# Multidisciplinary Care in a Public University Family Medicine Group in Québec (Canada): Data on Patients’ Follow-Up and Cardiometabolic Risk Management

## TL;DR

This study examines the implementation and effectiveness of a multidisciplinary care model for cardiometabolic risk management in a public healthcare clinic in Québec.

## Contribution

The study provides real-world data on patient follow-up and outcomes in a public university family medicine group offering multidisciplinary care.

## Key findings

- Over 90% of patients had anthropometry and blood pressure measured upon entry, but only 50% had plasma glucose assessed.
- Pharmaceutical interventions were associated with small but statistically significant reductions in diastolic blood pressure.
- No significant associations were found between the number of appointments and changes in BMI or waist circumference.

## Abstract

Background/Objectives: Generating real-world data on the efficacy of multidisciplinary care in cardiometabolic risk management is essential to ensure that guidelines are both applicable and effective, especially in public healthcare settings, where organizational structures may impede healthcare professionals’ agility. This study aimed to generate data on patient follow-up and cardiometabolic risk management during the early years of a public university family medicine group in Québec (Canada) that provides multidisciplinary care to adults with cardiometabolic conditions, in order to evaluate the implementation and effectiveness of its care model. Methods: This was a retrospective longitudinal study. Patients treated at the clinic from 31 January 2020 (clinic opening) to 8 May 2024 (n = 96) were invited to consent to the use of their medical data for research. Results: A total of 52 patients consented and were included in the study. Upon entry at the clinic, >90% of patients had anthropometry and blood pressure (BP) measured, but plasma glucose and lipids were assessed among 50% and 79% of patients, respectively. A total of 36 patients completed the personalized multidisciplinary care program. No evidence of associations between the total number of appointments or appointments with the registered dietitian specifically with changes in BMI, waist circumference, and BP was found. However, each pharmaceutical intervention was associated with a −0.51 cm (95%CI: −1.03, 0.02; p = 0.06) change in waist circumference and a −1.49 mm Hg (95%CI: −2.56, −0.43, p = 0.01) change in diastolic BP. Conclusions: These data highlight the challenges of implementing a research-oriented clinic within Québec’s public healthcare system.