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Meta-analysis: Effect of Interactive Communication Between Collaborating Primary Care Physicians and Specialists

Robbie Foy, MBChB, PhD; Susanne Hempel, PhD; Lisa Rubenstein, MD, MSPH; Marika Suttorp, MS; Michelle Seelig, MD, MSHS; Roberta Shanman, MLS; and Paul G. Shekelle, MD, PhD
[+] Article, Author, and Disclosure Information

From University of Leeds, Leeds, United Kingdom; Southern California Evidence-based Practice Center (RAND Health Division), Santa Monica, California; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; and Group Health Cooperative, Seattle, Washington.

Acknowledgment: The authors thank Breanne Johnsen, Jason Carter, Martha Timmer, and Aneesa Motala for their administrative and analytical support and Martin Roland, DM, and Michael Von Korff, ScD, for their comments and suggestions on earlier versions of the manuscript.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-0612.

Requests for Single Reprints: Robbie Foy, MBChB, PhD, Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds LS2 9LJ, United Kingdom; e-mail, r.foy@leeds.ac.uk.

Current Author Addresses: Dr. Foy: Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds LS2 9LJ, United Kingdom.

Drs. Hempel and Shekelle and Ms. Suttorp: Evidence-based Practice Center, RAND Health, 1776 Main Street, Santa Monica, CA 90407.

Dr. Rubenstein: RAND Health, 1776 Main Street, Santa Monica, CA 90407.

Dr. Seelig: Clinical Knowledge Development and Support, 201 16th Avenue East, Seattle, WA 98112.

Ms. Shanman: RAND Corporation Library, 1776 Main Street, Santa Monica, CA 90407.

Author Contributions: Conception and design: R. Foy, S. Hempel, L. Rubenstein, M. Seelig, P.G. Shekelle.

Analysis and interpretation of the data: R. Foy, S. Hempel, L. Rubenstein, M. Suttorp, P.G. Shekelle.

Drafting of the article: R. Foy, S. Hempel, L. Rubenstein, M. Suttorp, P.G. Shekelle.

Critical revision of the article for important intellectual content: R. Foy, S. Hempel, L. Rubenstein, M. Seelig, P.G. Shekelle.

Final approval of the article: R. Foy, S. Hempel, L. Rubenstein, M. Suttorp, M. Seelig, P.G. Shekelle.

Provision of study materials or patients: R. Foy.

Statistical expertise: M. Suttorp.

Obtaining of funding: R. Foy, P.G. Shekelle.

Administrative, technical, or logistic support: S. Hempel, L. Rubenstein.

Collection and assembly of data: R. Foy, S. Hempel, L. Rubenstein, M. Suttorp, R. Shanman.

Ann Intern Med. 2010;152(4):247-258. doi:10.7326/0003-4819-152-4-201002160-00010
Text Size: A A A

Background: Whether collaborative care models that enable interactive communication (timely, 2-way exchange of pertinent clinical information directly between primary care and specialist physicians) improve patient outcomes is uncertain.

Purpose: To assess the effects of interactive communication between collaborating primary care physicians and key specialists on outcomes for patients receiving ambulatory care.

Data Sources: PubMed, PsycInfo, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Web of Science through June 2008 and secondary references, with no language restriction.

Study Selection: Studies that evaluated the effects of interactive communication between collaborating primary care physicians and specialists on outcomes for patients with diabetes, psychiatric conditions, or cancer.

Data Extraction: Contextual, intervention, and outcome data from 23 studies were extracted by one reviewer and checked by another. Study quality was assessed with a 13-item checklist. Disagreement was resolved by consensus. Main outcomes for analysis were selected by reviewers who were blinded to study results.

Data Synthesis: Meta-analysis indicated consistent effects across 11 randomized mental health studies (pooled effect size, −0.41 [95% CI, −0.73 to −0.10]), 7 nonrandomized mental health studies (pooled effect size, −0.47 [CI, −0.84 to −0.09]), and 5 nonrandomized diabetes studies (pooled effect size, −0.64 [CI, −0.93 to −0.34]). These findings remained robust to sensitivity analyses. Meta-regression indicated studies that included interventions to enhance the quality of information exchange had larger effects on patient outcomes than those that did not (−0.84 vs. −0.27; P = 0.002).

Limitations: Because collaborative interventions were inherently multifaceted, the efficacy of interactive communication by itself cannot be established. Inclusion of study designs with lower internal validity increased risk for bias. No studies involved oncologists.

Conclusion: Consistent and clinically important effects suggest a potential role of interactive communication for improving the effectiveness of primary care–specialist collaboration.

Primary Funding Source: RAND Health's Comprehensive Assessment of Reform Options Initiative, the Veterans Affairs Center for the Study of Provider Behavior, The Commonwealth Fund, and the Health Foundation.


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Figure 2.
Quality criteria for 38 included studies.
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Figure 3.
Forest plot for studies, stratified by type of collaborating specialist.

HbA1c = hemoglobin A1c; RCT = randomized, controlled trial.

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Submit a Comment/Letter
Will evidence be enough to promote interactive communication for the patient benefit?
Posted on March 1, 2010
Alain Braillon
80000 Amiens, France
Conflict of Interest: None Declared

Foy et al gave evidence to back up common sense: patients with depression or diabetes do better simply through family doctors and specialists working together as a team, the collaborations varying from place to place (eg. email, face-to-face conversations)(1).

Recently conducting a programme to improve quality of care, we specifically evaluated the follow-up after discharge in a series of 176 suicide attempts aged from 15to 25 years (mean: 20) hospitalized (mean duration 1,1 day) in the 9 main hospitals in Picardie (France). Among the 90 % who were referred for follow-up (refusal 2 %, not required 5 %, data not available 3 %) we observed that 42 % had to make the appointment by themselves despite that follow-up is important during the days after the attempt and especially for adolescents. As one could have expected, appointments were significantly (p<0.001) more honoured when the appointments were planned during the hospitalisation (60 %) than for those let to the patients' initiative (40 %).

Interactive communication for improving the effectiveness of primary care may remain a real challenge despite evidence-based medicine. Indeed, interactivity is complexity. Interactivity means that a message is related to a number of previous messages and to the relationship between them. This is a much more complex situation than too many paths of care which reduce the patient to an input (diagnosis-related group) in a streamlined and one way sequence of processes.


1 Foy R, Hempel S, Rubenstein L, Suttorp M, Seelig M, Shanman R, Shekelle PG. Meta-analysis: Effect of interactive communication between collaborating primary care physicians and specialists. Ann Intern Med 2010;152:247-58

Conflict of Interest:

AB has recently been sacked (BMJ 2010;340:c711)

No Title
Posted on May 5, 2010
Robbie Foy
Corresponding author
Conflict of Interest: None Declared

We thank Dr. Braillon for his response. We agree that implementing effective systems that can deal with the complexity of patient needs within an increasingly complex healthcare environment represents a significant challenge. Interestingly, our work suggests that the systems required to allow an effective line of interactive communication between collaborating primary care and specialist physicians need not in themselves be complex (e.g. planned telephone or face-to-face contact). We would encourage further work to delineate the core "active ingredients" of collaborative interventions to inform policy initiatives to improve the continuity and outcomes of primary care.

Conflict of Interest:

None declared

Submit a Comment/Letter

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