Impact of an integral assistance model between primary care and cardiology on the management of patients with ischemic heart disease or atrial fibrillation
Abstract
Aim: To analyze the impact of implementing a program integrating cardiology and primary care in clinical practice. Methods: In the integrated care model, every cardiologist was assigned to each primary care center. Results & conclusion: The implementation of the new care model was associated with a significant reduction of 31.2% in requests of first visits. In addition, the delay to the cardiologist consultation significantly decreased by 54.5% for the first visits, and by 57.1% for the follow-up visits. The proportion of patients that achieved recommended low density lipoprotein-cholesterol goals significantly increased from 20.8 to 29.6%. The proportion of patients submitted to anticoagulant therapy significantly increased from 69.3 to 74.2%, as well as the proportion of patients taking direct oral anticoagulants (from 7.9 to 28.4%).
Cardiovascular disease still remains the leading cause of death in Spain [1]. Despite the development of new therapies and the improvement of cardiovascular risk factor control rates, mortality rates are unacceptably high [1,2]. In addition, due to the aging of the population and the better management of acute cardiovascular events, it is very likely that the prevalence of chronic cardiovascular diseases will increase in the following years [3].
The adequate management of chronic conditions involves a correct coordination between different healthcare levels. Unfortunately, integration between cardiology and primary care is currently far from optimal [4–8]. Current clinical guidelines clearly state that a multidisciplinary approach is necessary to improve cardiovascular outcomes [9–11]. In this context, the coordination between general practitioners and cardiologists is mandatory [4,12]. However, the conventional care model has many limitations, including the inadequate communication and coordination between healthcare levels, delay in first and follow-up visits to the specialist, unnecessary visits to the specialist, different specialists for the same patient, delay to cardiologic complementary tests, and so forth. In this context, a change in the healthcare model is mandatory. Different studies have reported that assuring an adequate continuity of care between both healthcare systems may improve the management of patients with chronic cardiovascular conditions [4,8].
On December 2013, a new healthcare model that integrated primary care and cardiology was implemented in the Health Assistance Area of the Hospital Moisès Broggi in Barcelona, Spain. The aim of this study was to analyze the impact of implementing this model in the management of patients with cardiovascular disease, particularly in those with chronic ischemic heart disease or AF.
Methods
The effects of the change of the organizational model from a conventional specialty care to one of integrated care were analyzed. The new model started on December 2013, and was progressively implemented in the entire Health Assistance Area of the Hospital Moisès Broggi (Sant Joan Despi and Hospitalet de Llobregat). This is a regional hospital (level 2) with a total of 360 beds. This hospital is in the south metropolitan area of Barcelona (total area of 100 square kilometers, population density of 4360 inhabitants per square kilometer). This Health Assistance Area attended 424,959 inhabitants in 2013, 422,652 in 2014, 421,743 in 2015 and 421,482 in 2016, distributed in 19 primary care centers. The activity of the cardiology department included 1650 annual discharges, 18,600 ambulatory visits and 15,500 cardiac complementary tests.
Conventional care model
Specialty care in cardiology was performed in a specialized outpatient clinic or at hospital, but not in the primary care center. A total of 19 cardiologists worked in the outpatient clinic, the hospital or both. The cardiologists attended patients in three different outpatient centers that each cover between five and nine primary care centers. As a result, patients had to cover large distances to be attended by cardiologists and general practitioners. The medical histories of patients were recorded in electronic format in both healthcare levels but without any link between them. Communication between the general practitioners and the hospital was performed by means of referral reports.
Integrated care model
In the integrated care model, every cardiologist was assigned to each primary care center. The integrated care model started in the first primary care center January 2014 and progressively was extended to the rest of the Health Assistance Area. The implementation of this model was complete in March 2015. Each cardiologist attended patients every week in the corresponding primary care center. During the visit day, the cardiologist attended an average of seven first visits (one could be an urgent first visit), 11 follow-up visits and three virtual visits (virtual visits could also be performed during the other days of the week). In addition, discussion of clinical cases, ongoing medical education activities, the development of common protocols and periodic visits of the primary care physicians to the hospital were also performed. The electronic clinical history of patients was modified in order to allow a correct coordination between both healthcare levels. As a result, specialty care in cardiology was performed in the primary care center. The remaining days, the cardiologists performed hospital tasks. Since the number of cardiologists remained stable, a reorganization of daily activities at hospital was required. The period of study was from 2013 to 2016.
This study had two end points: to determine the impact of the programs on the visits to cardiology (management end point) and to determine the proportion of patients with ischemic heart disease that achieved low-density lipoprotein (LDL) cholesterol goals and among patients with atrial fibrillation (AF), the proportion of patients submitted to anticoagulant therapy (clinical end points).
To assess the efficacy of the new care model, the number of visits (first and follow-up visits) was determined, as well as the days of delay to the cardiologist consultation. The reduction of the first and follow-up visits were considered as an objective of the integrated care model, since this was considered the consequence of a better knowledge of management of cardiac disease by general practitioners, the appropriate referral to the specialist, the implementation of common protocols, virtual or on-site visits of cardiologists, better coordination between healthcare levels, and so forth. Other objective of the integrated care model was the reduction of the delay to the first and follow-up visits, as well as the number of outpatient visits at hospital, since this facilitates the adequate attention and the early treatment of patients. In addition, the use of cardiac complementary tests (echocardiogram, exercise stress testing, Holter monitoring) was also examined.
Moreover, patients attended with chronic ischemic heart disease or atrial fibrillation (AF) was also studied. Data were collected by reviewing the medical record of patients. Among patients with ischemic heart disease, LDL cholesterol levels were determined. Adequate LDL cholesterol control was considered when LDL cholesterol was less than 70 mg/dl, as current guidelines recommend [11]. The proportion of patients with ischemic heart disease and a LDL cholesterol less than 70 mg/dl was considered as a secondary objective of the study.
Among patients with AF, the use of antithrombotic therapy was specifically analyzed (none, antiplatelets or anticoagulants). In addition, the type of oral anticoagulant was also determined (vitamin K antagonists [VKA] vs direct oral anticoagulants [DOACs]). Among patients treated with VKA, the number of INR (International Normalized Ratio) determinations was calculated. To assess patients’ INR control, the time within therapeutic range was calculated by the direct method (percent time with INR values within therapeutic range) [13]. The proportion of AF patients treated with oral anticoagulants was also considered as a secondary objective of the study.
Statistical analysis
Categorical variables were expressed as absolute numbers, percentages or rates. Quantitative variables were expressed as mean and standard deviation. Statistical analysis was performed comparing 2016 with 2013 using the χ2 test or the Fisher test to compare categorical variables and Student t-test or Mann–Whitney U test to compare continuous variables as required. Statistical significance was set at 95% and results were expressed as p-value < 0.05 for significant results and p-value = NS for not significant results. To quantify the association between categorical variables, a logistic regression analysis adjusted by sex and age was applied and the results were expressed as odds ratio (OR) and 95% CI. The statistical analysis was performed using the SPSS statistics package, version 17.0 (SPSS, IL, USA).
Results
Before the implementation of the new healthcare model, the number of visits to the cardiologist was 5171 (12.2 visits per 1000 inhabitants) for the first visits and 7568 (17.8 visits per 1000 inhabitants) for the follow-up visits (year 2013). After the new care model started, the number of the first visits decreased by 31.2% to 3230 (8.4 visits per 1000 inhabitants; p < 0.05; Figure 1). In addition, the number of outpatient visits at hospital decreased from 1981 in 2013 to 1497 in 2016 and from 2433 to 2349, for the first and follow-up visits, respectively (both p < 0.05). After the establishment of the new model, the average delay to the cardiologist consultation significantly decreased from 101 days in 2013 to 46 days in 2016 for the first visits (55 days reduction, 54.5% relative risk reduction compared with the previous model), and from 196 days in 2013 to 84 days in 2016 for the follow-up visits (112 days reduction, 57.1% relative risk reduction; Figure 2).
Figure 1. Prevalence of visits to the cardiologist per 1000 inhabitants.
p-value between 2016 and 2013.
Figure 2. Days of delay until the cardiologist consultation.
First visits: p-value between 2016 and 2013 < 0.05.
Follow-up visits: p-value between 2016 and 2013 < 0.05.
The requests for cardiac complementary tests are presented in Table 1. Overall, whereas the requests for complementary tests performed by general practitioners significantly increased, the requests performed by cardiologists significantly decreased during the follow-up. In addition, the ordinary and the urgent delays for performing the echocardiogram and the exercise stress testing were significantly reduced between 2014 and 2016 (data were not available for 2013).
| Requests for cardiac complementary tests | Conventional care model | Transition to integrated model | Integrated care model | p-value | |
|---|---|---|---|---|---|
| 2013 | 2014 | 2015 | 2016 | ||
| Echocardiogram (number per 1000 inhabitants) | |||||
| Primary care + cardiology | 9209 (21.67) | 9780 (23.14) | 9805 (23.25) | 9764 (23.17) | < 0.05† |
| Cardiology | 5555 (13.07) | 5706 (13.50) | 5509 (13.06) | 4835 (11.93) | < 0.05† |
| Primary care | 3654 (8.60) | 4074 (9.64) | 4296 (10.19) | 4734 (11.23) | < 0.05† |
| Ordinary delay (mean of days) | – | 78.29 | 76.78 | 29.67 | < 0.05‡ |
| Urgent delay (mean of days) | – | 57.72 | 15.00 | 12.00 | < 0.05‡ |
| Holter monitoring (number per 1000 inhabitants) | |||||
| Primary care + cardiology | 2622 (6.17) | 2626 (6.21) | 2764 (6.55) | 2974 (7.06) | < 0.05† |
| Cardiology | 1852 (4.36) | 1727 (4.09) | 1711 (4.06) | 1788 (4.24) | NS† |
| Primary care | 770 (1.81) | 899 (2.13) | 1053 (2.50) | 1186 (2.81) | < 0.05† |
| Ordinary delay (mean of days) | – | 87.94 | 33.07 | 56.33 | NS‡ |
| Urgent delay (mean of days) | – | 40.67 | 30.07 | 34.44 | NS‡ |
| Exercise stress testing (number per 1,000 inhabitants) | |||||
| Primary care + cardiology | 1241 (2.92) | 1300 (3.08) | 1144 (2.71) | 1233 (2.93) | NS† |
| Cardiology | 795 (1.87) | 815 (1.93) | 519 (1.23) | 611 (1.45) | < 0.05† |
| Primary care | 770 (1.05) | 899 (1.15) | 1053 (1.48) | 1186 (1.48) | < 0.05† |
| Ordinary delay (mean of days) | – | 78.94 | 16.39 | 47.94 | < 0.05‡ |
| Urgent delay (mean of days) | – | 56.75 | 14.83 | 36.25 | < 0.05‡ |
†p-value between 2016 and 2013.
‡p-value between 2016 and 2014.
The total number of patients with ischemic heart disease significantly increased between 2013 and 2016, and from 9150 to 10,122 patients. The incidence of ischemic heart disease remained stable during this period, but the prevalence significantly increased from 221.7 to 260.8 per 10,000 inhabitants, respectively (Table 2). In patients with coronary heart disease, the proportion of patients with ≥1 determination of LDL cholesterol levels increased from 55.7% in 2013 to 62.1% in 2016 (p < 0.05). Between 2013 and 2016, mean LDL cholesterol levels significantly decreased from 92.5 mg/dl to 86.8 mg/dl and the proportion of patients that achieved recommended LDL cholesterol goals significantly increased from 20.8 to 29.6%, respectively (OR: 1.61; 95% CI: 1.47–1.75; p < 0.001; Table 2). Men achieved LDL cholesterol targets more frequently than women (28.5 vs 19.5%; OR: 1.65; 95% CI: 1.5–1.87; p < 0.001). From 2013 to 2016, LDL cholesterol goals increased from 17.1 to 21.4% in women (OR: 1.32; 95% CI: 1.12–1.57; p < 0.001) and from 22.5 to 33.4% in men (OR: 1.73; 95% CI: 1.56–1.91; p < 0.001). After adjusting by age and sex, the integrated care model increased the probability of achieving the LDL cholesterol targets by 31% at the end of the follow-up (p < 0.001).
| Variable | Conventional care model | Transition to integrated model | Integrated care model | p-value† | |
|---|---|---|---|---|---|
| 2013 | 2014 | 2015 | 2016 | ||
| Number of patients with IHD | 9150 | 9281 | 9548 | 10,122 | |
| New Cases of IHD | 669 | 614 | 653 | 617 | |
| Prevalence of IHD per 10,000 inhabitants | 221.7 | 226.4 | 233.2 | 260.8 | <0.05 |
| Incidence of IHD per 10,000 inhabitants | 16.3 | 14.7 | 16.1 | 15.1 | NS |
| Proportion of patients with ≥1 determination of LDL cholesterol levels (%) | 55.7 | 57.5 | 61.4 | 62.1 | <0.05 |
| Mean LDL cholesterol (mg/dl) | 92.5 | 89.2 | 89.6 | 86.8 | <0.05 |
| Proportion of patients with LDL cholesterol <100 mg/dl (%) | 65.5 | 69.6 | 69.3 | 71.9 | <0.05 |
| Proportion of patients with LDL cholesterol <70 mg/dl (%) | 21.1 | 24.7 | 25.3 | 29.5 | <0.001 |
†p-value between 2016 and 2013.
IHD: Ischemic heart disease; LDL cholesterol: Low-density lipoprotein cholesterol; NS: Non-significant.
The prevalence of patients with AF significantly increased between 2013 and 2016 (Table 3). Regarding antithrombotic therapy, the proportion of anticoagulated patients significantly increased during this period, from 69.3% in 2013 to 74.2% in 2016 and the proportion of patients treated with antiplatelets significantly decreased from 21.9 to 13.2% during this period, leading to a 70% increase in the prescription of oral anticoagulants between 2013 and 2016 (adjusted ORoral anticoagulants vs antiplatelets 1.70; 95% CI: 1.57–1.85, regardless of age or sex). Among anticoagulated patients, the proportion of patients taking DOACs instead of VKA significantly increased from 7.9% in 2013 to 28.4% in 2016 (adjusted ORDOACs vs VKA 4.50; 95% CI: 4.01–5.05, regardless of age or sex) (Table 3).
| Variable | Conventional care model | Transition to integrated model | Integrated care model | p-value† | |
|---|---|---|---|---|---|
| 2013 | 2014 | 2015 | 2016 | ||
| Total number of patients with AF (n) | 7356 | 7738 | 7952 | 9138 | <0.05 |
| New cases of AF (n) | 993 | 1046 | 1083 | 1119 | <0.05 |
| Number of patients according to antithrombotic treatment, n (%) None Antiplatelets Anticoagulants | 651 (8.8) 1610 (21.9) 5095 (69.3) | 782 (10.1) 1343 (17.4) 5613 (72.5) | 716 (7.7) 1154 (14.5) 6082 (76.5) | 1154 (12.6) 1208 (13.2) 6776 (74.2) | <0.05 |
| Type of oral anticoagulant in anticoagulated patients n (%) VKA DOACs | 4694 (92.1) 401 (7.9) | 4767 (84.9) 846 (15.1) | 4741 (78.0) 1341 (22.0) | 4853 (71.6) 1923 (28.4) | <0.05 |
| Among patients taking VKA Anticoagulation control performed in primary care setting (%) Number of INR determinations performed in primary care setting Proportion of patients with adequate INR control (%) | 59.4 38,834 61.9 | 69.7 48,047 61.6 | 76.8 54,586 60.3 | 88.2 60,755 59.4 | <0.05 <0.05 NS |
†p-value between 2016 and 2013.
AF: Atrial fibrillation; DOAC: Direct oral anticoagulant; INR: International normalized ratio; VKA: Vitamin K antagonist.
Among patients with AF anticoagulated with VKA, although the control of anticoagulation was performed predominantly in primary care setting, this proportion significantly increased from 59.4% in 2013 to 88.2% in 2016 (adjusted ORanticoagulation control in primary care vs other specialists 5.16; 95% CI: 4.64–5.73, regardless age or sex). Similarly, the number of INR determinations performed in primary care setting significantly increased between 2013 and 2016. Thus, during this 4-year period, primary care progressively took care of anticoagulation control over other specialists (e.g., hematologist). However, the proportion of patients with adequate INR control remained stable during this period (Table 3).
Discussion
Traditionally, outpatient care of patients with cardiac disease has been based on a model of two separate levels of care. In addition, communication between these levels has been usually very scarce, mainly limited to consultation reports with incomplete information and patients had to visit different offices, usually far from where they lived [4,5,12,14–17]. As a result, new models that enhance the collaboration between different healthcare levels are mandatory to improve the management of patients with chronic conditions [4,6,18].
In our model, a cardiologist was integrated in each specific primary care center. After the implementation of the new healthcare model, the request for first visit significantly decreased by 31.5%, and the delay to the cardiologist consultation significantly decreased in 54.5% for the first visits and 57.1% for the follow-up visits. In addition, the number of outpatient visits at hospital was also reduced. Therefore, the new model favored integration between both healthcare levels and reduced unnecessary visits or delays, not only in the primary care setting but also at hospital. Previous studies have reported that integration between healthcare levels has similar effects [4,6,18,19]. The reduction in the number of visits to the cardiologist allowed a more rational reorganization of the resources in the cardiology department. Remarkably, the cost of implementing this program was low, as the total number of cardiologists was the same and only the number of assistant nurses slightly increased and implementing the computer support connection between primary care-hospital was also required.
Importantly, our study also showed that despite the requests for complementary tests performed by general practitioners significantly increased, the ordinary and the urgent delays for performing cardiac tests were significantly reduced during this period. In this study, only three cardiac tests (echocardiogram, holter monitoring and exercise stress testing) were specifically analyzed because both physicians and primary care physicians were able to ask for these tests. Other tests or procedures, such as coronariography or electrophysiological studies, cannot be performed in our hospital and patients, and have to be referred by a cardiologist to other hospital. Interestingly, during this period, the number of coronariography and electrophysiological studies increased from 550 to 652 (18.5%) and from 27 to 41 (51.9%), respectively.
On the other hand, as our study showed, integrated care allowed greater adherence to clinical guidelines in patients with chronic ischemic heart disease and AF [9–11]. Reducing LDL cholesterol targets to recommended targets (<70 mg/dl) is one of the main goals in the management of patients with chronic ischemic heart disease. In our study, despite the total number of patients with ischemic heart disease significantly increased between 2013 and 2016, the proportion of patients with ≥1 determination of LDL cholesterol levels also increased and mean LDL cholesterol levels decreased. In fact, the probability of achieving LDL cholesterol goals in 2016 was a 61% higher than in 2013 (OR: 1.61). However, despite these improvements, the proportion of patients – in whom a LDL-cholesterol determination was not performed – was unacceptably high and many patients did not attain LDL-cholesterol goals. A recent study that compared two national registries of patients with chronic ischemic heart disease carried out in 2006 and 2014 in Spain have shown that LDL cholesterol control rates have improved only from 9.5 to 27.3%, likely due to an insufficient treatment [2]. Since these patients were treated according to the conventional care model, it is possible that an integrated care model could have improved the management of these patients.
The majority of patients with AF require anticoagulation as antithrombotic therapy to reduce the risk of stroke or systemic embolism [20]. Importantly, current guidelines do not recommend the use of antiplatelets for this purpose [9]. A previous publication has shown that our patients had a mean CHA2DS2-VASc of 3.2 and only 5.0% of our patients had a CHA2-DS2-VASc of 0 [21]. As a result, the great majority of our patients had an indication for anticoagulation. In our study, the proportion of anticoagulated patients significantly increased from 69.3 to 74.2%. In addition, compared with antiplatelets, the probability of using oral anticoagulants increased by 70% in 2016 versus 2013 (OR: 1.70). It is likely that with this new integrated model, with the cardiologists attended patients in the corresponding primary care center, virtual visits, discussion of clinical cases as well as ongoing medical education, more physicians took aware about the high thromboembolic risk of this population and the need for anticoagulation for the prevention of stroke.
On the other hand, during the study period, patients with AF were more common, more primary care physicians assumed the control of anticoagulation with VKA and more INR determinations were performed. However, the proportion of patients with adequate INR control remained stable during this period. In fact, in our study, almost 40% of patients had a poor INR control. These numbers are in the line with the results reported in previous studies [22,23]. Consequently, more efforts are needed to improve the quality of anticoagulation. Unfortunately, therapeutic inertia in this context is high [24]. Integrated model should not only be focused on the need for anticoagulation, but also on assuring and adequate anticoagulation with VKA or with new oral anticoagulants, likely through a higher integration of cardiologists on ongoing medical education in the primary care center.
Compared with VKA, DOACs reduce the risk of stroke, intracranial hemorrhage and mortality, and may even reduce major bleeding in different cohorts of patients [25,26]. The DOACs are of particular benefit in patients with a high risk of stroke or bleeding, and also in patients with a poor anticoagulation control with VKA [13,26]. However, physicians must use the appropriate doses for each patient in order to achieve a perfect balance between thromboembolic and bleeding risk [27]. In 2016 compared with 2013, the use of DOACs was 4.5-times more probable than VKA (OR: 4.50), despite there are some restrictions for the reimbursement of DOACs that are limited to some specific conditions in Spain, such as poor anticoagulation control with VKA and high risk of intracranial bleeding [28]. Although it is possible that a higher number of patients could benefit from the use of DOACs instead of VKA, the increase in the use of DOACs reported in our study was clinically relevant. It is likely that the integration of a cardiologist in the primary care center could have an impact on improving knowledge, abilities and the perception of general practitioners about the importance of prescribing DOACs in clinical practice when indicated (i.e., poor anticoagulation control among patients taking VKA, high intracranial bleeding, etc.). In fact, in the last years, it has been reported an increased use of DOACs in Spain [29,30].
This study has some limitations. Since this was an observational and longitudinal study, some factors that could influence the management of these patients during a 4-year period might have not been completely controlled. As a result, the data seen in our study might not be exclusively associated with the implementation of the new care model. As this was a before-after study, the same population before moving to the integral assistance was the control group. In addition, the quality of data recorded was high, and no losses of follow-up occurred. Despite this type of studies may allow generating hypothesis, but not establishing causality with absolute confidence, it seems reasonable to assume that the change of model had a positive and relevant impact on the results of the study and, consequently, our data strongly suggest that implementing an integrated care model has actually improved some clinical end points. In our study, the impact of the programs on the visits to cardiology (management end point) was analyzed. Reducing the delay for visits to the cardiologist may be considered as an intermediate surrogate variable of a better coordination between primary care and cardiology, as it allows reducing unnecessary visits due to a better coordination between healthcare levels. On the other hand, the integrated care model was applied to a particular Health Assistance Area of Barcelona. As a result, this model cannot necessarily be extrapolated to other regions or Health Assistance Areas.
Conclusion
Implementing an integrated care model is feasible, reduces the number of visits and the delay to cardiologist consultation and associated with improvements in the management of chronic conditions, such as ischemic heart disease or AF. This new patient-centered care model improves coordination between healthcare levels. It is based on communication and confidence between sanitary professionals and promotes teamwork and the co-responsibility of patients with their cardiovascular disease. In addition, this new care model strengthens the leadership of general practitioners in the management of patients with chronic heart disease with the cardiologist as consultant and allows the cardiologists to be more focused on new diagnoses and more complex cases. Consequently, it is necessary to address care coordination between healthcare levels and to improve integrated disease management through multidisciplinary teams as part of the continuum of care.
Implementing an integrated care model was feasible and reduced the number of visits and the delay to cardiologist consultation.
Integration was associated with improvements in low-density lipoprotein cholesterol control rates.
Integration was associated with an increase in the proportion of patients with atrial fibrillation receiving oral anticoagulants.
Integration was associated with an increase in the proportion of anticoagulated patients with atrial fibrillation taking direct oral anticoagulants.
Although specific clinical trials are warranted, itis very likely that an integrated care model may be associated with better clinical outcomes.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Writing and editorial assistance was provided by Content Ed Net, Madrid, Spain.
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© 2018 Future Medicine Ltd.
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Received: 5 September 2018
Accepted: 5 November 2018
Published online: 14 December 2018
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Impact of an integral assistance model between primary care and cardiology on the management of patients with ischemic heart disease or atrial fibrillation. (2018) Journal of Comparative Effectiveness Research. DOI: 10.2217/cer-2018-0088
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