Integrated care teams improve outcomes, processes in patients with noncommunicable disease

Implementation of an integrated care team (ICT) in primary care results in enhanced clinical and process outcomes relative to usual care (UC), with more patients who have noncommunicable disease achieving treatment goals at 1 year, a Singapore study has shown.

“The proportion of patients with high cardiovascular risks [decreased] in the ICT group after a year, which may collectively translate into future reduction in cardiovascular complications,” said the researchers, led by Dr Pei Lin Hu, consultant at SingHealth Polyclinics.

Hu and her team retrospectively extracted data from electronic medical records (EMRs) of consecutive adult Asian patients empanelled to ICT and those in UC at a typical primary care clinical in Eastern Singapore in 2018. Participants had hypertension or hyperlipidaemia or type 2 diabetes mellitus (T2DM).

Clinical outcomes included the number of patients (ICT vs UC) who attained their treatment goals after 12 months, while process outcomes included the proportion of patients who completed annual diabetic eye and foot screenings, where applicable.

A total of 3,303 EMRs (ICT: n=1,723; UC: n=1,579) were accessed from January 2016 to September 2017 to obtain data for analysis. [Singapore Med J 2022;doi:10.11622/smedj.2022067]

Patients in the ICT cohort had a higher chance of achieving treatment goals for systolic blood pressure (SBP; adjusted odds ratio [aOR], 1.52, 95 percent confidence interval [CI], 1.38‒1.68), low-density lipoprotein cholesterol (LDL-C; aOR, 1.72, 95 percent CI, 1.49‒1.99), and glycated haemoglobin (HbA1c; aOR, 1.28, 95 percent CI, 1.09‒1.51).

In addition, more patients on ICT underwent diabetic retinal screening (89.1 percent vs 83.0 percent; p<0.001) and foot screening (85.2 percent vs 77.9 percent; p<0.001).

“Overall, the results revealed significant improvements in health and process outcomes in patients managed by ICT compared with those in UC,” the researchers said. “The proportions of patients achieving treatment goals and also improvements in the mean measurements of SBP, LDL-C, and HbA1c were higher in the ICT group.”

Patient empanelment

Assigning patients to the same ICT allows continuity of care, coordinates the care processes, and allocates resources depending on their care needs, according to the researchers. [BMC Fam Pract 2017;18:13; J Am Board Fam Med 2017;30:16-24]

Furthermore, patients with high cardiovascular risks or complex care needs are assigned to the more experienced senior polyclinic physician for management and are given more consultation time to attend to their multifaceted needs.

ICT members also have distinct roles. The care manager, for instance, is a nurse who functions as a health coach to “activate patients, set goals, and coordinate their care.”

A study by Boyd and colleagues found that older patients with multimorbidity reported higher quality care when a nurse was included in the team. [J Gen Intern Med 2010;25:235-242]

“The success of the ICT in this study is likely due to the multiple components within the care model. It will continue to evolve by incorporating evidence-based measures that have been shown to be effective in other clinical establishments involving ICT concept,” the researchers said. [BMC Fam Pract 2017;18:13]

“Future research should focus on staff and patient satisfaction and cost-effectiveness of this ICT model,” they added.