Abstract
Background: Multimorbidity and chronicity of disease ask for multidisciplinary management in a care continuum, integrating primary and hospital services. Aim: To evaluate cardiovascular risk management via linkage of health data sources, as an example of a multidisciplinary continuum. Design and setting: In this prospective cohort study we linked data from the Utrecht Cardiovascular Cohort(UCC) to the Julius General Practitioners Network database(JGPN). UCC offers structured CVRM at referral to the UMC Utrecht. JGPN consists of EHR data from referring GPs. Methods: We extracted the cardiovascular risk factors for each patient 13 months before referral, at UCC inclusion and during 12 months follow-up. We assessed registration of risk factors, detection of risk factor(s) requiring treatment at UCC, communication of risk factors and actionable suggestions from the specialist to the GP, and change of management during follow-up. Results: In 52% of patients, ≥1 risk factor was registered (i.e., extractable from structured fields within routine care health records) before UCC. In 12-72% of patients risk factor(s) existed requiring (change or start of) treatment at UCC inclusion. Specialist communication included the complete risk profile in 67% of letters, but lacked actionable suggestions in 86%. In 29% of patients at least one risk factor was registered after UCC, of them 21-58% showed change in management. Conclusion: Evaluation of a multidisciplinary LHS is possible via linkage of health data sources. Efforts have to be made to improve registration as well as communication on findings and actionable suggestions for follow-up to bridge the gap in the CVRM continuum.
- Received January 20, 2020.
- Accepted April 13, 2020.
- Copyright © 2020, The Authors
This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)