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Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes?



Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes?



Health Promotion and Chronic Disease Prevention in Canada 37(4): 105-113



Chronic disease management requires substantial services integration. A cardiometabolic risk management program inspired by the Chronic Care Model was implemented in Montréal for patients with diabetes or hypertension. One of this study's objectives was to assess the impact of care coordination between the interdisciplinary teams and physicians on patient participation in the program, lifestyle improvements and disease control. We obtained data on health outcomes from a register of clinical data, questionnaires completed by patients upon entry into the program and at the 12-month mark, and we drew information on the program's characteristics from the implementation analysis. We conducted multiple regression analyses, controlling for patient sociodemographic and health characteristics, to measure the association between interdisciplinary team coordination with primary care physicians and various health outcomes. A total of 1689 patients took part in the study (60.1% participation rate). Approximately 40% of patients withdrew from the program during the first year. At the 12-month follow-up (n = 992), we observed a significant increase in the proportion of patients achieving the various clinical targets. The perception by the interdisciplinary team of greater care coordination with primary care physicians was associated with increased participation in the program and the achievement of better clinical results. Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients. La gestion des maladies chroniques nécessite une grande intégration des services. Un programme de gestion du risque cardiométabolique inspiré du Chronic Care Model a été implanté à Montréal pour les patients atteints de diabète ou d’hypertension. Un des objectifs de notre étude était d’apprécier l’impact de la coordination des soins entre les équipes interdisciplinaires et les médecins sur la participation des patients au programme et sur l’amélioration des habitudes de vie et le contrôle de la maladie. Nous avons utilisé des données sur les résultats de santé issues d’un registre de données cliniques et de questionnaires aux patients à leur entrée dans le programme et à 12 mois de suivi, ainsi que des données sur les caractéristiques du programme provenant de l’analyse de son implantation. Nous avons réalisé des analyses de régression multiple, contrôlant pour les caractéristiques sociodémographiques et de santé des patients, pour mesurer l’association entre la coordination de l’équipe interdisciplinaire avec les médecins de première ligne et différents résultats de santé. Au total, 1689 patients ont participé à l’évaluation (taux de participation 60,1 %). Environ 40 % des patients ont abandonné le programme durant la première année. À 12 mois de suivi (n = 992), nous avons observé une augmentation significative de la proportion des patients atteignant les différentes cibles cliniques. La perception par l’équipe interdisciplinaire d’une meilleure coordination des soins avec les médecins de première ligne était associée à une plus grande participation des patients au programme et à l’atteinte de meilleurs résultats cliniques. Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.

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Accession: 059840984

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PMID: 28402799


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