SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
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
People making decisions concerning interventions to improve patient outcomes in ambulatory care.
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.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
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.
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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
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| Type of | What the review authors searched for | What the review authors found |
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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.
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11 randomised trials (6 cluster and 5 patient level), 1 non-randomised trial, 3 controlled before-after studies, an 8 uncontrolled before-after studies. |
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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. |
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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). |
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Outcomes |
Patient, process, and economic outcomes. |
Patient outcome data e.g. depression outcomes and improvement in HbA1c haemoglobin test results (23 estudies). |
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Date of most recent search: June 2008. |
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Limitations: A well-conducted systematic review with only minor limitations. |
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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.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
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:
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Interactive communication between primary care physicians and specialists |
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People: Primary care physicians and psychiatrists or endocrinologists. |
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| Outcomes |
Impact |
Certainty of the evidence (GRADE) |
Comments | |
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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*). |
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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. |
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| 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. |
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| Findings | Interpretation* |
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APPLICABILITY |
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| 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. |
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EQUITY |
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There was no information in the included studies regarding the differential effects of the interventions on resource-disadvantaged populations. |
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ECONOMIC CONSIDERATIONS |
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The review did not report the cost effectiveness of interactive communication between primary care physicians and specialists. |
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MONITORING & EVALUATION |
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No evidence from low-income countries was reported in this review. |
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*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 |
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Related literature
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.
