title: Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes?
abstract: BACKGROUND
  Chronic disease management requires substantial services integration. A cardiometabolic risk management program inspired by the Chronic Care Model was implemented in Montréal for patients with diabetes or hypertension. One of this study's objectives was to assess the impact of care coordination between the interdisciplinary teams and physicians on patient participation in the program, lifestyle improvements and disease control.
  
  
  METHODS
  We obtained data on health outcomes from a register of clinical data, questionnaires completed by patients upon entry into the program and at the 12-month mark, and we drew information on the program's characteristics from the implementation analysis. We conducted multiple regression analyses, controlling for patient sociodemographic and health characteristics, to measure the association between interdisciplinary team coordination with primary care physicians and various health outcomes.
  
  
  RESULTS
  A total of 1689 patients took part in the study (60.1% participation rate). Approximately 40% of patients withdrew from the program during the first year. At the 12-month follow-up (n = 992), we observed a significant increase in the proportion of patients achieving the various clinical targets. The perception by the interdisciplinary team of greater care coordination with primary care physicians was associated with increased participation in the program and the achievement of better clinical results.
  
  
  CONCLUSIONS
  Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.
authors.affiliation: Direction de santé publique du Centre intégré universitaire de santé et services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada.|Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada.|Institut de recherche en santé publique de l'Université de Montréal, Montréal, Quebec, Canada.
authors.forename: Sylvie
authors.initials: S
authors.lastname: Provost
authors.affiliation: Direction de santé publique du Centre intégré universitaire de santé et services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada.|Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada.|Institut de recherche en santé publique de l'Université de Montréal, Montréal, Quebec, Canada.|Institut national de santé publique du Québec, Montréal, Quebec, Canada.
authors.forename: Raynald
authors.initials: R
authors.lastname: Pineault
authors.affiliation: Direction de santé publique du Centre intégré universitaire de santé et services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada.
authors.forename: Dominique
authors.initials: D
authors.lastname: Grimard
authors.affiliation: Direction de santé publique du Centre intégré universitaire de santé et services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada.|Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada.
authors.forename: José
authors.initials: J
authors.lastname: Pérez
authors.affiliation: Direction de santé publique du Centre intégré universitaire de santé et services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada.
authors.forename: Michel
authors.initials: M
authors.lastname: Fournier
authors.affiliation: Direction de santé publique du Centre intégré universitaire de santé et services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada.
authors.forename: Yves
authors.initials: Y
authors.lastname: Lévesque
authors.affiliation: CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada.|Groupe de médecine de famille et Unité de médecine familiale de Verdun, Montréal, Quebec, Canada.
authors.forename: Johanne
authors.initials: J
authors.lastname: Desforges
authors.affiliation: Direction de santé publique du Centre intégré universitaire de santé et services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada.|Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada.|Institut de recherche en santé publique de l'Université de Montréal, Montréal, Quebec, Canada.|Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada.
authors.forename: Pierre
authors.initials: P
authors.lastname: Tousignant
authors.affiliation: Institut de recherche en santé publique de l'Université de Montréal, Montréal, Quebec, Canada.|Faculté des sciences infirmières de l'Université de Montréal, Montréal, Quebec, Canada.
authors.forename: Roxane
authors.initials: R
authors.lastname: Borgès Da Silva
mesh_terms: D000368:Aged; D001794:Blood Pressure; D002908:Chronic Disease; D019091:Critical Pathways / Q000458:organization & administration*; D003920:Diabetes Mellitus / Q000503:physiopathology / Q000517:prevention & control*; D004032:Diet; D015444:Exercise; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000503:physiopathology / Q000517:prevention & control*; D033183:Interdisciplinary Communication; D008019:Life Style; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000458:organization & administration*; D010358:Patient Participation; D011320:Primary Health Care / Q000458:organization & administration*; D016730:Program Development; D015397:Program Evaluation; D011792:Quebec; D012307:Risk Factors
chemical_list: D006442:Glycated Hemoglobin
keywords: Chronic Care Model; chronic diseases; coordination of care; medical practice; primary care services