TY - JOUR
T1 - Evaluating a cardiovascular disease risk management care continuum within a learning healthcare system
T2 - a prospective cohort study
AU - Groenhof, T Katrien J
AU - Lely, A Titia
AU - Haitjema, Saskia
AU - Nathoe, Hendrik M
AU - Kortekaas, Marlous F
AU - Asselbergs, Folkert W
AU - Bots, Michiel L
AU - Hollander, Monika
N1 - Funding Information:
The UCC-CVRM study group members: FW Asselbergs, Department of Cardiology; GJ de Borst, Department of Vascular Surgery; ML Bots, Julius Center for Health Sciences and Primary Care; MH Emmelot, Department of Geriatrics; IE Hoefer, Laboratory of Clinical Chemistry and Haematology; M Hollander, General Practice; PA de Jong, Department of Radiology; AT Lely, Department of Obstet-rics/Gynecology; NP van der Kaaij, Department of Cardiothoracic Surgery; YM Ruigrok, Department of Neurology; MC Verhaar, Department of Nephrology & Hypertension, FLJ Visseren, Department of Vascular Medicine, University Medical Center Utrecht and Utrecht University.
Funding Information:
The UCC is primarily financed by the UMC Utrecht. A grant from the Netherlands Organization for Health Research and Development (#8480-34001) was obtained to develop feedback procedures. UCC website: www.umuctrecht.nl/ucc (in Dutch). Contact information UCC: [email protected].
Publisher Copyright:
© 2020. The Authors. All Rights Reserved.
PY - 2020/12
Y1 - 2020/12
N2 - BACKGROUND: Many patients now present with multimorbidity and chronicity of disease. This means that multidisciplinary management in a care continuum, integrating primary care and hospital care services, is needed to ensure high quality care.AIM: To evaluate cardiovascular risk management (CVRM) via linkage of health data sources, as an example of a multidisciplinary continuum within a learning healthcare system (LHS).DESIGN & SETTING: In this prospective cohort study, data were linked from the Utrecht Cardiovascular Cohort (UCC) to the Julius General Practitioners' Network (JGPN) database. UCC offers structured CVRM at referral to the University Medical Centre (UMC) Utrecht. JGPN consists of electronic health record (EHR) data from referring GPs.METHOD: The cardiovascular risk factors were extracted for each patient 13 months before referral (JGPN), at UCC inclusion, and during 12 months follow-up (JGPN). The following areas were assessed: registration of risk factors; detection of risk factor(s) requiring treatment at UCC; communication of risk factors and actionable suggestions from the specialist to the GP; and change of management during follow-up.RESULTS: In 52% of patients, ≥1 risk factors were registered (that is, extractable from structured fields within routine care health records) before UCC. In 12%-72% of patients, risk factor(s) existed that required (change or start of) treatment at UCC inclusion. Specialist communication included the complete risk profile in 67% of letters, but lacked actionable suggestions in 86%. In 29% of patients, at least one risk factor was registered after UCC. Change in management in GP records was seen in 21%-58% of them.CONCLUSION: Evaluation of a multidisciplinary LHS is possible via linkage of health data sources. Efforts have to be made to improve registration in primary care, as well as communication on findings and actionable suggestions for follow-up to bridge the gap in the CVRM continuum.
AB - BACKGROUND: Many patients now present with multimorbidity and chronicity of disease. This means that multidisciplinary management in a care continuum, integrating primary care and hospital care services, is needed to ensure high quality care.AIM: To evaluate cardiovascular risk management (CVRM) via linkage of health data sources, as an example of a multidisciplinary continuum within a learning healthcare system (LHS).DESIGN & SETTING: In this prospective cohort study, data were linked from the Utrecht Cardiovascular Cohort (UCC) to the Julius General Practitioners' Network (JGPN) database. UCC offers structured CVRM at referral to the University Medical Centre (UMC) Utrecht. JGPN consists of electronic health record (EHR) data from referring GPs.METHOD: The cardiovascular risk factors were extracted for each patient 13 months before referral (JGPN), at UCC inclusion, and during 12 months follow-up (JGPN). The following areas were assessed: registration of risk factors; detection of risk factor(s) requiring treatment at UCC; communication of risk factors and actionable suggestions from the specialist to the GP; and change of management during follow-up.RESULTS: In 52% of patients, ≥1 risk factors were registered (that is, extractable from structured fields within routine care health records) before UCC. In 12%-72% of patients, risk factor(s) existed that required (change or start of) treatment at UCC inclusion. Specialist communication included the complete risk profile in 67% of letters, but lacked actionable suggestions in 86%. In 29% of patients, at least one risk factor was registered after UCC. Change in management in GP records was seen in 21%-58% of them.CONCLUSION: Evaluation of a multidisciplinary LHS is possible via linkage of health data sources. Efforts have to be made to improve registration in primary care, as well as communication on findings and actionable suggestions for follow-up to bridge the gap in the CVRM continuum.
KW - cardiovascular diseases
KW - cardiovascular risk management
KW - continuity of patient care
KW - learning healthcare system
UR - http://www.scopus.com/inward/record.url?scp=85100175516&partnerID=8YFLogxK
U2 - 10.3399/bjgpopen20X101109
DO - 10.3399/bjgpopen20X101109
M3 - Article
C2 - 33144367
SN - 2398-3795
VL - 4
SP - 1
EP - 10
JO - BJGP Open
JF - BJGP Open
IS - 5
M1 - bjgpopen20X101109
ER -