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Title: The design, implementation and evaluation of a shared-care scheme for hypertension
Author: Harrigan, Sarah Morag
Awarding Body: University of Glasgow
Current Institution: University of Glasgow
Date of Award: 1992
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Hypertension is a risk factor for stroke and for coronary heart disease but treatment could reduce the incidence of both. However, treatment is costly and requires lifelong follow-up. Current follow-up of hypertension is inadequate with duplication of medical work, inconsistencies in standards of care, poor information and inefficient use of resources. Registers, clinical information systems, nurses, facilitators, community programs, mini-clinics and shared-care have all been used for the follow-up of hypertensive patients Formal evaluation of the costs and benefits of these new methods of care is important and the cost-effectiveness of shared-care for hypertensive patients has not been examined. The West of Scotland Shared-Care Scheme for Hypertension was developed to co-ordinate specialist, general practitioner and laboratory services. The patient carries a summary record and arranges annual reviews with his/her general practitioner after prompting by the Scheme. Results of annual review are screened by a specialist, the computerised medical records are updated and copies are sent to the general practitioner. A rereferral clinic visit is available at short notice if required. The feasibility, acceptability and cost-effectiveness of the Shared-Care Scheme was compared with that of outpatient and nurse-practitioner care by measuring the number of complete reviews in year 2 for three comparable groups of 277 patients (SC, BPC and NPC groups respectively) as well as variables relating to health status, acceptability of each method and costs to the health service and to patients. Over the two years the SC drop-out rate was significantly less than the BPC and NPC rates (3%, 14% and 9% respectively) and the SC group had more complete reviews than the BPC group (82% versus 54%). There were no differences in self-perceived health status. Two thirds of the SC group apparently maintained or improved their blood pressure control over the two years. Seventeen people attended the re-referral clinic and all but 2 returned to shared-care. Mortality was similar in the three groups. Only two general practitioners withdrew from shared-care and 61% wanted the Scheme to continue with a further 25% having no clear opinion. Shared-care increased the number of general practitioner visits by one per year but the patients in the BPC and NPC groups visited the clinic approximately twice per year. SC patients spent less time and money on attending the consultation, The Personal Health Booklet was used by almost all SC patients and only 4% did not like it. Approximately half of the patients preferred shared-care to outpatient care while 22% had no preference. Around one third of general practitioners preferred shared-care but two thirds preferred their own routine care. The cost-effectiveness ratios for total costs were £28.96, £50.55 and £30.95 per successful review for the SC, BPC and NPC groups respectively ; the SC cost is based on a generous twenty-minute consultation. Shared-care was most cost-effective for patients , the NP clinic was most cost-effective for the NHS. The annual medicine cost is £160.60 for a shared-care patient, £142.35 for a BPC patient and £156.95 for an NPC patient. Including the costs of medicines does not change the ranking of the ratios. The conclusion drawn is that shared-care is acceptable to a majority of patients and general practitioners, provides a cost-effective way of ensuring patient follow-up, standardises care, improves specialist coverage of the population and provides the basis for ongoing evaluation of patient care.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available