Can chronic disease be managed through integrated care cost-effectively? Evidence from a systematic review

Facilitators and Barriers of Integrated Care for Older Adults with Multimorbidity: A Descriptive Qualitative Study

Purpose

A lack of coordinated care leads to multiple adverse effects for older adults with multimorbidity, including high treatment burdens, adverse health outcomes, reduplicated healthcare service utilization, and catastrophic healthcare expenditure. To foster healthy aging, person-centered integrated care that is responsive to older adults has been proposed by the World Health Organization. The objective of this study was to identify factors that impact the successful implementation of integrated care for older adults with multimorbidity in China.

Patients and Methods

From July 2022 to May 2023, 33 healthcare providers and managers involved in the delivery and management of healthcare services for older adults with multimorbidity were recruited from Zhejiang Province, China using purposeful and maximum variation sampling methods. Semi-structured, face-to-face in-depth interviews were conducted by the same interviewer in the participants' native Chinese language until data saturation was reached. Inductive thematic analysis was used to analyze the data, and then, themes were mapped onto six dimensions using the Rainbow Model of Integrated Care to allow for a comprehensive view of the study's findings.

Results

Eleven themes were generated as facilitators and barriers to integrated care for older adults with multimorbidity in China. These themes include (1) clinical integration: patient-centered care, (2) professional integration: interdisciplinary teams and training, (3) organizational integration: resources and accessibility, (4) system integration: community and funds, incentives, and health insurance, (5) functional integration: electronic health record systems, workforce, and guidelines, and (6) normative integration: shared mission.

Conclusion

Guided by the Rainbow Model of Integrated Care, various factors at both micro, meso, and macro levels that impact the implementation of integrated care for older adults with multimorbidity in the Chinese context have been identified in this study. The strategies for future interventions and policies should focus on promoting facilitators and addressing barriers.

Integration Challenges and Opportunity of Implementing Non-Communicable Disease Screening Intervention with Tuberculosis Patient Care: A Mixed Implementation Study

Background

Despite the comorbidity, early detection and treatment of the two diseases are highly recommended; however, a few pilot studies were conducted, which are mainly focused on diabetes mellitus screening and the integration opportunity and challenges were not known. The study aimed to identify integrated implementation challenges and opportunities of non-communicable disease and risk factors screening intervention with tuberculosis patient care.

Methods

A mixed implementation study design was used. Data were collected from a sample of 443 tuberculosis patients, 21 key informants and facility observations. For quantitative data, descriptive statistics for proportion were summarized in tables and figures. Four distinct implementation frame was adapted for thematic analysis of audio recordings, daily verbatim transcription, and descriptive field notes.

Results

The prevalence of hypertension and diabetes mellitus among tuberculosis patients were 6.55% and 5.64%, respectively. Totally 9 subthemes and 21 new codes were developed, of which 13 and 8 new codes were developed for integrated implementation challenges and opportunities, respectively. The absence of medical equipment, skill and knowledge training, record and report system, cooperative integration, feedback, referral system, shortage of supporting agencies, and services not free were external challenges, whereas lack of trained health workers, focal persons, and increased workload and absence of awareness creation were internal challenges. Despite the challenges, the presence of health extension programs, non-governmental organizations, community health care insurance and associations for diabetes mellitus were external opportunities. Availability of assigned focal persons, trained stakeholders, guidelines, information systems and compatible tuberculosis program structure were internal opportunities.

Conclusion

The majority of TB patients were not comorbid with NCDs. We build a favourable system for integrated implementation developing an integration platform and structural authority at a different organization by addressing identified challenges and applying facilitators is crucial.

Management of chronic conditions in resource limited settings: multi stakeholders' perception and experiences with receiving and providing integrated HIV, diabetes and hypertension services in Tanzania

BACKGROUND

The rising prevalence of non-communicable diseases (NCDs) alongside the continuing high burden of HIV poses a serious challenge to middle- and low-income countries' healthcare systems. Pilot studies of integrated models of service delivery for HIV, hypertension and diabetes have demonstrated that they are feasible and acceptable among patients and care providers. This study assessed multi-stakeholders' perspectives of the delivery and receipt of integrated care in Tanzania.

METHODS

A qualitative process evaluation was conducted in Dar es Salaam region of Tanzania where the integrated service delivery model was implemented from July to November 2021. In-depth interviews were held with seven key informants at the national, regional and district levels, eight healthcare providers, two researchers working at the integrated clinic and forty patients benefiting from integrated services at a large hospital. Three focus group discussions were held with community leaders and residents of the hospital's catchment area, and clinic level observations were conducted. Thematic analysis was conducted followed by the use of Bronfenbrenner's ecological model to identify factors pertinent to sustaining and scaling up of the integrated model.

RESULTS

Participants of the study at all levels were aware of the increased prevalence of NCDs specifically for hypertension and diabetes and were concerned about the trend of increasing co-morbid conditions among people living with HIV (PLHIV). The integrated service delivery model was positively perceived by stakeholders because of its multiple benefits for both patients and the healthcare system. These include stigma and discrimination reduction, improved quality of care, efficient use of limited resources, cost and time saving, reduced duplication of services and fostering of early detection for undiagnosed conditions. The organisation of the clinic was critical in increased satisfaction. Several challenges were observed, which included costs for NCD services relative to free care for HIV and inconsistent availability of NCD medications.

CONCLUSION

Stakeholders reported numerous benefits of the integrated service delivery model that are fundamental in improving the health of many Tanzanians living with NCDs and HIV. These benefits highlight the need for policy and decision-makers to sustain and expand the integrated service delivery model as a solution to many challenges facing the health system especially at the primary care level.

Ethical challenges and principles in integrated care

INTRODUCTION

Integrated care is an established approach to delivery in parts of the healthcare infrastructure, and an ideal which, it is claimed, should be realized system-wide. Its ethical weight derives from its defence of a view about how healthcare ought to operate. Although the goal of integration is laudable, it is ethically and practically complex, involving trade-offs.

SOURCES OF DATA

Considerable evidence attests to widespread enthusiasm for integration, given the need to prevent harm and extend the reach of scarce resources. Equally, evidence increasingly highlights the obstacles to successfully translating this ideal into practice.

AREAS OF AGREEMENT

The principle that healthcare should be seamless, ensuring that patients do not come to harm through gaps in care enjoys broad agreement. There is a similar consensus that placing the patient's perspective at the centre of decision-making is vital, since this enables identification of these gaps.

AREAS OF CONTROVERSY

Integrating care by making it seamless entails blurring boundaries of care domains. This risks undermining the locus of responsibility for care decisions via confusion about who has ownership of specialist knowledge where domains overlap. There is a lack of consensus about how successful integration should be measured.

GROWING POINTS

More research into the relative cost-effectiveness of upstream public health investment in preventing chronic ill-health caused by modifiable lifestyle factors vs integrating care for people already ill; further research into ethical implications of integration in practice, which can be obscured by the simplicity of the fundamental normative principle guiding integration in theory.

Economic evaluation of an integrated virtual care programme for people with chronic illness who are frequent users of health services in Australia

OBJECTIVE

The MeCare programme is a tailored virtual care initiative targeted at frequent users of health services who have at least one chronic condition including cardiovascular disease, chronic respiratory disease, diabetes or chronic kidney disease. The programme aims to prevent unnecessary hospitalisations by helping patients to self-manage, improve their health literacy and engage in positive health behaviours. This study investigates the impact of the MeCare programme on healthcare resource use, costs and patient-reported outcomes.

METHODS AND ANALYSIS

A retrospective pre-post study design was adopted. Data on emergency department presentations, hospital admissions, outpatient appointments and their associated costs were obtained from administrative databases. Probabilistic sensitivity analysis using Monte Carlo simulation was used to model changes in resource use and costs prior to, and following, participant enrolment on the MeCare programme. Generalised linear models were used to investigate the observed changes in patient-reported outcomes.

RESULTS

The MeCare programme cost $A624 per participant month to deliver. Median monthly rates of ED presentations, hospital admissions and average length of stay post-MeCare reduced by 76%, 50% and 12%, respectively. This translated to a median net cost saving of $A982 per participant month (IQR: -1936; -152). A significant, positive trend in patient experience based on responses to the Patient Assessment of Care for Chronic Conditions Questionnaire was observed over the duration of programme enrolment.

DISCUSSION

The MeCare programme is likely to result in substantial cost savings to the health system, while maintaining or improving patient-reported outcomes. Further research in multisite randomised studies is needed to confirm the generalisability of these results.

Challenges to Systems of Long-Term Care: Mapping of the Central Concepts from an Umbrella Review

The ageing of the population poses urgent challenges to the health and social protection sectors, including the need for greater adequacy and integration of health care services provided to older people. It is considered necessary and urgent to understand the state-of-the-art of community-based models of care for older people in institutional care and at home. This study aims to map the concepts that politicians and providers need to address through an umbrella review as a review method. Articles describing the structuring aspects of care models appropriate to the needs in long-term care and systematic reviews or meta-analyses targeting people aged 65 years or more were considered. A total of 350 studies met the inclusion criteria and were included in the review. The results identified the need to contribute to effective and more efficient integration and articulation of all the stakeholders, based essentially on professional care at the patient's homes, focused on their needs using the available technologies, empowering patients and families. Eight categories emerged that addressed factors and variables involved in care models for the long-term care needs of institutionalised and home-based older people as a guarantee of accessibility to healthcare and to enhance the well-being and quality of life of patients and family caregivers.

The acceptability of integrated healthcare services for HIV and non-communicable diseases: experiences from patients and healthcare workers in Tanzania

BACKGROUND

In sub-Saharan Africa, the prevalence of non-communicable diseases (NCDs) has risen sharply amidst a high burden of communicable diseases. An integrated approach to HIV and NCD care offers the potential of strengthening disease control programmes. We used qualitative methods to explore patients' and care-providers' experiences and perspectives on the acceptability of integrated care for HIV-infection, diabetes mellitus (DM), and hypertension (HT) in Tanzania.

METHODS

A qualitative study was conducted in selected health facilities in Dar es Salaam and Coastal regions, which had started to provide integrated care and management for HIV, DM, and HT using a single research clinic for patients with one or more of these conditions. In-depth interviews were held with patients and healthcare providers at three time points: At enrolment (prior to the patient receiving integrated care, at the mid-line and at the study end). A minimum of 16 patients and 12 healthcare providers were sampled for each time point. Observation was also carried out in the respective clinics during pre- and mid-line phases. The Theoretical Framework of Acceptability (TFA) underpinned the structure and interpretation of the combined qualitative and observational data sets.

RESULTS

Patients and healthcare providers revealed a positive attitude towards the integrated care delivery model at the mid-line and at study end-time points. High acceptability was related to increased exposure to service integration in terms of satisfaction with the clinic setup, seating arrangements and the provision of medical care services. Satisfaction also centred on the patients' freedom to move from one service point to another, and to discuss the services and their own health status amongst themselves. Adherence to medication and scheduling of clinic appointments appeared central to the patient-provider relationship as an aspect in the provision of quality services. Multi-condition health education, patient time and cost-saving, and detection of undiagnosed disease conditions emerged as benefits. On the other hand, a few challenges included long waiting times and limited privacy in lower and periphery health facilities due to infrastructural limitations.

CONCLUSION

The study reveals a continued high level of acceptability of the integrated care model among study participants in Tanzania. This calls for evaluation in a larger and a comparative study. Nevertheless, much more concerted efforts are necessary to address structural challenges and maximise privacy and confidentiality.

Integrated healthcare services for HIV, diabetes mellitus and hypertension in selected health facilities in Kampala and Wakiso districts, Uganda: A qualitative methods study

Health policies in Africa are shifting towards integrated care services for chronic conditions, but in parts of Africa robust evidence on effectiveness is limited. We assessed the integration of vertical health services for HIV, diabetes and hypertension provided in a feasibility study within five health facilities in Uganda. From November 2018 to January 2020, we conducted a series of three in-depth interviews with 31, 29 and 24 service users attending the integrated clinics within Kampala and Wakiso districts. Ten healthcare workers were interviewed twice during the same period. Interviews were conducted in Luganda, translated into English, and analysed thematically using the concepts of availability, affordability and acceptability. All participants reported shortages of diabetes and hypertension drugs and diagnostic equipment prior to the establishment of the integrated clinics. These shortages were mostly addressed in the integrated clinics through a drugs buffer. Integration did not affect the already good provision of anti-retroviral therapy. The cost of transport reduced because of fewer clinic visits after integration. Healthcare workers reported that the main cause of non-adherence among users with diabetes and hypertension was poverty. Participants with diabetes and hypertension reported they could not afford private clinical investigations or purchase drugs prior to the establishment of the integrated clinics. The strengthening of drug supply for non-communicable conditions in the integrated clinics was welcomed. Most participants observed that the integrated clinic reduced feelings of stigma for those living with HIV. Sharing the clinic afforded privacy about an individual's condition, and users were comfortable with the waiting room sitting arrangement. We found that integrating non-communicable disease and HIV care had benefits for all users. Integrated care could be an effective model of care if service users have access to a reliable supply of basic medicines for both HIV and non-communicable disease conditions.

Integrated disease management interventions for patients with chronic obstructive pulmonary disease

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A multi-disciplinary and multi-component programme that addresses different elements of care could improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations.

OBJECTIVES

To compare the effectiveness of integrated disease management (IDM) programmes versus usual care for people with chronic obstructive pulmonary disease (COPD) in terms of health-related quality of life (QoL), exercise tolerance, and exacerbation-related outcomes.

SEARCH METHODS

We searched the Cochrane Airways Group Register of Trials, CENTRAL, MEDLINE, Embase, and CINAHL for potentially eligible studies. Searches were current as of September 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared IDM programmes for COPD versus usual care were included. Interventions consisted of multi-disciplinary (two or more healthcare providers) and multi-treatment (two or more components) IDM programmes of at least three months' duration.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. If required, we contacted study authors to request additional data. We performed meta-analyses using random-effects modelling. We carried out sensitivity analyses for the quality of included studies and performed subgroup analyses based on setting, study design, dominant intervention components, and region.

MAIN RESULTS

Along with 26 studies included in the 2013 Cochrane Review, we added 26 studies for this update, resulting in 52 studies involving 21,086 participants for inclusion in the meta-analysis. Follow-up periods ranged between 3 and 48 months and were classified as short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Studies were conducted in 19 different countries. The mean age of included participants was 67 years, and 66% were male. Participants were treated in all types of healthcare settings, including primary (n =15), secondary (n = 22), and tertiary care (n = 5), and combined primary and secondary care (n = 10). Overall, the level of certainty of evidence was moderate to high. We found that IDM probably improves health-related QoL as measured by St. George's Respiratory Questionnaire (SGRQ) total score at medium-term follow-up (mean difference (MD) -3.89, 95% confidence interval (CI) -6.16 to -1.63; 18 RCTs, 4321 participants; moderate-certainty evidence). A comparable effect was observed at short-term follow-up (MD -3.78, 95% CI -6.29 to -1.28; 16 RCTs, 1788 participants). However, the common effect did not exceed the minimum clinically important difference (MCID) of 4 points. There was no significant difference between IDM and control for long-term follow-up and for generic QoL. IDM probably also leads to a large improvement in maximum and functional exercise capacity, as measured by six-minute walking distance (6MWD), at medium-term follow-up (MD 44.69, 95% CI 24.01 to 65.37; 13 studies, 2071 participants; moderate-certainty evidence). The effect exceeded the MCID of 35 metres and was even greater at short-term (MD 52.26, 95% CI 32.39 to 72.74; 17 RCTs, 1390 participants) and long-term (MD 48.83, 95% CI 16.37 to 80.49; 6 RCTs, 7288 participants) follow-up. The number of participants with respiratory-related admissions was reduced from 324 per 1000 participants in the control group to 235 per 1000 participants in the IDM group (odds ratio (OR) 0.64, 95% CI 0.50 to 0.81; 15 RCTs, median follow-up 12 months, 4207 participants; high-certainty evidence). Likewise, IDM probably results in a reduction in emergency department (ED) visits (OR 0.69, 95%CI 0.50 to 0.93; 9 RCTs, median follow-up 12 months, 8791 participants; moderate-certainty evidence), a slight reduction in all-cause hospital admissions (OR 0.75, 95%CI 0.57 to 0.98; 10 RCTs, median follow-up 12 months, 9030 participants; moderate-certainty evidence), and fewer hospital days per person admitted (MD -2.27, 95% CI -3.98 to -0.56; 14 RCTs, median follow-up 12 months, 3563 participants; moderate-certainty evidence). Statistically significant improvement was noted on the Medical Research Council (MRC) Dyspnoea Scale at short- and medium-term follow-up but not at long-term follow-up. No differences between groups were reported for mortality, courses of antibiotics/prednisolone, dyspnoea, and depression and anxiety scores. Subgroup analysis of dominant intervention components and regions of study suggested context- and intervention-specific effects. However, some subgroup analyses were marked by considerable heterogeneity or included few studies. These results should therefore be interpreted with caution.

AUTHORS' CONCLUSIONS

This review shows that IDM probably results in improvement in disease-specific QoL, exercise capacity, hospital admissions, and hospital days per person. Future research should evaluate which combination of IDM components and which intervention duration are most effective for IDM programmes, and should consider contextual determinants of implementation and treatment effect, including process-related outcomes, long-term follow-up, and cost-effectiveness analyses.

Implementing mHealth-Enabled Integrated Care for Complex Chronic Patients With Osteoarthritis Undergoing Primary Hip or Knee Arthroplasty: Prospective, Two-Arm, Parallel Trial

Background

Osteoarthritis is a disabling condition that is often associated with other comorbidities. Total hip or knee arthroplasty is an effective surgical treatment for osteoarthritis when indicated, but comorbidities can impair their results by increasing complications and social and economic costs. Integrated care (IC) models supported by eHealth can increase efficiency through defragmentation of care and promote patient-centeredness.

Objective

This study aims to assess the effectiveness and cost-effectiveness of implementing a mobile health (mHealth)–enabled IC model for complex chronic patients undergoing primary total hip or knee arthroplasty.

Methods

As part of the Horizon 2020 Personalized Connected Care for Complex Chronic Patients (CONNECARE) project, a prospective, pragmatic, two-arm, parallel implementation trial was conducted in the rural region of Lleida, Catalonia, Spain. For 3 months, complex chronic patients undergoing total hip or knee arthroplasty and their caregivers received the combined benefits of the CONNECARE organizational IC model and the eHealth platform supporting it, consisting of a patient self-management app, a set of integrated sensors, and a web-based platform connecting professionals from different settings, or usual care (UC). We assessed changes in health status (12-item short-form survey [SF-12]), unplanned visits and admissions during a 6-month follow-up, and the incremental cost-effectiveness ratio.

Results

A total of 29 patients were recruited for the mHealth-enabled IC arm, and 30 patients were recruited for the UC arm. Both groups were statistically comparable for baseline characteristics, such as age; sex; type of arthroplasty; and Charlson index, American Society of Anesthesiologists classification, Barthel index, Hospital Anxiety and Depression scale, Western Ontario and McMaster Universities Osteoarthritis Index, and Pfeiffer mental status questionnaire scores. Patients in both groups had significant increases in the SF-12 physical domain and total SF-12 score, but differences in differences between the groups were not statistically significant. IC patients had 50% fewer unplanned visits (P=.006). Only 1 hospital admission was recorded during the follow-up (UC arm). The IC program generated savings in different cost scenarios, and the incremental cost-effectiveness ratio demonstrated cost-effectiveness.

Conclusions

Chronic patients undergoing hip or knee arthroplasty can benefit from the implementation of patient-centered mHealth-enabled IC models aimed at empowering patients and facilitating transitions from specialized hospital care to primary care. Such models can reduce unplanned contacts with the health system and reduce overall health costs, proving to be cost-effective. Overall, our findings support the notion of system-wide cross-organizational care pathways supported by mHealth as a successful way to implement IC for patients undergoing elective surgery.

Effectiveness of nurse-led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface: A quantitative systematic review

BACKGROUND

Globally, chronic disease is a leading cause of illness, disability and death and an important driver of health system utilization and spending. Continuity of care is a significant component of quality healthcare. However, an association between nurse-led services, interventions, patient outcomes and continuity of care at the primary and secondary interface as an outcome, has not been established for people with chronic disease.

OBJECTIVE

To identify the effectiveness of nurse-led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface.

DESIGN

Quantitative systematic review.

DATA SOURCES

Systematic searches of Medline, Cochrane, Embase, Emcare, JBI and Scopus databases were conducted of studies published between 1946 and May 2019 using the search terms "nurse", "continuity of care" and "chronic disease".

REVIEW METHODS

Quality of the included studies was assessed using the Cochrane risk of bias tool for randomized controlled trials and Joanna Briggs Institute quality appraisal checklists. A second reviewer screened 10% of full text articles and all articles in critical appraisal. Studies were excluded from the review if they were of poor methodological quality or the description of the effect of the nurse-led service was inadequately reported.

RESULTS

Fourteen studies were included in the review (n=4,090 participants). All studies incorporated recognized continuity of care interventions. The nurse-led services were associated with fewer hospitalizations, reduced by 2-8.9% and re-admissions reduced by 14.8-51% (n=886). Reporting of positive patient experiences and improvement in symptoms and lifestyle was also evident. An association of nurse-led services with improved continuity of care between primary and secondary health services as an outcome per se could not be concluded.

CONCLUSION

Nurse-led services for adults provide coordinated interventions that support continuity of care for people with chronic disease in both the primary and secondary healthcare settings that are associated with reduced hospitalizations or readmissions and patient satisfaction. However, the limited use of validated continuity of care outcome measurement tools precluded establishing correlations between interventions, patient outcomes and continuity of care as a specific outcome.

Innovative Managed Care May Be Related to Improved Prognosis for Acute Myocardial Infarction Survivors

BACKGROUND

Mortality following discharge in myocardial infarction survivors remains high. Therefore, we compared outcomes in myocardial infarction survivors participating and not participating in a novel, nationwide managed care program for myocardial infarction survivors in Poland.

METHODS

We used public databases. We included all patients hospitalized due to acute myocardial infarction in Poland between October 1, 2017 and December 31, 2018. We excluded from the analysis all patients aged <18 years as well as those who died during hospitalization or within 10 days following discharge from hospital. All patients were prospectively followed. The primary end point was defined as death from any cause.

RESULTS

The mean follow-up was 324.8±140.5 days (78 034.1 patient-years; 340.0±131.7 days in those who did not die during the observation). Participation in the managed care program was related to higher odds ratio of participating in cardiac rehabilitation (4.67 [95% CI, 4.44-4.88]), consultation with a cardiologist (7.32 [6.83-7.84]), implantable cardioverter-defibrillator (1.40 [1.22-1.61]), and cardiac resynchronization therapy with cardioverter-defibrillator implantation (1.57 [1.22-2.03]) but lower odds of emergency (0.88 [0.79-0.98]) and nonemergency percutaneous coronary intervention (0.88 [0.83-0.93]) and coronary artery bypass grafting (0.82 [0.71-0.94]) during the follow-up. One-year all-cause mortality was 4.4% among the program participants and 6.0% in matched nonparticipants. The end point consisting of all-cause death, myocardial infarction, or stroke occurred in 10.6% and 12.0% (P<0.01) of participants and nonparticipants respectively, whereas all-cause death or hospitalization for cardiovascular reasons in 42.2% and 47.9% (P<0.001) among participants and nonparticipants, respectively. The difference in outcomes between patients participating and not participating in the managed care program could be explained by improved access to cardiac rehabilitation, cardiac care, and cardiac procedures.

CONCLUSIONS

Managed care following myocardial infarction may be related to improved prognosis as it may facilitate access to cardiac rehabilitation and may provide a higher standard of outpatient cardiac care.

Implementing Mobile Health-Enabled Integrated Care for Complex Chronic Patients: Intervention Effectiveness and Cost-Effectiveness Study

Background

Integrated care can generate health and social care efficiencies through the defragmentation of care and adoption of patient-centered preventive models. eHealth can be a key enabling technology for integrated care.

Objective

The aim of this study was to assess the effectiveness and cost-effectiveness of the implementation of a mobile health (mHealth)-enabled integrated care model for complex chronic patients.

Methods

As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, two-arm, parallel implementation trial was held in a rural region of Catalonia, Spain. During 3 months, elderly patients with chronic obstructive pulmonary disease or heart failure and their carers experienced the combined benefits of the CONNECARE organizational integrated care model and the eHealth platform supporting it, consisting of a patient self-management app, a set of integrated sensors, and a web-based platform connecting professionals from different settings, or usual care. We assessed changes in health status with the 12-Item Short-Form Survey (SF-12), unplanned visits and admissions during a 6-month follow up, and the incremental cost-effectiveness ratio (ICER).

Results

A total of 48 patients were included in the integrated care arm and 28 patients receiving usual care were included in the control arm (mean age 82 years, SD 7 years; mean Charlson index 7, SD 2). Integrated care patients showed a significant increase in the SF-12 physical domain with a mean change of +3.7 (SD 8.4) (P=.004) and total SF-12 score with a mean change of +5.8 (SD 12.8) (P=.003); however, the differences in differences between groups were not statistically significant. Integrated care patients had 57% less unplanned visits (P=.004) and 50% less hospital admissions related to their main chronic diseases (P=.32). The integrated care program generated savings in different cost scenarios and the ICER demonstrated the cost-effectiveness of the program.

Conclusions

The implementation of a patient-centered mHealth-enabled integrated care model empowering the patient, and connecting primary, hospital, and social care professionals reduced unplanned contacts with the health system and health costs, and was cost-effective. These findings support the notion of system-wide cross-organizational care pathways supported by mHealth as a successful way to implement integrated care.

Integrated care for the management of ageing-related non-communicable diseases: current gaps and future directions

Due to the increase in the older population in Europe and associated rise in the absolute number of persons with Non-Communicable Diseases (NCDs), it is becoming increasingly important to find ways to promote healthy ageing, which is defined as the process of developing and maintaining the functional ability that enables well-being in older age. Older persons with NCDs can have complex care needs due to the increased risk of frailty, multimorbidity, and polypharmacy. However, current health systems in Europe often provide fragmented care for older people with NCDs; many receive disjointed care from numerous specialists or via different levels of care. In the current article, we discuss barriers and challenges in implementing integrated care models in European settings for older NCD patients. Specifically, we discuss the need for greater use of case managers in the care and treatment persons with complex care needs as well as the lack of training and education in healthcare professionals on topics related to multimorbidity, frailty, and polypharmacy. We discuss the limitations that arise from the current focus on disease-specific guidelines and care models that do not take comorbid conditions into account, and the lack of good quality evidence that evaluates the effectiveness of integrated care interventions, especially in European health settings. We highlight the importance of evaluating and monitoring mental health in conjunction with somatic symptoms in NCD patients and discuss the integral role of information and communication technology in healthcare to streamline integrated care processes and help to achieve better outcomes for patients.

The cost and cost implications of implementing the integrated chronic disease management model in South Africa

BACKGROUND

A cost analysis of implementation of interventions informs budgeting and economic evaluations.

OBJECTIVE

To estimate the cost of implementing the integrated chronic disease management (ICDM) model in primary healthcare (PHC) clinics in South Africa.

METHODS

Cost data from the provider's perspective were collected in 2019 from four PHC clinics with comparable patient caseloads (except for one). We estimated the costs of implementing the ICDM model current activities for three (facility reorganization, clinical supportive management and assisted self-management) components and additional costs of implementing with enhanced fidelity. Costs were estimated based on budget reviews, interviews with management teams, and other published data. The standard of care activities such as medication were not included in the costing. One-way sensitivity analyses were carried out for key parameters by varying patient caseloads, required infrastructure and staff. Annual ICDM model implementation costs per PHC clinic and per patient per visit are presented in 2019 US dollars.

RESULTS

The overall mean annual cost of implementing the ICDM model was $148 446.00 (SD: $65 125.00) per clinic. Current ICDM model activities cost accounted for 84% ($124 345.00) of the annual mean cost, while additional costs for higher fidelity were 16% ($24 102.00). The mean cost per patient per visit was $6.00 (SD:$0.77); $4.94 (SD:0.70) for current cost and $1.06 (SD:0.33) for additional cost to enhance ICDM model fidelity. For the additional cost, 49% was for facility reorganization, 31% for adherence clubs and 20% for training of nursing staff. In the sensitivity analyses, the major cost drivers were the proportion of effort of assisted self-management staff and the number of patients with chronic diseases receiving care at the clinic.

CONCLUSION

Minimal additional cost are required to implement the ICDM model with higher fidelity. Further research on the cost-effectiveness of the ICDM model in middle-income countries is required.

Integrating health care in Australia: a qualitative evaluation

BACKGROUND

With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses.

METHODS

We aimed to investigate the WSICP's effectiveness through a qualitative evaluation focused on the 10 WSICP strategies using a framework analysis. We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners (GPs) and primary care nurses, and program managers. Most participants (71%) were interviewed twice. We analysed data within a framework describing how strategies were implemented and used, the experiences around these, their perceived value, facilitators and barriers, and participant-identified suggestions for improvement.

RESULTS

Care facilitators helped patients access services within the hospital and in primary care and connected general practices with hospital specialists and services. Rapid access and stabilisation clinics with their patient hotlines assisted patients and carers to self-manage chronic illness while connecting GPs to specialists through the GP support-line. Action plans from the hospital informed GPs and their shared care plans which could be accessed by other community health professionals and patients. HealthPathways provided GPs with local, evidence-based guidelines for managing patients. Difficulties persisted in effective widespread access to shared records and electronic communication across sectors.

CONCLUSIONS

The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research.

Reprint of: Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention: JACC Health Promotion Series

The primary objective of this study was to analyze the most up-to-date evidence regarding whether and how blood sugar regulation influences cardiovascular health promotion and disease prevention by carrying out an umbrella review. Three separate, systematic literature searches identified 2,343 papers in total. Overall, 44 studies were included for data extraction and analysis. The included systematic reviews and meta-analyses published between January 1, 2016, and December 31, 2017, were of good to very good quality (median Overview Quality Assessment Questionnaire score = 17). Identified evidence suggests that cardiovascular disease (CVD) prevention services should consider regulation of blood glucose as a key target for intervention. Furthermore, the recommendations for effective intervention and service development/training described here for prevention of CVD should be adopted into evidence-based practice guidelines. Multidisciplinary teams should be formed to deliver multicomponent interventions in community-based settings. There may be substantial opportunities for integrating CVD and diabetes prevention services.

Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention: JACC Health Promotion Series

The primary objective of this study was to analyze the most up-to-date evidence regarding whether and how blood sugar regulation influences cardiovascular health promotion and disease prevention by carrying out an umbrella review. Three separate, systematic literature searches identified 2,343 papers in total. Overall, 44 studies were included for data extraction and analysis. The included systematic reviews and meta-analyses published between January 1, 2016, and December 31, 2017, were of good to very good quality (median Overview Quality Assessment Questionnaire score = 17). Identified evidence suggests that cardiovascular disease (CVD) prevention services should consider regulation of blood glucose as a key target for intervention. Furthermore, the recommendations for effective intervention and service development/training described here for prevention of CVD should be adopted into evidence-based practice guidelines. Multidisciplinary teams should be formed to deliver multicomponent interventions in community-based settings. There may be substantial opportunities for integrating CVD and diabetes prevention services.

Multi-disciplinary decision making in general practice

Purpose Internationally, healthcare systems are moving towards delivering care in an integrated manner which advocates a multi-disciplinary approach to decision making. Such an approach is formally encouraged in the management of Atrial Fibrillation patients through the European Society of Cardiology guidelines. Since the emergence of new oral anticoagulants switching between oral anticoagulants (OACs) has become prevalent. This case study considers the role of multi-disciplinary decision making, given the complex nature of the agents. The purpose of this paper is to explore Irish General Practitioners' (GPs) experience of switching between all OACs for Arial Fibrillation (AF) patients; prevalence of multi-disciplinary decision making in OAC switching decisions and seeks to determine the GP characteristics that appear to influence the likelihood of multi-disciplinary decision making. Design/methodology/approach A probit model is used to determine the factors influencing multi-disciplinary decision making and a multinomial logit is used to examine the factors influencing who is involved in the multi-disciplinary decisions. Findings Results reveal that while some multi-disciplinary decision-making is occurring (64 per cent), it is not standard practice despite international guidelines on integrated care. Moreover, there is a lack of patient participation in the decision-making process. Female GPs and GPs who have initiated prescriptions for OACs are more likely to engage in multi-disciplinary decision-making surrounding switching OACs amongst AF patients. GPs with training practices were less likely to engage with cardiac consultants and those in urban areas were more likely to engage with other (non-cardiac) consultants. Originality/value For optimal decision making under uncertainty multi-disciplinary decision-making is needed to make a more informed judgement and to improve treatment decisions and reduce the opportunity cost of making the wrong decision.