Integrating care: what we know and what we do not kno · Figure 2: Incidence rates (per 1000 person-years) of two chronic conditions (second condition in a dyad) and of three chronic

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European Observatory on Health Systems and Policies

Integrating care: what we know and

what we do not knowMoving beyond the rhetoric to improve health

system performance in the EU

European Forum for Primary Care: "Integrated Primary Care: Research, Policy & Practice"

Amsterdam, 31 August 2015

Ellen Nolte

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The rising burden

of chronic disease:

a global risk

Source: World Economic Forum 2013

Figure 2: Global Risks Landscape 2013

In: World Economic Forum. Global Risks 2013. 8th edition. Cologny/Geneva: World Economic Forum, 2013.

URL: www3.weforum.org\docs\WEF_GlobalRisks_Report_2013.p df


The number of people with chronic

conditions is rising

� ~20% to over 40% of population in EU aged 15 years and over report a long

standing health problem

� ~65->80% of over 65s in 2013 Commonwealth Fund survey reported to

have at least one of chronic condition (11 high income countries)

� People with chronic diseases are more likely to utilise health care,

particularly when they have multiple problems

� 70% of total health expenditure associated with the treatment of the 30% of

the population with 1+ chronic condition (~15 million=> to increase to ~18

million by 2025) (England)

� Care for chronic conditions accounts for 55% of GP appointments, 68% of

outpatient and A&E appointments and 77% of inpatient bed days (England)

� Global expenditure on diabetes in 2013 estimated to be US$548 billion,

projected to increase to US$627 billion in 2035

� In 2013, expenditure in the US accounted for more than one-third of the global

expenditure (at US$299 billion), followed by the European region, at US$147

billion

Sources: Eurobarometer (2007); House of Commons (2014); IDF (2013); Osbon et al. (2014);

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Incidence of multimorbidity increases

steeply with age (US data)…

Source: St Sauver et al. (2015)

Figure 2: Incidence rates (per 1000 person-years) o f two chronic conditions (second condition in a dyad) and of three chronic c onditions (third condition in a triad) in men and women separately (A and C), and stratified by ethnicity (B

and D).

In: St Sauver JL, Boyd CM, Grossardt BR et al . Risk of developing multimorbidity across all ages in an historical cohort study: differences by sex

and ethnicity. BMJ Open 2015; 3;5(2):e006413.

URL: http://bmjopen.bmj.com/content/5/2/e006413.full.pdf +html


… but the actual number of people with

multimorbidity is higher at younger ages

Source: Koné Pefoyo et al. (2015)

Figure 1: Distribution of the number of individuals with multimorbidity in Ontario across ages, by number of common chronic co nditions and year.

In: Pefoyo AJ, Bronskill SE, Gruneir A et al . The increasing burden and complexity of multimorbidity. BMC Public Health 2015;15:415.

URL: http://www.biomedcentral.com/content/pdf/s12889-015 -1733-2.pdf

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… in particular affecting those living in

deprived areas

Source: McLean et al. (2014)

Figure 1: Number and type of chronic condition for overall population by number of patients (least and most deprived deciles ).

In: McLean G, Gunn J, Wyke S et al . The influence of socioeconomic deprivation on multimorbidity at different ages: a cross-sectional study. Br J

Gen Pract 2014 Jul;64(624):e440-7.

URL: http://bjgp.org/content/64/624/e440.long


Multimorbidity is associated with

unplanned admission to hospital

Source: Payne et al. (2013)

Figure 1: Predicted probability of unplanned admiss ions to hospital and potentially preventable unplanned admissions to hos pital by deprivation

quintile (1 = least deprived, 5 = most deprived), p hysical multimorbidity and presence of mental health conditions among male and female patients aged 45–

54 years.

In: Payne RA, Abel GA, Guthrie B, Mercer SW. The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. CMAJ 2013;

185(5):E221-8.

URL: http://www.cmaj.ca/content/185/5/E221.long

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What we know

� Rising number of people with complex care needs requires the

development of delivery systems that bring together a range of

professionals and skills from both the cure (healthcare) and

care (long-term and social care) sectors


Care coordination or integration can

improve selected outcomes





� Failure to better integrate or coordinate services may result in suboptimal outcomes

� Evidence that is available points to a positive impact of coordinated care on the quality of patient care and improved health or patient satisfaction outcomes

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Review of care coordination

interventions (Powell Davies et al. 2008)

Source: Powell Davies et al. (2008)

Main focus of intervention (number of studies) Proportion (%) of studies with positive outcome for

Health Service user satisfaction

Cost saving

Changed relationships between service providerse.g. co-location, case management, multi-disciplinary teams (33)

19/29(65.5%)

8/12(66.7%)

2/12(16.7%)

Coordination of clinical activitiese.g. joint consultations, shared assessments and priority access to another clinical service (37)

19/31(61.3%)

4/12(33.3%)

3/15(20%)

Improving communication between service providerse.g. case conferences (56)

26/47(55.3%)

12/22(54.5%)

2/21(14.3%)

Support for clinicianse.g. support or supervision for clinicians, training (joint or relating to collaboration), reminder systems (33)

16/28(57.1%)

8/14(57.1%)

1/12(8.3%)

Information systems to support co-ordinatione.g. care plans; decision support; user held/ shared records; shared information systems; service user register (47)

23/38(60.5%)

7/19(36.8%)

2/13(15.4%)

Support for health/social care service userse.g. education, reminders; assistance in accessing care (19)

6/17(35.3%)

3/6(50.0%)

1/7(14.3%)

All studies 36/65(55.4%)

14/31(45.2%)

5/28(17.9%)


Review of reviews of ‘integrated care

programmes’ (Ouwens et al. 2005)

Source: Ouwens et al. (2005)

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Review of reviews of comprehensive

disease management (Nolte et al. 2014)

Source: Nolte et al. (2014)


Review of reviews of integrated care(Martínez-González et al. 2014)

Source: Martínez-González et al. (2014)

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‘Integrated care’: widely but variously

used in different contexts

� Aim: to link the cure and care sector to enhance outcomes for

those with complex needs

� Different types of integration can occur at different levels

within the system

� Target: Functional, organisational, professional, clinical

� Hierarchical level / breadth: Horizontal, vertical

� Degree: Continuum of integration (linkage – coordination –

integration)

� Process: Normative, systemic

� Process of integration typically requires simultaneous action at

different levels, involving different functions, and it develops in

different phases

Source: Nolte & McKee (2008)


But…





� Failure to better integrate or coordinate services may result in

suboptimal outcomes

� Evidence that is available points to a positive impact of

integrated care on the quality of patient care and improved

health or patient satisfaction outcomes

� Uncertainty remains about the relative effectiveness of

different system-level approaches on care coordination and

outcomes, with particular scarcity of robust evidence on the

economic impacts of integrated care approaches

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Countries have recognised the need

to enhance the coordination of care

� EU-funded project ‘DISMEVAL’ (Developing and validating

disease management evaluation methods for European health

care systems)

� Review of approaches and models in place in 13 countries

across Europe

� Social health insurance systems: Austria, Estonia, France,

Germany, Hungary, Lithuania, Netherlands, Switzerland

� Tax-based systems: Denmark, England, Italy, Latvia, Spain

� Use of the Chronic Care Model as an organising principle


Approaches to enhance coordination

frequently focus on specific conditions

Improve quality of life; place patients at centre; reduce

hospitalisation

Interdisciplinary, intersectoral & coordinated effort

Improve coordination, efficiency and quality

Coordinated treatment and care across providers

Multidisciplinary cooperation; encompasses prevention, early

detection, treatment and rehabilitation

Diabetes type 2

Diabetes type 2 COPD

Asthma/COPD

Depression

Diabetes type 1

Diabetes type 2

IHD

Heart failure

Diabetes type 2 COPDVascular

risk

Diabetes type 1Diabetes

type 2

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Trend towards strengthening the role of nurses

in care delivery and coordination

� Common in systems with tradition in multidisciplinary team working

� Nurse-led clinics; nurse-led case management (England, Italy,

Netherlands, Spain)

� Challenging in systems where primary care traditionally provided by

doctors in solo-practice and few support staff

� Enhanced functions in care coordination or case management under

development/piloted (e.g. Denmark, France; Lithuania)

� Enhanced functions in patient self-management support and/or

selected medical tasks but under supervision of GP/physician (Austria,

France, Germany)


Approaches that seek to reduce barriers

between sectors remain less common

� Typically focus on managing the primary/secondary care and/or

secondary care/rehabilitation interface

� e.g. Provider networks (France); Integrated care contracting (Germany);

Stroke service Delft (Netherlands)

� Often (although not always) implemented as pilot projects

� e.g. (some) Integrated Care Pilots (England); Partnership for Older

People Project (England); Improving intersectoral collaboration (pilot)

(Lithuania); ‘SIKS’ project (Copenhagen, Denmark)

�Typically available in selected regions only

� e.g. Multifunctional community centres (Hungary); Care Coordination

Pilot (Hungary); ‘From On-demand to Proactive Primary Care’ (Tuscany,

Italy); (some) Reform pool projects (Austria)

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What difference do these new

approaches make?

� Improvements reported mainly on process measures (e.g.

eye examinations)

� Evidence of improvement of outcomes less certain

� Germany

� Evidence of improved survival of patients in German diabetes

disease management programmes => selection?

� Limited evidence from (few) controlled studies point to improved

outcomes (quality of life; mortality)

� Methodological challenges

� Some evidence of effect of improved clinical outcomes in

Austrian diabetes disease management programmes


… and to whom?

England� Evaluation of national Integrated Care Pilot programme (16 pilots) found

wide variation in nature and scope of integration

� Staff were more positive about new ways of working than patients

� There was an increase in emergency admissions (9% in case management

sites) but fewer elective admissions and outpatient attendance in the six

months following the intervention

Source: RAND Europe and E&Y (2012); Roland et al. (2012)

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Dutch diabetes care: Clinically relevant

improvements in patients with poor control

Source: Elissen et al. 2012


Evidence of economic impacts of

integrated care remains uncertain

� Review of 19 systematic reviews/meta-analyses

� None of the reviews explicitly focused on ‘integrated care’

� Case management, care coordination, collaborative care, disease management; considerable variation among studies

� Utilisation and cost tend to be the most common economic outcomes assessed but there was substantial variation in conceptualisation and measurement; quality of evidence typically low (small number of studies; before-after designs)

� Early supported discharge or discharge planning: Evidence of significant reduction of readmission rates for older people with heart failure and adults with mental health problems but not stroke patients

� ‘Hospital at home’: non-significant increase in admissions but also significant reduction in mortality at six months (Shepperd et al. 2008)

� Intervention may increase cost

� Impact of health system setting: cost differences for discharge planning for heart failure were smaller in non-US based trials than in US-based trials (Philips et al. 2004)

� Some evidence of cost-effectiveness of selected interventions but difficult to interpret

Source: Nolte & Pitchforth (2014)

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What is the impact of integrating

health and social care funds? � Of 24 schemes that assessed health outcomes only 5 found some evidence of

improved outcomes in the integrated scheme; 1 reported worse outcomes and 13 found no significant impact

� Of 34 schemes that assessed impact on secondary care costs or use only 3 found significantly lower secondary care, 11 found no significant effect

� Anecdotal evidence of unintended consequences such as premature hospital discharge and heightened risk of readmission

� “No scheme achieved a sustained reduction in hospital use.”

� Barriers: difficulty of implementing financial integration; limited control of budget holders over access to services; differences in priorities and governance (UK); difficulties in linking different information systems

� YET: access to care had improved in most schemes, with substantial levels of unmet need identified in some, leading to increase in total costs

� Link between integrating funding and better health outcomes and lower costs likely to be weak

� Integrated care may uncover unmet need which means that total care costs are likely to rise

“Provided that integration delivers improvements in

quality of life, even with additional costs, it may,

nonetheless, offer value for money.”

Source: Mason et al. (2015)


What to do with the available

evidence?

� Evidence needs to be set in the context of health and other outcomes of

the intervention

� Particularly important where evaluations of individual interventions show

an increase in cost while improving outcomes such as mortality

� Absence of evidence does not mean absence of effect: Evaluation

findings have to be placed in the broader context of implementation

� Length of evaluation period might not have been sufficient to demonstrate

economic gain

� Intervention effect will differ by target population and setting, in particular

where initiatives involve a complex interplay of different actors as in

integrated care approaches

� Need to revisit understanding of ‘integrated care’� Complex strategy to innovate and implement long-lasting change across

health and social care

� Requirement of continuous evaluation over extended periods

Source: Nolte & Pitchforth (2014)

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Source: Goodwin et al. (2014)


What needs to be done?

Providing the (regulatory) context to enable innovation

� Create incentive systems that encourage rather than hinder better

coordination among providers and sectors

� particular attention to be paid to changes in health services which

appear likely to fragment care

� Payment systems: e.g. activity-based payment

� Service provision: e.g. competition

�Create a policy environment that provides the means for those who

are asked to implement change to acquire the actual capacity and

competence to do so

� Deliver consistent messages: Policymakers and payers need to be

clear about whether their goal is quality improvement or cost

reduction

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What needs to be done?

Learning from experience

� Systematically assess existing inefficiencies in health service delivery and

disincentives for the patient or the provider to receive or deliver the highest

quality care (such as access or cost)

� Need to use existing evidence to better understand how specific local

conditions influence the outcomes of a given approach to inform

implementation

Incorporating the patient perspective

� Support for people with chronic conditions needs to account for the social

and cultural context and norms within which they live

� Need to understand patient preferences and the importance they place on health

outcomes

� Need to be considered partners in the care process that is sensitive to the

contexts within they make decisions (e.g. ‘experience-based co-design’)


Thank you!

Further reading:

http://www.healthobservatory.eu

Documents

Integrating care: what we know and what we do not kno · Figure 2: Incidence rates (per 1000 person-years) of two chronic conditions (second condition in a dyad) and of three chronic