Effectiveness of Intensive Primary Care Interventions: A Systematic Review
- 298 Downloads
Multicomponent, interdisciplinary intensive primary care programs target complex patients with the goal of preventing hospitalizations, but programs vary, and their effectiveness is not clear. In this study, we systematically reviewed the impact of intensive primary care programs on all-cause mortality, hospitalization, and emergency department use.
We searched PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Reviews of Effects from inception to March 2017. Additional studies were identified from reference lists, hand searching, and consultation with content experts. We included systematic reviews, randomized controlled trials (RCTs), and observational studies of multicomponent, interdisciplinary intensive primary care programs targeting complex patients at high risk of hospitalization or death, with a comparison to usual primary care. Two investigators identified studies and abstracted data using a predefined protocol. Study quality was assessed using the Cochrane risk of bias tool.
A total of 18 studies (379,745 participants) were included. Three major intensive primary care program types were identified: primary care replacement (home-based; three RCTs, one observational study, N = 367,681), primary care replacement (clinic-based; three RCTs, two observational studies, N = 9561), and primary care augmentation, in which an interdisciplinary team was added to existing primary care (five RCTs, three observational studies, N = 2503). Most studies showed no impact of intensive primary care on mortality or emergency department use, and the effectiveness in reducing hospitalizations varied. There were no adverse effects reported.
Intensive primary care interventions demonstrated varying effectiveness in reducing hospitalizations, and there was limited evidence that these interventions were associated with changes in mortality. While interventions could be grouped into categories, there was still substantial overlap between intervention approaches. Further work is needed to identify program features that may be associated with improved outcomes.
KEY WORDSprimary care primary care redesign care management home care comorbidity
We would like to thank the staff of the Evidence-based Synthesis Program Coordinating Center for their assistance.
Compliance with Ethical Standards
Conflict of Interest
All authors declare that they have no conflict of interest.
- 6.Koroukian SM, Schiltz N, Warner DF, et al. Combinations of chronic conditions, functional limitations, and geriatric syndromes that predict health outcomes. J Gen Intern Med 2016:1–8.Google Scholar
- 10.Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions. Agency for Healthcare Research and Quality, 2006.Google Scholar
- 16.Hong CS, Siegel AL, Ferris TG. Caring for high-need, high-cost patients: what makes for a successful care management program? Issue Brief (Commonw Fund) 2014;19:1–19.Google Scholar
- 19.Hickam DH, Weiss JW, Guise J-M, et al. Outpatient case management for adults with medical illness and complex care needs. Agency for Healthcare Research and Quality Effective Health Care Program, Comparative Effectiveness Review #99, 2013.Google Scholar
- 20.Rosenthal MB, Friedberg MW, Singer SJ, Eastman D, Li Z, Schneider EC. Effect of a multipayer patient-centered medical home on health care utilization and quality: the Rhode Island chronic care sustainability initiative pilot program. JAMA Intern Med 2013;173(20):1907–1913.CrossRefPubMedGoogle Scholar
- 25.Yee T, Lechner A, Carrier E. High-Intensity Primary Care: Lessons for Physician and Patient Engagement. 2012; October 2012:1–7. http://nihcr.org/analysis/improving-care-delivery/prevention-improving-health/high-intensity-primary-care/. Accessed 21 Jul 2017.
- 26.Peterson K, Heland M, Humphrey L, Christensen V, Carson S. Evidence brief: effectiveness of intensive primary care programs. VA-ESP Project #09–199; 2013.Google Scholar
- 30.Berkman ND, Lohr KN, Ansari M, et al. Grading the strength of a body of evidence when assessing health care interventions for the effective health care program of the agency for healthcare research and quality: an update methods guide for effectiveness and comparative effectiveness reviews. 2013.Google Scholar
- 38.Melin AL. A randomized trial of multidisciplinary in-home care for frail elderly patients awaiting hospital discharge. Aging (Milan, Italy). 1995;7(3):247–250.Google Scholar
- 45.Edwards ST, Saha S, Prentice JC, Pizer SD. Preventing hospitalization with Veterans affairs home-based primary care: which individuals benefit most? J Am Geriatr Soc. 2017.Google Scholar
- 49.Veterans Health Administration, Geriatrics and Extended Care. Home based primary care technical manual. 2009:1–33.Google Scholar
- 57.Bergman H, Beland F, Lebel P, et al. Care for Canada's frail elderly population: fragmentation or integration? Can Med Assoc J 1997;157(8):1116–1121.Google Scholar
- 60.Gawande A. The hot spotters: can we lower medical costs by giving the neediest patients better care? New Yorker (New York, NY : 1925). 2011:40–51.Google Scholar
- 61.MedPAC. March 2012 Report to the Congress: Medicare Payment Policy. 2012:1–443.Google Scholar
- 62.Milstein A, Kothari PP. Are higher value care models replicable? Health Aff Blog 2009.Google Scholar
- 63.Blash L, Chapman S, Dower C. The Special care center - a joint venture to address chronic disease. http://www.iorahealth.com/wp-content/uploads/2014/07/UCSF_The_Special_Care_Center_A_Joint_Venture_to_Address_Chronic_Disease.pdf, 2010. Last accessed 21 Jul 2017.
- 67.Stange K, Glasgow R. Considering and reporting important contextual factors in research on the patient-centered medical home. Agency Healthc Res Qual. 2013.Google Scholar
- 68.Kahwati L, Jacobs S, Kane H, Lewis M, Viswanathan M, Golin CE. Using qualitative comparative analysis in a systematic review of a complex intervention. Syst Rev 2016;5(1):1.Google Scholar
- 70.Pawson R, Tilley N. Realistic Evaluation. London: SAGE; 1997.Google Scholar
- 73.Zucco LJ, Urato C, McCall N, et al. Evaluation of the Extended Medicare Care Management for High Cost Beneficiaries (CMHCB) demonstration: Massachusetts General Hospital (MGH). 2013.Google Scholar