory care.

To assess the effects of interactive communication between collaborating primary
care physicians and key specialists on outcomes for patients receiving ambulatory care
Type of What the review authors searched for What the review authors found

Study designs & interventions

Intervention studies with concurrent comparison groups (randomised and non-randomised trials controlled before-after studies) and whitout concurrent comparison groups (time-series analyses) as well as uncontrolled before-after designs.

11 randomised trials (6 cluster and 5 patient level), 1 non-randomised trial, 3 controlled before-after studies, an 8 uncontrolled before-after studies.

Participants

Primary care physicians and specialists who work collaboratively as individuals or within clinical teams in psychiatry, endocrinology, and oncology.

18 studies of primary care collaborations with mental health services and 5 with primary care collaboartions with endocrinology (all of which addressed diabetes). No studies of primary care collaborations with oncology were identified.

Settings

Outpatient and community primary care in countries where the main attributes of the healthcare system were broadly known and generalisable to the context of the USA (for example, countries in Western Europe, or Australia and Canada).

Integrated healthcare systems such as the US Veterans Health Administration or the United Kingdom’s National Health Service (12 studies), and other non-integrated healthcare systems (11).

Outcomes

Patient, process, and economic outcomes.

Patient outcome data e.g. depression outcomes and improvement in HbA1c haemoglobin test results (23 estudies).

Date of most recent search: June 2008.

LimitationsA well-conducted systematic review with only minor limitations.

Foy R, Hempel S, Rubenstein L, et al. Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists.

Ann Intern Med 2010; 152:247-58.

Summary of findings

The review identified 23 studies. Eleven of these were randomised trials and seven were non-randomised studies of collaboration between primary care physicians and psychiatrists. Twelve of these 18 studies examined depression. The remaining studies examined other psychiatric conditions. Five nonrandomised studies included collaboration between primary care physicians and endocrinologists. The median duration of follow-up of all 23 studies was 9.5 months.

The interactive communication methods used included initial joint patient consultations, regular specialist attendance at primary care team meetings, scheduled telephone discussions, shared electronic progress notes, and telepsychiatry (psychiatric assessment and care through telecommunication technology, usually videoconferencing or email) with primary care physicians.

The 23 studies showed that:

  • Interactive communication between primary care physicians and specialists probably leads to improvement in patient outcomes. The certainty of this evidence is moderate.

Interactive communication between primary care physicians and specialists

People:  Primary care physicians and psychiatrists or endocrinologists.
Settings
:  Outpatient and community care in the USA, Canada, Australia, and western European countries.
Intervention
: Interactive communication through face-to-face meetings (9 studies), letters written on paper (8), telephone discussions (7), videoconferencing (3), electronic records or letters (2 studies), and combined methods of communication (14).
Comparison
: No intervention

Outcomes

Impact

Certainty of the evidence
(GRADE)
Comments

Patient outcomes

On average, interactive communication between primary care physicians and specialists probably improves patient outcomes (SMD –0.48, 95% CI -0.67 to -0.30*).

Moderate

An SMD of - 0.48 suggests a moderate effect. Several sensitivity analyses were conducted: the findings were consistent across different settings and across different study designs.

SMD: standard mean difference; CI: confidence interval; GRADE: GRADE Working Group grades of evidence (see above and last page)
*The post-intervention risk difference is adjusted for pre-intervention differences between the comparison groups.

Relevance of the review for low-income countries

Findings Interpretation*

APPLICABILITY

The studies included in the review were conducted in high-income countries. The studies, whose designs varied widely, consistently found that interactive communication between primary care and specialist mental and endocrinology services improves patient outcomes.
  • The consistency of effects across different primary care-specialty collaborations, healthcare conditions, and study designs suggests the potential of interactive communication to improve the effect of collaboration across other specialties, conditions, and settings.
  • However, when assessing the transferability of these findings to low-income country settings, one needs to consider the organisation of the health system as well as the availability and accessibility of specialist care in such settings.
  • The limited availability of specialists is an important consideration when providing healthcare in low-income countries. If specialists are already overburdnened, the introduction of time-consuming interventions may not be feasible or may compromise other aspects of specialist care.

EQUITY

There was no information in the included studies regarding the differential effects of the interventions on resource-disadvantaged populations.

  • There is a scarcity of specialists serving disadvantaged populations in most low-income countries. Collaboration between primary care and specialists therefore could potentially reduce inequalities in access to specialist care in under-served communities.
  • However, some communication interventions may not be appropriate for low-income health systems (e.g. videoconferencing, the use of electronic records) Collaborative programmes between primary and specialist care providers which do not consider local realities and limitations may exacerbate health inequities or fail to address them adequately.

ECONOMIC CONSIDERATIONS

The review did not report the cost effectiveness of interactive communication between primary care physicians and specialists.

  • The costs and cost-effectiveness of interactive communication are uncertain. Because costs, particularly for human resources, vary, consideration should be given to undertaking costing studies in settings where interactive communication strategies are being considered or implemented.

MONITORING & EVALUATION

No evidence from low-income countries was reported in this review.

  • In low-income countries, interactive communication and other forms of collaboration between primary care and specialist services should be implemented within the context of rigorous evaluation studies before they are scaled up. A rigorous assessment of their costs and impacts should also be undertaken.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods

Additional information

Related literature

  1. Smith SM, Allwright S, O'Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004910.
  2. Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD000072.
  3. Hedrick SC, Chaney EF, Felker B, et al. Effectiveness of collaborative care depression treatment in Veterans’ Affairs primary care. J Gen Intern Med 2003; 18:9-16.
  4. Katon WJ, Von Korff M, Lin EH, et al. The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry 2004 ;61:1042-9.
  5. van der Feltz-Cornelis CM, van Oppen P, Adèr HJ, van Dyck R. Randomised controlled trial of a collaborative care model with psychiatric consultation for persistent medically unexplained symptoms in general practice. Psychother Psychosom 2006 ;75:282-9.
  6. Abrahamian H, Schueller A, Mauler H, et al. Transfer of knowledge from the specialist to the generalist by videoconferencing: effect on diabetes care. J Telemed Telecare. 2002; 8:350-5.
  7. Maislos M, Weisman D, Sherf M. Western Negev Mobile Diabetes Care Program: a model for interdisciplinary diabetes care in a semi-rural setting. Acta Diabetol. 2002;39:49-53.
  8. King EB, Gregory RP, Flannery ME. Feasibility test of a shared care network for children with type 1 diabetes mellitus. Diabetes Educ. 2006; 32:723-33.
  9. Post PN, Wittenberg J, Burgers JS. Do specialized centers and specialists produce better outcomes for patients with chronic diseases than primary care generalists? A systematic review. Int J Qual Health Care 2009;21:387-96.

 

This summary was prepared by

Charles Shey Wiysonge, Centre for Evidence-based Health Care, Stellenbosch University, & Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa.

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

Acknowledgements

This summary has been peer reviewed by: Cristian Herrera, Robbie Foy and Hanna Bergman.

This review should be cited as

Foy R, Hempel S, Rubenstein L, et al. Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists. Ann Intern Med 2010; 152:247-58.

The summary should be cited as

Wiysonge CS. Does interactive communication between primary care physicians and specialists improve patient outcomes? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org

Keywords

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, communication between physicians, collaboration between physicians, coordination of care.



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