Managing Continuity of Care through Integrated Care Pathways: A Study of Atrial Fibrillation and Congestive Heart Failure

Transcription

1 Managing Continuity of Care through Integrated Care Pathways: A Study of Atrial Fibrillation and Congestive Heart Failure January 31, 2004 H. Jay Biem, MD, MSc Heather D. Hadjistavropoulos, PhD Funding Provided by: Canadian Health Services Research Foundation Saskatchewan Industry and Resources Regina Qu Appelle Health Region Saskatoon Health Region Saskatchewan Health Health Quality Council Dr. J. Biem is supported by a Canadian Institutes of Health Research/ Regional Partnership award

2 Principle Investigators: H. Jay Biem, MD, MSc, FRCPC Associate Professor Division of General Internal Medicine Department of Medicine University of Saskatchewan 103 Hospital Drive Saskatoon Saskatchewan S7N 0W8 Telephone: (306) Fax: (306) Heather Hadjistavropoulos, PhD, RDPsych Associate Professor & Director of Clinical Training Department of Psychology University of Regina 3737 Wascana Parkway Regina Saskatchewan S4S 0A2 Telephone: (306) Fax: (306) This document is available on the Canadian Health Services Research Foundation Web site ( For more information on the Canadian Health Services Research Foundation, contact the Foundation at: 1565 Carling Avenue, Suite 700 Ottawa, Ontario K1Z 8R1 Telephone: (613) Fax: (613) Ce document est disponible sur le site web de la Fondation canadienne de la recherche sur les services de santé ( Pour obtenir de plus amples renseignements sur la Fondation canadienne de la recherche sur les services de santé, communiquez avec la Fondation : 1565, avenue Carling, bureau 700 Ottawa (Ontario) K1Z 8R1 Courriel : communications@fcrss.ca Téléphone : (613) Télécopieur : (613)

3 Managing Continuity of Care through Integrated Care Pathways: A Study of Atrial Fibrillation and Congestive Heart Failure Team members: Regina Qu Appelle Health Region: Dr. Edward Busse, Clinical Department Head, Cardiosciences Ms. Carol Klassen, Vice-President, Corporate Services Ms. Diane Larrivee, Vice-president, Specialty Care Dr. Derrick Larsen, Executive Director, Research & Performance Support Dr. Brian Laursen, Senior Vice-President, Medical Services Ms. Bobbi Lochbaum, CPG/ICP Co-ordinator Ms. Dawn McNeil, Executive Director, Family Medicine, Homecare, & Palliative Care Dr. William Semchuk, Manager, Clinical Pharmacy Services Past Dr. Naiyer Habib, Past Section Head, Cardiology, RQHR Ms. Carol Ringer, Past Vice-president, Integrated Clinical Services Mr. Mark Sagan, Past Research Associate, Research and Performance Support Dr. Warren Skea, Past Director, Researches and Utilization Management Dr. Gil White, Past Chairman, Department of Family Medicine, U of S Saskatoon Health Region & U of S: Ms. Joanne Franko, Manager, Research Services Unit, Saskatoon Health Region Dr. Andrew Kirk, Division of Neurology, Department of Medicine, U of S Dr. Cordell Neudorf, Medical Health Officer, Saskatoon Health Region Myra Parcher, Supervisor, Homecare, Saskatoon Health Region Ms. Vivian Ramsden, Research Co-ordinator, Department of Family Medicine, U of S Dr. Bruce Reeder, Dept of Community Health and Epidemiology, U of S Mr. Loren Regier, Pharmacist RxFiles, Saskatoon Health Region Ms. Diane Treppel, Project Co-ordinator, Health Services Analysis & Reporting Unit, Saskatoon Health Region Past Dr. James McMeekin, Past Head, Division of Cardiology, U of S Saskatchewan Health Dr. MaryRose Stang, Research Consultant, Saskatchewan Health Health Quality Council Ms. Maureen Bingham, Director of Linkage and Exchange and Deputy CEO Ms. Bonnie Brossart, Senior Researcher and Program Manager Past Mr. Laurie Thompson, Past CEO, Health Services Utilization and Research Commission

4 Table of Contents Key Implications for Decision Makers... i Executive Summary... ii Context...1 Project implications...2 Measuring patient perceptions of continuity of care...2 Problems in care for congestive heart failure...2 An integrated care pathway for congestive heart failure...3 Problems in care for atrial fibrillation...3 An integrated care pathway for atrial fibrillation...3 Costs of integrated care pathways...3 Challenges in integrated care patheay development and implementation...4 Approach...4 Baseline study of continuity of care for congestive heart failure and atrial fibrillation...4 Congestive heart failure integrated care pathway...5 Atrial fibrillation integrated care pathway...7 Effect of integrated care pathways...9 Integrated care pathway costs...9 Qualitative study of integrated care pathway development and implementation...10 Results...11 Measurement of perceptions of continuity of care...11 Factor analysis of heart continuity of care questionnaire...12 What continuity of care problems do patients with congestive heart failure face?...13 Effectiveness of a congestive heart failure integrated care pathway...15 What continuity of care problems do patients with atrial fibrillation face?...16 Effectiveness of an atrial fibrillation integrated care pathway...18 Costs of integrated care pathways...20 Experiences with integrated care pathway development...20 Experiences with integrated care pathway implementation...21 Additional Resources...22 Further Research...22 References...24

5 Key Implications for Decision Makers Congestive heart failure (a weakness of the heart muscle causing fluid build-up in the lungs and elsewhere) and atrial fibrillation (an irregular heart rhythm predisposing to clots which can move to the brain causing stroke) require continuity of care. The Heart Continuity of Care Questionnaire measures key aspects of continuity of care, including provision of information, relationships and follow-up management. Chart audits can assess processes of care such as medication use and health services utilization. According to the questionnaire answers, congestive heart failure patients were concerned about the amount of education received and the way their follow-up care was managed. Chart audits found room for improvement in patient education, follow-up care, echocardiography use, weight monitoring, mobilization, discharge communication and readmission rates. According to the questionnaire answers, atrial fibrillation patients wanted more education about symptoms, potential medication side effects, diet, and activity, as well as better communication at discharge. Most patients at risk of stroke without contraindications were treated with warfarin on discharge and during the subsequent six months. However, the drug dose was therapeutic only about half the time. Chart audits found room for improvement in patient education and discharge communication. Integrated care pathways are designed to improve continuity of care by explicitly defining what care patients should receive, when they should receive it, and how the various members of their multidisciplinary care team should work together in the hospital and in the community. Congestive heart failure patients managed according to an integrated care pathway found their continuity of care to be better than patients who were in the baseline and control groups. This was particularly true for information provided and follow-up care. Chart audits also showed improvements in use of healthcare services. Patients with atrial fibrillation managed according to a pathway did not perceive better continuity of care compared to baseline and control groups. Chart audits did not show any improvements either. The cost of developing and implementing integrated care pathway was substantial. It took 1,984 hours at a salary cost of $67,827 to develop the congestive heart failure integrated care pathway. It took 2,083 hours at a salary cost of $66,890 to implement the integrated care pathway. Development of the atrial fibrillation integrated care pathway took 900 hours, at a salary cost of $41,989. While less time was spent on implementation (476 hours), it cost more in terms of salary ($49,693). In focus groups and structured interviews, the healthcare professionals involved in developing and implementing the integrated care pathways viewed the pathways favourably and believed they could address problems related to continuity of care. They believed pathways improve communication among different providers and with the patient and encourage evidence-based best practice. Some challenges to implementing integrated care pathways included getting frontline providers to take ownership of the care tool, co-ordinating staff education, and managing duplicate documentation. As well, the use of integrated care pathways for atrial fibrillation and congestive heart failure was challenged by the complexity of the conditions and by the fact that many of these patients also have other medical conditions. i

6 Executive Summary Ensuring continuity of care for congestive heart failure (a weakness of the heart muscle causing fluid build-up in the lungs and elsewhere) and atrial fibrillation (an irregular heart rhythm predisposing to clots which can move to the brain causing stroke) is a challenge. These patients have complex medication regimens, require frequent monitoring, and are seen by many different healthcare providers in multiple settings. Integrated care pathways are designed to improve continuity of care by explicitly defining what care patients should receive, when they should receive it, and how the various members of their multidisciplinary care team should work together in the hospital and in the community. Use of integrated care pathways is increasing, despite a lack of evidence about their effectiveness and cost. What we did We looked at the consequences of poor continuity of care by interviewing 176 congestive heart failure patients and 178 atrial fibrillation patients. This established our baseline before implementing integrated care pathways. We developed a disease-specific measure (Heart Continuity of Care Questionnaire) to assess patient perception of continuity of care encompassing information, provider relationships, and follow-up management when being discharged from the hospital. To determine the impact of integrated care pathways on continuity of care, we developed and implemented integrated care pathways (an atrial fibrillation integrated care pathway in Saskatoon Health Region and a congestive heart failure integrated care pathway in Regina Qu Appelle Health Region) and then examined patient perceptions of continuity of care and health outcomes approximately six months after hospital discharge. Saskatoon and Regina Qu Appelle health regions acted as each other s control group. To put a price tag on our integrated care pathways, we added up what it cost in time and salaries to develop and implement the integrated care pathways. We also conducted focus groups and structured interviews with providers involved with ii

7 the integrated care pathways to gauge their perceptions about developing and implementing integrated care pathways. What we found Consequences of poor continuity of care Patients with congestive heart failure wanted more information about their condition and better followup care. The quality of care audit also identified several areas that needed improvement. Patients with atrial fibrillation wanted information about potential symptoms, side effects of medication, and clearer communication about diet, daily activity, and discharge. The quality of care audit found room for improvement in drug use, patient education, and counselling. Effectiveness of integrated care pathways in improving continuity and quality of care Patients with congestive heart failure who received care based on an integrated care pathway said they had better continuity of care than did patients in the baseline or control groups. Chart audits also showed improvements in care. Patients with atrial fibrillation on an integrated care pathway did not find a similar improvement, nor did the chart audit show improvements. Estimated costs of developing and implementing integrated care pathways It took 1,984 hours, at a salary cost of $67,827, to develop the congestive heart failure integrated care pathway. A similar amount (2,083 hours costing $66,890) was needed to implement the integrated care pathway. Developing the atrial fibrillation integrated care pathway took 900 hours, at a salary cost of $41,989. While less time was spent on implementation (476 hours), it cost more in terms of salary ($49,693). iii

8 Perceptions of people involved with integrated care pathways Providers believed there are problems in continuity of care for patients with atrial fibrillation and congestive heart failure, and that integrated care pathways can address some of these problems. Specifically, integrated care pathways provide information on best practices and opportunities for providers to communicate with other members of the care team. There were several barriers to using the integrated care pathways, however. First, the providers involved did not develop a sense of ownership of the care tools. Second, it was difficult to deliver consistent education about the integrated care pathways to providers from various disciplines and working in various care settings. Finally, the complexities of these diseases and a lack of interest by some patients in being involved in their own care made it difficult to adopt the integrated care pathways. What we think it means Our baseline study found that congestive heart failure and atrial fibrillation patients perceive problems with continuity of care. Among congestive heart failure patients whose care was guided by an integrated care pathway, the improvements we saw in patients perceptions about continuity of care and in measures of quality of care were promising. For atrial fibrillation, we found the integrated care pathway to be poorly utilized and observed no effect on patient perception of continuity of care, and no effect on quality of care indicators. Our sample sizes were too small and follow-up too short to draw conclusions on patient outcomes; however, we await data on health services utilization. Decision makers contemplating the use of integrated care pathways also need to consider both costs and organizational challenges. iv

9 Context Congestive heart failure (a weakness of the heart muscle causing fluid build-up in the lungs and elsewhere) and atrial fibrillation (an irregular heart rhythm predisposing to clots which can move to the brain causing stroke) and affect two to four percent of the adult population, become increasingly common with advancing age, and are associated with significant morbidity and mortality and high healthcare costs. 1 2 Despite strong evidence and practice guidelines, 6 7 providing high-quality care is a challenge. For example, some drugs like angiotensin converting enzyme inhibitors for congestive heart failure and warfarin for atrial fibrillation have been underused or not prescribed in the best way A contributing factor may be a discontinuity of care caused by the need for many providers in multiple settings, combined with a lack of standardized communication processes and organizational co-ordination. Integrated care pathways have become popular as a means of improving quality and continuity of care. Based on guidelines, they map out interdisciplinary roles and responsibilities, required elements of care, and expected patient outcomes They aim to improve communication and coordination across providers and settings. 15 However, evidence for the effectiveness of pathways for chronic cardiac care is limited Previous research has focused on components of care, 18 transition processes, 19 nursing education, 20 and home monitoring. 21 These studies have shown improvements in drug utilization, health service utilization, and quality of life. Consequently, decision makers in the health regions of Regina Qu Appelle and Saskatoon have become interested in the effectiveness and cost of integrated care pathways for improving patient care. The objectives of this study were to: identify continuity of care problems for congestive heart failure and atrial fibrillation; determine whether integrated care pathways improve continuity and quality of care (perceptions of information, relational and management continuity, quality of care indicators, medication use) and decrease costs (re-admissions, lengths of stay, physician visits) associated with lack of continuity of care; determine the added value of an extended integrated care pathway that provides patients with the care plan and follow-up phone calls after discharge; estimate the costs of developing and implementing integrated care pathways; and 1

10 record the experiences and lessons learned about integrated care pathways as system interventions for improving continuity of care. In this study, a congestive heart failure integrated care pathway was implemented in Regina Qu Appelle Health Region. Patients who received the pathway were compared to a pre-study group in Regina Qu Appelle and a concurrent control group in Saskatoon Health Region. Similarly, an atrial fibrillation integrated care pathway was implemented in Saskatoon. These patients were compared to a baseline group in Saskatoon and a concurrent control group in Regina Qu Appelle. For each integrated care pathway, some patients were randomly assigned to receive additional patient education and post-discharge phone calls (the extended integrated care pathway). Project implications Measuring patient perceptions of continuity of care Our first task was to measure the broad concept of continuity of care for chronic cardiac patients. The Heart Continuity of Care Questionnaire appeared to be an acceptable, reliable, and valid measure of perceptions of continuity of care for patients. The questionnaire s subscales corresponded to recently proposed theoretical components of continuity of care: relational, informational, and management The questionnaire appeared to identify potential problems contributing to poor continuity of care. Problems in care for congestive heart failure Patients perceived problems with information provision and follow-up management for congestive heart failure. Areas of concern were information about congestive heart failure, symptoms to expect, discussion about possible side effects, influence of congestive heart failure on lifestyle, advice about physical activity, and information for family or friends. Quality of care audits revealed room for improvement in congestive heart failure care, including beta-blocker use (52 percent), echocardiography use in past year (49 percent), weight monitoring (32.8 percent), mobilization in less than 48 hours (21.3 percent), patient education (43.9 percent), and discharge communication of monitoring parameters (27.3 percent). Readmissions were frequent (28.3 percent in six months). 2

11 An integrated care pathway for congestive heart failure Compared to baseline in Regina Qu Appelle and compared to a control group in Saskatoon, congestive heart failure patients in Regina Qu Appelle on the integrated care pathway perceived higher continuity of care, especially related to information provision and follow-up care. Chart audits showed improvement in provision of patient education, weight monitoring, echocardiography use, and patient mobilization. No significant differences were observed between the standard and extended congestive heart failure integrated care pathways. Problems in care for atrial fibrillation Patients perceived problems with information provision. For example, patients wanted more information about the symptoms to expect and what to do about them, potential medication side effects and what to do about them, advice on diet and daily activity, and discharge communication. Overall, in both centers, warfarin was prescribed for 71 percent of those for whom it was appropriate, based on contemporary guidelines. However, of patients on warfarin, their blood thickness was in a therapeutic range only 47 percent of the time in the six months. Quality of care audits found sub-optimal use of patient education, educational videos, pharmacy counselling, and discharge communication about hospital blood thickness test results. An integrated care pathway for atrial fibrillation No significant differences were found in patient perception of continuity of care for Saskatoon patients on the atrial fibrillation integrated care pathway compared to control patients in Regina Qu Appelle Health Region or to baseline patients in Saskatoon. As well, there was no added benefit from the extended integrated care pathway compared to the standard integrated care pathway. Data on drug and health services utilization are pending. Costs of integrated care pathways There were many problems with tracking the costs associated with developing and implementing integrated care pathways. These included different accounting methods in different organizations and difficulty in estimating in-kind costs. Although an existing congestive heart failure integrated care pathway was used, it required modification for local use. This took 1,984 hours at a salary cost of $67,827. A similar amount of time was required to implement the integrated care pathway within 3

12 the region 2,083 hours costing $66,890. The development time for the atrial fibrillation integrated care pathway took 900 hours at a salary cost of $41,989. The amount of time spent on implementation within Saskatoon Health Region was 476 hours at a salary cost of $49,693. Differences between the costs for integrated care pathways may be related to differences in the disease and management, as well as variation in the experience and number of providers. Challenges in integrated care pathway development and implementation In focus groups and structured interviews with providers, integrated care pathways were viewed positively. Providers believed that integrated care pathways addressed some issues of continuity of care by providing knowledge on best practice and by improving communication. A number of challenges were identified while developing integrated care pathways, including management of the change process, increasing commitment by physicians and decision makers, ensuring motivation for change rests with quality of care, and addressing negative perceptions of integrated care pathways. During implementation, a lack of a sense of ownership of integrated care pathways was observed to be a major barrier. Although integrated care pathway co-ordinators were viewed as essential, the coordinators also appeared to detract from the frontline provider s sense of ownership. Consistent education of all disciplines involved in an integrated care pathway was a challenge. Documentation was problematic because of different charting methods between different hospitals and wards. An additional barrier to standardized care plans was the variability in the cardiac condition, medical comorbidity, and therapy complexity of the patients. Approach Baseline study of continuity of care for congestive heart failure and atrial fibrillation patients: Before implementing the integrated care pathways, consecutive patients who were residents of either region and who had a most responsible or primary diagnosis of atrial fibrillation or congestive heart failure were contacted after discharge from hospital (Regina Qu Appelle-atrial fibrillation, n = 90; Regina Qu Appelle-congestive heart failure, n = 89; Saskatoon-atrial fibrillation, n = 88; Saskatoon-congestive heart failure, n = 87). Interviews: The interviews took place from September 2001 to April Patients were informed of the study by phone and an interview was scheduled. Health status was assessed using the SF-8, 4

13 which produces summary scores for physical and mental health status. 26 The Minnesota Living with Heart Failure Questionnaire assessed heart-specific physical and psychological impairment and has been found appropriate for use with both congestive heart failure and atrial fibrillation patients Disease symptoms were assessed with the Specific Symptom Scale, a measure of frequency and severity of arrhythmia-related symptoms, and the New York Heart Association Functional Classification Scale (New York Heart Association, 1994), a measure of heart failurerelated symptoms. The Heart Continuity of Care Questionnaire was used to measure continuity of care. Chart Audits: Chart audit forms were developed. A congestive heart failure chart audit form was used by research nurses to gather information on echocardiogram use in the last year, patient mobilization within 48 hours, weight monitoring, documentation of patient education, and the comprehensiveness of discharge letters. An atrial fibrillation chart audit form was used by research nurses and an internist to gather information on use of pharmacy counselling, nurse education, patient educational material, discharge communication (with information on blood thickness), and arrangements for follow-up. An internist assessed whether the patient should receive warfarin according to contemporary guidelines. Health service utilization: Information about medications and use of health services for the six months following admission was obtained through Saskatchewan Health. Congestive heart failure integrated care pathway Details regarding the development and implementation of the congestive heart failure integrated care pathway are available in the appendix. The congestive heart failure integrated care pathway focused on patients who had a primary or most responsible diagnosis of congestive heart failure. Patients who underwent cardiothoracic surgery, were younger than age 30, resided in a personal care home or nursing home, lived outside of the homecare area, or were also being treated for chronic renal failure were excluded. The congestive heart failure integrated care pathway had the following components: 1. physician orders for admission tests, assessments and treatments, consults and referrals, medications, and discharge instructions; 5

14 2. discharge summary/congestive heart failure resource sheet for family physicians. This required the attending physician and nurse to record pertinent information on the day of discharge, including key problems, recommendations for further treatment, discharge medications, monitoring parameters, key investigations/procedures, and follow-up appointments. At discharge, this information was faxed to the family physician and homecare. On the back of this sheet was a congestive heart failure resource sheet for family physicians, outlining congestive heart failure management guidelines; 3. hospital integrated care pathway documentation. Care was mapped out over six days: acute phase days one and two, stabilization phase days one and two, discharge planning day, and discharge final day. Providers made progress notes and tracked variances on the back of each day of the integrated care pathway; 4. congestive heart failure patient education activity booklet. An education activity booklet was developed for patient use (permission granted from authors of Partners in Care for Congestive Heart Failure and the American Dietetic Association for reproduction of selected written material); 5. congestive heart failure community integrated care pathway. The community integrated care pathway outlined homecare nursing care during an assessment phase (visits one and two) and a maintenance-discharge phase. The first visit took place within 48 hours of discharge from hospital, unless otherwise specified. Progress notes were completed on the back of each day of the integrated care pathway document. A flow sheet allowed for tracking of key assessments by the nurse per visit; 6. patient integrated care pathway. This was a simplified version of the integrated care pathway that was used to inform patients and families about the care plan. Patients were randomly assigned to receive this information; and 7. co-ordinator follow-up phone calls. Patients were randomly assigned to receive standardized phone calls at three and six weeks after discharge. The co-ordinator inquired about selfmanagement of congestive heart failure, knowledge of congestive heart failure, person to call in an emergency, compliance with medication, follow-up appointments, readmissions to hospital, emergency room care, and homecare nursing visits. In April 2002, the integrated care pathway was gradually introduced at the two hospitals in the units that cared for congestive heart failure patients. The co-ordinator identified a potential patient and 6

15 approached the physician for permission to use the integrated care pathway. Staff and physicians were reminded about how to use the congestive heart failure integrated care pathway. The coordinator provided the necessary forms and addressed challenges. The co-ordinator ensured ongoing education was provided to new staff. By June 2003, 155 patients had been put on the integrated care pathway; however, 41 of these did not participate in the study (17 lived outside the health region, eight were unable to consent, six did not meet the inclusion requirements, four did not give the coordinator consent, three refused, and three died or were discharged before giving consent). Of the 114 patients in the study, 67 were randomly assigned to the extended integrated care pathway, which included a care pathway sheet and follow-up phone calls. Of the 114 integrated care pathway patients, 54 (24 in the standard group; 30 in the extended group) did not complete the follow-up interviews for various reasons (20 died, 16 refused, 18 could not be contacted). Of the 60 who were interviewed, 23 were in the standard integrated care pathway group and 37 were in the extended integrated care pathway group. Utilization CHF-ICP No. (%) n = 114 Completed all acute days on ICP 103 (91%) Completed stabilization days 95 (84%) Completed discharge days 82 (73%) Documentation of patient education 101(96%) standard 43 (98%) extended 58 (95%) Discharge summary complete 106(100%) Inclusion of all monitoring parameters in discharge summary 62(54%) standard 23 (52%) extended 39 (63%) Included at least 1 homecare follow-up visits 57 (66%) In extended ICP group - completed one follow-up call 51 (81%) Completed all follow-up phone calls 37 (59%) Atrial fibrillation integrated care pathway Details regarding the atrial fibrillation integrated care pathway development and implementation are provided in the appendix. The atrial fibrillation integrated care pathway focused on patients with a primary or most responsible diagnosis of atrial fibrillation who were potentially eligible for warfarin treatment. Patients who underwent cardiothoracic surgery, were younger than age 40, resided in a personal care home or nursing home, lived outside of city limits, or were also being treated for chronic renal failure were excluded. The atrial fibrillation integrated care pathway had of the following components: 1. physician standardized order sheet, including some routine tests and referrals; 7

16 2. multi-disciplinary time-task care plan with sections for nurses, pharmacists, and physicians. The nursing section documented fall risk, patient education about symptoms needing medical attention, and follow-up arrangements. The pharmacy section documented current medications as well as over-the-counter and herbal products, warfarin patient education (including potential drug interactions), and recommendation for a Medic-Alert bracelet. A community pharmacist was to verify medications, answer medication-related questions, and recommend dosing aids. The hospital physician section documented atrial fibrillation-related stroke risk factors, atrial fibrillation precipitants, and potential contraindications to antithrombotic therapy. The family physician section documented patient understanding of medications, communication about blood thickness test results, and methods of prescription renewal; 3. a physician resource sheet included current guidelines about anti-arrhythmic therapy and anticoagulation, as well as a list of common drug interactions; 4. an atrial fibrillation patient education booklet included information about atrial fibrillation and medications; and 5. patients were randomly assigned to receive an extended integrated care pathway that included co-ordinator follow-up phone calls at two, four, and 12 weeks after discharge. During these calls the co-ordinator verified that the patient had seen the family physician and had gone for blood thickness testing. The co-ordinator answered questions and reinforced the need to take medication as prescribed. The integrated care pathway co-ordinator identified potential patients, approached the physician for permission to place the patient on integrated care pathway, and then obtained patient consent for the study. The co-ordinator reminded providers about how to use the integrated care pathway, and provided education to new staff. Chart review showed that the physician section was completed infrequently. However, the pharmacist and nurse sections were usually completed according to the time-task care plan. 8

17 Utilization AF-ICP Standard no. (%) n =44 Extended no. (%) n = 46 Overall no. (%) n=90 Fall risk (nursing) 13 (30%) 15(33%) 28 (31%) Next INR appointment after discharge (nursing) 11(25%) 13(28%) 24 (27%) Review indications for medication (nursing) 12 (27%) 14 (30%) 26 (29%) next visit to family doctor (nursing) 11 (25%) 15 (33%) 26 (29%) Sign/symptoms and prevention of bleeding (nursing) 12 (27%) 14 (30%) 26 (29%) Patient education booklet (nursing) 16 (36%) 25 (54%) 41 (46%) Effect of drug/food and drug/drug interactions (pharmacy) 28 (64%) 29 (63%) 57 (63%) Target INR (pharmacy) 29 (66%) 28 (61%) 57 (63%) Importance of frequent INR monitoring (pharmacy) 29(66%) 29 (63%) 58 (64%) Bleeding risks (pharmacy) 29 (66%) 29 (63%) 58 (64%) Need for Medic alert bracelet (pharmacy) 29 (66%) 29(63%) 58 (64%) Importance of Seeing Usual Pharmacist (Pharmacy) 29 (66%) 28 (61%) 57 (63%) Extended Group - 1 follow-up call 43 (93%) Completed all follow-up phone calls 22 (48%) Effect of integrated care pathways In all, 114 congestive heart failure patients (47 standard and 67 extended) in Regina Qu Appelle Health Region and 90 atrial fibrillation patients (44 standard and 46 extended) in Saskatoon Health Region participated in the study. In addition, data were collected on 51 atrial fibrillation patients in Regina Qu Appelle Health Region and 96 congestive heart failure patients in Saskatoon Health Region, each serving as a control group for the other site. Data as outlined at baseline were collected on patients enrolled in the study. Interview data, however, were available only from a proportion of the patients for a variety of reasons. Due to data lag, Saskatchewan Health data are not yet available for integrated care pathway patients (most remaining data expected by summer 2004). Due to limited funds, chart audit data was only collected in Regina Qu Appelle Health Region. Data Consent Chart Audit Interviewed Refusals Death No Contact CHF RQHR Standard RQHR Extended SHR Control Atrial Fibrillation SHR Standard SHR Extended RQHR Control Integrated care pathway costs Three major dimensions were tracked: 1) the cost of developing the pathway; 2) the cost of implementing the pathway (such as training staff to use the integrated care pathway); and 3) the cost 9

18 of doing evaluation and research. Some of these costs were paid for through external grants, and the rest was paid for through in-kind contributions. Data were collected through: 1. Individual team member hours: All hours spent by team members were collected through a detailed activity form. The amount of time was recorded as well as the nature of the activity (that is, integrated care pathway development, implementation, or evaluation). 2. Integrated care pathway education attendance: It was necessary to record the time and salary costs of those who were oriented (decision makers, managers) or educated (staff) about the integrated care pathways. Through sign-in sheets at education sessions, the number of participants and their disciplines were recorded. The cost of training was based on the average wage for that discipline obtained from human resources. 3. Non-personnel related costs: Related expenses (such as printing, travel, office supplies) were recorded. While some costs were based on actual expenditures, others were estimated (for example, one office operations in-kind contribution of $50 to $75 per month for staff committing a major portion of their time to the project). It was expected the costs of developing and implementing an integrated care pathway in the Regina Qu Appelle and Saskatoon health regions would be different because of the different levels of experiences with integrated care pathways, as well as the different nature of congestive heart failure and atrial fibrillation. In addition, it was expected that initial development costs would be higher than ongoing maintenance costs; however, the study timeframe was not long enough to address this. Because this was a research study, the evaluation and research costs tracked are higher than one would expect for an integrated care pathway implemented in a non-research environment. Qualitative study of integrated care pathway development and implementation This component of the study involved collecting qualitative information from providers regarding their concerns about continuity of care for patients with congestive heart failure and atrial fibrillation, as well as the development and implementation of the integrated care pathways. From an administrative perspective, these data provide guidance on how to improve the integrated care pathways. Developmental phase: Two focus groups, one in each region, of six providers involved in developing the integrated care pathway were carried out before the integrated care pathway was 10

19 implemented. The providers were asked 1) what issues do patients face with continuity of care; 2) how might an integrated care pathway facilitate continuity of care; 3) what barriers may prevent an integrated care pathway from facilitating continuity of care for patients; 4) what was positive about the development of the integrated care pathway; and 5) what was challenging about developing the integrated care pathway? Implementation phase: Two focus groups were conducted; one in Regina Qu Appelle Health Region (eight of 10 invited participated; 80 percent) and one in Saskatoon Health Region (four of 14 invited participated; 29 percent). We also elected to conduct four additional interviews with Saskatoon Health Region physicians and pharmacists. The two primary pathway co-ordinators from both regions were interviewed separately because of their in-depth experience. The following areas were explored: 1) general perceptions of how integrated care pathways effect continuity of care; 2) recollections of their experiences with the integrated care pathway implementation process; 3) positive and negative perceptions about the integrated care pathway implementation process; and 4) recommendations for improving the integrated care pathway implementation process. The data were then coded by one researcher and validated by a second. Results Measurement of perceptions of continuity of care Before conducting other analyses, the Heart Continuity of Care Questionnaire was assessed by item and principal components analysis. This analysis identified three factors. Factor one had questions that pertained to being provided with sufficient information to manage one s condition, and thus was named informational continuity. Factor two had questions that pertained to communication between the patient and providers and communication among providers, and thus was named relational continuity. Factor three had questions that pertained to the existence of management structures in place to reinforce follow-up care, and thus was named follow-up continuity. 11

20 Factor analysis of heart continuity of care questionnaire Item Factor 1 Factor 2 Factor 3 25 Told what symptoms should lead to calling doctor.80 2 Condition clearly explained Explained influence on lifestyle.76 3 Told what symptoms to expect.76 5 Medication explained.71 1 Provided with information Explained physical activity Told what changes to make to diet Instruction to plan own daily meals Consistent information about symptoms to seek help.67 4 Given opportunity to ask questions.64 7 Told of potential side effects.63 8 Told of what to do if side effects Well prepared for discharge.56 6 Told how to take medication Providers communicated well while in hospital Given same information about meds Family/friends given information 10 Told when to get blood tests 20 Providers obtained needed information from other providers Providers communicated well after discharge Doctor is aware of blood test results Family physician involved in care Satisfied with care after discharge Providers communicated well in planning move Consistent information from doctors Consistent info from doctors and other providers After discharge, could access services Knew who to contact about problems after discharge Explained again how medication to be taken Explained again potential side effects Reviewed heart medications Explained again what to do about side effects Reviewed treatment plan Standard scheduled appointments Access to information to deal with condition In addition to providing information on the factorial structure of the questionnaire, this study supported the internal consistency of the subscales and provided further information about the validity of the scales. The three-factor solution was further supported by high alpha coefficients of 0.93 for factor one, 0.86 for factor two, and 0.84 for factor three. Further, as would be expected, continuity of care was lower for those with more severe medical conditions. We also found that the questionnaire s total score and its subscales were lower for patients with poor health status as reflected by the Minnesota Living with Heart Failure Questionnaire and SF-8. These correlations were weak but statistically significant. Examination of the overall means for each of the factors revealed that no broad component of continuity fell below the cut-off of 3.75; however, there were disparities among the subscales. The mean score for factor one was 3.89 (SD =.99), for factor two 12

21 4.36 (SD =.73), and for factor three 3.93 (SD = 1.11). In this study, relational continuity was rated much higher than informational or management continuity. What continuity of care problems do patients with congestive heart failure face? Sample: Baseline data were collected from congestive heart failure patients in Regina Qu Appelle Health Region. Of 89 available patients, a sample of 68 was identified (38 males and 30 females) after exclusion criteria were applied. The mean age of the sample was 74.3 years of age (SD = 9.72); most patients were married or living common-law (60.3 percent) or widowed (27.9 percent). Further, half of the patients (54.4 percent) had less than a high school education, and 25 percent had only finished high school. The mean length of stay was 8.5 days (SD = 9.5). All but three participants (five percent) were found to have no impairment or only mild impairments in their cognitive functioning. In cases where significant cognitive impairment was found, relatives provided responses on behalf of the patient. Continuity of care: On the Heart Continuity of Care Questionnaire, congestive heart failure patients obtained an average rating of 3.9 (SD = 0.9) on the total scale (SD = 0.9), 3.7 (SD = 1.1) on the informational continuity subscale, 4.3 (SD = 0.9) for relational continuity, and 3.6 (SD = 1.2) for follow-up continuity. Items with an average rating of less than 3.5 included the following: information on symptoms to expect, discussion of possible side effects, influence of congestive heart failure on lifestyle, physical activity suggestions or limitations, and provision of information about condition to family or friends. Health status: The study participants reported moderate impairments in several areas of their life on the Minnesota Living with Heart Failure Questionnaire (Total X = 39.0, SD = 23.4; Physical X = 20.7, SD = 11.6), Mental X = 7.9, SD = 7.2). The total and subscale scores obtained on this measure are within one standard deviation of the scores obtained by a sample of congestive heart failure patients attending a multidisciplinary, nurse practitioner-managed congestive heart failure clinic (Total X = 44.5, SD = 26.6; Physical X = 19.2, SD = 11.3, Mental X = 8.7, SD = 8). The average SF-8 physical component summary score was 36.3 (SD = 10.9) and the mental component summary score was 47.5 (SD = 11.1). Both the physical and mental component summary scores obtained on this measure are within one standard deviation of physical (X = 32.8, SD = 8.8) and mental health scores (X = 46.6, SD = 12) obtained by a sample of congestive heart failure patients attending a 13

22 multidisciplinary, nurse practitioner-managed congestive heart failure clinic on the SF-36. Based on the New York Heart Association functional classification system, most participants were identified as experiencing slight limitations in their physical activity as a result of the symptoms of their heart condition. Hospitalizations, physician visits, and use of other services: Within one month of their first hospital admission in the study, five (8.3 percent) of the congestive heart failure patients were readmitted to hospital. The rate of readmission increased to 12 (20 percent) patients within three months and to 17 (28.3 percent) patients within six months. The readmission rate reported in this sample is higher than that reported by Tsuyuki and colleagues, 32 based on data from the Canadian Institute for Health Information data for the 2000/2001 fiscal year (reported to be 20 percent). Readmissions may be underestimated because hospital data were incomplete for 50 patients. Repeated visits to the physician were common for patients. On average, patients saw at least one physician on 17.3 days (SD = 13.4) in the six months after the first study admission. In addition, homecare visits were made to 22 (32 percent) patients following their hospitalization. The mean number of homecare visits for a variety of services (such as nursing, homemaking, meal-making) was 5.9 (SD = 1.5). Quality of care audit: In all, 49.2 percent of patients had an echocardiogram in the year prior to admission. Monitoring of body weight occurred at least once during a hospital stay for 42.6 percent of the congestive heart failure patients. Only 32.8 percent of patients were weighed on at least 50 percent of the days they were in hospital. Education was documented for 43.9 percent of patients. Mobilization of the patient within 48 hours of admission was reported for 21.3 percent of the sample. A discharge summary was dictated for 88.5 percent of the admissions. Monitoring parameters such as acceptable blood pressure and goal weight were included in the discharge summary for only 27.3 percent of the cases. A suggested acceptable blood pressure was recorded in 6.7 percent, goal weight in 20 percent, and a recent weight in none of the discharge summaries. Angiotensin converting enzyme inhibitors were prescribed during the hospital stay for 69 percent of the sample. Angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers were prescribed for 79 percent of patients during their hospital stay and to 65 percent at discharge. This rate is similar to previous reports. 33 Beta-blockers were prescribed for 52 percent of patients, a rate that changed little at discharge or during the six-month follow-up period. Researchers have found 14

23 beta-blocker use in hospital and at discharge to range from 17 to 77 percent among heart failure patients. Effectiveness of a congestive heart failure integrated care pathway Compared to baseline (before the congestive heart failure integrated care pathway was implemented) and compared to a control group in Saskatoon Health Region, congestive heart failure patients in Regina Qu Appelle Health Region on the integrated care pathway perceived greater continuity of care, primarily related to follow-up care and information provided. Compared to Saskatoon patients, they also reported health benefits, such as better physical and mental health functioning as measured by the SF-8. Similarly, compared to Regina Qu Appelle baseline patients, congestive heart failure patients on the integrated care pathway reported better physical functioning on the SF-8 and the Minnesota Living with Heart Failure Questionnaire. Chart audits showed that care improved in several ways: provision of patient education, daily weighing while in hospital, echocardiograms, and patient mobilization. No significant differences were observed between the standard and the extended congestive heart failure integrated care pathways. Data from Saskatchewan Health on healthcare and drug utilization are not yet available for analysis. RQHR CHF-ICP Patients vs. RQHR CHF Matched Pre-ICP Patients RQHR CHF-ICP RQHR CHF Matched Pre-ICP mean (SD) mean (SD) n = 61 n = 68 Age (10.67) (9.72).30 SF-8 Physical (11.89) (10.90) SF-8 Mental (8.85) (11.06) 0.62 MLHFQ Physical (11.86) (11.57) 0.02 MLHFQ Emotional 7.62 (7.64) 7.85 (7.17) 0.86 HCCQ Information 4.28 (0.85) 3.63 (1.15) 0.00 HCCQ Relationship 4.49 (0.72) 4.31 (0.84) 0.23 HCCQ Management 4.33 (0.91) 3.64 (1.19) 0.00 Length of Stay 9.62 (6.20) 8.51 (9.45) 0.44 % (n = 106) % (n = 61) p Readmissions (6 37.7% (40) 26.2% (16) 0.13 months.) Echocardiogram 62.9% (66) 47.5% (29) 0.05 Weight monitored 100.0% (106) 44.3% (27) Mobilization in 48 h 53.8% (57) 24.6% (15) Education documented 96.2% (101) 41.0% (25) p 15