As part of the EU-funded Project INTEGRATE, the research sought to develop an evidence-based understanding of the key dimensions and items of integrated care associated with successful implementation ...across varying country contexts and relevant to different chronic and/or long-term conditions. This paper identifies the core dimensions of integrated care based on a review of previous literature on the topic.
The research reviewed literature evidence from the peer-reviewed and grey literature. It focused on reviewing research articles that had specifically developed frameworks on integrated care and/or set out key elements for successful implementation. The search initially focused on three main scientific journals and was limited to the period from 2006 to 2016. Then, the research snowballed the references from the selected published studies and engaged leading experts in the field to supplement the identification of relevant literature. Two investigators independently reviewed the selected articles using a standard data collection tool to gather the key elements analyzed in each article.
A total of 710 articles were screened by title and abstract. Finally, 18 scientific contributions were selected, including studies from grey literature and experts' suggestions. The analysis identified 175 items grouped in 12 categories.
Most of the key factors reported in the literature derive from studies that developed their frameworks in specific contexts and/or for specific types of conditions. The identification and classification of the elements from this literature review provide a basis to develop a comprehensive framework enabling standardized descriptions and benchmarking of integrated care initiatives carried out in different contexts.
Integrated care interventions introduced in response to the increased demand for long-term care entail profound changes to the health workforce. This exploratory study aims to provide an overview of ...the workforce changes implemented as part of integrated chronic care interventions.
An interactive and emergent research design was used consisting of a literature review, qualitative expert questionnaires and case reports. We defined integrated care as interventions targeting at least two of the six Chronic Care Model components. Workforce changes were defined as those changes experienced by clinical and non-clinical staff responsible for public and individual health intervention.
Seven workforce changes were identified: (1) nurse involvement, (2) multidisciplinary staff, (3) multidisciplinary protocols/pathways, (4) provider training, (5) case manager/care coordinator, (6) team meetings, and (7) new positions. Most interventions included more than one of these workforce changes.
The results of this study provide detailed insights into the current implementation of workforce changes in integrated care interventions and thereby pave the way for further investigations into the relative effectiveness of different workforce changes within the scope of complex interventions. Advancing knowledge in this area is essential for fostering health systems' capacity to cope with the challenges related to the current demographic and epidemiological trends.
Frailty represents an emerging challenge and has major implications for clinical practice, public health, and the sustainability of health systems. It is a geriatric condition, related to but ...distinct from disability and multimorbidity and characterized by a diminished physiological reserve of multiple organs. Despite limited consensus and evidence, it has been argued that cognitive and social aspects influence the condition. Therefore, we aim to provide evidence on the importance of taking a broader approach in defining frailty, by investigating the role of its physical, social, and psychological subdomains to predict healthcare utilisation in elderly Europeans. The study is based on the Survey of Health, Ageing and Retirement in Europe (SHARE), and uses 185,169 total observations from 12 European countries included in wave 4, 5, 6, and 8. The analysis investigates the influence of the physical frailty index (a proxy of the Frailty Phenotype definition), psychological and social frailty indexes (built to proxy the Tilburg Frailty Index) on the likelihood of hospitalisation and the number of doctor visits. We addressed missing values due to item non-response with fully conditional specification multivariate imputation and exploited the longitudinal structure of the data to control for time-fixed unobserved characteristics. In addition, our two multivariate models included regressors to correct for demand side factors (health status, socio-economic status, and behavioral risk) as well as for country-specific characteristics. Physical and psychological frailty positively influence the likelihood of hospitalisation (OR = 1.90 and OR = 1.31, respectively) and the number of doctor visits (IRR = 1.30 and IRR = 1.07), while social frailty reduces the two types of health services utilisation (OR = 0.53 and IRR = 0.90). The three frailty dimensions are relevant risk stratification factors in elderly Europeans, and health policies should focus more on the psycho-social aspects of this condition, as a strategy to both contain expenditures and avoid potential healthcare inequalities.
The Scaling Integrated Care in Context (SCIROCCO) tool has been developed to facilitate knowledge transfer and learning about the implementation and scaling-up of integrated care in European regions. ...To adequately test the functionality of the tool in assessing the maturity for integrated care within regions, this study evaluated its structural validity, internal consistency and convergent validity.
Exploratory factor analysis was used to investigate the structural validity of the 12-items of the SCIROCCO tool. Hereafter, the internal consistency was assessed by calculating Cronbach's and ordinal alpha. The convergent validity was explored by testing 23 pre-hypothesized relationships between items of the SCIROCCO tool and items of an instrument measuring a similar construct.
Factor analysis revealed a one-factor structure. Cronbach's alpha of the overall instrument was 0.92, ordinal alpha was 0.94. Only 30.34% of the hypotheses for testing the convergent validity were met.
The one-factor structure is considered relevant in representing the structural validity of the SCIROCCO tool. The scale of the SCIROCCO tool shows good internal consistency. The tool (DMIC Quickscan) used to assess the convergent validity might measure a different aspect of integrated care than the SCIROCCO tool. Further research is needed to continue investigating the validity and reliability of the tool.
Objective
To examine the patterns of health care utilization by the elderly and test the influence of functional decline.
Data Source and Study Design
We used the three regular waves of the SHARE ...survey to estimate the influence of frailty on health care utilization in 10 European countries. We controlled for the main correlates of frailty and unobserved individual effects.
Results
The frail elderly increase their primary and hospital care utilization before the onset of disability. Multimorbidity moderates the effect of frailty on care utilization.
Conclusions
The prevalence of frailty is high in most countries and is expected to increase. This renders frailty prevention and remediation efforts imperative for two complementary reasons: to promote healthier aging and to reduce the burden on health systems.
The aim of the study is to investigate the barriers and facilitators to the implementation of workforce changes implemented as part of integrated chronic care interventions.
We used a qualitative ...multimethod design that combined expert questionnaires, a systematic literature review, and secondary analysis of two case reports. Twenty-five experts, twenty-one studies and two case reports were included in the study.
Most barriers related to problematic delivery structures, health professionals' skills and enthusiasm, IT, funding, culture and cooperation and communication. Most facilitators related to health professionals' motivation and enthusiasm, good delivery structures, communication and cooperation, IT, patients, leadership and senior management. Overall, similar categories of barriers and facilitators were found.
We recommend that future research focusses on more complex designs including multiple data sources, as these are better able to capture the complexity of interventions such as integrated care. We recommend that health managers and policy-makers should invest in delivery structures and skills and motivation of health professionals to improve the implementation of workforce changes in integrated chronic care interventions.
The added value of the present study lies in its provision of information on which factors might mitigate the success of an intervention, which helps to prevent premature conclusions of ineffectiveness for complex interventions.
Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the ...incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs.
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: (“regional anesthesia” OR “nerve block”) AND (“complications” OR “nerve lesion” OR “nerve damage” OR “nerve injury”). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed.
Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000.
Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.
Several studies have contributed to the development of theoretical frameworks for integrated care implementation. The scholarly articles and technical reports published on the topic identify factors ...or structures of elements fostering care integration: most often they target people suffering from chronic and/or long term conditions. In addition, the majority of these studies focus on a specific context of implementation, hence they do not appreciate the influential role that contextual factors in care integration can play in determining outcomes (González et al., 2018). In particular, most of the literature in the field deals with initiatives implemented in European countries, Australia or North America. While relatively few studies have been conducting specifically for Latin American countries, where high levels of health care fragmentation are evident. A pioneering work concerning integrated care in Latin American’s networks was done by Vázquez et al. (2009). Based on a review of the literature published in the period 1983-2007, the authors presented a conceptual framework for the analysis of the different types of integrated health care networks operating in the Latin American context. More recently, Montenegro et al. (2011) published a contribution where they discussed the lessons learned from the PAHO’s integrated health service delivery networks (IHSDNs) initiative aimed to address the challenges of care integration and continuity of care in Latin American countries. Results suggest that the context matter and, therefore, different contexts require different strategies to achieve success. Based on the Project INTEGRATE’s conceptual framework (www.projectintegrate.eu.com/integrated-care/resource/the-project-integrate-framework) and on a preliminary pilot study conducted in the Summer School at the University of Lugano (July 2018) – involving health professionals/managers from Argentina, Chile and Brazil – we intend to test which elements of the Project INTEGRATE framework are fully suitable to foster implementation of integrated care in the Latin America context, which ones needs to be adapted, and which ones should be further included. Our objective is to propose a framework tailored for Latin American, capturing contextual differences that may be determinant for implementing care integration in the countries of this specific geographic area (for instance, due to the peculiarities of the health systems). The research strategy will involve local experts, decision makers and managers from different health organizations experiencing or seeking care integration. Preliminary results arising from the pilot study suggest that the Latin American context has some particularities that must be taken into account in order to develop a suitable framework to analyze or implement integrated care in such setting. Results may contribute to tackle fragmentation of care and to foster care integration in Latin American countries.
Background and objectives Same-day surgery is common for foot surgery. Continuous regional anesthesia for outpatients has been shown effective but the economic impact on the perioperative ...process-related healthcare costs remains unclear. Methods One hundred twenty consecutive patients were included in this assessor-blinded, prospective cohort study and allocated according to inclusion criteria in the day-care or in the in-patient group. Standardized continuous popliteal sciatic nerve block was performed in both groups for 48 h using an elastomeric pump delivering ropivacaine 0.2 % at a rate of 5 ml/h with an additional 5 ml bolus every 60 min. Outpatients were discharged the day of surgery and followed with standardized telephone interviews. The total direct health costs of both groups were compared. Moreover, the difference in treatment costs and the difference in terms of quality of care and effectiveness between the groups were compared. Results Total management costs were significantly reduced in the day-care group. There was no difference between the groups regarding pain at rest and with motion, persistent pain after catheter removal and the incidence of PONV. Persistent motor block and catheter inflammation/infection were comparable in both groups. There was neither a difference in the number of unscheduled ambulatory visits nor in the number of readmissions. Conclusions Day-care continuous regional analgesia leads to an overall positive impact on costs by decreasing the incidence of unplanned ambulatory visits and unscheduled readmissions, without compromising on the quality of analgesia, patients' satisfaction, and safety.
In several health systems of advanced countries, reforms have changed primary care in the last two decades. The literature has assessed the effects of a variety of interventions and individual ...factors on the behavior of general practitioners (GPs). However, there has been a lack of investigation concerning the influence of the resources embedded in the GPs' personal advice networks (i.e., social capital) on GPs' capacity to meet defined objectives. The present study has two goals: (a) to assess the GPs' personal advice networks according to the social capital framework and (b) to test the influence of such relationships on GPs' capacity to accomplish organizational goals.
The data collection relied on administrative data provided by an Italian local health authority (LHA) and a survey administered to the GPs of the selected LHA. The GPs' personal advice networks were assessed through an ad-hoc instrument and interpreted as egocentric networks. Multivariate regression analyses assessed two different performance measures.
Social capital may influence the GPs' capacity to meet targets, though the influence differs according to the objective considered. In particular, the higher the professional heterogeneity of a GP personal advice network, the lower her/his capacity is to meet targets of prescriptive appropriateness.
Our findings might help to design more effective primary care reforms depending on the pursued goals. However, further research is needed.
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