Shared care across the interface between primary and specialty care in chronic disease management

What is the aim of this review?

We conducted this Cochrane review to find out if shared care between primary and specialty care physicians improves outcomes for patients with chronic conditions. Cochrane researchers collected and analysed studies to answer this question and found 42 studies relevant for inclusion.

Key messages

This review suggests that shared care is effective for managing depression. Shared care interventions for other conditions should be developed within research settings, so that further evidence can be considered before they are introduced routinely into health systems.

What was studied in this review?

We have defined shared care across the primary/specialty interface as joint participation of primary care physicians and specialty care physicians in planned delivery of care. This may be informed by enhanced information exchange, over and above routine discharge and referral notices. This approach has the potential to improve the management of chronic disease while leading to better outcomes than are attained by primary or specialty care alone.

What are the main results of the review?

Review authors found 42 relevant studies; 39 were randomised controlled trials. Studies were based in 12 different countries that use a range of healthcare systems. Investigators examined shared care for a range of chronic conditions, with diabetes and depression the most commonly included. Most studies examined shared care interventions that consisted of multiple elements and lasted an average of 12 months.

Study results suggest that shared care Interventions lead to improved outcomes for patients with depression. However, effects of shared care on a range of other outcomes are less certain. Shared care probably has limited or no effect on clinical outcomes, apart from modest effects on improving blood pressure management and mixed effects on patient-reported outcome measures (such as quality of life and ability to carry out daily tasks), medication prescribing and use, participation in shared care services and management of risk factors. Shared care probably would have little or no effect on hospital admissions, use of services and patient health behaviours.

How up-to-date is this review?

Review authors searched for studies that had been published up to October 2015.

Authors' conclusions: 

This review suggests that shared care improves depression outcomes and probably has mixed or limited effects on other outcomes. Methodological shortcomings, particularly inadequate length of follow-up, may account in part for these limited effects. Review findings support the growing evidence base for shared care in the management of depression, particularly stepped care models of shared care. Shared care interventions for other conditions should be developed within research settings, with account taken of the complexity of such interventions and awareness of the need to carry out longer studies to test effectiveness and sustainability over time.

Read the full abstract...
Background: 

Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than primary or specialty care alone; however, little is known about the effectiveness of shared care.

Objectives: 

To determine the effectiveness of shared care health service interventions designed to improve the management of chronic disease across the primary/specialty care interface. This is an update of a previously published review.

Secondary questions include the following:

1. Which shared care interventions or portions of shared care interventions are most effective?

2. What do the most effective systems have in common?

Search strategy: 

We searched MEDLINE, Embase and the Cochrane Library to 12 October 2015.

Selection criteria: 

One review author performed the initial abstract screen; then two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series analyses (ITS) evaluating the effectiveness of shared care interventions for people with chronic conditions in primary care and community settings. The intervention was compared with usual care in that setting.

Data collection and analysis: 

Two review authors independently extracted data from the included studies, evaluated study quality and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of results when possible and carried out a narrative synthesis of the remainder of the results. We presented the results in a 'Summary of findings' table, using a tabular format to show effect sizes for all outcome types.

Main results: 

We identified 42 studies of shared care interventions for chronic disease management (N = 18,859), 39 of which were RCTs, two CBAs and one an NRCT. Of these 42 studies, 41 examined complex multi-faceted interventions and lasted from six to 24 months. Overall, our confidence in results regarding the effectiveness of interventions ranged from moderate to high certainty. Results showed probably few or no differences in clinical outcomes overall with a tendency towards improved blood pressure management in the small number of studies on shared care for hypertension, chronic kidney disease and stroke (mean difference (MD) 3.47, 95% confidence interval (CI) 1.68 to 5.25)(based on moderate-certainty evidence). Mental health outcomes improved, particularly in response to depression treatment (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.22 to 1.62; six studies, N = 1708) and recovery from depression (RR 2.59, 95% CI 1.57 to 4.26; 10 studies, N = 4482) in studies examining the 'stepped care' design of shared care interventions (based on high-certainty evidence). Investigators noted modest effects on mean depression scores (standardised mean difference (SMD) -0.29, 95% CI -0.37 to -0.20; six studies, N = 3250). Differences in patient-reported outcome measures (PROMs), processes of care and participation and default rates in shared care services were probably limited (based on moderate-certainty evidence). Studies probably showed little or no difference in hospital admissions, service utilisation and patient health behaviours (with evidence of moderate certainty).

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