Collaborative Primary Care Improves Outcomes in Diabetes, Hypertension

Jeannie K. Lee, PharmD

Collaboration among healthcare providers in the primary care setting leads to markedly better patient outcomes in patients with hypertension and diabetes, according to a new systematic review and meta-analysis.

The study focused on the concept of interprofessional collaborative practice (ICP), which the World Health Organization defines as when “multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care.”

Corresponding author Jeannie K. Lee, PharmD, of the University of Arizona College of Pharmacy, and colleagues, noted that while ICP aligns philosophically with many of the goals of the modern healthcare system, there remains little thorough evidence to show its effect, if any, on patient outcomes.

In an effort to change that, Lee and colleagues searched a number of databases for studies published between 2013 and 2018 that evaluated ICP in a primary care setting and which involved adults with diabetes and/or hypertension and assessed HbA1c and systolic and diastolic blood pressure. In the study, ICP was defined as using 3 or more healthcare professionals, including physicians, nurses, dieticians, pharmacists, and other providers.

Out of more than 6,000 articles identified through the searches, the team screened 3,543 studies and identified 50 articles that met their criteria for systematic review. Of those, 39 were included in the meta-analysis; the remaining 11 did not have adequate data. Fifteen of the 39 studies in the meta-analysis were randomized controlled trials (RCTs).

The team used standardized mean difference (SMD) as its metric to determine the impact of ICP. In the case of HbA1c, the investigators found suitable data in 34 studies encompassing 12,599 people. They found collaborative practices in the primary care setting had a positive effect on HbA1c in all settings, but the effect was most pronounced in patients with the highest HBA1c at baseline.

The SMDs in patients with baseline HbA1c of less than 8 had an SMD of -0.13 in ICP settings; those with HbA1c between 8 and 9 had an SMD of -0.24; those with HbA1c of 9 or higher had an SMD of -0.60 in the studies.

Meanwhile, systolic (SBP) and diastolic (DBP) blood pressure had SMDs of -0.31 (based on 25 studies) and -0.28 (based on 24 studies), respectively, in an ICP setting. The observed blood pressure effects were not linked with baseline levels.

Lee and colleagues said they believe their study offers the most comprehensive and up-to-date picture of the impact of ICP in these patients. One strength of their study, they said, was that they included both RCTs and real-world studies.

“Conducted in controlled environments involving specified patient populations and using precise interventions, RCTs have a superior study design with a lower risk of bias,” the investigators said. “Yet, the findings from RCTs may lack real-life scenarios and patient behaviors in response to clinical interventions that more closely reflect everyday experience.”

The authors said the data make a strong case that ICP helps improve patient outcomes in diabetes and hypertension. However, they also said there is a practical reason practices should consider using ICP. They said global increases in chronic diseases like diabetes and the growing elderly population could overwhelm primary care physicians, particularly in areas with limited healthcare resources.

“ICP appears to be a plausible option for areas with limited access to care and in patients with poorer diabetes control,” Lee and colleagues wrote. “Using our findings, primary care practices may wish to consider providing ICP involving at least 3 professions to improve diabetes and hypertension outcomes.”

The study, "Assessment of Interprofessional Collaborative Practices and Outcomes in Adults With Diabetes and Hypertension in Primary Care," was published online in JAMA Network Open.