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

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.

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 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 follow-up 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).

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.