Improving chronic disease management

Submitted by Carlyn Zwarenstein on May 16, 2013 - 12:05

Providing better care for patients with chronic disease requires well-connected networks, each consisting of a primary care provider, specialists, and hospitals. Ideally, the combination of good care and good communication between a family doctor and specialists will reduce re-hospitalizations and improve patients’ well-being, while reducing the costs to an overburdened health care system facing ever more chronically ill patients with long-term, complex care needs.

This week Open Medicine published a paper in which the authors investigated the possibility of identifying existing multispeciality physician networks.

Therese Stukel and her coauthors (from the Institute for Clinical Evaluative Sciences) found creative ways of identifying existing networks of care providers who are linked not as a formal network but rather by the natural patterns of where people seek out health care and where they get referred. The authors used available health administrative data for the province of Ontario to link Ontario residents to their primary care providers, specialists to the hospitals where they provided most in-patient services, and primary care physicians to the hospitals where their patients were most often admitted. Then they measured “loyalty” as the proportion of care that patients received from the physicians and hospitals in their networks.

The findings? The authors identified 78 multispecialty physician networks across the province. In fact, they found that an informal, multispecialty, relatively self-contained network could indeed be identified for virtually all Ontario residents eligible for inclusion in the study.

It’s like you look into the sky and you see a blur of stars and someone suddenly says ‘hey, there’s a pattern’,” lead author Dr. Stukel told Open Medicine about her team’s findings. “We’ve revealed the patterns which are virtual networks in which hospitals and physicians are already practising.”

As policy-makers fret over better ways to organize the health care system to improve outcomes (including, in Ontario, by establishing a system of Health Links),they would do well to check out this research, which will be relevant for any region struggling to improve chronic disease care and reduce re-hospitalizations.

Commenting on this Blog entry is closed.