CARE COORDINATION: WHAT WORKS? MAKING SENSE OF A VAST LITERATURE VIA A SYSTEMATIC REVIEW OF REVIEWS

Purpose: Improved coordination of care is a national priority and while many coordination interventions have been shown to be effective, the “active ingredients” of these interventions are not well understood.

Method: We systematically searched MEDLINE and other sources (indexed 1/1966-9/2009) for systematic reviews evaluating care coordination interventions, assessed quality, abstracted results, and synthesized the evidence for each component. We update the evidence from systematic reviews that have been published since 6/2006 and that focus on team-based approaches to care.

Result: We identified 1,418 potentially relevant articles and 31 systematic reviews met our criteria for inclusion.   Fourteen studies examined team-based approaches, 8 of which used quantitative methods (meta-regression or subgroup analysis) to identify specific strategies that were effective. Reviews generally focused on one disease population. Strong evidence from diverse chronic disease populations (diabetes, multiple sclerosis, stroke, depression, congestive heart failure) suggests that multidisciplinary teams improve patient outcomes; the involvement of the primary care physician and specialized providers (psychiatrist/psychologist, mental health experienced case manager, endocrinologist, cardiac nurse, cardiologist) was significantly associated with improved outcomes.  Five reviews examined how decisions are made within teams and came to mixed conclusions about the effect of different levels of communication, but generally support that improved communication between health care providers can lead to better health outcomes. Two reviews that examined patient characteristics found that care coordination interventions were not necessarily more effective with increased disease severity.

Conclusion: Multi-disciplinary team interventions that involve the primary care doctor and specialists can improve outcomes.  Little is known about the impact of these interventions on total health care costs and whether these interventions are cost-effective, especially in less ill populations. Future interventions should examine best strategies to enhance communication between providers and evaluate the impact of interventions on total health care costs.