Shared care models: a high-level literature review
Shared care has been implemented in various clinical settings to enhance the delivery of services, especially in areas affected by shortages in specialist services.
by Tasia Malinowski, Penny Adams
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Background
Data from the Cancer Institute NSW indicates that in NSW, the risk of cancer is one in two for men and one in three for women by the age of 85 years. 1 The Cancer Institute NSW projection data estimates that over the next 10 years there will be approximately 380,000 new cases of cancer and 130,000 expected deaths in NSW. 2
In recent years, significant gains have been made in the treatment of various cancers, increasing the survival periods for many cancer patients. Increasing numbers of cancer diagnoses due to an ageing population, together with increased survival, places an additional burden on our health system requiring careful resource planning to meet this demand. 3
Shared care – defined as the joint participation of primary care physicians and specialty care physicians in the planned delivery of care informed by an adequate education program and information exchange over and above routine referral notices 4 – has been implemented in various clinical settings to enhance the delivery of services, especially in areas affected by shortages in specialist services.
Shared care presents an opportunity to provide patients with the benefits of specialist intervention combined with continuity of care.
Shared care presents an opportunity to provide patients with the benefits of specialist intervention. This is combined with continuity of care and management of co-morbidities from primary health care doctors and nurses who maintain a responsibility for aspects of the patients’ healthcare beyond the specified chronic disease.
Despite the variation in shared care approaches across different clinical contexts, the majority of models include GPs at the primary care level.
Objectives
To present a high-level literature review to inform the development of a subsequent research paper on shared care.
Methods
The Cochrane Review indicated that shared care has been used in the management of a range of chronic conditions, with the assumption that it delivers better care than either primary or secondary care alone. 5
Results
In the analysis of the effectiveness of shared care, we found that, apart from improved prescribing and medication adherence, there is a lack of available evidence so far to demonstrate significant benefits as is the case with many service innovations. It is suggested that this is most likely due to inadequate research to generate the evidence and methodological shortcomings in evaluation, rather than an inherent absence of benefits.
In particular, inadequate length of follow up and low levels of consumer involvement in evaluation design are noted as areas requiring consideration in future project design for shared care programs. A focus on these components is likely to yield important information on physical or mental health outcomes, cost-effectiveness, psychosocial outcomes and satisfaction with services. Further research needs to be undertaken in the area of shared care to better describe the effects on patient health, quality of life and survival. 6
If shared care models involving GPs form part of future service planning it is important to develop a better evidence base for this model.
Even though many shared care studies have considered cost data, only a small number have included economic analyses. This component of research and analysis is also required, as shared care models can present major resource implications.
Reports from shared care models in coronary care indicate that primary care practitioners feel they are being asked to take on more services without appropriate resources and are beginning to resist such developments. 7 Specifically for cancer, it is important to explore the motivation of rural practitioners to take on the responsibility of shared care oncology and how safe this model would be in the hands of less enthusiastic practitioners. 6
While the literature supports further research to confirm the benefits of shared care models across the healthcare spectrum before they are embedded into mainstream services, the need to urgently invest further in special cancer skills in primary care oncology is separate. Nearly all priorities for cancer services are affected by actions in primary health: reducing the risk of cancer, early detection, faster access to specialist treatment and improved support for patients living with cancer. 6
Research to gain a better understanding of the role of primary care in cancer management is vital if GPs are to become more involved in improving outcomes and quality of life for cancer patients. 8 At present, there is little evidence on which to base service redesign and innovation.
Conclusions
Shared care models are currently used and promoted across Australia and the rest of the world with the underlying assumption they improve patient care or improve access to continuing care especially in remote communities. However, the evidence base to prove the efficacy and benefits of these models in various settings has not been generated and remains inadequate. Anecdotally there are examples of successful models.
If shared care models involving GPs form part of future service planning to accommodate increasing numbers of cancer patients or provide better care, especially in rural and remote settings, it is important to develop a better evidence base for this model. Such evidence could be generated through long-term pilot projects that may confirm the sustainability of the models and check that patient and provider needs can be met. However, the success of working models provide an incentive to further explore this approach within a solid evaluation framework to make sure that health gains are well documented. A driver for future success will be a well received and structured education and orientation program of motivated GPs within participating cancer specialist cancer centres.
References
- Cancer Incidence and Mortality Report. Cancer Institute NSW, Sydney 2006.
- NSW Cancer Plan 2007–2010. Cancer Institute NSW, Sydney 2006.
- Aitken R, Morrell S, Barraclough H, Baker D, Clements M, Jelfs P, Bishop J. Cancer incidence and mortality projections in New South Wales, 2007 to 2011.
- Hickmann M, Drummond N, Grimshar J: A taxonomy of shared care for chronic disease. Journal of Public Health Medicine 16:4 -447-454, 1994.
- Smith SM, Allwright S, O’Dowd T. Effectiveness of shared care across the interface between primary and speciality care in chronic disease management. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004910.DOI:10.1002/14651858.CD004910.pub2.
- Campbell N, Ritchie LD, Cassidy J et al: Systematic review of cancer treatment programmes in remote and rural areas, British Journal of Cancer 80:8 1275 -1280, 1999.
- Hippesley-Cox J, Pringle M. General practice workload implications of the National Service Framework for coronary heart disease; a cross sectional survey. BMJ 2001:;332:259-63.
- Weller D, Harris M. Cancer care: what role for the general practitioner, MJA 189:2, 2008-07-23.