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McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.)

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Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).

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4Review of Systematic Reviews of Care Coordination Interventions

4A. Background

Increasingly, aspects of care coordination are being evaluated. In this chapter we provide a summary of this evidence by synthesizing systematic reviews of care coordination interventions intended to improve the quality of care of outpatients. Our intent was to describe the broad extent of the care coordination literature regarding outpatient care coordination programs. We did not limit our review to a specific clinical area or patient population.

4B. Methodological Approach

We sought articles reporting systematic reviews of care coordination interventions to improve quality of care provided to patients. We used our working definition of care coordination presented in the previous chapter to inform our inclusion and exclusion criteria.

Inclusion and Exclusion Criteria

We searched for English language systematic reviews of care coordination interventions, irrespective of clinical condition, patient population, or specific outcomes. We considered an article to be a systematic review, if, at a minimum, the authors described conducting a systematic review, and performed a defined literature search.

We included reviews in which interventions were conducted either exclusively in an outpatient setting or were conducted across settings and included the outpatient setting (i.e., were started in an in-patient setting but continued in the outpatient setting). We also included systematic reviews where only a part of the review evaluated a care coordination intervention (typically, these were articles in which the reviews had a broader focus than care coordination but where some of the included articles met our definition of care coordination).

We excluded reviews where the only two participants were a clinician and the patient because these situations presumably have lower demands for coordination activities. We also excluded reviews that did not report evaluations of care coordination interventions and those reviews that were conducted solely in an inpatient setting.

Search Strategy

We initially searched the following databases with the help of a research librarian: MEDLINE® (through April 7, 2005), CINAHL® (through May 17, 2005), Cochrane database of systematic reviews (through June 2, 2005), American College of Physicians Journal Club (through June 2, 2005), Database of Abstracts of Reviews of Effects (through June 2, 2005), PsychInfo (through June 2, 2005), Sociological Abstracts (through June 3, 2005), and Social Services Abstracts (through June 3, 2005). We searched with terms that were either synonymous with the term “coordination” or terms which have been used in the literature to suggest care coordination, as indicated by our work on definitions of care coordination (Chapter 3) and discussions with experts and librarians, including: “disease management,” “case management,” and “patient care planning.” We restricted our search to systematic reviews using the search strategy developed by Shojania et al.206

In response to comments received by our peer reviewers, we updated our search through to September 30, 2006 for MEDLINE® and to November 15, 2006 for the remaining databases. Complete search strategies for each database are presented in Appendix A *. We performed additional data abstraction (described below) on these additional reviews, referred to as “the most recent reviews.”

Data Abstraction and Evaluation

A single investigator reviewed titles and abstracts of each article identified in our search to determine whether the article met inclusion criteria. Investigators identified those articles about which they were unsure. These articles were then reviewed and discussed by the full research team and agreement on inclusion or exclusion for full text review was reached by group consensus. Two independent investigators reviewed and abstracted all articles requiring full text review. Disagreements on extracted data were discussed and resolved by the research team by reviewing the article. Additionally, the investigators met regularly and engaged in an active dialogue about specific articles.

From each of the included reviews, we abstracted data about whether the entire focus of the review or only a partial focus was on care coordination. For those reviews where the entire focus was on care coordination, we abstracted data on the research methodology used, setting of the care coordination intervention, terms and definitions used to describe the care coordination intervention, and the reported outcomes. For those reviews that only partially focused on care coordination, we limited our data abstraction to the purpose of the review, the care coordination strategies included, and outcomes. The complete full-text abstraction form is provided in Appendix B *.

In response to comments received from our peer reviewers, we also abstracted information, from the most recent reviews, on specific components of the care coordination intervention (Chapter 3, Table 6). We sought information on components of the specific care coordination intervention (e.g., case management, disease management) as well as whether details about the care coordination components were provided by the review.

Quality Assessment of Reviews

We assessed the quality of the systematic reviews by abstracting information about specific systematic review research methodology criteria (Appendix B). These criteria have been used previously by the drug effectiveness review project of the Oregon Evidence-based Practice.207

Statistical Analysis

Given the heterogeneity of the included articles, we were limited in our ability to conduct quantitative analyses of the data. We report the results of our review as a narrative synthesis.

4C.Results

Results of Literature Search and Article Review Process

The results of our search strategy and article review process are presented in Figure 1. Our searches yielded 4,730 potentially relevant articles of which 429 articles merited full-text review. Of these, 75 systematic reviews met our eligibility criteria for data abstraction. Appendix C * provides the citations of articles excluded after the full text review, along with the reason for exclusion.

Figure 1. Search results.

Figure

Figure 1. Search results.

In the sections that follow, we present 1) the results of the 43 reviews for which care coordination was the sole focus of the systematic review, 2) narrative syntheses of systematic reviews by common care coordination strategies and common patient populations, followed by the results of the 32 systematic reviews for which care coordination was only a partial focus and, 3) components of the interventions described in the most recent systematic reviews.

Summary of Reviews With Entire Focus on Care Coordination

We identified 43 reviews that focused entirely on one or more care coordination strategy. These reviews were highly heterogeneous with respect to the care coordination interventions evaluated, their definitions, and the clinical topics evaluated (Tables 16–k).

Quality Assessment of Reviews

Table 9 presents the results of our quality assessment of the included reviews. Overall, most of the reviews were rigorously conducted. All of them reported a research question. All but three of the reviews reported the specific search terms used and time frame covered by the search; five reviews did not provide specific inclusion/exclusion criteria. The quality of the reviews regarding the data abstraction process was mixed: 18 of the 43 reviews reported title/abstract review by at least two reviewers; 23 reported data abstraction by at least two reviewers and explained how disagreements between reviewers were resolved. About three-quarters of the included reviews provided some assessment of the validity of the articles they included in their analysis, almost all provided sufficient details on each individual article, and all provided an appropriate synthesis (either narrative, quantitative or both) of their results. Seven reviews reported using a research librarian to help with their search and 19 reviews included a topic or methods expert as part of their team (Figure 2).

Table 9. Quality assessment of reviews with entire focus on care coordination.

Table 9

Quality assessment of reviews with entire focus on care coordination.

Figure 2. Quality assessment of reviews.

Figure

Figure 2. Quality assessment of reviews.

Systematic Review Characteristics

The characteristics of each systematic review are presented in Table 10. Most of the included reviews restricted their included articles to either randomized controlled trials (RCT), or other controlled trials. Nine reviews did not restrict their inclusion criteria by study design.

Table 10. Selected characteristics of reviews with entire focus on care coordination.

Table 10

Selected characteristics of reviews with entire focus on care coordination.

The clinical topics that the included reviews addressed were varied. Care coordination interventions for improving care to patients with mental health problems (13 reviews) was the most common topic studied followed by heart failure (9 reviews) and diabetes (3 reviews). Eleven reviews did not have a specific clinical area of focus but instead studied interventions that crossed diseases, such as discharge planning or interprofessional education (i.e., training individuals from different professions interactively).

Eight of the reviews focused on elderly populations while most of the remaining reviews focused on adults in the general population for the specific disease of interest. Surprisingly, given the interest in care coordination for special need children, we did not find any reviews pertinent to this topic.

Interventions in about half the reviews were conducted across multiple settings, for example, from hospital to home or community, in outpatient clinics and at home or in outpatient and specialist clinics. Five of the reviews did not provide information on the specific settings of the interventions. Few studies provided detail on other setting-related factors (e.g., public versus private, HMO versus not, etc.).

Care Coordination Strategies

The terms used to define the care coordination strategies were highly heterogeneous; 43 individual reviews reported 20 different care coordination interventions (Table 11). Most reviews reported on a single care coordination intervention, however, six reviews reported at least two types of interventions.152, 214, 217, 219, 222, 235 The most commonly used terms were multidisciplinary teams, case management, and disease management. Across reviews, there were varying definitions of the same care coordination term used (Tables 16a–k). For example, all ten reviews reporting on disease management152, 218, 223, 230 defined it differently (Tables 16a–k). Nine reviews217, 224226, 233, 235, 241, 244, 246 failed to provide a clear definition for the intervention under study; we included these reviews because the descriptions of the interventions of their included articles related to a care coordination strategy.

Table 11. Distribution of reviews with entire focus on care coordination by care coordination intervention.

Table 11

Distribution of reviews with entire focus on care coordination by care coordination intervention.

Table 16. Components described or evaluated by the systematic reviews.

Table 16

Components described or evaluated by the systematic reviews.

Our review of the evidence, provided in the sections that follow, suggests that care coordination strategies may improve health outcomes. Given the heterogeneity of the different interventions studied, it is unclear whether one particular strategy is more likely to work than others; however, interventions using multidisciplinary teams and disease management programs consistently reported improved outcomes. We provide further evidence to support this finding in our summary tables (Tables 16a–k) and in our narrative synthesis section below.

Outcomes Reported

Due to the heterogeneity of clinical topics, settings, patient populations and interventions, the systematic reviews reported a broad range of endpoints. In many cases, there was not any quantitative summary across included studies. For the 16 systematic reviews with some patient or utilization outcome synthesized, Table 12 summarizes the specific endpoints reported quantitatively for five general categories: clinical outcomes, adherence outcomes, other patient experience outcomes, and utilization outcomes. Specific quantitative results are provided in the summary tables (Tables 16a–k).

Table 12. Quantitative outcomes reported by systematic reviews.

Table 12

Quantitative outcomes reported by systematic reviews.

Costs

Background. Given the costs associated with poorly coordinated care, even intensive care coordination interventions have the potential to be cost-saving.

Results. 22 reviews reported some cost estimates or comparisons for the care coordination intervention under study (Table 13). The reported results were extremely heterogeneous. Only one review reported results from cost-effectiveness/cost-utility analysis223 that suggested disease management programs were cost-effective. Another review229 conducted a meta-analysis to evaluate the economic effectiveness of disease management programs. Krause229 reports economic effectiveness in terms of effect size which is a summary outcome measure created from the direct economic outcome measures (cost, hospitalizations, clinic visit, emergency department visit) reported in each individual study. The findings from this review suggest that disease management programs were economically effective. Nine reviews213, 215, 217219, 222, 227, 231 reported lower costs for the care coordination intervention when compared to usual care; however, none of these reviews conducted any formal cost-effectiveness analysis. Seven reviews reported mixed cost results of the intervention208, 214, 220, 226, 233, 245, 247 and five reviews reported insufficient evidence to draw any definitive conclusions about the costs of interventions.211, 212, 232, 236, 241 (Table 13).

Table 13. Reviews with entire focus on care coordination: cost results.

Table 13

Reviews with entire focus on care coordination: cost results.

Summary. We conclude that there is insufficient evidence from the included reviews to draw definitive conclusions about the costs associated with care coordination interventions.

Given the heterogeneity of the included reviews, we did a separate synthesis for selected care coordination strategies, clinical topics, vulnerable populations, and across settings. We report the results of our narrative synthesis in the following sections; the synthesis includes reviews that focused entirely on care coordination and where possible, those that focused partially on care coordination.

Narrative Syntheses of Selected Systematic Reviews by Care Coordination Strategy

We identified five care coordination strategies that were reported in more than one systematic review: use of teams (usually multidisciplinary), case management, disease management, integrated care, and interprofessional education. Thus, we were able to provide a narrative synthesis of the evidence on each of these care coordination strategies.

Systematic Reviews Evaluating Multidisciplinary Teams as a Care Coordination Strategy

Background. Multidisciplinary teams usually involve two or more providers from different specialties providing care to a group of patients. Presumably, teams consisting of health care personnel from different fields are more likely to address all the components of patient care, are more likely to share information and thereby, provide more coordinated care. Interventions that involve the use of multidisciplinary teams in managing a patient's care may be associated with better outcomes.217

Results. Among the reviews that focused entirely on care coordination, we found 15 reviews208222 that evaluated the effects of multidisciplinary teams (Table 14a, Table 14b, Table 14g, Table 14i, Table 14j); among the reviews that partially focused on care coordination, 11249259 included multidisciplinary teams as part of their interventions (Table 15).

Table 14a. Summary of reviews with entire focus on care coordination interventions: mental health.

Table 14a

Summary of reviews with entire focus on care coordination interventions: mental health.

Table 14b. Summary of reviews with entire focus on care coordination interventions: heart failure.

Table 14b

Summary of reviews with entire focus on care coordination interventions: heart failure.

Table 14g. Summary of reviews with entire focus on care coordination interventions: pain management.

Table 14g

Summary of reviews with entire focus on care coordination interventions: pain management.

Table 14i. Summary of reviews with entire focus on care coordination interventions: rheumatoid arthritis.

Table 14i

Summary of reviews with entire focus on care coordination interventions: rheumatoid arthritis.

Table 14j. Summary of reviews with entire focus on care coordination interventions: stroke.

Table 14j

Summary of reviews with entire focus on care coordination interventions: stroke.

Table 15. Summary of reviews with partial focus on care coordination interventions.

Table 15

Summary of reviews with partial focus on care coordination interventions.

Mental Health. Two systematic reviews212, 215 examined the effect of assertive community treatment for patients with severe mental disorders (Table 14a). Assertive community treatment (ACT) has been defined as an approach to providing care that is characterized by a multidisciplinary team who care exclusively for a group of patients and share responsibility for their patients; it emphasizes team work and coordination of activities. Marshall and Lockwood212 included 26 articles in their review of severely mentally ill patients, and found significantly improved outcomes for patients receiving ACT when compared to standard care, or hospital-based rehabilitation. Patients receiving ACT were less likely to be admitted to a hospital [0.59 (0.41–0.85)], be unemployed [0.31 (0.17–0.57)], or become homeless [0.24 (0.08–0.65)]. They were also more likely to remain in contact with services [OR: 0.51 (95% CI: 0.37–0.70)], and more likely to be living independently [0.46 (0.25–0.86)] when compared to standard care. These findings were consistent when compared to hospital-based rehabilitation; there was insufficient data to allow comparison to case management. In their meta-analysis of 19 articles that compared ACT to usual treatment, Ziguras and Stuart215 found improved outcomes for assertive community treatment for severely mentally ill patients when compared to standard care (Table 14a). ACT had a significant positive effect on hospital days [Weighted mean r = 0.28 (95% confidence interval 0.24–0.32), p<0.001]; clients receiving ACT were likely to have more contact with mental health services [0.18 (0.12–0.23), p<0.001); lower dropout rates from mental health services [0.37 (0.27–0.46), p<0.001) and greater family satisfaction [0.46 (0.33–0.58), p<0.001). The review also found that both assertive community treatment and case management reduced hospitalization, but assertive community treatment was more effective in reducing hospitalization (p<0.001 for difference in effect sizes between the two groups).

Gunn et al.210 also studied the effect of “system interventions” to improve recovery from depression (Table 14a). Their definition specifically included multidisciplinary teams and enhanced communication. They included eight trials that reported an increase in the proportion of patients recovering from depression in favor of the intervention group (range 10% to 33%); however the included studies did not account for attrition rates ranging from 5% to 50%.

Wadhwa and Lavizzo-Mourey214 studied whether multidisciplinary teams and case management models improved care for patients with either mental or terminal illness. Neither of these interventions improved functional, clinical, or psychological outcomes; although multidisciplinary teams were effective in reducing hospitalizations among mentally ill patients (Table 14a).

Craven and Bland209 evaluated the effectiveness of collaborative care for mental health; however, their definition of collaborative care includes health care professionals from different disciplines working together (Table 14a). The authors did not conduct a quantitative analysis, but provide data on each included study. They reported the following best practices for collaborative care: collaborative relationships at either a system-level or provider level require time, supportive structures and preparation; the degree of collaboration does not appear to predict outcomes; for collaboration to be effective, it should be paired with treatment guidelines; collaboration works best when clinicians and specialists are located in the same place; systematic followup was a strong predictor of positive clinical outcomes; patient choice about treatment may be important; and collaborative care interventions established as part of a research study may be difficult to sustain once the study is complete. Based on their review, it was not possible to evaluate the effectiveness of different elements of collaborative care.

Crawford et al.252 reported their results of a review on providing continuity of care for patients with severe mental illness (Table 15). They included 60 articles identifying factors that either promoted or impeded the continuity of care among these patients; assertive community treatment and community mental health teams were among two of the care coordination strategies evaluated in some of the included articles. The authors categorized continuity of care as either longitudinal (continuity of care over a period of time, most likely characterized by the provision by a single provider) or cross-sectional (continuity of care between different services, characterized mostly by different providers or settings). Care coordination was an important component in the provision of care between primary and secondary services and between medical, social and other services. Unfortunately, most of the included articles did not define continuity of care and the articles addressing care coordination were limited to epidemiologic studies, nonrandomized trials and qualitative research. However, the review identified three meta-analyses of care coordination interventions, such as case management, assertive community treatment and community mental health teams (already included in our reviews that focused entirely on care coordination212, 213, 232), which suggested that the use of such interventions can decrease the likelihood that patients will lose contact with services.

Heart Failure. McAlister et al.217 and Holland et al.216 both examined the effect of multidisciplinary teams on the management of heart failure patients (Table 14b). The review by Holland et al.216 was an update of the McAlister review, with nearly double the included studies; therefore, there was considerable overlap of the included studies between the two reviews. McAlister et al.217 did not provide a definition of multidisciplinary teams; however, Holland et al.216 provided a clear definition. Both studies reported improvements in outcomes when interventions included multidisciplinary teams. McAlister et al.217 reported that follow-up by a specialized multidisciplinary team reduced mortality [risk ratio (RR) 0.75, (95% confidence interval (CI) 0.59–0.96)], and hospitalizations (heart failure hospitalizations: [0.74 (0.63–0.87)]; all-cause hospitalizations: [0.81 (0.71–0.92)] (Table 14b). Holland et al.216 reported similar results: multidisciplinary team interventions reduced all cause admission [RR: 0.87 (95% CI: 0.79–0.95), p=0.002], all cause mortality [0.79 (0.69–0.92), p=0.002] and heart failure admission [0.7 (0.61–0.81), p<0.001]. Holland et al.216 also conducted subgroup analysis to determine the effect of setting and intensity. Interventions with a home-based component or those with telephone follow-up were more effective than those based in the hospital or clinic; home-based interventions showed reductions in both all cause [0.8 (0.71–0.89), p<0.0001] and heart failure [0.62 (0.51–0.74), p<0.001] admissions. Intensity of the intervention [high or low] and risk of the patient (high or low) did not appear to have an impact on effectiveness. It was not possible to evaluate the effect of specific intervention components; however, almost all the included interventions had two elements in common: symptom monitoring and self-management advice; and one-to-one patient education.

Pain Management. Higginson et al.220 conducted a meta-regression and meta-analysis that included 44 articles to determine if palliative care teams improve patient outcomes and found significant improvements on patients' pain [OR 0.38 (95% confidence interval 0.23–0.64)] and other symptoms [0.51 (0.30–0.88)] (Table 14h).

Table 14h. Summary of reviews with entire focus on care coordination interventions: palliative care.

Table 14h

Summary of reviews with entire focus on care coordination interventions: palliative care.

Stroke. Langhorne et al.219 studied the effect of early supported discharge interventions among elderly stroke patients (Table 14j). They assessed whether team coordination and delivery (seven studies) or team coordination alone (two studies) had any effect on death or dependency in activities of daily living. They specifically examined the amount of effort that would be required by teams (staffing levels, case load) as well as how teams worked together (effect of weekly team meetings, an example of a coordinating process in one conceptual model on organizational theory described in Chapter 5). They found that coordination of teams through weekly team meetings were more effective in reducing the risk of death or dependency (OR: 0.70, 95% CI: 0.56–0.88, p=0.02) compared to no team coordination (Table 14j).

No Specific Clinical Focus. Lemieux-Charles and McGuire221 conducted a systematic review to study the overall effectiveness of health care teams for a general patient population (Table 14k). They reported information on 12 studies evaluating the effectiveness of team versus no team interventions; nine studies evaluating team redesign interventions; and 12 multi-site field studies. The authors presented descriptions of the included studies and provided a narrative analysis. They suggested that the diversity and type of clinical expertise involved in team decisionmaking may account for improved patient care and organizational effectiveness. Some factors likely to influence staff satisfaction and perceived team effectiveness are: collaboration, conflict resolution, participation and cohesion. They also stated, however, that the existing evidence does not provide clear direction on how to design or maintain high-functioning teams. The lack of quantitative synthesis makes it difficult to evaluate their findings.

Table 14k. Summary of reviews with entire focus on care coordination interventions: no specific clinical topic.

Table 14k

Summary of reviews with entire focus on care coordination interventions: no specific clinical topic.

Summary. Multidisciplinary teams have been shown to improve select patient outcomes in stroke, heart failure, severe mental illness, and terminal conditions. Specifically, the evidence suggests that among patients with mental illness, multidisciplinary teams can reduce hospitalizations and improve the rates with which clients remain in contact with services. Furthermore, in the clinical areas of heart failure and stroke, multidisciplinary teams can improve mortality and dependency. Hospital admissions are also reduced by this intervention for heart failure patients. For patients needing palliative care, a team approach can reduce symptoms. The evidence also suggests that multidisciplinary teams are more effective when team members deliberately coordinate their activities (e.g., schedule regular team meetings to facilitate exchange of information).219

Systematic Reviews Evaluating Disease Management as a Care Coordination Strategy

Background. In the reviews we identified, disease management has been defined in numerous ways and there does not appear to be a consensus from systematic reviewers about specific components that should be included in a disease management program. Disease management programs include the involvement of both patients and clinicians. The intent of all the disease management programs, however, is to improve the coordination of patient care, provide support to patients, and improve patient outcomes.

Results. Among the reviews that focused entirely on care coordination, we found ten reviews152, 218, 223 230 (Tables 16a–k) that evaluated the effects of disease management; we found eight reviews148, 260266 among those that focused partially on care coordination using a disease management approach (Table 15).

Mental Health. Neumeyer-Gromen et al.223 conducted a meta-analysis of disease management programs for depression (10 included articles). Disease management programs when compared with usual primary care, significantly improved depression severity [RR 0.75 (95% CI: 0.70–0.81)], adherence to treatment regimen [0.59 (0.46–0.75)] and patient [0.57 (0.37–0.87)] and provider satisfaction. They also reported on the cost-effectiveness of disease management programs which were reported in six articles that were deemed high quality by the authors. The cost utility ratios (not defined by the review) per quality adjusted life years ranged from $9,051 to $49,500 (Table 14a).

Heart Failure. We included four reviews224227 that studied the effectiveness of disease management programs on improving outcomes for patients with heart failure (Table 14b). Three of the four reviews conducted meta-analyses of the included studies; there was considerable overlap of the included studies across all four reviews. Disease management was not well-defined by any of the reviews, though two reviews225, 227 provided extensive descriptions of the disease management programs reported in each included study. The meta-analysis by Roccoforte et al.225 found that disease management programs significantly reduced mortality [OR: 0.8 (95% CI: 0.69–0.93), p=0.003], all-cause re-admission rates [0.76 (0.69–0.94), p< 0.00001] and HF-related admission rates [0.58 (0.5–0.67), p<0.00001] compared to usual care. They also conducted sensitivity analysis looking at type of care provider and duration of intervention. Type of care provider had an effect on outcomes: mortality was reduced in multidisciplinary interventions [0.58 (0.44–0.75)] but not in nurse-based only interventions [0.93 (0.77–1.11]. Length of intervention had mixed results; long term interventions (> 6 months) appeared to reduce all outcomes; however, short-term (0–3 months) and medium term (3–6 months) also reduced admission rates. Yu et al.227 categorized the disease management programs for heart failure patients into effective or ineffective on the basis of the characteristics for disease management programs recommended by the European Society of Cardiology (ESC). Effective programs (n=11) significantly decreased hospital readmissions by 29%–85% (mean 44.15 +/- SD: 14.36%); four programs significantly reduced mortality rates by 28%–78% (57.6 +/- 21.9%). They also reported that effective disease management programs improved quality of life and were cost saving. When comparing specific components of the intervention, effective disease management programs had the following: multidisciplinary teams, or care that involved both a cardiac nurse and cardiologist; provided a wider range of in-hospital care; were more likely to include home visits; and ongoing surveillance and management.

Diabetes. Knight et al.228 also studied the effectiveness of diabetes disease management programs and found a mean reduction in glycated hemoglobin of 0.5 (95% CI: 0.3–0.6) percentage points among disease management programs (Table 14c). They also reported that programs associated with the greatest decrease in glycated hemoglobin involved pharmacists counseling patients and combined physician and patient interventions. The specific components of the interventions were not reported by the review.

Table 14c. Summary of reviews with entire focus on care coordination interventions: diabetes.

Table 14c

Summary of reviews with entire focus on care coordination interventions: diabetes.

Table 14d. Summary of reviews with entire focus on care coordination interventions: asthma.

Table 14d

Summary of reviews with entire focus on care coordination interventions: asthma.

Table 14e. Summary of reviews with entire focus on care coordination interventions: cancer.

Table 14e. Summary of reviews with entire focus on care coordination interventions: cancer.

Table 14e

Summary of reviews with entire focus on care coordination interventions: cancer.

Norris et al.152 studied the effectiveness of both disease management (27 articles) and case management (15 articles) on outcomes for patients with diabetes. They reported improvements in glycemic control [median net change: -0.5% (interquartile range: -1.35% to -0.1%)] and on screening for and monitoring of lipid concentrations [15.6% (4% to 39%)], dilated eye exams [9% (3% to 20%)] and foot exams [26.5% (10.9% to 54%)] among patients who received the disease management program. These improvements were applicable to adults with diabetes in both community clinics and managed care organizations in the U.S. and Europe (Table 14c).

Multiple Clinical Focus. Krause229 examined economic outcomes of disease management programs (Table 14f). His meta-analysis included 67 studies on disease management programs for asthma, diabetes or heart failure. Overall, there was a positive effect on economic outcomes for disease management programs [effect size 0.311 (95% CI: 0.272–0.35)]. Program interventions were significantly different, with team-based interventions being the most effective: team-based [0.395 (0.32–0.47)], self-managed [0.916 (0.148–0.243)], and nurse-based [0.306 (0.253–0.359)]. Disease severity significantly affected economic outcomes of programs; interventions aimed at more severely and moderately ill patients were more effective than those aimed at patients with mixed severity [0.35 (0.306–0.396) versus 0.175 (0.142–0.208), respectively]. The effect on economic outcomes did not differ by disease type (asthma, diabetes or heart failure).

Table 14f. Summary of reviews with entire focus on care coordination interventions: multiple clinical topics.

Table 14f

Summary of reviews with entire focus on care coordination interventions: multiple clinical topics.

Rheumatoid Arthritis. Badamgarav et al.230 evaluated the effects of disease management programs on the functional status of patients with rheumatoid arthritis (11 included articles). Overall, disease management did not improve functional status in patients with rheumatoid arthritis [Effect size: 0.27; 95% CI: -0.01–+0.54)]. The authors performed a sensitivity analysis to determine the effect of intervention intensity and duration. Interventions lasting longer than 5 weeks showed significant improvements in patient functional status [0.49 (0.12–0.86)] compared with those lasting <= 5 weeks [0.13 (–0.25–0.52)]; the intensity of the intervention did not have a similar effect (Table 14i).

Among the reviews that only partially focused on care coordination, eight included disease management programs (Table 15).148, 260 266 Even though the definition of disease management as provided by the authors did not indicate a clear care coordination component, we included these reviews because the intent of all the programs was to improve the coordination of care through a disease management program. Furthermore, the descriptions provided for the interventions of the included articles within the reviews suggested a care coordination element. The reviews included heterogeneous interventions. Five of the reviews148, 260, 261, 263, 264 reported an overall positive effect of disease management programs on outcomes. One review262 reported promising results in its study of disease management programs for congestive heart failure, hypertension and hyperlipidemia-coronary artery disease. However, all of the reviews lacked a focused analysis on coordination-related activities and functions (e.g., clear definition, intensity, and structure).

Summary. Disease management programs appear to be effective in improving depression severity and adherence to treatment in patients with mental illness, glycemic control in patient with diabetes and mortality and re-admission rates in patients with heart failure. However, the heterogeneity of the definitions of disease management and the limited analysis on the specific components that may contribute to the effectiveness of disease management programs makes it difficult to interpret the findings with respect to the overall effectiveness of care coordination. Some of the reviews suggest improved outcomes based on patient targeting, multi-disciplinary teams, home visits, ongoing monitoring, pharmacist counseling on medications, and other less-well specified factors.

Systematic Reviews Evaluating Case Management as a Care Coordination Strategy

Background. Case management (also referred to as care management in some instances - particularly in the United Kingdom — without any distinction in meaning) typically involves the assignment of a single person (case manager or “key worker”, so named in one study234) who coordinates all aspects of a patient's care (e.g., providing information to multiple providers, seeing that the patient receives services in a timely manner etc.). The assumption behind case management is that having one person perform all the coordinating functions for a patient's care is likely to lead to improved coordination and possibly better outcomes.

Results. Among the reviews that focused entirely on care coordination, we found nine reviews152, 214, 215, 222, 231235 (Tables 16a–k) that evaluated the effects of case management on patient outcomes; among those reviews that only partially focused on care coordination, 12249, 250, 252, 254, 256, 257, 259, 267271 (Table 15) included case management as part of their included interventions.

Mental Health. Gorey et al.231 evaluated the effectiveness of case management in improving outcomes for mentally ill patients (24 articles). They found that case management was effective in reducing re-hospitalization (mean effect size r-index: 0.277, standard deviation: 0.235). They also analyzed characteristics of case management (e.g., case load) and found that patients receiving more intense case management (case load of less than 15 per case manager) were 30% less likely to be re-hospitalized (Table 14a).

Wadhwa and Lavizzo-Mourey214 studied whether multidisciplinary teams and case management models improve care for patients with either mental or terminal illness. Their results suggested that aggressive case management may be beneficial to patients with mental illness; however, they only included one study of case management among patients with terminal cancer which did not report any significant differences between the intervention and control group with respect to functional, clinical, or psychological outcomes (Table 14a).

Gilbody et al.269 conducted a systematic review to evaluate whether organizational and educational interventions improve management of depression in primary care (Table 15). Since they were unsuccessful in their attempt to identify active components of successful interventions, they provided examples of successful and unsuccessful strategies that improved outcomes such as treatment adherence, depression outcomes and improved uptake of therapy. Most of the effective strategies presented in the review included some elements of care coordination. These were: collaborative care, defined as programs that included shared care among different care providers; stepped collaborative care, which included enhanced collaborative management by a psychiatrist in the primary care setting; quality improvement programs that included nurse case management and integration with specialist care; and case management, which was usually done by nurses and involved some element of follow up.

Heart Failure. Windham et al.233 studied the effect of care management interventions for congestive heart failure among older patients (32 articles). The purpose of their review was to identify components of successful care management programs. They found that the key elements of an effective care management program (defined as a program in which most of the outcomes measured were significantly positive) included employing a physician and either a nurse or case manager to coordinate care; close monitoring and follow up of patients by nurses or case managers; and patient education combined with regular contact with a nurse or a physician (Table 14b).

Diabetes. Norris et al.152 studied the effectiveness of both disease management (27 articles) and case management (15 articles) on outcomes for patients with diabetes. They reported improvements in glycemic control [median net change: -0.4% (interquartile range: -0.6% to -0.16%)] and provider monitoring in patients receiving case management.

No Specific Clinical Focus. Payne et al.234 assessed the effectiveness of different methods of transferring information from the hospital to the community at the time of discharge in 31 articles (Table 14k). Presumably, good and effective information transfer forms the basis for improved care coordination. They found that using a key worker to facilitate information transfer improved the quality of the information provided, improved patient and caregiver satisfaction and increased “patient concordance” with services; however, they were unable to report sufficient evidence as to the professional background of such a worker or where this person should be located (community or hospital).

Summary. Case management as a care coordination strategy appears to improve patient outcomes for patients who have mental health problems, heart failure or diabetes. Among the included reviews, there was insufficient evidence to make a summary determination as to the training required for effective case managers (e.g., nurse, social worker, other provider), the ideal qualifications of effective case managers, and the specific duties that should be performed for case management to be effective. Close patient monitoring was identified as an important component in two reviews.

Systematic Reviews Evaluating Integrated Care as a Care Coordination Strategy

Background. Integration of patient services either across diseases or between providers may improve care coordination. In both situations, health personnel work closely together and have the opportunity to share information, which should lead to improved coordination. The reviews included here focused on integrating care programs as an approach to improving care coordination.

Results. Among reviews that focused entirely on care coordination, we identified three235237 that evaluated the effectiveness of integrated care programs (Tables 16a, 16k). Jeffery et al.235 studied the effect of integrating services for patients with mental illness and substance misuse (offering treatment to address both problems in a single location) (Table 14a). Briggs et al.236 studied integration of primary care services (bring together different types of services, for example, packaging together services around a particular set of needs such as sexually transmitted disease services integrated with provision of contraceptives and/or family planning) (Table 14k). Both reviews found a lack of evidence regarding any clear benefit or harm from integrating services.

Johri et al.237 reported a narrative synthesis of seven successful integrated care programs that provided care to the elderly (Table 14k). They did not summarize their findings but instead reported the key elements that were common across the seven programs. However, since they only reported on the successful programs and did not provide information on unsuccessful programs, it is difficult to analyze the effectiveness of integrated care programs from their review.

Summary. There is insufficient evidence to either support or refute the effectiveness of integrated care programs.

Systematic Reviews Evaluating Interprofessional Education as a Care Coordination Strategy

Background: Interprofessional education is defined as the provision of training and education to professionals from different health and social areas, who learn together interactively. The aim of interprofessional education is to improve the coordination of patient care by improving the way professionals collaborate with each other. We considered this a care coordination strategy since it is an approach to improving patient care through improved coordination among multiple providers.

Results. Among the reviews that focused entirely on care coordination, we identified three reviews238240 that evaluated the usefulness of interprofessional education. Zwarenstein et al.240 were unable to find any articles of methodological rigor that met their inclusion criteria (Table 14k). Reeves238 extended the work by Zwarenstein et al.240 by broadening the inclusion criteria to articles of all study designs. His review concluded that the evidence relating to the effectiveness of interprofessional education was “patchy” (Table 14a). Irajpour et al.239 found that the evidence was “broadly supportive” of interprofessional education, but was insufficient to determine the best way to improve pain management (Table 14g).

Summary. There is insufficient evidence to determine the effectiveness of interprofessional education in improving collaboration among professionals.

Narrative Syntheses of Systematic Reviews by Selected Clinical Topic, Population, and Setting

Systematic Reviews of Care Coordination Strategies Among Patients With Mental Health Problems

Among our included reviews that focused entirely on care coordination, we found that care coordination interventions were most often studied among patients with mental health problems (mental illness, severe mental illness, depression). These patients are more likely to require complex care and services across different areas, thereby putting them at higher risk for poorly coordinated care. Among reviews that focused entirely on care coordination, we identified 13 reviews that focused on patients with mental health problems (Table 14a); among reviews that focused only partially on care coordination, we identified 15 reviews251, 252, 254256, 258, 261, 263266, 269, 270, 272, 273 that included patients with mental health problems (Table 15). A variety of different care coordination strategies were evaluated among this population: multidisciplinary teams, assertive community treatment, case management, collaborative care, disease management, integrated care programs and interprofessional education. Most of the reviews reported improved outcomes within each strategy studied. Several reviews compared different types of intervention, and no single strategy appeared to be more effective than other strategies. Since the interventions were not always described in enough detail, we are unable to draw any firm conclusions, but it appeared that strategies that included a more intense approach and involved community outreach (e.g., assertive community treatment, community mental health teams) were associated with positive outcomes, including better contact with services, fewer suicides, and reduced hospitalizations (or days hospitalized). Given the heterogeneity of the strategies studied and the lack of evidence pointing toward the success of one strategy over another, we were limited in our ability to interpret the findings with respect to the comparative effectiveness of any particular strategy for improving outcomes among patients with mental health problems.

Systematic Reviews of Care Coordination Strategies Among Patients With Heart Failure

Among our included reviews that focused entirely on care coordination, we found nine reviews that focused on patients with heart failure or heart disease (Table 14b); among reviews that focused partially on care coordination, we identified five reviews250, 260, 262, 268, 270 that included patients with heart failure (Table 15). Multidisciplinary teams and disease management were the two main care coordination interventions evaluated in these reviews. Four reviews224227 reported reductions in either readmission rates or mortality associated with disease management programs; four reviews216218, 241 also reported the effectiveness of multidisciplinary teams in reducing readmission rates or mortality. However, there was considerable overlap of the included studies across these reviews. Holland et al.216 reported significant reductions in all-cause admission, all-cause mortality and heart failure admission in interventions with multidisciplinary teams. They also reported that interventions with a home-based component or telephone follow-up were more effective than those based in the hospital or a clinic. Intervention intensity and patient risk did not have an impact on effectiveness. Roccoforte et al.225 reported that disease management programs were also associated with reductions in mortality, and all-cause and heart failure readmission rates; additionally, mortality was significantly reduced in interventions provided by multidisciplinary teams but not in nurse-based only interventions. Length of intervention did not appear to have an impact on effectiveness. Our findings suggest that multidisciplinary teams and disease management programs are associated with improved outcomes for patients with heart failure. However, it is unclear what components of the interventions contribute toward this improvement since the findings regarding intensity of intervention were mixed and there was insufficient analysis on specific intervention components. Furthermore, most of the reviews did not provide a clear definition of the care coordination intervention. Although some specific components of multidisciplinary teams and disease management programs that were associated with positive outcomes were described in some of the reviews, further research is needed to assess relative contributions of these components for improving outcomes among patients with heart failure or heart disease.

Systematic Reviews of Care Coordination Strategies Among Patients With Diabetes

Among our included reviews that focused entirely on care coordination, we found only three reviews that included patients with diabetes (Table 14c); among our reviews that focused partially on care coordination, we identified four reviews148, 254, 271, 274 that included patients with diabetes (Table 15). One review evaluated the effectiveness of disease management and case management on diabetes outcomes and care.152 Norris et al.152 found that both disease management and case management improved glycemic control (Table 14c); disease management also improved screening and monitoring of selected outcomes associated with diabetes; one review evaluated the effectiveness of diabetes disease management programs;228 and the third review focused on identifying factors that contributed to the success or failure of shared care where care of the patient was shared by a general practitioner and a specialist.242 Given the heterogeneity of the care coordination strategies evaluated and the few studies evaluating care coordination strategies for diabetes care, we are limited in our ability to synthesize the evidence and draw any definitive conclusions about the comparative effectiveness of different coordination strategies in improving outcomes among patients with diabetes. However, disease management and case management both showed improved outcomes, including reductions in glycated hemoglobin.

The remaining clinical areas (stroke, rheumatoid arthritis, asthma, pain management, and palliative care) were each studied in a single systematic review and so were not further synthesized.

Systematic Reviews of Care Coordination Strategies Among Elderly Patients

Elderly patients are likely to have co-morbid conditions with poorly coordinated care and constitute a vulnerable population that we were interested in. Among the reviews that focused entirely on care coordination, we identified eight219, 222, 227, 233, 234, 237, 241, 246 that included articles on care coordination strategies to improve care for elderly patients (Tables 16a–k). Three studies focused on heart failure patients, and one on stroke patients. The remaining four did not have a specific clinical focus. An assortment of care coordination strategies were evaluated (e.g., multidisciplinary teams, case management, disease management, geriatric assessment and evaluation) in these reviews, and most reported improved outcomes associated with each individual strategy studied. Overall, the results indicate that the use of care coordination strategies may improve outcomes among elderly patients (particularly reduction in hospital admissions); however, the heterogeneity of the included strategies do not permit any further synthesis that would allow us to assess the effectiveness of one particular strategy over another.

Systematic Reviews of Care Coordination Strategies Across Settings

When patient care is provided across different settings (e.g., discharge from the hospital or emergency department, patients are referred by primary care physicians for specialist care), it is possible for the care to be poorly coordinated. The transition of patient care from one setting to another constitutes another area we were interested in. Among the reviews that focused entirely on care coordination, we identified 12 reviews that studied different interventions specifically aimed to improve patient care across settings. Four reviews242, 244, 245, 247 evaluated the effectiveness of interventions that linked primary care with specialist care. Greenhalgh242 evaluated the effect of shared care between general practitioners and specialists for patients with diabetes and reported the common elements of successful shared care programs (Table 14c). Mitchell et al.247 evaluated the effect of a introducing a formalized arrangement to link general practitioners with specialists which they referred to as organized cooperation (Table 14k). They reported mixed success for physical and functional health outcomes and a modest benefit of this intervention for some chronic mental health conditions. Gruen et al.245 studied the effects of regular, planned visits by a specialist practitioner from a usual location to a primary care or rural setting, a multifaceted outreach that involved increased collaboration between primary care providers and specialists. They found that this type of specialist outreach can improve measures of access (decreased cost, distance and travel time for patients), attendance to clinics, quality of care (guideline-concordant care and adherence to treatment) and health outcomes (Table 14k). Grimshaw et al.244 studied interventions to improve referrals from primary care to specialists and reported that such improvements may occur if guidelines for referrals are distributed with standard forms and involve consultants in education, or if a second opinion or enhanced services are provided before a referral (Table 14k). There was insufficient evidence to determine which intervention is effective in linking primary care with specialist care.

Three reviews235237 evaluated the effect of integrating services received by patients in different settings into one setting (Tables 16a, 16k). The evidence was insufficient to determine the effectiveness of this strategy in improving patient care.

Four reviews219, 222, 234, 246 studied different interventions aimed at improving discharge planning for patients from hospital or the emergency department to reduce future readmissions. Langhorne et al.219 reported the effectiveness of multidisciplinary teams in reducing death or dependency, for patients who had a stroke, when coordinating discharge from the hospital and providing post-discharge care and rehabilitation at home (Table 14j). McCusker246 and Richards222 both evaluated the use of comprehensive geriatric assessment and evaluation. Richards222 found limited evidence that implementation of care plans after discharge was effective. McCusker246 reported that interventions with greater integration with primary medical care were effective (Table 14k). Payne et al.234 studied current methods for transfer of patient information at discharge and found them to be inadequate (Table 14k). They also reported insufficient evidence to determine where key workers, who can facilitate information transfer, should be located or what their professional qualifications should be. There was insufficient evidence to determine the effectiveness of a specific intervention in improving discharge planning to reduce future admissions.

One review192 aimed at reducing disparities in cancer care by addressing barriers to care. The authors evaluated whether navigation programs reduce barriers. The review reports descriptions of 11 navigation programs to reduce barriers to cancer care and distinguish between the types of personnel who serve as navigators. There is limited data evaluating whether these programs address barriers; the existing literature “suggests that navigation is associated with improved rates of screening and follow-up, lower clinical stage of presentation, and higher patient satisfaction.” There is also some indication that “navigation services improve the clinic's ability to engage, track, and support patients and to develop communication and trust between clinics and disadvantaged populations.” (Table 14k)

In summary, the reviews studying transition of patient care across different settings evaluated a wide variety of interventions. The included interventions were not clearly defined in most of the reviews and only one review provided clear evidence of the effectiveness of its intervention (multidisciplinary teams for hospital discharge and post-discharge of stroke patients). The heterogeneity of the included interventions and the lack of quantitative analysis do not permit any further synthesis that would allow us to determine the effectiveness of any particular care coordination intervention to improve patient care across settings.

Summary of Reviews With Partial Focus on Care Coordination

We included 32 reviews that had a partial focus on care coordination (Table 15). All of these reviews aimed at evaluating the effectiveness of a broad set of interventions across a variety of clinical conditions (e.g., nonpharmacological approaches to improving heart failure outcomes, strategies to improve medication use). As a result of these broad inclusion criteria, some of the articles included in these reviews involved interventions with a care coordination component. The care coordination strategies included in these reviews were highly heterogeneous and included the following: multidisciplinary teams, case management, disease management, integrated care, collaborative care and shared care, among others. The effect of these different strategies on outcomes was difficult to assess since most of the reviews failed to present analysis related to individual strategies but instead presented overall results for the broad set of included interventions.

Narrative Synthesis of Recent Systematic Reviews by Coordination Component

Decisionmakers are interested in a more granular analysis of the effect of components of care coordination interventions. As described in Chapter 3, we developed a components list of essential tasks of care for a patient, associated care coordination activities, and features to support the activities. We reviewed 15 recent systematic reviews to assess if the reviews provided any information on specific components of the care coordination intervention. We mapped the information provided to the components deemed important when evaluating care coordination interventions (Table 16). Of the 15 reviews, 13 provided some detail on either the care coordination intervention or details on the individual studies included in the review; six reviews performed some analysis by selected components; four provided quantitative analysis.

When we apply this type of components list, we see that some interventions are aimed at (or incorporate delivery of) a subset of tasks and may have a few specific features to accomplish those tasks. Our ability to determine the presence or absence of each component reflects some assumptions, given the modest level of detail typically supplied for the intervention reviewed. Fairly uniformly, the systematic reviews provide little to no meaningful analysis at the component level. However, the application of a component list allows us to observe potentially important nuances. For example, one of the systematic reviews compared multidisciplinary teams to nurse-led teams, and found the former to appear more effective. We note that the tasks specified in the review were fairly limited - care planning and communication. The authors did not describe details about assessment, execution of care plan, monitoring and evaluation tasks, even though these activities may have been present. They noted that the nurse-led interventions tended to be more focused on patient education and follow-up visits or calls. Therefore the differences between the two types of interventions are more complex than simply “nurse-led” or “multidisciplinary”, and application of the list reminds us to examine each component that could affect the outcomes.

Summary. The current evidence base does not support a granular, component-level analysis from systematic reviews. Our impression from the literature reviews presenting detailed intervention descriptions of the primary studies is that they also will fall short of being able to address the question of what components of interventions are most critical for a given coordination challenge. Therefore, we anticipate that new primary research with appropriate (and likely novel) designs is necessary as a basis for later syntheses to provide definitive answers on what to do for each coordination challenge.

4D. Discussion

Our review of systematic reviews evaluating care coordination interventions suggests that many care coordination strategies have demonstrated effectiveness for selected outcomes within a particular clinical area, though the cumulative evidence across systematic reviews is less clear. Our review had the following key findings: First, care coordination interventions that have been evaluated are highly heterogeneous and tend to focus on several discrete clinical areas. Second, coordination strategies are defined differently across reviews, with no single definition for very similar strategies. Third, the evidence suggests that care coordination interventions can improve outcomes in different diseases (mortality and hospital re-admission in patients with heart failure, glycemic control in patients with diabetes, depression severity and treatment adherence in patients with mental illness, death or dependency in patients with stroke); however, there is a lack of evidence about the superiority of one particular strategy over another. Finally, there is insufficient evidence regarding the costs and cost-effectiveness of care coordination interventions. In summary, the diversity of the care coordination interventions evaluated, the heterogeneity of the definitions of the interventions, and the diversity across clinical conditions and populations limit our ability to synthesize the reviews; however, the evidence does suggest that multidisciplinary teams, case management and disease management programs are associated with improved outcomes.

4E. Limitations

This review has several limitations. First, we attempted to find all reviews that addressed some element of care coordination; however, we may have missed certain reviews that were not clearly focused on care coordination but which may have included articles that addressed care coordination as a result of a part of a broader search. Second, the included reviews were highly heterogeneous with respect to the care coordination interventions included. Many reviews failed to provide a clear definition of the care coordination intervention being studied. Additionally, a single care coordination term (e.g., disease management, assertive community treatment) was defined in different ways across different reviews, making it impossible to draw firm conclusions across reviews. Third, care coordination interventions were studied across several different clinical topics (heart failure, mental illness, diabetes, asthma, stroke, rheumatoid arthritis, pain management, palliative care) and it was unclear if interventions that were effective in one area would be effective in another area. Fourth, because reviews did not always have a clear focus on the analysis of the care coordination process or structure, it was difficult to interpret the effectiveness of care coordination in improving outcomes. Finally, we were limited by the methodology used for this chapter; our strategy of reviewing systematic reviews left us unable to review the primary findings of the articles included in the reviews. Therefore, it is possible that key pieces of information were missed since they were not provided in our included reviews.

4F. Summary Answers to Key Questions

Research Question 5: Which Care Coordination Interventions Have Been Evaluated by Systematic Reviewers and How Were They Defined?

Among our included reviews, we identified various care coordination interventions that have been evaluated. The terms used to define the care coordination strategies were highly heterogeneous. The 43 individual reviews that focused entirely on care coordination referred to 20 different care coordination interventions. The most common strategy evaluated the use of multidisciplinary teams involving two or more providers from different specialties providing care to a group of patients (15 reviews); the terms applied to this strategy included multidisciplinary teams, team coordination, assertive community treatment, collaborative care, integrated programs, and shared care. The next most common strategy evaluated was disease management (ten reviews). It was defined variably or not at all in the included reviews and there did not appear to be a consensus about the components that should be included in a disease management program; however, the intent of all the disease management programs reviewed was to improve the coordination of patient care, provide support to patients, and improve patient outcomes. Finally, nine reviews assessed the role of case management (also referred to as care management) which typically involves the assignment of a single person (case manager or “key worker”, so named in one study) who coordinates all aspects of a patient's care (e.g., providing information to multiple providers, seeing that the patient receives services in a timely manner etc.). The qualifications and exact duties of case managers were poorly described in most reviews. Other strategies evaluated were integration of care (three reviews), and interprofessional education, defined as the provision of training and education to professionals from different health and social areas, who learn together interactively (three reviews).

Research Question 6: What is the Evidence Regarding the Health Benefits of These Care Coordination Interventions as Summarized in the Systematic Review(s)? In Particular, is the Effectiveness of Care Coordination Interventions Related to the Setting in Which Care is Being Coordinated, the Component of Care Being Coordinated, or the Type of Disease or Patients for Whom Care is Being Coordinated?

Numerous care coordination interventions were evaluated across several diseases among the included systematic reviews, with different outcomes being reported within each review. Only three care coordination strategies-multidisciplinary teams, case management, and disease management-were evaluated across different clinical topics (e.g., heart failure, diabetes). Overall, the reviews reported a positive effect of these strategies on the outcomes studied (improved mortality and hospital readmission rates in patients with heart failure, improved glycemic control in patients with diabetes, improved service continuity in patients with mental illness). The remaining reviews evaluated other care coordination strategies (comprehensive, multidisciplinary program, integrated care, shared care, organized clinic) within a single clinical topic thereby limiting our ability to synthesize the evidence on the effectiveness of those care coordination strategies across clinical topics.

Interventions were conducted across different settings (home, community, outpatient clinic), with half of the reviews conducting interventions across multiple settings. One review216 reported that interventions with a home-based component or telephone follow-up were more effective than those based in the hospital or clinic; however, due to a lack of analysis of the effectiveness of the care coordination intervention by setting, there is insufficient evidence to allow for any definitive conclusions regarding the effect of setting on the effectiveness of care coordination interventions. Furthermore, there was also insufficient evidence to determine the effectiveness of any particular care coordination intervention in improving patient outcomes across care boundaries.

In our included systematic reviews, care coordination interventions were frequently evaluated among patients with mental health problems. Several different strategies were studied among this population. Most of the reviews reported improved outcomes for each strategy; however, there was insufficient evidence that one particular strategy was more effective than others in improving outcomes. Care coordination interventions among patients with heart failure were also studied extensively, with multidisciplinary teams and disease management being the main interventions. While the reviews reported improved outcomes (mortality, hospital re-admission) associated with both these interventions, there was considerable overlap of the included studies across the reviews. The remaining reviews evaluated care coordination interventions among a diverse group of clinical conditions (diabetes, asthma, heart condition, stroke, rheumatoid arthritis) thereby limiting our ability to synthesize the findings for a given intervention.

Most of the included systematic reviews evaluated care coordination interventions in adults in the general population. Eight of the reviews evaluated interventions among the elderly, a vulnerable group more likely to have poorly coordinated care. The findings from these reviews suggest that care coordination strategies may improve outcomes among elderly patients (specifically by decreasing hospital admissions); however, the heterogeneity of the included strategies do not permit any further synthesis that would allow us to assess the effectiveness of one particular strategy over another.

The intervention descriptions provided by the most recent systematic reviews were generally not adequate enough for a complete categorization of the intervention components. The current evidence does not support a granular, component-level analysis from systematic reviews.

The overall quality of the included systematic reviews was very good, with most reviews providing detailed search terms, inclusion/exclusion criteria and appropriate synthesis of their included articles.

Research Question 7: Have the Costs of Care Coordination Interventions Been Evaluated in any of These Systematic Reviews, and if so What is Known?

Costs were evaluated in approximately half of the included reviews that focused solely on care coordination; however, only one of the reviews reported findings on the cost-effectiveness/cost-benefit of the care coordination intervention. The evidence from this review suggests that comprehensive disease management programs are cost-effective for improving outcomes in patients with depression. One other review reported a summary effect size of the economic effectiveness of disease management programs indicating that disease management programs were economically effective. The remaining reviews provided some cost estimates of the interventions evaluated; however, the evidence was insufficient to allow for any definitive conclusions regarding the costs and benefits of the care coordination interventions evaluated.

Appendixes cited in this report are provided electronically at http://www​.ahrq.gov/clinic/tp/caregaptp​.htm

Footnotes

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Appendixes cited in this report are provided electronically at http://www​.ahrq.gov/clinic/tp/caregaptp​.htm

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