Integrated Health Organization Research Articles

Abordaje de la sexualidad en las personas en tratamiento renal sustitutivo desde el punto de vista de pacientes y profesionales

Introduction: Chronic kidney disease affects multiple areas of individuals’ lives, with sexuality being one of them. Few studies analyze the approach taken by dialysis units on these aspects.Objetives: To analyze the perception of patients and professionals in dialysis units regarding the approach to sexuality in individuals undergoing dialysis.Material and Method: Cross-sectional descriptive observational study conducted between April and May 2022 in the Integrated Health Organization of Araba. Participants included patients undergoing dialysis (peritoneal dialysis and hemodialysis, both in-center and at home) and professionals (nurses, nursing care technicians, and physicians) from these units. They completed an ad-hoc questionnaire collecting sociodemographic data and aspects related to the approach to sexuality in individuals undergoing dialysis.Results: 20.2% of patients and 50.0% of the team participated. 67.7% of patients reported that the treatment had affected their sexual needs “much” or “to some extent.” 66.7% of the team felt “not at all” or “not very” confident in addressing sexuality in this population.Conclusions: Sexuality is impacted in individuals undergoing renal replacement therapy with dialysis, and a significant portion of professionals do not feel confident in addressing this issue with them. Addressing this need remains an important area for improvement. It is necessary to provide professionals with the necessary tools to address this need.

Integration of a web application in Osakidetza Basque Health Service information system to optimize and adapt pharmacy therapeutic of multimorbid patients.

Background: Due to population aging and advances in medical science, people with chronic diseases and polypharmacy are living longer. Challenges are how healthcare systems can cope with the cost burden of chronic disease, sustain a quality independent living for patients; and ensure sustainable healthcare and social care systems. Innovative solutions as well as sustainable integrated workforce solutions are emerging as an alternative to tackle this challenge.
 Methods: Within Gatekeeper, the Basque Country region is carrying out a “management of people with chronic diseases and polypharmacy"" quasi-experimental study (non-randomized, concurrent and controlled study). The aim is to assess the effectiveness and experience of using a mobile application (My Treatment) to improve adherence of patients with polypharmacy and boost the optimization of pharmacological prescriptions by using a web platform (CheckTheMeds). This study plans to advance as well in the enhancement of Primary Care teamwork, coordination, and communication to acquire new roles to support each other, and offer holistic care to patients.
 The intervention has been deployed in 11 Integrated Health Organizations of Osakidetza Basque Health Service, Basque Country (Spain). More than 275 healthcare professionals (doctors, nurses, and pharmacy staff) from Primary Care (PC) centers are participating in the intervention. Trained PC healthcare professionals have started the piloting. They have recruited 690 patients who meet the inclusion criteria (65 years of age or older, with 2 or more chronic diseases and 9 or more chronic or on-demand medicines prescribed). The piloting will last until June 2023.
 Results: 690 patients (intervention and control group) have been included in the study. After signing the informed consent, their health status (Barthel test), prescribed drugs (CheckTheMeds platform), and adherence to treatment (Morisky Green test) are completed at baseline and after a 6-month follow-up. Preliminary data extracted from OAS (Oracle Analytics Services) of Osakidetza reflected that the average age of the recruited patients is 77.9 years, and 58% are male. The average prescription of these patients is 13.10 medicines. 51% of the users are independent (Barthel Test) and 80% of the patients are compliant (Morinsky Green test).
 The evaluation is being conducted with a mixed methods approach, integrating quantitative and qualitative techniques, by organizing a workshop (November 2022) and a focus group. 
 Discussion and Conclusions: Improved appropriate polypharmacy, together with adherence to prescribed medication, will result in more effective treatments with fewer PRMs and health complications, and therefore, in improved efficiency in the use of healthcare resources. As a consequence, a better use of resources, increasing coordination, and teamwork among primary care healthcare professionals,s and introduction of new roles can improve the efficiency of health systems. Thus, the coordinated action of healthcare professionals, in close collaboration with the patient, is postulated as a common denominator in strategies aimed at improving adherence to treatment and offering new caring skills. This integrated care model is flexible and can be replicated at large scales in different environments.

Evaluation of county-level integrated health organizations: Combination of the weighting-grey synthetic evaluation method

This paper aims to improve the efficacy assessment of County-level Integrated Health Organizations (CIHOs) in China. By analyzing CIHOs in Fujian Province, an empirical study was done to confirm the efficacy of the combined weighted-grey synthetic evaluation approach. The combined weights of evaluation indicators are calculated using the suggested method, which combines the analytical network process method and the coefficient of variation method. The grey center points of the CIHOs to be evaluated are determined, the whitenization weight functions is constructed, a comprehensive evaluation matrix is established, and then the composite score values are calculated and ranked. A more thorough evaluation of CIHOs can be accomplished scientifically using this comprehensive approach.

Carga administrativa, motivación y bienestar entre médicos de atención primaria. Comparación entre modelos de gestión

ObjectiveTo analyze the relationship between administrative burden and intrinsic motivation and between administrative burden and professional well-being among family and community medicine physicians. To analyze the extent to which attention to three basic needs (autonomy, sense of competence and relationship capacity) that one of the main motivation theories identifies as a generator of intrinsic motivation compensates for the negative effect of the administrative burden. To compare management models. MethodData from a survey (542 valid questionnaires) carried out through the Catalan Society of Family and Community Medicine are used. Data analysis is based on multiple regression and ANOVA techniques. ResultsThe perception of administrative burden and “red tape” are clearly demotivating and reduce job satisfaction. On the contrary, individual autonomy, networking opportunities between professionals and performance feedback are motivating and feed the perception of professional well-being. The EBA (Association Based Entity) model presents results above the ICS (Catalan Health Institute) and OSI (Integrated Health Organizations) models both in controlling the negative effect of administrative burden and in the management of basic psychological needs. ConclusionsThe motivation and professional well-being of primary care physicians would benefit from reforms that limit the administrative burden of some procedures and red tape. At the primary health center level, greater attention to individual autonomy, improving relatedness between professionals and the sense of competence based on better information on individual performance can offset the negative effects of the administrative burden.

Evaluation of results and costs of high precision radiotherapy (VMAT) compared with conventional radiotherapy (3D) in the treatment of cancer patients with spinal cord compression of metastatic origin.

BackgroundThe aim of this study was to evaluate the results and economic costs of using volumetric modulated arc therapy (VMAT) (5 fr × 5 Gy), compared with other conventional 3D radiotherapy schemes such as “5 × 4 Gy” and “10 × 3 Gy”.Materials and methodsThe data about the direct costs for the public health system was obtained from the Economic Information “Management per Patient” System available at the Integrated Health Organization Ezkerraldea Enkarterri Cruces. It is a model of real costs per patient which uses a bottom-up methodology which connects all sources of information generated in clinical practice, integrating healthcare information with economic information. This system presents the real cost per individualized patient, and shows the traceability of all clinical care. The costs of “typical patients” requiring hospital admission were identified for each of the three radiotherapy schemes based on the clinical activity and the material and human resources that were used.ResultsThe 5 × 5 Gy scheme has a cost of EUR 4,801.48, which is 1.64% higher (EUR 77) than the “5 × 4 Gy” scheme (EUR 4,724.05). The “10 × 3 Gy” scheme has a cost of EUR 8,394.61, which is 74.8% higher (EUR 3,593) than the “5 × 5 Gy” scheme. The main cost factor in the “10 × 3 Gy” scheme is hospitalization, since patients are at hospital for 2 weeks compared with 1 week in the “5 × 5 Gy” scheme.ConclusionsThe cost per patient of the VMAT “5 × 5 Gy” radiotherapy scheme is notably lower than that of the “10 × 3 Gy” scheme (conventional 3D radiotherapy), with the advantage of being administered in half the time. In relation to the scheme with 5 Gy × 4 sessions, the cost is similar to that of the “5 × 5 Gy” scheme.

Characteristics of genital herpes in Bilbao (Northern Spain): 12-year retrospective study

BackgroundHerpes simplex virus type 2 (HSV-2) is the most common cause of genital herpes (GH), but genital infection by herpes simplex virus type 1 (HSV-1) is increasing. The aim of this study was to analyze and compare epidemiological characteristics of patients with GH. MethodsRetrospective study conducted from January 2004 to December 2015 in patients with GH attended at two Sexually Transmitted Diseases (STDs) medical consultation of Bilbao-Basurto Integrated Health Organisation in Northern Spain. Patient's medical history was reviewed and data of interest was analyzed. ResultsOne thousand three patients (524 male and 479 female) were reviewed. HSV-2 was detected in 74%. The proportion of HSV-1 increased during the study period, significantly in men (28% in 2004–2007 vs. 50% in 2012–2015). More female than male had HSV-1 infection (56% vs. 44%). The proportion of primary infection was higher among HSV-1 compared to HSV-2 (79% vs. 21%). Among the patients with HSV-1, primary infection was higher among men (86%) and in younger than 30 years. Recurrent GH was higher among HSV-2 infections (63%). In a multivariate model older age, geographic origin outside Spain, recurrent infection, prior contact with a partner's genital herpetic lesions, previous N. gonorrhoeae infection and prostitution were significantly associated with HSV-2 infection. ConclusionsHSV-2 was the most common causative agent of GH, but the proportion of HSV-1 increased. Overall, antecedent of STD and sexual risk behaviors were more frequent in patients with genital HSV-2 infection.

Evaluación de la colaboración entre atención primaria y hospitalaria para mejorar la polimedicación inapropiada

Introduction and objectivesTo evaluate the implementation of a collaborative experience between Primary (PC) and Hospital Care (HC) aimed at reducing potentially inappropriate prescribing (PIP) in patients with polypharmacy. Materials and methodsCollaborative experience including a controlled before-after intervention study, carried out in the Donostialdea Integrated Health Organization (IHO), with Bilbao Basurto IHO as control group, Osakidetza, Basque Health Service.Participant were 227 PC physicians and physicians from 7 hospital services, and patients with 5 or more drugs meeting at least one PIP criteria.The intervention consisted of communication and knowledge between professionals, PC-HC consensus, training, identification of patients at risk, medication review, evaluation and feed-back.The collaboration process (agreements, consensus documents, training activities) and the change in the prevalence of PIP in polymedicated patients (using computerised health records) were evaluated. ResultsA total of 21 PIP criteria and 6 recommendation documents were agreed. An analysis was performed on 15,570 PIP from OSI Donostialdea and 24,866 from the control group. The prevalence of PIP in polymedicated patients was reduced by -4.53% (95% CI: -4.71 to -4.36, P< .0001) in comparison with the control group. The before-after differences were statistically significant across the 7 services. ConclusionsPC-HC collaboration is feasible and, along with other intervention components, reduces inappropriate polypharmacy in the context of a recently integrated healthcare organisation. The collaboration process is complex and requires continuous monitoring, policy involvement, leadership that encourages health professional participation, and intensive use of information systems.

Challenges for medical libraries in times of COVID-19: Making clinical decisions that uphold research quality

Distance working in the context of the COVID-19 crisis has engendered a new model of collaborative activity for the Library of Donostialdea Integrated Health Organisation (San Sebastián, Spain). Promoted by the Clinical Epidemiology and Research Unit, this initiative has enabled Hospital Management to respond to some of the gaps in information revealed during the pandemic. Changes in editorial policies offering open access information, the lack of peer-reviewed literature, and the spread of scientific literature through social media are some of the factors that stand out in the search for the best evidence during the COVID-19 pandemic.

Developing the Human Factor in an Integrated Health Organization

Developing the Human Factor in an Integrated Health Organization

Characteristics of genital herpes in Bilbao (Northern Spain): 12-year retrospective study

BackgroundHerpes simplex virus type 2 (HSV-2) is the most common cause of genital herpes (GH), but genital infection by herpes simplex virus type 1 (HSV-1) is increasing. The aim of this study was to analyze and compare epidemiological characteristics of patients with GH. MethodsRetrospective study conducted from January 2004 to December 2015 in patients with GH attended at two Sexually Transmitted Diseases (STDs) medical consultation of Bilbao-Basurto Integrated Health Organisation in Northern Spain. Patient's medical history was reviewed and data of interest was analyzed. ResultsOne thousand three patients (524 male and 479 female) were reviewed. HSV-2 was detected in 74%. The proportion of HSV-1 increased during the study period, significantly in men (28% in 2004–2007 vs. 50% in 2012–2015). More female than male had HSV-1 infection (56% vs. 44%). The proportion of primary infection was higher among HSV-1 compared to HSV-2 (79% vs. 21%). Among the patients with HSV-1, primary infection was higher among men (86%) and in younger than 30 years. Recurrent GH was higher among HSV-2 infections (63%). In a multivariate model older age, geographic origin outside Spain, recurrent infection, prior contact with a partner's genital herpetic lesions, previous N. gonorrhoeae infection and prostitution were significantly associated with HSV-2 infection. ConclusionsHSV-2 was the most common causative agent of GH, but the proportion of HSV-1 increased. Overall, antecedent of STD and sexual risk behaviors were more frequent in patients with genital HSV-2 infection.

Impact on the use of services and quality of life of a continuity of care unit for multi-pathological patients

Introduction: Bidasoa Integrated Health Organisation was the first integrated health care organization IHO created in the Basque Country in January 2011. It comprises the hospital 96 beds and 3 primary care centres. The IHO catchment population is around 90,000 citizens. As has happened in other organisations, care delivery in Bidasoa area was fragmented, with poor communication between primary and secondary care professionals. This fragmentation affected especially chronic patients with several pathologies. Description: In answer to this problem and focused on the management of complex chronic patients, Continuity of Care Unit CCU was created in Bidasoa IHO. Nowadays more than 200 patients are being taken care there. CCU worked as follows: the referral internist RI, one for each health centre, is responsible for the admission of patients with complex or multiple conditions in the event that they require admission to hospital. The mission of CCU is to stabilize patients and facilitate continuity of care by the general practitioner GP. These patients have a continuity of care plan between levels of care and they are admitted to the hospital through a special circuit not A&E when needed. The role of the liaison nurse is to support the patient in the transition from hospital to home, where they are followed up by the GP. The RI visits the health center every other week to undertake clinical sessions. Aim: The aim is to improve the quality of life and care provided to complex chronic patients, by a multidisciplinary team, based on a patient-centred care and collaborative work among primary care, hospital care and social services. Targeted population: Patients with two or more chronic conditions who have been admitted at hospital more than two times in the last year. Timeline: CCU was created in 2011.Since 2016 the quality of life of patients that are incorporated in CCU is evaluated Highlights: All patients n=247 included in the unit between 1st January 2011 and 31st December 2014, with a minimum one year follow up are analysed. These patients have an average age of 84.1 years. 56.4% are man. It is observed 45.5% reduction in emergency department visits and 41.9% in hospital admissions. Simultaneously, the number of nurse home visits increased significantly after patient CCU inclusion. Furthermore, analyzing a sample of these patients it is observed a significant improvement in the self-perceived health status that is related to age greater improvement in the youngest. Sustainability: The change in the care model has been made with the reorganization of existing resources. Transferability: That model could be transferred to a care model based on primary care as patients referral. Conclusions: A care model based on a multidisciplinary team between primary and hospital care has improved the quality of care of chronic complex patients and their self-perceived health status Discussions: The implementation of this practice involves a cultural change among professionals, new functional roles nurse, RI and a greater collaboration. Lessons learned: The necessary cultural change is a slow process. The existence of shared areas plays are key role to get it.

Multipronged management strategy for patients with complex needs using an integrated organizational model

Introduction : The Basque healthcare system is facing an overwhelming problem due to chronicity and an aging population. In our setting (San Sebastian, Gipuzkoa province, Basque Country) more than 25% of the population (400,000) will be over 65 years old in the next decade out of which 10,000 people will be multi-pathological. Traditionally, these patients have been managed without a coordinated strategy, leading to multiple hospital admissions, patient discomfort and a large economic impact. Description of practice change implemented : A multipronged management strategy for patients with complex needs using an integrated organizational model that included liaison nurse, call center and new technologies (web/ app-based monitoring). Aim : Improving quality of life and perceived quality of health assistance Training patients and healthcare providers Reducing length of stay and Emergency Department (ED) visits Respecting patients’ will on intensity of treatment and place of care provision Target population : - Multi-pathological patients with high readmission rates - Home-dependent patients - Nursing home residents - End of life patients Timeline : 2003: New Evidence-based practice unit started within Internal Medicine Dpt. 2005: Prediction rule development and validation for readmission risk 2006: Before and after study with a multipronged strategy (PAMI) targeting patients with high readmission rates. 2009: Creation of a management unit for chronic patients. 2010: Comparative study of telemedicine vs PAMI 2010: Cluster randomized clinical trial of PAMI in nursing homes 2012: Creation of a diabetes pathway 2012: Creation of an integrated health organization (OSI) Highlights : - Development of a single electronic medical record - Stratification of the population and tagging of chronic patients. - Conciliation of treatment with an e-prescription tool. - Conciliation of information (hospital/primary care meetings, communication tools) - Case management of complex patients (PAMI programme) with process-specific questionnaires, liaison nurse, call center and web/app monitoring activating changes in prescription, GP appointments or direct hospital admission. With 4,200 patients followed within this programme, we have achieved 30-50% of direct admissions (avoiding ED visit). Days spent at the hospital were reduced by 25% for nursing home residents, 55% for home-dependents, 58% for heart failure patients, and 25% for patients with COPD. The number of ED visits made by each group was also reduced by 58%, 70%, 70% and 45% respectively. 80-100% found the level of training satisfactory, 90-100% rated the hospital accessibility “excellent” and 90-100% perceived significant improvements in the global management of the process. -Integration of the primary care-internal medicine and nursing home-internal medicine pathway -Improvement on the social care with a calculator of social support needs. Sustainability : Cost-effectiveness of the management of these patients improved Transferability : The technology and protocols are available to all in the Basque Country. Geographical differences exist in hospital accessibility. Conclusions : This strategy improved perceived quality of life and length of stay while avoiding many ED visits. Integration of levels and IT tools are essential to make it possible. Discussion : Integration specially benefits multi-pathological and complex patients, offering opportunities for case management strategies. Lessons learned : The anticipation of problems, new technologies and integrated assistance focused on the user will be the keys of the future care.

Empowering minorities. Pathways for basque language integration in a bilingual setting

Introduction: The Basque Country is a bilingual setting, where a significant part of the population have Basque as its mother tongue. The Basque NHS, Osakidetza, offers public universal assistance. It adopts an integrated approach through merging hospitals and primary care to achieve better quality of care and efficiency. Communicating in the mother tongue helps patients enjoy equitable and better care. In this context the first clinical pathway in Basque has been recently set up reflecting patient centered care, where fostering Basque is a safety and quality issue. Organization, objectives and result management of the bilingual pathways: Pathways are started from the general practitioners´ (GP) surgeries. Medical consultations, information booklets, test results and informed consents are bilingual. When specialized care is needed, the GP must also point out the patients` language preference by means of an on line request to the specialist. This means that there is a direct clinical pathway available entirely in Basque, from primary to specialized care. This paper offers an evaluation of the bilingual pathway established in 2015 at the urology unit at Debagoiena Integrated Health Organisation (IHO) and paediatric urology at Araba IHO where weekly consultations were provided. During the first year, 987 consultations in Basque were counted in Debagoiena unit, that is, 21.3% of the total. These figures closely reflect the language profile of the local population where, although 60.5% are Basque speakers, only 28.3% use the language on a daily basis. Considering that 25% of the specialists are fluent Basque speakers, only 56% of these patients could be offered the full pathway in Basque. Nevertheless, 100% of them have shown their full commitment to the scheme. The most remarkable results were found amongst the Araba IHO users, in the paediatric urology service. 18.6% of the consultations were in Basque. Considering that just 23% of the population speaks Basque in Araba, this appears to be a high percentage. All those who request provision in Basque can enjoy it, as all the urologist at this unit are bilingual. 100% of the patients assert their satisfaction with the pathway. Although patients were given assitance in Basque, the majority of online notifications between consultants were answered back in Spanish. Conclusions: In line with patient centered care, Basque language pathways have been developed, improving Basque use, patients self-esteem and empowerment. This step forward is specially important in Araba, striving for the positive development of quality care in a bilingual setting. Despite these facts, there is still hard work to be done regarding the normalisation of the Basque language, especially because nowadays Basque is not a common means of comunication between professionals.

Is there enough Amour in the Basque Health Service? Evaluating Interprofessional cooperation using D’Amour Questionnaire

Introduction : D’Amour Questionnaire was validated by the Basque Ministry of Health and BIOEF in 2010 (1) to measure the degree of collaboration among health professionals from different levels of care. It is one of the qualitative indicators that were introduced by the Ministry in 2015 to all 18 Integrated Care Organisations (ICOs) and it helps to evaluate how integration policy is perceived among health professionals. Methods : The questionnaire has 10 items and uses a Likert scale. In addition to this, an 11th question has been added where respondents are asked to propose actions to improve collaboration between care levels. Traditionally this survey was conceived for health professionals, however in 2016 non health personnel, such as social workers, admin and ancillary staff have been included. They also participate in pathways and other integration processes and their opinion should be equally valued. Results : In 2016 there have been 1975 answers (10% answer rate) of which 75% are female. The number of participants coming from hospital care is slightly higher than from primary care (see Figure 2) and nurses are the more frequent respondents (35%) followed by doctors (33%) (see Figure 3). Quantitative : Figure 1 shows the evolution of D’Amour since 2012 and in colored numbers the results of 2016´s evaluation (green=improvement, yellow=same result, red=worse). The worst valued item across time is “Forums for Meetings” and the two most valued items are “Shared Goals” and “Trust”. Qualitative : More than 800 proposals of actions to improve collaborations coming from the 11th item were analyzed. Figure 4 shows that 48% of the respondents demand actions related with item “Forums for meetings” followed by “Protocolisation” (23%), improvements in “Information Systems” (10%) and one item that does not appear in D’Amour: “Shared Training” (8%). Discussion : There is a slight but continuous improvement across time, especially if the first and last evaluation are analyzed. This is important since in 2012-13 only part of the ICOs had been created and it gives an idea of how perception has changed.. “Forums for meetings” is one of the improvement areas identified both in the quantitative and qualitative analysis, this pattern also occurs in the best performing ICOs, when analyzed individually (2). However professionals perceive “Shared Goals” and “Trust” as one of the most valued items. This could imply that despite sharing a common narrative of what working and trusting each other means they lack the resources (space and time) to get to know each other better. This is also reflected on the item “Shared Training” that has been identified in the qualitative analysis. Conclusions : D’Amour Questionnaire is a valid tool for Organisations to identify one of the non tangible aspects of integrated care, which is how professionals collaborate with each when they work in a different level of care but have the goal to serve the same patient. Moreover, it also gives the opportunity to health professionals to engage in this process by providing ideas/actions to improve it. References : 1- Nuno Solinis R, Berraondo Zabalegui I, Sauto Arce R, San Martin Rodriguez L, Toro Polanco N. Development of a questionnaire to assess interprofessional collaboration between two different care levels. International Journal of Integrated Care. 2013;13(2). DOI: http://doi.org/10.5334/ijic.984 2- Toro Polanco N, Berraondo Zabalegui I, Perez Irazusta I, Nuno Solinis R, Del Rio Camara M. Building integrated care systems: a case study of Bidasoa Integrated Health Organisation. International Journal of Integrated Care. 2015;15(2). DOI: http://doi.org/10.5334/ijic.1796

“Counting the intangible”: The use of evaluation tools and indicators to measure integrated care outcomes in the Basque Country

Introduction : There is currently the debate about how to measure the elements that are key to “successful integrated care”, which are the outcomes that should be achieved and which evaluation tools can be used. The Basque Country has been implementing integrating care policies since 2010. One of the cornerstones of this strategy has been the launch of 13 Integrated Care Organisations (ICOs) to integrate under the same structure Primary and Secondary Care Services (1). Since 2014, changes have been introduced in the metrics of the Contract-Programme (CP) that regulates de relationship between the Ministry of Health (commissioner) and each ICO (health providers). These changes, based on Kelly and Hurst (2), are both qualitative and quantitative and aim to provide the Ministry of Heath with a new framework to evaluate the success of all integrated care policies being implemented. Moreover, one of the new indicators being introduced in the new Contract Programme is IEMAC-ARCHO (3), which is an instrument with 75 items for ICOs to perform a self-assessment in terms of their degree of implementation of chronic care management models and is based on the Chronic Care Model (4). Aims, objectives and results : In this abstract we would like to explore the co-relation in the evolution of the results of both the CP and IEMAC across time. In order to do that we have selected some of the actions/policies behind the new indicators in the CP (see in Figure 1) such as: (i) the provision of case managers and liaison nurses, (ii) systematized agreements with ”outsiders” such as social and community care, (iii) unified health care records, (iv) patient empowerment and participation among others. All these elements aim to improve continuity of care and improve the experience of care across settings. On the other hand in Figure 2 shows the results from 20 evaluations using IEMAC sessions that were conducted with 18 ICOs. Each session was run by health professionals and managers from both levels of care (Primary and Hospital Care) and actors from other areas such as mental health and social care were also represented. The self assessment o IEMAC allows each ICO to identify areas of improvement, define a plan and implement it following what the CP requests. Conclusions : Integrated care is a dynamic process that involves cultural change and measuring that can be rather hard. However evaluation tools are necessary for tracking the evolution of key aspects for integrated care and the various changes that occur when implementing integrated care policies. Looking at the results we can observe a positive evolution of both CP indicators and IEMAC-ARCHO, which indicates good degree of achievement of the policies implemented by the Ministry of Health. In addition to being useful for evaluation purposes, both the CP and IEMAC are powerful tools to identify line of actions and improvement areas that can be supported by the Ministry of Health. References : 1- Toro Polanco N, Berraondo Zabalegui I, Perez Irazusta I, Nuno Solinis R, Del Rio Camara M. Building integrated care systems: a case study of Bidasoa Integrated Health Organisation. International Journal of Integrated Care. 2015;15(2). DOI: http://doi.org/10.5334/ijic.1796 2- Kelley E, Hurts J. Health Care Quality Indicators Project. Conceptual framework Paper. Organization for Economic Co-operation and Development Health Working. Papers No 23, 2006 3- IEMAC. Assessment of Readiness for Chronicity in Heath Care Organisations. [cited 2016 24 Oct] Available from: http://www.iemac.es/internacional.asp 4- Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood). 2009 Jan-Feb;28(1):75-85

Analysing a Chinese Regional Integrated Healthcare Organisation Reform Failure using a Complex Adaptive System Approach.

Introduction:China’s organised health system has remained outdated for decades. Current health systems in many less market-oriented countries still adhere to traditional administrative-based directives and linear planning. Furthermore, they neglect the responsiveness and feedback of institutions and professionals, which often results in reform failure in integrated care. Complex adaptive system theory (CAS) provides a new perspective and methodology for analysing the health system and policy implementation.Methods:We observed the typical case of Qianjiang’s Integrated Health Organization Reform (IHO) for 2 years to analyse integrated care reforms using CAS theory. Via questionnaires and interviews, we observed 32 medical institutions and 344 professionals. We compared their cooperative behaviours from both organisational and inter-professional levels between 2013 and 2015, and further investigated potential reasons for why medical institutions and professionals did not form an effective IHO. We discovered how interested parties in the policy implementation process influenced reform outcome, and by theoretical induction, proposed a new semi-organised system and corresponding policy analysis flowchart that potentially suits the actual realisation of CAS.Results:The reform did not achieve its desired effect. The Qianjiang IHO was loosely integrated rather than closely integrated, and the cooperation levels between organisations and professionals were low. This disappointing result was due to low mutual trust among IHO members, with the main contributing factors being insufficient financial incentives and the lack of a common vision.Discussion and Conclusions:The traditional organised health system is old-fashioned. Rather than being completely organised or adaptive, the health system is currently more similar to a semi-organised system. Medical institutions and professionals operate in a middle ground between complete adherence to administrative orders from state-run health systems and completely adapting to the market. Thus, decision-making, implementation and analysis of health policies should also be updated according to this current standing. The simplest way to manage this new system is to abandon linear top-down orders and patiently wait for an explicit picture of IHO mechanisms to be revealed after complete and spontaneous negotiation between IHO allies is reached. In the meantime, bottom-up feedback from members should be paid attention to, and common benefits and fluid information flow should be prioritised in building a successful IHO.

Conciliación de la medicación: desde el ingreso hasta la atención primaria

ObjectivesTo implement a medication reconciliation circuit of inter-level, comprehensive and multidisciplinary approach in an integrated health organization. To measure the discrepancies detected in each of the steps studied. MethodA prospective intervention study of one-year duration. The medication is reconciled at admission to the hospital, at discharge and when the patient goes to his Primary Care physician. The number and type of discrepancies detected each time the medication is reconciled are collected and resolved, as well as the total number of drugs before and after each reconciliation process quantified. ResultsBetween November 1, 2013 and October 31, 2014 the medication had been reconciled to 77 patients, 63% male, mean age 69,5 years. Mean admission discrepancy per patient was 7,85, 3,67 at discharge and 2,19 at Primary Care. ConclusionsThis program of medication reconciliation, in addition to detect and resolve discrepancies, has been a starting point for establishing new channels of communication between the different health professionals who have participated in the program and disseminate the safety culture within the organization.

Establishing pathways for access to pharmacist-provided patient care

Objective: To describe the pathways being established for access to pharmacist-provided patient care and supply recommendations for the next steps in this process. Data sources:A series of reports published by the American Pharmacists Association regarding pharmacist-provided patient care services. Summary: Community pharmacies and integrated health organizations have emerged as the two predominant pathways for patient access to pharmacist-provided patient care. We view these two pathways as complementary in helping cover patients’ entire medication therapy needs as they traverse acute and chronic health care services. However, gaps in access to pharmacist-provided care remain, especially during transitions in care. Conclusion: In further establishing pathways for access to pharmacist-provided patient care, we propose that the application of collaboration theory will help close gaps that currently exist between health care organizations. Such an approach carries risk and will require trust among participating organizations. This approach is also likely to require updating and contemporizing pharmacy practice acts and other statutes to allow pharmacists to practice at maximum capacity within new models of care. To perform their new roles and create sustainable business models to support these new functions, pharmacists will need to be paid for their services. To this end, changes will need to be made to payment and documentation systems, incentives, and contracting approaches to develop proper reimbursement and accounting for pharmacists’ new roles.

Building integrated care systems: a case study of Bidasoa Integrated Health Organisation.

This paper analyses the implementation of integrated care policies in the Basque Country through the deployment of an Integrated Health Organisation in Bidasoa area during the period 2011-2014. Structural, functional and clinical integration policies have been employed with the aim to deliver integrated and person-centred care for patients, especially for those living with chronic conditions. This organisational case study used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the organisational development over a 4-year period. In order to measure the progress of integration three concepts have been measured: (i) readiness for chronicity measured with Assessment of Readiness for Chronicity in Healthcare Organisations tool; (ii) collaboration between clinicians from different care levels measured with the D'Amour Questionnaire, and (iii) overall impact of integration through several indicators based on the Triple Aim Framework. The measurement of organisational readiness for chronicity showed improvements in five of the six areas under evaluation. Similarly the collaboration between professionals of different care levels showed a steady improvement in each of the 10 items. Furthermore, the Triple Aim-based indicators showed a better experience of care in terms of patients' perceptions of care coordination; a reduction in hospital utilisation, particularly for patients with complex chronic conditions; and cost-containment in terms of per capita expenditure. There is a significant amount of data that shows that Bidasoa Integrated Health Organisation has progressed in terms of delivering integrated care for chronic conditions with a positive impact on several Triple Aim outcomes.

The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy.

Hydroxychloroquine sulfate is widely used for the long-term treatment of autoimmune conditions but can cause irreversible toxic retinopathy. Prior estimations of risk were low but were based largely on short-term users or severe retinal toxicity (bull's eye maculopathy). The risk may be much higher because retinopathy can be detected earlier when using more sensitive screening techniques. To reassess the prevalence of and risk factors for hydroxychloroquine retinal toxicity and to determine dosage levels that facilitate safe use of the drug. Retrospective case-control study in an integrated health organization of approximately 3.4 million members among 2361 patients who had used hydroxychloroquine continuously for at least 5 years according to pharmacy records and who were evaluated with visual field testing or spectral-domain optical coherence tomography. Hydroxychloroquine use for at least 5 years. Retinal toxicity as determined by characteristic visual field loss or retinal thinning and photoreceptor damage, as well as statistical measures of risk factors and prevalence. Real body weight predicted risk better than ideal body weight and was used for all calculations. The overall prevalence of hydroxychloroquine retinopathy was 7.5% but varied with daily consumption (odds ratio, 5.67; 95% CI, 4.14-7.79 for >5.0 mg/kg) and with duration of use (odds ratio, 3.22; 95% CI, 2.20-4.70 for >10 years). For daily consumption of 4.0 to 5.0 mg/kg, the prevalence of retinal toxicity remained less than 2% within the first 10 years of use but rose to almost 20% after 20 years of use. Other major risk factors include kidney disease (odds ratio, 2.08; 95% CI, 1.44-3.01) and concurrent tamoxifen citrate therapy (odds ratio, 4.59; 95% CI, 2.05-10.27). These data suggest that hydroxychloroquine retinopathy is more common than previously recognized, especially at high dosages and long duration of use. While no completely safe dosage is identified from this study, daily consumption of 5.0 mg/kg of real body weight or less is associated with a low risk for up to 10 years. Knowledge of these data and risk factors should help physicians prescribe hydroxychloroquine in a manner that will minimize the likelihood of vision loss.