Tuesday, 26 July 2011

Co-ordination of care - does it work?

Increasing value for money in healthcare by improving quality, particularly the quality of patient outcomes, while reducing costs is a challenge facing health systems across the globe. The NHS has the “Nicholson challenge” said to be visible from space - to save £20 billion over the next 4 years at a time when demand on services continues to increase at around 7% per year. Shortly after the scale of the global financial crisis became apparent, John Ovretveit wrote an influential report “Does quality save money?”. John’s conclusion was that there is insufficient evidence to demonstrate a link between improving quality and saving money – the studies just have not been done. He did however highlight some areas where further work should urgently be undertaken and one of these was clinical coordination that could play a role in reducing waste, improving patient outcomes and delivering care at lower costs. Dr Ovretveit has now examined the evidence base for clinical coordination and how it can help in the decision making of clinicians and managers as new models of care and ways of organising services are developed.

The strength of the evidence is weak, as many of the changes tried to improve coordination have not been well evaluated. By its nature, coordination is dependent on the local context so opportunities and costs will vary in each healthcare system and in each different setting within particular systems. Attempts to replicate what’s happening in one clinic at the other end of the country or on the other side of the world are not always successful. Locally in Salford the development of a dialysis co-ordinator role led to removal of unnecessary blocks in offering patients the most appropriate dialysis location and timing for them. It took a lot of hassle away from the nurses and doctors and improved efficiency; a change for the better that ticked all the boxes and for which Vicky Jewell won the Salford Royal’s staff award for “administrative worker of the year” in 2008. It was written up as a poster for the BRS “you really can’t do without one of these – the role of the dialysis co-ordinator”.

More coordination and more care does not always result in better outcomes. Brendan Barrett and colleagues from Canada recently published the results of their randomised control trial of a nurse coordinated model of care versus usual care for patients with stage 3 / 4 chronic kidney disease in the community. It was a well conducted and reasonably large study. It confirmed that patients with stage 3 / 4 CKD identified through community laboratories largely had non progressive kidney disease but did have a high cardiovascular risk. Over the 2 year study period the nurse coordinated team did not affect the rate of GFR decline or provide better control of most risk factors compared to usual care. One conclusion might be that in people with a low rate of kidney disease progression and good management of traditional cardiovascular risk factors, the vascular event rate remains high and the nurse coordinated model of care has no additional beneficial effect over and above usual care provided by a family doctor. Perhaps what we need for this population is a better understanding of why the vascular risk in kidney disease is not as responsive to traditional interventions as other populations – we have a research need rather than a coordination and service delivery need . That’s also one of the messages from the recent SHARP study of cholesterol lowering agents in kidney disease – yes lowering cholesterol adds benefit but the risk reduction in people with kidney disease is only half of what we might expect from the studies in people without kidney disease .

John Ovretveit’s work however did identify many good ideas for better clinical coordination which are likely to be effective, especially if used in conjunction with other approaches to improving care such as disease management and self care programmes. These ideas are as likely to be beneficial in kidney care as in other long term conditions.

Perhaps the most important message is the importance of identifying which patients are most affected by poor coordination and the factors which are most influential in determining the effectiveness of interventions. In Kidney care that’s likely to be patients during the period of time before the need for renal replacement therapy when care planning , preparation and choice can have dramatic effect on experience of care and clinical outcomes; and in those who have elected for conservative kidney care, the non dialysis option. John concludes that in future, healthcare needs to operate as a value improvement system which makes the whole healthcare outcome for the patient greater than the sum of the help that each carer provides, and supports a patient to be independently healthy and more active in their care. That’s something for healthcare professionals to think about at every clinical encounter , needs to be borne in mind by health care managers when services are being designed and commissioned and should be a question patients , carers and families are invited to answer .

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