title: Shared care: a quality improvement initiative to optimize primary care management of constipation.
abstract: BACKGROUND
  Pediatric constipation is commonly managed in the primary care setting, where there is much variability in management and specialty referral use. Shared Care is a collaborative quality improvement initiative between Boston Children's Hospital and the Pediatric Physician's Organization at Children's (PPOC), through which subspecialists provide primary care providers with education, decision-support tools, pre-referral management recommendations, and access to advice. We investigated whether Shared Care reduces referrals and improves adherence to established clinical guidelines.
  
  
  METHODS
  We reviewed the primary care management of patients 1 to 18 years old seen by a Boston Children's Hospital gastroenterologist and diagnosed with constipation who were referred from PPOC practices in the 6 months before and after implementation of Shared Care. Charts were assessed for patient factors and key components of management. We also tracked referral rates for all PPOC patients for 29 months before implementation and 19 months after implementation.
  
  
  RESULTS
  Fewer active patients in the sample were referred after implementation (61/27,365 [0.22%] vs 90/27,792 [0.36%], P = .003). The duration of pre-referral management increased, and the rate of fecal impaction decreased after implementation. No differences were observed in documentation of key management recommendations. Analysis of medical claims showed no statistically significant change in referrals.
  
  
  CONCLUSIONS
  A multifaceted initiative to support primary care management of constipation can alter clinical care, but changes in referral behavior and pre-referral management may be difficult to detect and sustain. Future efforts may benefit from novel approaches to provider engagement and systems integration.
authors.affiliation: Divisions of Gastroenterology, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; daniel.mallon@childrens.harvard.edu.
authors.forename: Daniel
authors.initials: D
authors.lastname: Mallon
authors.affiliation: Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Pediatric Physicians' Organization at Children's, Brookline, Massachusetts; and.
authors.forename: Louis
authors.initials: L
authors.lastname: Vernacchio
authors.affiliation: Pediatric Physicians' Organization at Children's, Brookline, Massachusetts; and.
authors.forename: Emily
authors.initials: E
authors.lastname: Trudell
authors.affiliation: Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; General Pediatrics, Boston Children's Hospital, Boston, Massachusetts;
authors.forename: Richard
authors.initials: R
authors.lastname: Antonelli
authors.affiliation: Divisions of Gastroenterology, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;
authors.forename: Samuel
authors.initials: S
authors.lastname: Nurko
authors.affiliation: Divisions of Gastroenterology, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;
authors.forename: Alan M
authors.initials: AM
authors.lastname: Leichtner
authors.affiliation: Divisions of Gastroenterology, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Pediatric Gastroenterology, University of Massachusetts Memorial Children's Medical Center, Worcester, Massachusetts.
authors.forename: Jenifer R
authors.initials: JR
authors.lastname: Lightdale
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003248:Constipation / Q000628:therapy*; D005260:Female; D005762:Gastroenterology; D006801:Humans; D007223:Infant; D008297:Male; D011320:Primary Health Care; D058996:Quality Improvement; D012017:Referral and Consultation / Q000706:statistics & numerical data*
keywords: constipation; quality improvement