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Managing Continuity of Care Through Integrated Care Pathways: A Study of Congestive Heart Failure and Atrial Fibrillation (RCI - 0072-08)

Challenges in Continuity of Care

Ensuring continuity of care is a challenge in managing patients with atrial fibrillation (AF) and congestive heart failure (CHF). These patients have complex medication regimens, require frequent monitoring, and are seen by many different health care providers in multiple settings. Integrated care pathways (ICPs) 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. ICP use 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 CHF patients and 178 AF patients and, in doing so, established our baseline before implementation of ICPs. 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 during the transition of hospital discharge. To determine the impact of ICPs on continuity of care, we developed and implemented ICPs (an AF-ICP in SHR and a CHF-ICP in RQHR) and then examined patient perceptions of continuity of care and health outcomes approximately six months after hospital discharge. SHR and RQHR acted as each others' concurrent control group. To put a price tag on our ICPs, we added up what it cost - in time and salaries - to develop and implement the ICPs. We also conducted focus groups and structured interviews with providers involved with the ICPs, to gauge their perceptions about ICP development and implementation.

What We Found

Consequences of Poor Continuity of Care

CHF patients wanted more information about their condition and better follow-up care. In particular, they asked for additional instruction about symptoms they could expect, possible side effects, and the influence of CHF on lifestyle and physical activity, as well as that their relatives/friends receive information about CHF.

AF patients wanted to know more about symptoms they should expect and how to manage them, potential side effects of medication and how to manage these, and clearer communication about diet, daily activity, and discharge.

For CHF, quality of care chart audits identified several areas for improvement, including: echocardiography use (49%); weight monitoring (33%); patient education (44%); mobilization within 48 hours (21%); inclusion of key monitoring parameters in discharge summary (27%); beta-blocker use (52%); home care use (22%); and readmission rate (28%).

For AF, quality of care chart audits found that most (71%) patients, for whom it was indicated according to contemporary guidelines, received Warfarin. However, among patients on Warfarin for six months, the drug was in a target range only 47% of the time. There was room for improvement in education about AF, dietary counseling, use of educational videos, and medication counseling.

Effectiveness of ICPs in Improving Continuity and Quality of Care

CHF patients who received care based on an ICP rated their continuity of care more positively than did patients in our baseline group or control group, particularly for follow-up care and information. Chart audits showed improvements in proportions of patients receiving education, daily weighing, echocardiography, and being mobilized within 48 hours. 

AF patients whose care was guided by an ICP did not perceive their continuity of care to be significantly better than our baseline (non-ICP) group or control group of AF patients in RQHR. There was no improvement in the proportion of time that Warfarin was in a therapeutic range. 

Estimated Costs of Developing and Implementing ICPs

It took 1,984 hours, at a salary cost of $67,827, to develop the CHF-ICP. A similar amount (2,083 hours costing $66,890) was needed to implement the ICP.

Development and implementation for the AF-ICP totaled 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 ICPs

Providers believed there are problems in continuity of care for patients with AF and CHF.

Providers thought ICPs addressed some of these problems, by providing information on best practices and opportunities for communication with other members of the care team.

Failure on the part of people using ICPs to take ownership of these care tools was seen as a major barrier to their ongoing use.


The delivery of consistent education about ICPs to the various disciplines of the cardiac care team, across the various care settings, was seen by providers as a challenge to successful ICP implementation.

Providers identified the complexities of AF and CHF, and a lack of interest on the part of some patients to be involved in their own care, as further barriers to ICP adoption.

What We Think it Means

Our baseline study found that CHF and AF patients perceived problems with continuity of care. Among CHF patients whose care was guided by a CHF-ICP, the improvements we saw in patients' perceptions about continuity of care and in measures of quality of care were promising. For AF, we found the AF-ICP to be poorly utilized and observed no effect on both patient perception of continuity of care and quality of care indicators. Our sample sizes were too small and follow-up too short to draw conclusions on patient outcomes. Decision-makers contemplating the use of ICPs also need to consider both costs and organizational challenges.


Dr. Jay Biem, Department of Medicine, U of S
Dr. Heather D. Hadjistavropoulos, Department of Psychology, U of R


Canadian Health Services Research Foundation - $100,000
Saskatchewan Economic and Development Innovation and Science Fund - $100,000


Regina Qu'Appelle Health Region
Saskatoon Health Region
Health Quality Council
Saskatchewan Health

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