Specialized community-based care: an evidence-based analysis.

BACKGROUND: Specialized community-based care (SCBC) refers to services that manage chronic illness through formalized links between primary and specialized care. OBJECTIVES: The objectives of this evidence-based analysis (EBA) were as follows: to summarize the literature on SCBC, also known as intermediate careto synthesize the evidence from previous Medical Advisory Secretariat (now Health Quality Ontario) EBAs on SCBC for heart failure, diabetes, chronic obstructive pulmonary disease (COPD), and chronic woundsto examine the role of SCBC in family practice RESULTS: PART 1: SYSTEMATIC REVIEW OF INTERMEDIATE CARE Seven systematic reviews on intermediate care since 2008 were identified. The literature base is complex and difficult to define. There is evidence to suggest that intermediate care is effective in improving outcomes; however, the effective interventions are still uncertain. PART 2: SYNTHESIS OF EVIDENCE IN INTERMEDIATE CARE MORTALITY: • Heart failure: Significant reduction in patients receiving SCBC. • COPD.: Nonsignificant reduction in patients receiving SCBC. HOSPITALIZATION: • Heart failureNonsignificant reduction in patients receiving SCBC. • COPD.: Significant reduction in patients receiving SCBC. EMERGENCY DEPARTMENT VISITS: • Heart failure:Nonsignificant reduction in patients receiving SCBC. • COPD.: Significant reduction in patients receiving SCBC. DISEASE-SPECIFIC PATIENT OUTCOMES: • COPD.: Nonsignificant improvement in lung function in patients receiving SCBC. • Diabetes: Significant reduction in hemoglobin A1c (HbA1c) and systolic blood pressure in patients receiving SCBC. • Chronic wounds: Significant increase in the proportion of healed wounds in patients receiving SCBC.. QUALITY OF LIFE: • Heart failure: Trend toward improvement in patients receiving SCBC • COPD.: Significant improvement in patients receiving SCBC, PART 3: INTERMEDIATE CARE IN FAMILY PRACTICE: EVIDENCE-BASED ANALYSIS: Five randomized controlled trials were identified comparing SCBC to usual care in family practice. Inclusion criteria were 1) the presence of multiple chronic conditions, and 2) interventions that included 2 or more health care professions. The GRADE quality of the evidence was assessed as low for all outcomes due to the inconsistency and indirectness of the results. LIMITATIONS: This review did not look at disease-specific studies on intermediate care in family practice. CONCLUSIONS: Specialized community-based care effectively improves outcomes in patients with heart failure, COPD, and diabetes. The effectiveness of SCBC in family practice is unclear.