Precision public-health intervention for care coordination: a real-world study

Area of Science:

• Public Health
• Health Informatics
• Gerontology

Background:

• Health emergencies disproportionately impact vulnerable populations, necessitating effective patient outreach strategies.
• Digital tools offer a promising avenue for primary care providers to identify and engage at-risk patients.
• Timely primary care access is crucial for managing chronic conditions and preventing adverse health outcomes, especially during crises.

Purpose of the Study:

• To compare the effectiveness of digital interventions versus postal interventions in promoting primary care appointments for vulnerable veterans during the COVID-19 pandemic.
• To evaluate the impact of integrating digital messaging directly into general practitioners' (GPs) clinical software for patient care coordination.
• To assess the timeliness of primary care appointments following different intervention delivery methods.

Main Methods:

• A real-world, non-randomised, interventional study was conducted across Australian GP practices.
• Intervention materials promoting care coordination for vulnerable older veterans were delivered digitally to GP software or via post.
• Cox proportional hazards models were used to analyze the time to the first primary care appointment, adjusting for pre-intervention factors.

Main Results:

• The study involved 51,052 veterans receiving digital messaging and 26,859 receiving postal messaging.
• Digital interventions delivered to GP software were associated with significantly earlier primary care appointments (adjusted hazard ratio 1.38).
• The findings were observed during the initial weeks of COVID-19 social distancing restrictions in Australia.

Conclusions:

• Data-driven digital solutions can effectively promote large-scale care coordination during national health emergencies.
• Integrating digital tools into clinical workflows enhances primary care accessibility for vulnerable populations.
• These findings open new avenues for precision public health initiatives leveraging technology for improved health outcomes.