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.
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 notices4 - 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.
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