Integrated Health Care Organizations Research Articles

The safety of live attenuated influenza vaccine in children and adolescents 2 through 17years of age: A Vaccine Safety Datalink study.

To evaluate the safety of live attenuated influenza vaccine (LAIV) in children 2 through 17years of age. The study was conducted in 6 large integrated health care organizations participating in the Vaccine Safety Datalink (VSD). Trivalent LAIV safety was assessed in children who received LAIV between September 1, 2003 and March 31, 2013. Eighteen pre-specified adverse event groups were studied, including allergic, autoimmune, neurologic, respiratory, and infectious conditions. Incident rate ratios (IRRs) were calculated for each adverse event, using self-controlled case series analyses. For adverse events with a statistically significant increase in risk, or an IRR>2.0 regardless of statistical significance, manual medical record review was performed to confirm case status. During the study period, 396173 children received 590018 doses of LAIV. For 13 adverse event groups, there was no significant increased risk of adverse events following LAIV. Five adverse event groups (anaphylaxis, syncope, Stevens-Johnson syndrome, adverse effect of drug, and respiratory failure) met criteria for manual medical record review. After review to confirm cases, 2 adverse event groups remained significantly associated with LAIV: anaphylaxis and syncope. One confirmed case of anaphylaxis was observed following LAIV, a rate of 1.7 per million LAIV doses. Five confirmed cases of syncope were observed, a rate of 8.5 per million doses. In a study of trivalent LAIV safety in a large cohort of children, few serious adverse events were detected. Anaphylaxis and syncope occurred following LAIV, although rarely. These data provide reassurance regarding continued LAIV use.

“Looking from the other side”: Using Design Thinking for Strategic Projects at the Basque Health Service

Introduction and description of the practice implemented: The Basque Country has been implementing integrating care policies since 2010 (1). One of the cornerstones of this strategy has been the launch of 13 Integrated Health Care Organisations (IHOs) to integrate under the same structure Primary and Secondary Care Services (2). Nevertheless, structural integration does not deliver better care by its own; and in 2015 the Basque Health Service (BHS) launched a project called IntegraSarea (Network for Integration in Basque) to facilitate cultural change and to create a shared narrative of what integration means based on a People Centred Care approach (3). More than 100 people including managers, patients, carers and health professionals across the Basque Country have been part of this network and the rest of the health workforce (30.000 people) is informed via newsletter, fb and twitter in order to have the maximum amount of people onboard. In this context Design Thinking was chosen to be the method used to help health professionals think “out of the box” and analyse the challenges the health system faces from a user/patient perspective. To reach this goal, four different workshops involving more than 100 people were conducted. Methodology: (Theory of change) Design Thinking (DT) is a methodology that originates from Service Design and was first used in urban planning in 1987 (4). Nowadays the shift to the customer-in-the center of the process is one factor that has motivated companies and other institutions to use Design Thinking as a method to improve and re-design processes from a user perspective. Although the term has changed across time (5) it is widely accepted that DT is a methodology for problem-solving and has five basic steps (see figure 1): empathize, define, ideate, prototype and test. Its use in the health sector is still to be developed and has a huge potential since there is often a gap between patient experience & expectations and the care provided. The latter can be outstanding following traditional indicators of efficacy and efficiency (ie: hip replacement with no complications) and the former could still be bad (ie: despite replacement patient cannot walk due to pain). In the Basque context DT has been fully applicable since the challenges the health sector faces demand multidisciplinary teams and consensus to be successfully implemented, and these are two aspects that DT helps to build. Discussion: Four workshops were designed based on three key areas (Person Cantered Care, care pathways and community networks). After an introductory session on DT, each participant had to carry out fieldwork using different qualitative and ethnographic techniques to identify improvement areas from a patient perspective. This has allowed each Organisation in the BHS to have several of its professionals trained on this methodology, which will have a snowball effect in the future. Moreover, it should be emphasized the importance of inviting patients/users into internal strategic and training projects, which brings in different views and also challenges the status quo of everything for the patient without the patient. Conclusion: The methodology has been strongly accepted by the participants of the workshops like a valid instrument to identify the gaps between patient experience & expectations and the care provided. The Final Report of the workshops details all 52 actions that are proposed to tackle the improvement areas identified and will be presented at the Conference.

Better Evidence to Guide Payment Reforms

While considerable uncertainty exists about the future of health care reform in the United States, interest continues to grow in benefit and payment reforms that support models of care that control costs and improve quality. Despite the large number of reforms being implemented, such as bundled episode payments and per-beneficiary payments to primary care groups and integrated health care organizations, evidence on the effectiveness of these “value-based” financing reforms is mixed and limited,1 leading to ongoing questions about how such reforms affect outcomes and costs in various contexts. This makes it difficult to know which initiatives should be scaled up and which need further refinement or replacement to support a more efficient, high-value health care system.

IntegraSarea: Building up a Network for Integration in the Basque Country

Introduction : The Basque Country has been implementing integrating care policies since 2010 [1]. One of the cornerstones of this strategy has been the launch of 13 Integrated Health Care Organisations (IHOs) to integrate under the same structure Primary and Secondary Care Services [2]. However, structural integration does not deliver better care by its own. Each of the IHOs has had its own experience in integration/”IHOrmation” (ranging from 2010 to 2016) and best practices have not been systematically shared among them. In fact, merging structures could have the opposite desired effect if not followed by a cultural change among health professionals from both levels of care. IntegraSarea (Network for Integration in Basque) was launched in June 2015 with the aim to facilitate cultural change and uses a collaborative methodology to do so. It should be highlighted that professionals, managers and patients from all Integrated Care Organisations are invited to agree on a set of actions that at the end of the project will be incorporated in the integration narrative of the Basque Country. The objective is to combine a traditional top-down approach (the creation of the network is a priority set by the Governing Body of the Health System) together with a bottom-up approach (the actions to be implemented will be agreed by the people who work at the IHO´s) so that all actors at macro, meso and micro level take ownership of the project. Aims : The aim of IntegraSarea is that IHOs share and agree on their best practices and create a common narrative of integration that is shared by everyone. The idea behind this goal is: (i) to foster integration instead of competition between IHOs, (ii) homogenize best practices and certain key aspects of integration so that everyone can benefit, (iii) engage with health professionals and allow them to take ownership of integration policies in the Basque Country and (iv) incorporate the discourse for People and Person Centred Care to the core of the health care system as suggested by WHO [3]. Methodology : Firstly, a literature review to select the most relevant areas of work for integration was conducted and contrasted with relevant actors both internally (Managers of IHOs) and internationally (IFIC and AQuA). The areas that came after this review are: People Centred Care, Social and Care Coordination, Community Health, Model of care for Chronicity and Management. Secondly, one working group per area of work and formed by health professionals from all IHOs has been created and given the task of: (i) co-create a status report of their area of work in the Basque Country, (ii) review the best practices that exist at a local level (iii) agree on a series of actions/practices to scale them up. It should be stated that participants, mostly clinicians and intermediate cadres will play a vital role as agents of change back in their own IHO. Thirdly, in order to overcome the challenge of dissemination among all 35.000 professionals a newsletter is being sent monthly and an online repository in the intranet has been created to allow interaction of professionals from different IHOs. And last but not least, a panel of experts from both inside and outside the Basque Country has been given the mission to guide each workforce throughout the project in order to give technical support when needed. Results : This stage of the project will be completed in June 2016 and preliminary results will be presented in the Conference. In addition to the fulfilment of the deliverables described above a series of evaluation tools linked with integrated care will be used: IEMAC-ARCHO [4], D’Amour Questionnaire [5].

Modeling approach to managing the deployment of integrated organizational models for multi-morbid patients in the CareWell study. The Basque Country case

Modeling approach to managing the deployment of integrated organizational models for multi-morbid patients in the CareWell study. The Basque Country case

Prevalence of Chronic Pain in a Large Integrated Healthcare Delivery System in the U.S.A.

There is a paucity of published data on the prevalence of chronic pain conditions within large, integrated healthcare organizations in the U.S.A. Such data are essential to inform the development of appropriate treatment programs. Twenty-five selected pain conditions were used to identify patients receiving care within the Henry Ford Health System (HFHS) who were enrolled in the Health Alliance Plan (HAP), a subsidiary of HFHS. Patients aged ≥18years, enrolled in HAP in 2010, and having ≥2 encounters, ≥30days apart, with an ICD-9-CM diagnosis code for a pain condition of interest during 2010 were counted. Variables included in the study were as follows: age, gender, body mass index (BMI), and Charlson comorbidity conditions and index score. Altogether, 14,784 persons (11.6% of the total adult population) met the criteria for having a chronic pain condition. Overall, the study population was 64.4% female and had mean age (SD) of 61.2 (15.6) years and mean BMI of 31.4 (7.2) kg/m(2) . Musculoskeletal pain conditions were the most common diagnoses, comprising 75.4% of all pain diagnoses. Diabetes and chronic pulmonary disease were the most common medical comorbidities. In this comprehensive analysis of 2years of data from a large, vertically integrated metropolitan health system, chronic pain was identified in 12% of adult patients. Approximately 75% of chronic pain conditions were musculoskeletal. The triad of age ≥60years, BMI≥30, and female sex were the most salient demographic characteristics of patients with chronic pain conditions. These diagnostic and demographic data may be used to inform treatment program development.

Preventable major cardiovascular events associated with uncontrolled glucose, blood pressure, and lipids and active smoking in adults with diabetes with and without cardiovascular disease: a contemporary analysis.

The objective of this study was to assess the incidence of major cardiovascular (CV) hospitalization events and all-cause deaths among adults with diabetes with or without CV disease (CVD) associated with inadequately controlled glycated hemoglobin (A1C), high LDL cholesterol (LDL-C), high blood pressure (BP), and current smoking. Study subjects included 859,617 adults with diabetes enrolled for more than 6 months during 2005-2011 in a network of 11 U.S. integrated health care organizations. Inadequate risk factor control was classified as LDL-C ≥100 mg/dL, A1C ≥7% (53 mmol/mol), BP ≥140/90 mm Hg, or smoking. Major CV events were based on primary hospital discharge diagnoses for myocardial infarction (MI) and acute coronary syndrome (ACS), stroke, or heart failure (HF). Five-year incidence rates, rate ratios, and average attributable fractions were estimated using multivariable Poisson regression models. Mean (SD) age at baseline was 59 (14) years; 48% of subjects were female, 45% were white, and 31% had CVD. Mean follow-up was 59 months. Event rates per 100 person-years for adults with diabetes and CVD versus those without CVD were 6.0 vs. 1.7 for MI/ACS, 5.3 vs. 1.5 for stroke, 8.4 vs. 1.2 for HF, 18.1 vs. 40 for all CV events, and 23.5 vs. 5.0 for all-cause mortality. The percentages of CV events and deaths associated with inadequate risk factor control were 11% and 3%, respectively, for those with CVD and 34% and 7%, respectively, for those without CVD. Additional attention to traditional CV risk factors could yield further substantive reductions in CV events and mortality in adults with diabetes.

Is there a relationship between the degree of readiness to chronicity and the expected outcomes in Basque Integrated Healthcare Organisations?

Introduction: Three years ago several Integrated Healthcare Organisations (IHOs) were created in the Basque Country, involving primary and secondary level into one single organisation. These brand new structures aim at achieving a more proactive, coordinated and integrated approach to care so that quality and efficiency is improved. In order to monitor the evolution of these organisations some assessment tools have been applied. On the one hand, the ARCHOIEMAC1,2 (Assessment of Readiness for Chronicity in Health Care Organisations)instrument, that is based on the Chronic Care Model” and allows self-assessment of healthcare organisations with respect to their degree of readiness to provide integrated care, has been extensively used. On the other hand, a questionnaire3 to assess interprofessional collaboration between two different care

Evaluation of the new integrated care approach in the Basque Country

In 2010 the Basque Government launched its "Strategy for tackling the challenge of chronicity in the Basque Country", in order to transform healthcare organisations into more integrated care models, with the aim of improving quality and efficiency in chronicity management. Four Integrated Healthcare Organisations (IHOs) were created to unify primary and specialised care into one single organisation. The aim of this study is to measure the degree of readiness of these IHOs to cope with chronicity, using the Chronic Care Model (CCM) as a reference. Self-assessment processes using ARCHO (Assessment of Readiness for Chronicity in Health Care Organisations) were carried out in four IHOs by the management teams. The average score was 16 out of 100 points, which signals that healthcare organisations are undertaking action plans in the realm of integrated care, but with limited deployment and without a systematic process for evaluating outcomes. The dimension that ranks best is "Organization of the health system", while "Community health" has the lowest ranking. IHOs are the key for achieving integrated care for chronic illnesses. Integration of community resources and evaluation of results are two of the fields that need to be improved in order to achieve the set of interventions proposed in ARCHO. The organisational changes involved in the CCM require periods longer than two years.

Risk of Intussusception after Monovalent Rotavirus Vaccination

BackgroundAlthough current rotavirus vaccines were not associated with an increased risk of intussusception in large trials before licensure, recent postlicensure data from international settings suggest the possibility of a small increase in risk of intussusception after monovalent rotavirus vaccination. We examined this risk in a population in the United States.MethodsParticipants were infants between the ages of 4 and 34 weeks who were enrolled in six integrated health care organizations in the Vaccine Safety Datalink (VSD) project. We reviewed medical records and visits for intussusception within 7 days after monovalent rotavirus vaccination from April 2008 through March 2013. Using sequential analyses, we then compared the risk of intussusception among children receiving monovalent rotavirus vaccine with historical background rates. We further compared the risk after monovalent rotavirus vaccination with the risk in a concurrent cohort of infants who received the pentavalent rotavirus vaccine.ResultsDuring the study period, 207,955 doses of monovalent rotavirus vaccine (including 115,908 first doses and 92,047 second doses) were administered in the VSD population. We identified 6 cases of intussusception within 7 days after the administration of either dose of vaccine. For the two doses combined, the expected number of intussusception cases was 0.72, resulting in a significant relative risk of 8.4. For the pentavalent rotavirus vaccine, 1,301,810 doses were administered during the study period, with 8 observed intussusception cases (7.11 expected), for a nonsignificant relative risk of 1.1. The relative risk of chart-confirmed intussusception within 7 days after monovalent rotavirus vaccination, as compared with the risk after pentavalent rotavirus vaccination, was 9.4 (95% confidence interval, 1.4 to 103.8). The attributable risk of intussusception after the administration of two doses of monovalent rotavirus vaccine was estimated to be 5.3 per 100,000 infants vaccinated.ConclusionsIn this prospective postlicensure study of more than 200,000 doses of monovalent rotavirus vaccine, we observed a significant increase in the rate of intussusception after vaccination, a risk that must be weighed against the benefits of preventing rotavirus-associated illness. (Funded by the Centers for Disease Control and Prevention.)

Training in clinical research within individual health organizations: a strategic tool devised for enhancing predictive, preventive and personalized medicine within a comprehensive participative framework

We report our experience in a University Hospital (2012-2013) and in the School of Medicine (2001-2013) in courses committed to promote original thought, to provide basic and operationally useful skills, to teach and to explore the possibilities of setting up networks and existing collaborations. The contribution of ideas, resources, skills and tenacity is the basis for strategic researches aimed at promoting quality, effectiveness and efficiency of health systems. The specific environments and healthcare organizations for which the research is a structural mission need quality and visibility, indicators of quality and efficiency. Vocational training integrated and participated within all the active components with a clinical profile (doctors, nurses, technicians, biologists, dietitians, physiotherapists, others) will facilitate those who wish to plan projects also with international European profile [1,2]. The interaction and contribution of participants are the core of the training methodology and research is developed as a permanent mode of professional development. The course is intended as a modality of updating professionalism and expertise in the field of integrated health care organizations. It has a modular structure and enhances the articulation of medical and surgical areas with the services committed with the evaluation of the quality and with preventive and occupational medicine. The course is based on the enrichment of independent thinking for challenging established concepts and ideas, using also the reappraisal of already accomplished projects [3-5]. 1) Actual research ongoing in the individual clinical institutions, by the presentation of projects implemented or under way, regardless of specific funding. 2) Strategies of Project Management through an analysis of the context (scenario), feasibility, impact and contingency plans. 3) Realistic prospects for fundraising, public and private, building-up overviews of applied research with the contribution of all students. The course implements the explicit use of methodologies of data-mining and the subsequent elemental analysis of usable information: a) predictive models, b) assessments of sensitivity/specificity (diagnostic tests), c) comparative analysis of the risks in case-control or randomized studies, and the calculation of the required number, d) comparison of averages or changes of measures in sequential studies, d) definition of some possibilities for translational research with the development of models.

Rural Health Networks: Adapting to a Changing Health Care Environment

Unemployment and financial struggles affect big and small communities alike. The current economic climate, coupled with changes to the health care environment, presents a unique opportunity for health care providers and community leaders to collaborate, integrate and network. The benefits of health networks are and can be tremendous during times of economic hardships. It takes great effort to assimilate different entities, but the effort is well worth the positive health impact on a community. The Rural Health Network Development Program (RHND) in the federal Office of Rural Health Policy (ORHP) provides an opportunity not only to assist rural communities in meeting unmet health needs, but also to collect data to document health impact in a way that can allow duplication of successes in both rural and urban communities. A rural health network is defined as “a formal organizational arrangement among rural health care providers (and possibly insurers and social service providers) that uses the resources of more than one existing organization and specifies the objectives and methods by which various collaborative functions are achieved.” Rural health networks are designed to respond to an unmet community need and provide benefits to both network partners and the community served by the network in a collaborative or integrative matter. Rural health care providers and rural communities have a plethora of stories relating to how networks have provided substantial benefit in the form of cost savings, implementation of electronic health records, integration of behavioral health care in primary care settings, and a multitude of other healthrelated projects. Yet, there is very little evidence-based data to support the claim that networks can and have improved the rural health care system, which limits the duplication of many of these rural health network projects. The RHND Program was initially created in the late 1990s in response to modifications to the health care delivery system that directly impacted rural providers. During that era, changes were being made to the underlying system of health care financing and delivery, including: a move from fee-for-service payments to capitation and other risk-sharing payment methods; the implementation of market-based strategies for containing costs; an increase in integrated health care organizations; and a move toward more managed care. Rural stakeholders were concerned that the shift to more managed costs would cause people to lose sight of the unique needs of rural patients and providers. Similarly, there are significant changes to our current health care environment, and rural communities and their providers will need to adapt to ensure adequate health services. The current changes that may affect rural health care providers and communities include: (1) improving the quality of care by focusing on patient value as opposed to patient volume;

Readiness for chronicity in Basque Integrated Healthcare Organisations: a cross sectional study

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Organizaciones sanitarias integradas y otros ejemplos de colaboración entre proveedores. Informe SESPAS 2012

Because of the steady increase in healthcare complexity, due to high specialization and the involvement of a number of services, as well as the increase in patients with chronic diseases and pluripathology, coordination has become a high-priority need in healthcare systems. The distinct regional services that comprise the decentralized Spanish National Health System have developed a number of experiences to improve collaboration among the providers involved in the healthcare process. The present article aims to analyze the experiences with integrated healthcare providers in Catalonia and the Basque Country and the chronic diseases programs of the latter. In Catalonia, which promoted the purchaser-provider split and maintained diversity in providers’ ownership, organizations were slowly created that manage the provision of the healthcare continuum, known as integrated healthcare organizations (IHO). These organizations have evolved and, despite some common characteristics, they also show some differences, such as the emphasis on formal instruments or on coordination mechanisms and organic structures. This is also reflected in their results regarding culture and perceived coordination across the organization. In the Basque Country, in addition to the establishment of an IHO, a variety of integration experiences have been developed to improve the care of chronic diseases.

PS2-29: KRAS Testing in Metastatic Colorectal Cancer: The CERGEN-C Comparative Effectiveness Study

Pamala Pawloski, PharmD on behalf of the CERGEN Study Team HealthPartners Research Foundation

Health Information Technology and Disparities in Quality of Care

Health Information Technology and Disparities in Quality of Care

The March to Accountable Care Organizations-How Will Rural Fare?

This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs). ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the literature to describe successful integrated health care organizations that will likely become the first ACOs. Previous research studying rural managed care organizations found rural success stories that can inform the ACO discussion. Preconditions for success as ACOs include enrolling a minimum number of patients to manage financial risk and implementing medical care policies and programs to improve quality. Rural managed care organizations succeeded because of care management experience, nonprofit status, and strong local leadership focused on improving the health of the population served. Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural-relevant ACO-performance measures and provide necessary technical assistance to rural providers and organizations.

Commentary: Health Care Payment Reform and Academic Medicine: Threat or Opportunity?

Discussion of the flaws of the current fee-for-service health care reimbursement model has become commonplace. Health care costs cannot be reduced without moving away from a system that rewards providers for providing more services regardless of need, effectiveness, or quality. What alternatives are likely under health care reform, and how will they impact the challenged finances of academic medical centers? Bundled payment methodologies, in which all providers rendering services to a patient during an episode of care split a global fee, are gaining popularity. Also under discussion are concepts like the advanced medical home, which would establish primary care practices as a regular source of care for patients, and the accountable care organization, under which providers supply all the health care services needed by a patient population for a defined time period in exchange for a share of the savings resulting from enhanced coordination of care and better patient outcomes or a per-member-per-month payment. The move away from fee-for-service reimbursement will create financial challenges for academic medicine because of the threat to clinical revenue. Yet academic health centers, because they are in many cases integrated health care organizations, may be aptly positioned to benefit from models that emphasize coordinated care. The author also has included a series of recommendations for how academic medicine can prepare for the implementation of new payment models to help ease the transition away from fee-for-service reimbursement.

California dreaming.

WHILE IN California recently, I visited Kaiser Permanente, which is one of the most successful integrated healthcare organisations in the United States.

Estimation of the Period Prevalence of Inflammatory Bowel Disease Among Nine Health Plans Using Computerized Diagnoses and Outpatient Pharmacy Dispensings

There are few contemporary estimates of prevalence rates for inflammatory bowel disease (IBD) in diverse North American communities. We estimated the period prevalence of IBD for January 1, 1999, through June 30, 2001, among 1.8 million randomly sampled members of nine integrated healthcare organizations in the US using computerized diagnoses and outpatient pharmaceutical dispensing. We also assessed the positive predictive value (PPV) and sensitivities of 1) the case-finding algorithm, and 2) the 30-month sampling period using medical chart review and linkage to a 78-month dataset, respectively. The PPV of the case-finding algorithm was 81% (95% confidence interval [CI], 78-87) and 84% (95% CI, 79-89) in two different organizations. In both, the sensitivity of the optimal algorithm, compared with the most inclusive, exceeded 90%. The sensitivity of the 30-month sampling period compared with 78 months was 61% (95% CI, 57-64) in one organization. Applying a slightly more sensitive case-finding algorithm, the average period prevalence of IBD across the nine organizations, standardized to the age- and gender-distribution of the US population, 2000 census, was 388 cases (95% CI, 378-397) per 100,000 persons (range 209-784 per 100,000; average follow-up 26 months). The prevalence of Crohn's disease, ulcerative colitis, and unspecified IBD was 129, 191, and 69 per 100,000, respectively. The observed average prevalence was similar to prevalence proportions reported for other North American populations (369-408 per 100,000). Additional research is needed to understand differences in the occurrence of IBD among diverse populations as well as practice variation in diagnosis and treatment of IBD.