The objective of this evidence brief is to evaluate the effectiveness of interdisciplinary, multicomponent
intensive primary care programs in reducing mortality and hospital use among
patients identified at highest risk for hospital admission and death while still in the ambulatory
The Evidence-based Synthesis Program (ESP) Coordinating Center investigators and
representatives of the Health Delivery Committee Workgroup worked together to identify the
population, intervention, comparator, timing, setting and study design characteristics of interest.
The Health Delivery Committee Workgroup approved the following eligibility criteria to guide
Population: Patients identified as high risk for hospital admission and/or death, regardless
of whether or not there was a disease-specific focus, such as heart failure.
Interventions: Multi-component, interdisciplinary intensive primary care programs.
Comparator: Usual care (without the utilization of an intensive primary care program).
Outcomes: All-cause mortality, hospitalization, emergency department use, hospital days.
Timing: Studies that include a follow-up period of more than 30 days.
Setting: Ambulatory setting.
Study design: Systematic reviews, controlled clinical trials, observational studies.