Coordination of care in health systems for users with diabetes and hypertension: a scoping review.
Virgílio Luiz Marques de Macedo, Naira Pereira de Sousa, Ana Cristina Dos Santos and 3 others
PMID 39879481WHAT IT FOUND
Care coordination for diabetes and hypertension relies heavily on electronic health records, but these tools alone are insufficient.
While shared care with specialists often improves outcomes, many systems fail because secondary services do not send patients back to primary care, leaving gaps in continuity and increasing fragmentation.
Key findings
01Information and communication, care management, and care sharing were the main categories identified in the included studies.
02Electronic health records improve information transfer, but referral and counter-referral forms are often underused, particularly for returning patients to primary care.
03Users with diabetes managed only at the primary level had higher mortality rates than those shared with specialized services, though cost savings were not consistently significant.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The term 'care coordination' is not a standard MeSH/DeCS descriptor, requiring a combination of search terms which may have missed some relevant studies. Most included studies were from the United States (25 of 40), limiting the generalizability to other health systems like Brazil's SUS. The review did not find any existing systematic or scoping reviews on this specific question prior to this search, which may indicate a fragmented literature base. There was a lack of studies addressing the role of Specialized Outpatient Care in coordination, with most focusing on the primary care perspective.
Declared interests
The authors declared no conflicts of interest and stated that the study received no external funding.
The easy way to misread this
Do not assume that implementing electronic health records alone solves coordination problems. The review found that technology is a necessary but insufficient tool; without structured processes for counter-referral and active communication from specialists, patients remain fragmented across the system.