Taking a “shared care” approach to managing constipation in children

shaking hands shared care constipation

Pediatric constipation results in 2.5 million health care provider visits every year. Nearly 625,000 of these visits are funneled to pediatric gastroenterology specialists, costing, by some estimates, nearly $3.9 billion per year in the United States.

According to members of Boston Children’s Hospital’s Division of Gastroenterology, Hepatology and Nutrition, constipation is one of the most common diagnoses for which children are referred to pediatric GI across the United States. This large volume of referrals presented an opportunity to improve care outcomes by supporting decision- making in the primary care setting.

In an effort to address these challenges, the division joined with the hospital’s Integrated Care Program and the Pediatric Physician’s Organization at Children’s (PPOC) to launch a shared care/quality improvement initiative. This initiative armed primary care providers (PCPs) with education, decision-support tools, pre-referral diagnosis and management advice about treating children with constipation. The primary goal of the study was to investigate whether a “shared care” model might reduce unnecessary referrals and improve adherence to established clinical guidelines. 

Notes sat down with Richard Antonelli, MD—Boston Children’s medical director of integrated care and one of the initiative’s leaders—to discuss the initiative, its results (recently reported in Pediatrics) and what he and his colleagues learned about how PCPs and GI specialists can work together to improve the management of constipation.

Q: What were the shared care initiative’s goals and objectives?

A: Because constipation has been such a common referral diagnosis, it made sense to foster partnerships between PCPs and pediatric GI specialists at Boston Children’s, enabling a more integrated approach to caring for children and youth with constipation. We wanted to broaden the notion of access beyond the traditional face-to-face appointment to include access to timely, actionable information.

Our goal was to help PCPs and GI specialists make joint decisions—in partnership with the patient and the family—related to constipation care, and for all this to happen transparently to the family.

Q: How did the initiative work?

A: In collaboration with primary care providers in the PPOC, Boston Children’s gastroenterologists utilized the widely accepted, evidence-based care guidelines for constipation management, a rapid access call line and secure email messaging to quickly reach GI subspecialists. This enabled PCPs and families to receive actionable diagnoses and management advice in a timely fashion.

If the advice sufficiently addressed the needs of the family and the PCP, no referral to GI was necessary. If the family or PCP felt the need for an additional consultation, a referral was made to the GI clinic.

When indicated, care was shared longitudinally between the PCP and subspecialists. Ideally, that decision was made together with the families, so that clear expectations for follow-up care were set.

What made this different from traditional decision support was the fact that we invested time and energy into creating inter-professional relationships. The members of the clinical teams developed trust, which grew out of authentic familiarity with each other.

Q: What did your formal study of the intervention’s impact reveal?

A: We showed that, through this shared care approach, PCPs can provide longer-term management of childhood constipation in the primary care setting. At the end of the study period, we saw:

  • a reduction in patient referrals
  • a reduction in cases of fecal impaction
  • a rise in collaborative pre-referral management

We did not, however, see any differences in documentation of key management recommendations. Also, our analysis of medical claims revealed no statistically significant changes in referral patterns.

Together, our data suggest that optimizing primary care management of constipation can positively alter clinical care.

Q: What did the gastroenterologists think about the initiative?

A: My colleague Menno Verhave, MD, who is the clinical director of pediatric GI here at Boston Children’s, told me that his team is committed to implementing these new models of care. They felt the project was like going “back to the future,” reminding them of the way care used to be, when primary and subspecialty care providers knew each other, communicated more directly and knew what to expect from one another.

Q: Next steps and hopes for the future?

A: As expectations rise for health care providers to achieve higher value outcomes and lower costs, we expected that this shared care project would serve as a proof of concept. Given this early experience, we expect that these new models of collaborative or shared care will become more commonplace. Certainly our gastroenterologists think so; they have already expanded their efforts to provide shared care, and see it as an essential model for care delivery as the U.S. health care system continues to evolve under the Affordable Care Act (ACA).

Personally, I feel that the ACA provides unprecedented opportunities to fundamentally change how families access care. In the current health policy environment, we have the ability to support high-performing primary care providers, enabling them to keep care local, while at the same time wisely allocating specialty resources to make them more available to those who need the face-to-face contact. Patients and families will be able to receive the right care in the right setting in the right time.

Help your patients learn more about constipation and other gastrointestinal conditions with our complementary ebook, “When is a tummy ache not just a tummy ache?,” available for download at bostonchildrens.org/tummyache.