Integrated care for chronic respiratory disease: a narrative review

Experiencing integration in Australian primary health care: a pilot study

PurposeDesign, implementation, and evaluation are all important for integrated care. However, they miss one critical factor: education. The authors define “integrated care education” as meaningful learning that purposefully supports collaboration and the development of adaptive expertise in integrated care. The ECHO (Extensions for Community Health Outcomes) model is a novel digital health solution that uses technology-enabled learning (TEL) to facilitate, support, and model integrated care education. Using ECHO Concussion as a case study, the authors describe the effects of technology-enabled integrated care education on the micro-, meso-, and macro-dimensions of integrated care.Design/methodology/approachThis case study was constructed using data extracted from ECHO Concussion from video-archived sessions, participant observation, and internal program evaluation memos. The research team met regularly to discuss the development of relevant themes to the dimensions of integrated care.FindingsOn the micro-level, clinical integration occurs through case-based learning and the development of adaptive expertise. On the meso-level, professional integration is achieved through the development of the “specialist generalist,” professional networks and empathy. Finally, on the macro-level, ECHO Concussion and the ECHO model achieve vertical and horizontal system integration in the delivery of integrated care. Vertical integration is achieved through ECHO by educating and connecting providers across sectors from primary to quaternary levels of care. Horizontal integration is achieved through the establishment of lateral peer-based networks across sectors as a result of participation in ECHO sessions with a focus on population-level health.Originality/valueThis case study examines the role of education in the delivery of integrated care through one program, ECHO Concussion. Using the three dimensions of integrated care on the micro-, meso-, and macro-levels, this case study is the first explicit operationalization of ECHO as a means of delivering integrated care education and supporting integrated care delivery.

“Integrated care” is often used to describe concepts such as coordinated and seamless care instead of the often fragmented and episodic care that patients receive.1 Integrated care reflects the aspirations of modern health care systems and receives significant academic attention. A PubMed search yields >53 000 articles, including >7000 publications about children <18 years old, some of which are published in journals wholly dedicated to the topic (eg, International Journal of Integrated Care).Integrated care is particularly important for the children and youth with chronic conditions who frequently require care by multiple providers in multiple locations over time.2 Achieving integrated care in pediatric health systems adds layers of complexity because of the incorporation of educational and developmental services and other community supports to optimize health. Transitions within and across these systems occur frequently in childhood, including transitions across settings (eg, hospital to home) and across time (eg, preschool to school age), adding further challenges. Pediatric-specific barriers to integrated care include the diversity and/or rarity of underlying conditions among children with chronic illness, the distinct stakeholders in the health ecosystem (eg, parents), and the need to tailor to specific needs at different developmental stages of the child.3 Although support for integrated care is nearly universal, little is known about the effectiveness of pediatric integrated care.Addressing this knowledge gap is the systematic review and meta-analysis published by Wolfe et al.4 The authors conducted a broad search strategy to identify randomized controlled trials comparing integrated care with usual care. They defined integrated care as those having either vertical integration (between primary and secondary and/or subspecialty care), horizontal integration (between sectors like health and education), or longitudinal integration (eg, transition to adult services). Trials describing 18 different interventions were found among diverse populations, with varied, often contradictory outcomes. Some outcomes appeared to improve, such as health-related quality of life in studies of obesity, asthma, or diabetes, whereas others were more mixed (eg, health service use, education, cost outcomes). No studies were focused on longitudinal integration.One of the challenges highlighted by the authors in studying integration is definitional vagueness. Integration is a diffuse term and is often interchangeably used with other terms included in the authors’ search strategy (“care transitions,” “coordinated care,” “shared care,” “whole system thinking,” “medical home”). The effectiveness of some of these concepts have been systematically reviewed. For instance, reviews of the medical home for both broad populations5 as well as children with special health care needs6 have also noted inconsistent definitions but nevertheless overall positive impacts.As the authors note, the absence of measures on intervention implementation makes interpretation challenging. Although individual interventions may have been ineffective, it is plausible that even effective interventions could have resulted in negative findings if either poorly implemented or if the wrong outcomes were selected. A theory-based logic model is essential to link interventions to outcomes, and it is unfortunate that none of the studies identified in the review by Wolfe et al4 described such a model with their intervention.Perhaps the most important question arising from this review is to what extent integration is an intervention in need of evaluation or simply a key health system outcome, as has been proposed for the medical home.7 Although specific integration initiatives may not achieve certain selected outcomes, it would be hard to argue that the construct of integration can be meaningfully determined to be ineffective as a whole. Is there a realistic scenario in which one would conclude that receiving integrated care is not a desirable goal? The more pressing question researchers may need to ask is not “does integration improve child health outcomes?” but rather “does a particular intervention improve integration and at what cost?”To answer this question requires a meaningful measurement of different types of integration outcomes, likely along a continuum because integration itself is multidimensional rather than a simple binary construct. This framework can include that which was used in this review (horizontal, vertical, or longitudinal) but also other highly relevant ones as well (such as integration of behavioral health and/or social determinants of health into medical care). To better understand such outcomes requires clear logic models to illuminate why (and why not) integration improves. Perspectives matter as well because integration outcomes may differ from the viewpoint of patients, health systems, payers, and other stakeholders.8As health systems continue to incentivize integration such as within accountable care organizations or by bundled payments, it is critical that integration is meaningfully assessed. Some dimensions of integration will be easier to improve than others. It is likely much easier, for instance, to integrate vertically (eg, via care coordination between primary and subspecialty care), rather than horizontally, across sectors. Future study of the outcomes of such initiatives requires more clarity than research conducted to date to help ensure that interventions achieve the important integration objectives of a high-functioning child health system.

Lung cancer and chronic non-malignant respiratory disease cause pervasive, multifactorial suffering for patients and informal carers alike. Palliative care aims to reduce suffering and improve quality of life for patients and their families. An established evidence base exists that has demonstrated the essential role of specialist palliative care for people with lung cancer. Emerging evidence supports similar benefits among people with chronic respiratory disease. Many lessons can be learnt from lung cancer care, particularly as the model of care delivery has transformed over recent decades due to major advances in the diagnostic pathway and the development of new treatments. This narrative review aims to summarize the evidence for specialist palliative care in lung cancer and chronic respiratory disease, by highlighting seven key lessons from lung cancer care that can inform the development of proactive, integrated models of palliative care among those with chronic respiratory disease. These seven lessons emphasize (1) managing challenging symptoms; (2) the efficacy of specialist palliative care; (3) the importance of providing specialist palliative care integrated with disease-directed care according to patients' needs not prognosis; (4) the need for new models of collaborative palliative care, (5) which are culturally appropriate and (6) able to evolve with changes in disease-directed care. Finally, we discuss (7) some of the critical research gaps that persist and reduce implementation in practice.

Respiratory diseases in Italy already now represent an emergency (they are the 3rd ranking cause of death in the world, and the 2nd if Lung cancer is included). In countries similar to our own, they result as the principal cause for a visit to the general practitioner (GP) and the second main cause after injury for recourse to Emergency Care. Their frequency is probably higher than estimated (given that respiratory diseases are currently underdiagnosed). The trend is towards a further increase due to epidemiologic and demographic factors (foremost amongst which are the widespread diffusion of cigarette smoking, the increasing mean age of the general population, immigration, and pollution). Within the more general problem of chronic disease care, chronic respiratory diseases (CRDs) constitute one of the four national priorities in that they represent an important burden for society in terms of mortality, invalidity, and direct healthcare costs. The strategy suggested by the World Health Organization (WHO) is an integrated approach consisting of three goals: inform about health, reduce risk exposure, improve patient care. The three goals are translated into practice in the three areas of prevention (1-primary, 2-secondary, 3-tertiary) as:1) actions of primary (universal) prevention targeted at the general population with the aim to control the causesof disease, and actions of Predictive Medicine - again addressing the general population but aimed at measuring the individual’s risk for disease insurgence; 2) actions of early diagnosis targeted at groups or - more precisely - subgroups identified as at risk; 3) continuous improvement and integration of care and rehabilitation support - destined at the greatest possible number of patients, at all stages of disease severity. In Italy, COPD care is generally still inadequate. Existing guidelines, institutional and non-institutional, are inadequately implemented: the international guidelines are not always adaptable to the Italian context; the document of the Agency for Regional Healthcare Services (AGE.NA.S) is a more suited compendium for consultation, and the recent joint statement on integrated COPD management of the three major Italian scientific Associations in the respiratory area together with the contribution of a Society of General Medicine deals prevalently with some critical issues (appropriateness of diagnosis, pharmacological treatment, rehabilitation, continuing care); also the document “Care Continuity: Chronic Obstructive Pulmonary Disease (COPD)” of the Global Alliance against chronic Respiratory Diseases (GARD)-Italy does not treat in depth the issue of early diagnosis. The present document – produced by the AIMAR (Interdisciplinary Association for Research in Lung Disease) Task Force for early diagnosis of chronic respiratory disease based on the WHO/GARD model and on available evidence and expertise –after a general examination of the main epidemiologic aspects, proposes to integrate the above-mentioned existing documents. In particular: a) it formally indicates on the basis of the available evidence the modalities and the instruments necessary for carrying out secondary prevention at the primary care level (a pro-active,‘case-finding’approach; assessment of the individual’s level of risk of COPD; use of short questionnaires for an initial screening based on symptoms; use of simple spirometry for the second level of screening); b) it identifies possible ways of including these activities within primary care practice; c) it places early diagnosis within the “systemic”, consequential management of chronic respiratory diseases, which will be briefly described with the aid of schemes taken from the Italian and international reference documents.

Respiratory diseases in Italy already now represent an emergency (they are the 3rd ranking cause of death in the world, and the 2nd if Lung cancer is included). In countries similar to our own, they result as the principal cause for a visit to the general practitioner (GP) and the second main cause after injury for recourse to Emergency Care. Their frequency is probably higher than estimated (given that respiratory diseases are currently underdiagnosed). The trend is towards a further increase due to epidemiologic and demographic factors (foremost amongst which are the widespread diffusion of cigarette smoking, the increasing mean age of the general population, immigration, and pollution). Within the more general problem of chronic disease care, chronic respiratory diseases (CRDs) constitute one of the four national priorities in that they represent an important burden for society in terms of mortality, invalidity, and direct healthcare costs. The strategy suggested by the World Health Organization (WHO) is an integrated approach consisting of three goals: inform about health, reduce risk exposure, improve patient care. The three goals are translated into practice in the three areas of prevention (1-primary, 2-secondary, 3-tertiary) as: 1) actions of primary (universal) prevention targeted at the general population with the aim to control the causes of disease, and actions of Predictive Medicine - again addressing the general population but aimed at measuring the individual’s risk for disease insurgence; 2) actions of early diagnosis targeted at groups or - more precisely - subgroups identified as at risk; 3) continuous improvement and integration of care and rehabilitation support - destined at the greatest possible number of patients, at all stages of disease severity. In Italy, COPD care is generally still inadequate. Existing guidelines, institutional and non-institutional, are inadequately implemented: the international guidelines are not always adaptable to the Italian context; the document of the Agency for Regional Healthcare Services (AGE.NA.S) is a more suited compendium for consultation, and the recent joint statement on integrated COPD management of the three major Italian scientific Associations in the respiratory area together with the contribution of a Society of General Medicine deals prevalently with some critical issues (appropriateness of diagnosis, pharmacological treatment, rehabilitation, continuing care); also the document “Care Continuity: Chronic Obstructive Pulmonary Disease (COPD)” of the Global Alliance against chronic Respiratory Diseases (GARD)-Italy does not treat in depth the issue of early diagnosis. The present document – produced by the AIMAR (Interdisciplinary Association for Research in Lung Disease) Task Force for early diagnosis of chronic respiratory disease based on the WHO/GARD model and on available evidence and expertise –after a general examination of the main epidemiologic aspects, proposes to integrate the above-mentioned existing documents. In particular: a) it formally indicates on the basis of the available evidence the modalities and the instruments necessary for carrying out secondary prevention at the primary care level (a pro-active,‘case-finding’approach; assessment of the individual’s level of risk of COPD; use of short questionnaires for an initial screening based on symptoms; use of simple spirometry for the second level of screening); b) it identifies possible ways of including these activities within primary care practice; c) it places early diagnosis within the “systemic”, consequential management of chronic respiratory diseases, which will be briefly described with the aid of schemes taken from the Italian and international reference documents.

Palliative care is essential for patients with chronic pulmonary diseases, especially in low- and middle-income countries (LMICs). Chronic respiratory diseases (CRDs), such as chronic obstructive pulmonary disease and interstitial lung diseases, cause significant morbidity and mortality globally, with a heavy burden in LMICs. Despite the need, access to palliative care in LMICs is limited, leading to inadequate symptom management and support. Palliative care benefits include improved quality of life, reduced healthcare costs, and increased patient and family satisfaction. However, barriers in LMICs, including limited resources, infrastructure, and trained providers, as well as cultural and regulatory challenges, hinder care delivery. Early integration of palliative care for patients with CRDs can enhance outcomes and reduce healthcare utilization, yet it remains underutilized in these regions. This review highlights the challenges and impact of palliative care for CRDs in these regions. Addressing these issues requires regulatory reforms, provider education, and investments in healthcare infrastructure. Solutions include national policies, training healthcare professionals, telemedicine, and research collaborations. Understanding and addressing barriers to palliative care in LMICs is crucial for improving care quality and outcomes for patients with CRDs.

The impacts of different R&D organizational structures on performance of firms: Perspective of absorptive capacity

SUMMARY Important elements in the curriculum at the Faculty of Health Sciences in Linköping are vertical integration, i.e. integration between the clinical and basic science sections of the curriculum, and horizontal integration between different subject areas. Integration throughout the whole curriculum is time-consuming for both teachers and students and hard work is required for planning, organization and execution. The aim was to assess the importance of vertical and horizontal integration in an undergraduate medical curriculum, according to opinions among students and teachers. In a questionnaire 102 faculty teachers and 106 students were asked about the importance of 14 different components of the undergraduate medical curriculum including vertical and horizontal integration. They were asked to assign between one and six points to each component (6 points = extremely important for the quality of the curriculum; 1 point = unimportant). Students as well as teachers appreciated highly both forms of integration. Students scored horizontal integration slightly but significantly higher than the teachers (median 6 vs 5 points; p=0.009, Mann-Whitney U-test), whereas teachers scored vertical integration higher than students (6 vs 5; p=0.019, Mann-Whitney U-test). Both students and teachers considered horizontal and vertical integration to be highly important components of the undergraduate medical programme. We believe both kinds of integration support problem-based learning and stimulate deep and lifelong learning and suggest that integration should always be considered deeply when a new curriculum is planned for undergraduate medical education.

Review question/objective The objective of this systematic review is to identify the best available research evidence related to the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy in people with chronic respiratory diseases, focusing on measures of adherence and health outcomes. The specific review questions to be addressed are: 1. What is the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy in terms of inhalation regimens and inhalation techniques in people with chronic respiratory diseases? 2. What is the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy on health service utilization and patient outcomes including symptoms, pulmonary function, and quality of life? 3. What is the effectiveness of various designs, in terms of components, modes and intensities, of educational and supportive interventions for improving adherence to inhalation therapy? Inclusion criteria Types of participants This review will consider studies that include adults aged 18 or above, with a clinical diagnosis of chronic respiratory disease and prescribed self-administered inhalation therapy as a long term regular treatment, irrespective of the type of inhaler used. For the purposes of this review, "chronic respiratory diseases" is defined by WHO in 2007 as "the chronic diseases of the airways and other structures of the lung" (p.5). 1 Inhalation therapy is defined as "a treatment in which a substance is administered to the respiratory tract with inspired air". 6 This review will focus on inhalation of drugs. Those studies with prescribed administration of oxygen and water will be excluded. There is no universal standard for how long a treatment is undertaken to be defined as a "long term treatment". Acute episodic drug treatments, such as a course of antibiotics, will be excluded. Types of interventions of interest All educational interventions, with or without supportive programs, designed to improve the chronic respiratory disease sufferers inhalation technique and adherence to their prescribed inhalation therapy will be considered. Those studies that involve comparison of different types of inhalation medications, inhaler devices or inhalation methods to improve the adherence to inhalation therapy will be excluded. For the TRUNCATED AT 350 WORDS

Integrated care represents a transformative approach to delivering person-centred healthcare, aiming to reduce health inequalities, improve outcomes and boost system efficiency. The WHO advocates integrated care, which is also a central pillar of the UK government's National Health Service (NHS) 10-year plan. However, there remains a significant evidence gap regarding optimal organisational strategies for designing and delivering integrated care services. Multiple long-term conditions (MLTCs) refer to the coexistence of two or more chronic physical and/or mental health conditions in a person. This complex need requires coordinated support from multiple healthcare services, and individuals with MLTCs may particularly benefit from integrated care services. This review aims to identify and synthesise evidence regarding the organisational structures (care set-up) and processes (care delivery) that support integrated care models for adults with MLTCs. An information specialist and research team will co-develop a search strategy and search databases (MEDLINE, EMBASE and PsycINFO) for empirical articles between January 1990 and December 2025. Date restrictions reflect the establishment of integrated care as a concept for organising and delivering health services. Screening, data extraction and methodological assessment using the Mixed Methods Appraisal Tool will be independently conducted by two researchers. Eligible studies include any empirical studies, including all study designs that investigate adults (aged 18+ years) with MLTCs in high-income countries. This review aims to identify the way integrated care services are designed and delivered. As such, studies must identify and explain the organisational structures and processes involved in implementing and delivering integrated care services to be eligible for inclusion. Extracted data will be categorised according to the two integrated care mechanisms: vertical and horizontal integration. Data will then be examined in relation to how these mechanisms function and/or interact across the macro (system-wide structures and policies), meso (organisational arrangements) and micro (clinical practice and patient-level interactions) levels of integrated care. Review findings will be reported narratively. Ethical approval is not required. This work may directly inform health policy by providing evidence-based understanding of how to organise and deliver integrated care for people living with MLTCs. The findings will be disseminated through publication in a peer-reviewed journal and shared with relevant stakeholders. CRD420251143298.

Novel therapies such as type 2 targeting biologics are emerging treatment options for patients with chronic inflammatory respiratory diseases, fulfilling the needs of severely uncontrolled patients. The majority of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and over half of patients with asthma show a type 2 inflammatory signature in sinonasal mucosa and/or lungs. Importantly, both chronic respiratory diseases are frequent comorbidities, ensuring alleviation of both upper and lower airway pathology by systemic biological therapy. Type 2‐targeting biologics such as anti‐IgE, anti‐IL4Rα, anti‐IL5, and anti‐IL5Rα have entered the market for selected pheno/endotypes of asthma patients and may soon also become available for CRSwNP patients. Given the high prevalence of chronic respiratory diseases and the high cost associated with biologics, patient selection is crucial in order to implement such therapies into chronic respiratory disease care pathways.The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) organized a multidisciplinary Expert Board Meeting to discuss the positioning of biologics into the care pathways for CRSwNP patients with and without comorbid asthma.

As the population ages, informal carers play an increasingly essential role in supporting patients with chronic respiratory diseases (CRDs), often at the expense of their own health. While the psychological effects are well documented, less is currently known about the physical toll of caregiving. Some trials have shown promising outcomes from pulmonary rehabilitation (PR) interventions targeting both patients and informal carers, but study designs have been limited. This trial aims to better understand informal carers' experience by assessing their physical, psychological and social well-being at home, before and after the individual they care for participates in either a home-based or centre-based PR programme. This is a multicentre, convergent parallel mixed-methods study using a before-and-after intervention design. 54 informal carers of patients with CRDs will be recruited from two PR services-27 from a home- and 27 from a centre-based programme. Assessments of the physical, psychological and social well-being of the informal carers will be conducted at home. Semistructured interviews, conducted within 2-weeks post-PR, will explore informal carers' expectations, experiences and support needs. The home-based PR programme will involve weekly 90-min sessions for 8 weeks, supervised at home by a care manager. Informal carers will have the opportunity to participate in PR sessions in accordance with their needs, availability and patient preferences. At the centre-based PR site, patients with CRDs will be enrolled in a 4-week inpatient PR programme or in a 5- to 10-week outpatient PR programme, consisting of 2 or 4 supervised sessions per week (for a total of 20 supervised sessions). Informal carers' attendance will be tracked at both sites. Ethical approval was obtained from the University Sud Mediterranean 3 (24.04596.000457;2024/10/07). The trial results will be presented at scientific conferences, submitted to peer-reviewed journals and shared with decision-makers. NCT06832709.

Introduction: System-wide integrated care cases across the world have often been recognised as “groundbreaking”, “disruptive” or “pioneer”. We all have heard narratives of success, usually by inspirational leaders and told at the initial take-off phases of programmes. But we now little about the challenges faced by these innovators as time passes, leaders perhaps move on, new policy agendas come to compete with integrated care and expectations on the outcomes decline. The programme then rests on decisions makers who have to muddle through the challenges and eventually crises, aiming to advanced integrated health and care in their territories. Aim: Workshop will discuss the experience of decision makers from well-known international cases of system-wide integrated care that have been in place for a few years and have endured various challenges over their journey. Purpose will be to discuss informally the challenges of putting in place and implementing integrated care systems, and the efforts to muddle them through over the years. Four international cases will be discussed by decision-makers. At present, it can be confirmed the inclusion of Catalonia (Spain) and the Basque Country (Spain) and other two experiences are suggested now as a placeholder (one of the Well-being counties in Finland; one of the cases of the Body Corporate model in Scotland; examples from Australia; New Zealand; Canada; etc.) until they can be confirmed. Participants will engage with the following questions: oWhat would we have done differently? oHow much structure did we deploy over the years? oHow far have we moved towards changing relationships, power, involving people, etc? oWhich new governance arrangements and distribution of power has been redesigned? oHow much has the journey changed “whole system”? oHow much the journey has changed me as leader? Do we need a new updated “system leadership” orientation? oWhich main outcomes and measures are being used to monitor progress, from the patient/citizen, workforce and system perspective? oWhich digital transformation are you developing related to Integrated Care agenda? Who is it for? Representatives from other international organisations that have been on the integrated care journey. Representatives from organisations and policymakers from different countries and regions who have recently started or are about to start their own journey. What are you going to do? oIntroduction oRoundtable with different experiences (60 min): Short presentation of each panellist (12 min) Q&amp;A (15 min) oOpen discussion with the audience (20 min) oConclusions (10 min) How are you going to engage with the audience? Special focus on policy and action to develop Integrated Care strategy both within health (vertical integration) and also between health and social care sector (horizontal integration) How are you going to summarize the take home messages? Special focus on practical lessons which could be feasible and scalated in other countries and regions related to Integrated and key core elements of new model of care, governance, outcome framework, finance and commissioning arrangements and integrated information systems to facilitate Integrated care in practice.

BackgroundHow do health systems in the United States view the concept of merger and acquisition (M&A) in a post-COVID 19 “new normal”? How do new entrants to the market and incumbents influence horizontal and vertical integration of health systems? Traditionally, it has been argued that M&A activity is designed to reduce inequities in the market, shift toward value-based care, or enhance the number and quality of health care offerings in a given market. However, the recent history of M&A activity has yielded fewer noble results. As might be expected, the smaller the geographical region in which M&A activity is pursued, the higher the likelihood that monopolistic tendencies will result.ObjectiveWe focused on three types of competition perceptions, external environment uncertainty–related competition, technology disruption–driven competition, and customer service–driven competition, and two integration plans, vertical integration and horizontal integration. We examined (1) how health system characteristics help discern competition perceptions and integration decisions, and (2) how environment-, technology-, and service-driven competition aspects influence vertical and horizontal integration among US health systems in the post-COVID-19 new normal.MethodsWe used data for this study collected through a consultant from a robust group of health system chief executive officers (CEOs) across the United States from February to March 2021. Among the 625 CEOs, 135 (21.6%) responded to our survey. We considered competition and integration aspects from the literature and ratified them via expert consensus. We collected secondary data from the Agency for Healthcare Research and Quality (AHRQ) Compendium of the US Health Systems, leading to a matched data set for 124 health systems. We used inferential statistical comparisons to assess differences across health systems regarding competition and integration, and we used ordered logit estimations to relate competition and integration.ResultsHealth systems generally have a high level of the four types of competition perceptions, with the greatest concern being technology disruption–driven competition rather than environment uncertainty–related competition and customer service–driven competition. The first set of estimation results showed that size, teaching status, revenue, and uncompensated care burden are the main contingent factors influencing the three competition perceptions. The second set of estimation results revealed the relationships between different competition perceptions and integration plans. For vertical integration, environment uncertainty–related competition had a significant positive influence (P<.001), while the influence of technology disruption–driven competition was significant but negative (P<.001). The influence of customer service–driven competition on vertical integration was not evident. For horizontal integration, the results were similar for environment uncertainty–related competition and technology disruption–driven competition; however, the significance of technology disruption–driven competition was weak (P=.05). The influence of customer service–driven competition in the combined model was significant and negative (P<.001).ConclusionsCompetition-driven integration has subtle influences across health systems. Environment uncertainty–related competition is a significant factor, with underlying contingent factors such as revenue concerns and leadership as the leading causes of integration plans. However, technology disruption may hinder integrations. Undoubtedly, small- and low-revenue health systems facing a high level of competition are likely to merge to navigate the health care business successfully. This trend should be a focus of policy to avoid monopolistic markets.