The evaluation of a Dutch cardiology Primary Car Plus intervention

Abstract

Background. In an attempt to deal with the pressures on the health-care system and to guarantee sustainability, changes are needed. This study focuses on a cardiology primary care plus intervention. Primary care plus (PC+) is a new health-care delivery model focused on substitution of specialist care in the hospital setting with specialist care in the primary care setting. The intervention consists of a cardiology PC+ centre in which cardiologists, supported by other health-care professionals, provide consultations in a primary care setting. The PC+ centre aims to improve the health of the population and quality of care as experienced by patients, and reduce the number of referrals to hospital-based outpatient specialist care in order to reduce health-care costs. These aims reflect the Triple Aim principle. Hence, the objectives of the study are to evaluate the cardiology PC+ centre in terms of the Triple Aim outcomes and to evaluate the process of the introduction of PC+.

Methods/Design. The study is a practice-based, quantitative study with a longitudinal observational design, and an additional qualitative study to supplement, interpret and improve the quantitative study. The study population of the quantitative part will consist of adult patients (≥18 years) with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre (intervention group) or hospital-based outpatient cardiology care (control group). All eligible patients will be asked to complete questionnaires at three different time points consisting of questions about their demographics, health status and experience of care. Additionally, quantitative data will be collected about health-care utilization and related health-care costs at the PC+ centre and the hospital. The qualitative part, consisting of semi-structured interviews, focus groups, and observations, is designed to evaluate the process as well as to amplify, clarify and explain quantitative results.

Conclusions. This study will evaluate a cardiology PC+ centre using quantitative and supplementary qualitative methods. The findings of both sub-studies will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes.

Keywords. primary care, primary care plus, hospital care, Triple Aim, substitution, referral, cardiology

This overall study aims to evaluate the effects of cardiology PC+ centre on the Triple Aim outcomes. The underlying premises of the researchers on the effects of the intervention are that the cardiology PC+ centre will result in an (at least) equivalent health of the population, improved quality of care as experienced by patients and a reduced number of referrals to hospital-based outpatient cardiology care, and hence reduced health-care costs.

The data will be collected at four different time points, namely at baseline, before the patient has the first consultation with the cardiologist (T0), a week after the first consultation (T1), three months after the first consultation (T2) and six months after the first consultation (T3).

Intervention: cardiology primary care plus centre

The PC+ intervention is a cardiology PC+ centre in which cardiologists, supported by other health-care professionals, provide specialist consultations in a primary care setting. Hospital diagnostic tools are available including an ultrasound device, an ergometer and an electrocardiogram (ECG). All GPs in the region participate in the PC+ intervention and are able to refer non-acute and low-complexity patients with cardiology-related complaints to the PC+ centre. Patients who are already diagnosed with cardiology-related health problems by a cardiologist are not appropriate for PC+ and (if needed) they will be treated by the cardiologist in the hospital-care setting. The consultation at the PC+ centre consists of the following diagnostic tests: a blood test, an ECG, an echo and an exercise test. The diagnostic tests are carried out by multiple health-care professionals, such as nurses, laboratory technicians and physicians, all specialized in cardiology. After the tests the patient meets the cardiologist, who explains the results of the diagnostic tests. The cardiologist sends a comprehensive description of the results of the tests, the diagnosis and his recommendation regarding further treatment (if needed) to the GP. The GP discusses the cardiologist’s recommendation with the patient and based on the principles of shared decision-making the GP and the patient discuss the options for further treatment [24]. Moreover, the GP remains clinically in charge of the patient. The further treatment will depend on the results of the tests and the recommendation of the cardiologist; the three overall options are: 1) the patient needs no care (i.e. the patient has no health problems that need further attention), 2) the patient will remain in the primary care setting (the patient needs low-complexity care, e.g. medication) or, 3) the patient will be referred to secondary care (the patient needs specialist care).



Control: hospital-based outpatient cardiology care (care-as-usual)

Hospital-based outpatient cardiology care is considered care-as-usual. All GPs are allowed to refer non-acute and low-complexity patients with cardiology-related complaints to the hospital-based outpatient cardiology care. These patients receive the same care as within the PC+ centre, i.e. the same diagnostic tests carried out by health-care professionals with the same level of expertise. After the tests the patient meets the cardiologist, the cardiologist explains the results and they discuss further treatment (if needed). This underlines a significant difference with the intervention: in the PC+ centre the cardiologist provides only a recommendation on further treatment and the GP discusses the options for further treatment (instead of the cardiologist), i.e. within PC+ the GP remains in charge.