Integrated Health Care Delivery Research Articles

Education Model for Paediatric Palliative Care

Introduction: Meeting the palliative care needs of children and their families is complex and challenging. For countries such as Australia, whose relatively small paediatric palliative care population is dispersed across a very large geographical area, one challenge is maintaining a skilled workforce in regional, rural, and remote areas, where, when compared to major cities, there are fewer resources, and the workforce is often transient. Methods: The Quality of Care Collaborative Australia (QuoCCA) Pop-up Model of Education was used to provide palliative care education to health professionals across three geographical locations and facilities, to facilitate a 2,500-km transfer of a child with complex palliative care needs from a tertiary hospital to the remote family home on Country. Results: Each Pop-Up provided effective education to facilitate the successful transfer of the child to the next hospital location. Over 18 months, three Pop-Ups occurred. Relational learning and real-time problem solving enabled health professionals to build confidence and capacity to successfully transfer the child from the regional hospital to the remote family home. Implications: The QuoCCA Education Pop-up Model is a feasible method to deliver timely access to speciality education. The model can be successfully applied in multiple settings. Keywords: paediatric, palliative care, integrated health care delivery, learning, rural, education models.

The Impact of Supplemental Nutrition Assistance Program (SNAP) Enrollment on Health and Cost Outcomes

Summary In the United States, food insecurity is prevalent in low-income households and is associated with elevated risk of chronic disease, poor health outcomes, and excess avoidable health care utilization and costs. Individuals dually eligible for Medicare and Medicaid are a unique low-income group with significant social challenges, complex health conditions, and higher-than-average health care costs. Interventions to address social determinants of health (SDOH) — such as food insecurity — have the potential to reduce avoidable health care utilization and cost, and the health insurers are increasingly integrating them into care delivery. Using Supplemental Nutrition Assistance Program (SNAP) data from the Pennsylvania Department of Human Services and health care claims data from an integrated health care delivery and finance system, this study reports findings of an innovative collaboration between a health care payer and a nonprofit organization to enroll dual-eligible individuals in SNAP. Data were collected prospectively from 661 SNAP-enrolled individuals and 1,320 individuals in a matched comparison group to explore the effect of SNAP enrollment on health care utilization (inpatient hospitalization, ED visits, and unplanned care) and health care costs (medical, pharmacy, and total cost of care) during the first and second years after SNAP enrollment. Data analysis was designed to answer questions that are important to payer and health care stakeholders, namely, when (i.e., how long after the start of SNAP benefits), how (i.e., what health outcome), and for whom (i.e., what population subgroups) is SNAP enrollment associated with health and cost outcomes. Compared with a propensity score–matched group not enrolled in SNAP, the SNAP enrollees had 16% and 21% lower total health care costs and pharmacy costs, respectively, within the first year postenrollment in SNAP. These group differences remained significant during the second year postenrollment, when SNAP enrollees had 16% and 20% lower total health care costs and pharmacy costs, respectively. Specifically, lower costs were seen among individuals who do not qualify for skilled nursing care. This study contributes to the growing evidence that novel payer-led interventions to address SDOH can influence positive changes in health care utilization and cost reduction, especially among disadvantaged populations.

Prevalence of prediabetes and diabetes vary by ethnicity among U.S. Asian adults at healthy weight, overweight, and obesity ranges: an electronic health record study

BackgroundAsian adults develop Type 2 diabetes at a lower body mass index (BMI) compared to other racial/ethnic groups. We examined the variation in prevalence of prediabetes and diabetes among Asian ethnic groups within weight strata by comparing middle-aged Chinese, Filipino, South Asian, and White adults receiving care in the same integrated healthcare delivery system.MethodsOur retrospective cross-sectional U.S. study examined data from 283,110 (non-Hispanic) White, 33,263 Chinese, 38,766 Filipino, and 17,959 South Asian adults aged 45–64 years who were members of a Northern California health plan in 2016 and had measured height and weight. Prediabetes and diabetes were classified based on laboratory data, clinical diagnoses, or diabetes pharmacotherapy. Age-standardized prevalence of prediabetes and diabetes were compared by race/ethnicity within healthy weight, overweight, and obesity categories, using standard BMI thresholds for White adults (18.5 to < 25, 25 to < 30, ≥ 30 kg/m2) and lower BMI thresholds for Asian adults (18.5 to < 23, 23 to < 27.5, ≥ 27.5 kg/m2). Prevalence ratios (PRs) were used to compare the prevalence of diabetes and prediabetes for Asian groups to White adults in each weight category, adjusted for age and BMI.ResultsAcross all weight categories, diabetes prevalence was higher for Asian than White adults, and among Asian groups it was highest for Filipino and South Asian adults. Compared to White, PRs for South Asian men/women at healthy BMI were 1.8/2.8 for prediabetes and 5.9/8.0 for diabetes, respectively. The PRs for Filipino men/women at healthy BMI were 1.8/2.6 for prediabetes and 5.0/7.5 for diabetes, respectively. For Chinese men/women at healthy BMI, the PRs for prediabetes (2.1/2.9) were similar to Filipino and South Asian, but the PRs for diabetes were lower (2.1/3.4).ConclusionChinese, Filipino, and South Asian adults have higher prevalence of prediabetes and diabetes than White adults in all weight categories, despite using lower BMI thresholds for weight classification in Asian groups. Within Asian ethnic groups, Filipino and South Asian adults had considerably higher diabetes prevalence than Chinese adults. Our data emphasize the disproportionate metabolic risk among middle-aged Asian adults and underscore the need for diabetes screening among high-risk Asian groups at healthy BMI levels.

Effect of Medically Tailored Meals on Clinical Outcomes in Recently Hospitalized High-Risk Adults.

Background:Inability to adhere to nutritional recommendations is common and linked to worse outcomes in patients with nutrition-sensitive conditions.Objectives:The purpose of this study is to evaluate whether medically tailored meals (MTMs) improve outcomes in recently discharged adults with nutrition-sensitive conditions compared with usual care.Research Design:Remote pragmatic randomized trial.Subjects:Adults with heart failure, diabetes, or chronic kidney disease being discharged home between April 27, 2020, and June 9, 2021, from 5 hospitals within an integrated health care delivery system.Measures:Participants were prerandomized to 10 weeks of MTMs (with or without virtual nutritional counseling) compared with usual care. The primary outcome was all-cause hospitalization within 90 days after discharge. Exploratory outcomes included all-cause and cause-specific health care utilization and all-cause death within 90 days after discharge.Results:A total of 1977 participants (MTMs: n=993, with 497 assigned to also receive virtual nutritional counseling; usual care: n=984) were enrolled. Compared with usual care, MTMs did not reduce all-cause hospitalization at 90 days after discharge [adjusted hazard ratio, aHR: 1.02, 95% confidence interval (CI), 0.86–1.21]. In exploratory analyses, MTMs were associated with lower mortality (aHR: 0.65, 95% CI, 0.43–0.98) and fewer hospitalizations for heart failure (aHR: 0.53, 95% CI, 0.33–0.88), but not for any emergency department visits (aHR: 0.95, 95% CI, 0.78–1.15) or diabetes-related hospitalizations (aHR: 0.75, 95% CI, 0.31–1.82). No additional benefit was observed with virtual nutritional counseling.Conclusions:Provision of MTMs after discharge did not reduce risk of all-cause hospitalization in adults with nutrition-sensitive conditions. Additional large-scale randomized controlled trials are needed to definitively determine the impact of MTMs on survival and cause-specific health care utilization in at-risk individuals.

Chefs in Future Integrated Healthcare - Current State and Innovation Needs: A First Overview of the NECTAR Project (aN Eu Curriculum for Chef gasTro-Engineering in Primary Food Care).

People in need of care, chronic or acute, often present problematic food intake and special nutritional needs. Integrated, person-centred and pro-active food and nutritional care delivery has been proven effective for people in health care. However, skills mismatches have been reported in different professions involved, which also applies to the role of chefs in healthcare. The EU funded project NECTAR aims at closing this gap by creating a new job profile, called Chef Gastro-Engineering (CGE). The current publication summarizes the status quo in hospitals and gives a perspective on the future role of chefs in integrated healthcare delivery.

Prognostic Accuracy of Presepsis and Intrasepsis Characteristics for Prediction of Cardiovascular Events After a Sepsis Hospitalization.

OBJECTIVES:Sepsis survivors face increased risk for cardiovascular complications; however, the contribution of intrasepsis events to cardiovascular risk profiles is unclear.SETTING:Kaiser Permanente Northern California (KPNC) and Intermountain Healthcare (IH) integrated healthcare delivery systems.SUBJECTS:Sepsis survivors (2011–2017 [KPNC] and 2018–2020 [IH]) greater than or equal to 40 years old without prior cardiovascular disease.DESIGN:Data across KPNC and IH were harmonized and grouped into presepsis (demographics, atherosclerotic cardiovascular disease scores, comorbidities) or intrasepsis factors (e.g., laboratory values, vital signs, organ support, infection source) with random split for training/internal validation datasets (75%/25%) within KPNC and IH. Models were bidirectionally, externally validated between healthcare systems.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Changes to predictive accuracy (C-statistic) of cause-specific proportional hazards models predicting 1-year cardiovascular outcomes (atherosclerotic cardiovascular disease, heart failure, and atrial fibrillation events) were compared between models that did and did not contain intrasepsis factors. Among 39,590 KPNC and 16,388 IH sepsis survivors, 3,503 (8.8%) at Kaiser Permanente (KP) and 600 (3.7%) at IH experienced a cardiovascular event within 1-year after hospital discharge, including 996 (2.5%) at KP and 192 (1.2%) IH with an atherosclerotic event first, 564 (1.4%) at KP and 117 (0.7%) IH with a heart failure event, 2,310 (5.8%) at KP and 371 (2.3%) with an atrial fibrillation event. Death within 1 year after sepsis occurred for 7,948 (20%) KP and 2,085 (12.7%) IH patients. Combined models with presepsis and intrasepsis factors had better discrimination for cardiovascular events (KPNC C-statistic 0.783 [95% CI, 0.766–0.799]; IH 0.763 [0.726–0.801]) as compared with presepsis cardiovascular risk alone (KPNC: 0.666 [0.648–0.683], IH 0.660 [0.619–0.702]) during internal validation. External validation of models across healthcare systems showed similar performance (KPNC model within IH data C-statistic: 0.734 [0.725–0.744]; IH model within KPNC data: 0.787 [0.768–0.805]).CONCLUSIONS:Across two large healthcare systems, intrasepsis factors improved postsepsis cardiovascular risk prediction as compared with presepsis cardiovascular risk profiles. Further exploration of sepsis factors that contribute to postsepsis cardiovascular events is warranted for improved mechanistic and predictive models.

Innovative and Integrated Contact Tracing: Indian Health Service, Arizona, December 2020-January 2021.

SARS-CoV-2 has exposed limitations of public health mitigation measures such as traditional case investigations and contact tracing. The Whiteriver Service Unit is a rural, acute care hospital on the Fort Apache Indian Reservation in Arizona with integrated health care delivery and public health services. During the first wave of COVID-19 cases in May-June 2020, we developed an innovative case investigation contact tracing approach that relied heavily on cross-trained personnel, in-person encounters, and baseline clinical evaluations. A second COVID-19 surge during December 13, 2020-January 31, 2021, caused incidence to peak at 413 cases per 100 000 community members. During that second surge, we investigated all 769 newly identified COVID-19 cases and notified 1911 (99.4%) of 1922 reported contacts. Median time interval from nasopharyngeal specimen collection to both case investigation and contact notification was 0 days (range, 0-5 days and 0-13 days, respectively). Our primary lesson was the importance of cross-trained personnel who integrated tasks along the testing-tracing continuum (eg, in-person interviews, prompt referral for additional testing and evaluation). These successive steps fed forward to identify new cases and their respective contacts. Our innovative community-based approach was both successful and efficient; our experience suggests that when adapted based on local needs, case investigation and contact tracing remain valuable and feasible public health tools, even in rural, resource-limited settings.

Validation of Respiratory Rate-Oxygenation Index in Patients With COVID-19-Related Respiratory Failure.

OBJECTIVES:The respiratory rate-oxygenation (ROX) index is a fraction of oxygen saturation, Fio2, and respiratory rate that has been validated to predict receipt of invasive mechanical ventilation in patients receiving high-flow nasal cannula (HFNC). This study aimed to validate ROX in a cohort of inpatients with COVID-19–related respiratory failure.DESIGN:Retrospective validation of the ROX index. We calculated sensitivity, specificity, positive predictive value, negative predictive value, and 95% CIs of ROX for invasive mechanical ventilation any time during hospitalization.SETTING:Twenty-one hospitals of Kaiser Permanente Northern California, an integrated healthcare delivery system.PATIENTS:We identified adults with positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test within 3 weeks of, or during, hospitalization between February 1, 2020, and December 31, 2020. We calculated ROX at 12 hours after HFNC initiation. We grouped patients as low (≥ 4.88), intermediate (< 4.88 and ≥ 3.85), or high (< 3.85) risk using previously published thresholds.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:We identified 1,847 patients who had no limitation of life support. Of these, 525 (31.7%) received invasive mechanical ventilation any time during hospitalization and 511 died (27.7%). The sensitivity, specificity, positive predictive value, and negative predictive value of 12-hour ROX threshold (< 3.85) predicting invasive mechanical ventilation were 32.3% (95% CI, 28.5–36.3%), 89.8% (95% CI, 88.0–91.4%), 59.4% (95% CI, 53.8–64.9%), and 74.1% (95% CI, 71.8–76.3%), respectively.CONCLUSIONS:The 12-hour ROX index has a positive predictive value (59.4%) using threshold of less than 3.85 for COVID-19 patients needing invasive mechanical ventilation. Our health system has embedded ROX into the electronic health record to prioritize rounding during periods of inpatient surge.

Integrated Healthcare Delivery and Telemedicine: Existing Legal Impediments in India

Integrated Healthcare Delivery and Telemedicine: Existing Legal Impediments in India

The NUDGE trial pragmatic trial to enhance cardiovascular medication adherence: study protocol for a randomized controlled trial

BackgroundNearly half of patients do not take their cardiovascular medications as prescribed, resulting in increased morbidity, mortality, and healthcare costs. Mobile and digital technologies for health promotion and disease self-management offer an opportunity to adapt behavioral “nudges” using ubiquitous mobile phone technology to facilitate medication adherence. The Nudge pragmatic clinical trial uses population-level pharmacy data to deliver nudges via mobile phone text messaging and an artificial intelligent interactive chat bot with the goal of improving medication adherence and patient outcomes in three integrated healthcare delivery systems.MethodsThe Theory of mHealth, the Expanded RE-AIM/PRISM, and the PRECIS-2 frameworks were used for program planning, implementation, and evaluation, along with a focus on dissemination and cost considerations. During the planning phase, the Nudge study team developed and piloted a technology-based nudge message and chat bot of optimized interactive content libraries for a range of diverse patients. Inclusion criteria are very broad and include patients in one of three diverse health systems who take medications to treat hypertension, atrial fibrillation, coronary artery disease, diabetes, or hyperlipidemia. A target of approximately 10,000 participants will be randomized to one of 4 study arms: usual care (no intervention), generic nudge (text reminder), optimized nudge, and optimized nudge plus interactive AI chat bot. The PRECIS-2 tool indicated that the study protocol is very pragmatic, although there is variability across PRECIS-2 dimensions.DiscussionThe primary effectiveness outcome is medication adherence defined by the proportion of days covered (PDC) using pharmacy refill data. Implementation outcomes are assessed using the RE-AIM framework, with a particular focus on reach, consistency of implementation, adaptations, cost, and maintenance/sustainability. The project has limitations including limited power to detect some subgroup effects, medication complications (bleeding), and longer-term outcomes (myocardial infarction). Strengths of the study include the diverse healthcare systems, a feasible and generalizable intervention, transparent reporting using established pragmatic research and implementation science frameworks, strong stakeholder engagement, and planning for dissemination and sustainment.Trial registrationClinicalTrials.govNCT03973931. Registered on 4 June 2019. The study was funded by the NIH; grant number is 4UH3HL144163-02 issued 4/5/19.

From the bench to practice - Field integration of community-based services for older citizens with different levels of functional limitation across European Regions.

The meeting of the European Innovation Partnership on Active and Healthy Ageing (EIPonAHA) action group A3 together with members of the Reference site collaborative network (RSCN) in December 2019 in Rome focused on integration of evidence-based approaches on health and care delivery for older citizens at different levels of needs with expertise coming from stakeholder across Europe. It was the final aim of the group to co-create culturally sensitive pathways and facilitate co-ownership for further implementation of the pathways in different care systems across Europe.The study design is a mixed method approach. Based on data analysis from a cohort of community-dwelling over-65 citizens in the framework of a longitudinal observational study in Rome, which included health, social and functional capacity data, three personas profiles were developed: the pre-frail, the frail and the very frail personas. Based on these data, experts were asked to co-create care pathways due to evidence and eminence during a workshop and included into a final report.All working groups agreed on a common understanding that integration of care means person-centered integration of health and social care, longitudinally provided across primary and secondary health care including citizens’ individual social, economic and human resources.Elements for consideration during care for pre-frail people are loneliness and social isolation, which, lead to limitation of physical autonomy in the light of reduced access to social support. Frail people need adaption of environmental structures and, again, social resource allocation to maintain at home. Very frail are generally vulnerable patients with complex needs. Most of them remain at home because of a strong individual social support and integrated health care delivery.The approach described in this publication may represent a first approach to scaling-up care delivery in a person-centered approach.

Differences between medical school and PGY1 learning outcomes: An explanation for new graduates not being “work ready”?

Background: Widespread concerns about new medical graduates’ ‘work readiness’ may reflect, in part, differences in mandatory learning outcomes for medical students and new medical graduates.Purpose: To examine differences between required medical student and PGY1 (first year resident) training program outcomes, and the nature and magnitude of these differences.Method: Comparison, systematic identification and thematic analysis of differences between the graduate outcomes in the Australian Medical Council Standards for the Assessment and Accreditation of Primary Medical Programs and those in the New Zealand Curriculum Framework for Prevocational Training.Results: The relationship between these outcome statements were categorized as: essentially similar; continuity; partial discontinuity; and complete discontinuity of learning trajectory. Areas requiring substantial new learning may reflect medical schools’ focus on individual student performance, and on learning and assessments based on single episodes of often uncomplicated illness. This contrasted with a post-graduate focus on integrated health care delivery by teams and management of complex illnesses over the whole patient care journey.Conclusions: Characterizing these marked differences between pre-graduate and postgraduate standards, within a trajectory of learning, explains some of the difficulties in students’ preparation for work readiness. These could inform learning interventions to support new graduates’ professional development to ensure patient safety. Development and revision of accreditation standards should include formal review against the expectations of the preceding and succeeding phases of learning.

Cumulative Antidepressant Use and Risk of Dementia in a Prospective Cohort Study.

To determine whether antidepressant use is associated with dementia risk. Prospective cohort study. Kaiser Permanente Washington (KPWA), an integrated healthcare delivery system. Community-dwelling individuals aged 65 and older without dementia and with 10 years or more of KPWA enrollment at baseline (N=3,059). Primary exposures were selective serotonin reuptake inhibitors (paroxetine vs other), tricyclic antidepressants, and serotonin antagonist and reuptake inhibitors. Using health plan pharmacy data, we calculated cumulative medication exposure, defined as total standardized daily doses (TSDDs), over rolling 10-year windows. Exposure in the most recent year was excluded to avoid use related to prodromal symptoms. The Cognitive Abilities Screening Instrument was administered every 2 years; low scores triggered clinical evaluation and consensus diagnosis procedures. Dementia risk was estimated according to medication use using Cox proportional hazards models. During a mean follow-up of 7.7 years, 775 participants (25%) developed dementia; 659 (22%) developed possible or probable Alzheimer's disease. Individual antidepressant classes were not associated with differences in dementia risk, although paroxetine use was associated with higher risk of dementia for all TSDD categories than no use (0-90 TSDDs: hazard ratio (HR)=1.69, 95% confidence interval (CI)=1.18-2.42; 91-365 TSDDs: HR=1.40, 95% CI=0.88-2.23; 366-1095 TSDDs: HR=2.13, 95% CI=1.32-3.43; ≥1095 TSDDs: HR=1.42, 95% CI=0.82-2.46). Most commonly prescribed nonanticholinergic depression medications used in late life do not appear to be associated with dementia risk. Paroxetine and other anticholinergic antidepressants may be exceptions in older individuals. Future studies are warranted to improve scientific understanding of potential associations in other settings and populations.

Carer Needs Assessment Development - A Republic of Ireland led International Joint Working Project to Support Delivery of Integrated Health and Social Care

Despite an increasing share of societal income being used to deliver health and social care services, families accross the globe continue to provide upwards of 80% of the overall care delivered (Huber & Hennessy, 2005; Dieleman et al, 2016). Such carers often experience inadequate recognition of their unique and crucial role in keeping their care recipients well and at home, and in the wider scheme of sustaining national and international healthcare infrastructure. While family carers availability and willingness to provide care is crucial; stress, isolation and ill health are frequently experienced;all of which may impact on their quality of life and ability to care, and further may impact on the availability of this under resourced pool of caregivers into the future. Identifying the needs of family carers is increasingly being viewed as a key intervention in the development of fully integrated health and social care (Guberman et al, 2007). The positive impact of such assessments to carers is wide and varied, particularly in reducing their burden of stress and depressive symptoms (Guberman et al, 2003; Becker et al, 2005; Kwak et al, 2011). Internationally, Carer Needs Assessments (CNA's) have been enshrined in law in the UK for over 20 years and are significantly embedded in assessment processes; while in the US in particular- there has been some legislative initiatives to bring Family Carers closer to the centre of care. This paper discuses the Carer Needs Assessment Development Project and presents preliminary findings on Irish data from the Carer Needs Assesment international pilot study. In giving expression to the Irish National Carers Strategy which seeks to work with Family Carers as partners in care (Department of Health (IRL), 2012), the HSE Single Asessment Tool (SAT) Project established a collaborative Working Group to develop a Carer Needs Assessment for national and international use. This group comprised of HSE SAT national team members, not-for profit national Carer/Advocacy Organisations (NGOs),and the international not-for-profit organisation ‘interRAI™’ who specialise in evidence-based assessment systems development. The Working Group are developing a CNA, initially paper based, which is currently being piloted with adult family carers in a longitudinal study across 11 countries, including Ireland, in order to finalise the tool. Once the pilot is complete, the CNA will be available as part of the interRAI integrated suite of assessment tools which are in use Ireland and internationally in an electronic format across health care settings. The target population for the pilot study are adult family carers who are providing an ongoing and significant level of care to an older person person who is in need due to illness, disability, or frailty. A family carer can be a relative, friend or neighbour. Approximately 600 Family Carers will be recruited internationally. The final potential target population in Ireland is all Family Carers who provide significant levels of care. This initiative is innovate as it represents a first between a state health agency, a number of not-for profit agencies and a leading academic health care assessment systems design collaboration (interRAI), in developing, testing and (potentially) implementing a comprehensive standardised assessment tool. Current models of CNA have not been exposed to sufficiently comprehensive evaluation. This paper charts the progression and challenges of this initiative, using an Implementation Science Framework. There will be a discussion on the learnings from the process together with a wider assessment of the future potential for Carer Needs Assessments in general.

Primary Care Physician Roles in Health Centers with Oral Health Care Units.

Integrating oral health care and primary care is a priority for improving population health. Primary care physicians (PCP) are filling expanded roles within oral health care to secure strong overall health for their patients. This comparative case study examines the roles of PCPs at 5 federally qualified health centers that have integrated oral health care and primary care. Administrative data were obtained directly from the Health Resources and Services Administration. Key informant interviews were performed with administrators and clinical care team members at each of the health centers. Data were reviewed by 2 experts in oral health to identify emerging roles for physicians. PPCPs' roles in health centers' integration models vary, but 3 distinct roles emerged: (1) the physician as a champion, (2) the physician as a collaborator, and (3) the physician as a member of an interprofessional team. In addition, providing physicians with the necessary training to identify oral health issues was critical to preparing physicians to take on expanded roles in integrated health care delivery models. Regardless of the roles that they play, family physicians can contribute a great deal to the success of integration models.

Evaluation of ICT supported integrated healthcare for frail patients with comorbidities: Baseline assessment of the CareWell Project

Introduction : One of the distinctive characteristics of frail elder patients with comorbidities is the complexity of the health and social needs they present as well as their vulnerability and high risk to develop dependence and high services consumption. The provision of healthcare to these individuals should be able to respond to their complex needs in order to improve their health status and to prevent avoidable resource consumption and suffering. Integrated care may be an adequate strategy to achieve this goal. The CareWell Project, co-funded by the European Commission, is aimed to assess the impact of new organisational models to provide ICT supported integrated healthcare (IHC) to frail elderly patients with comorbidities. The overall aim of the evaluation carried out in CareWell is to assess the impact of the implementation of ICT supported integrated healthcare. Evaluation will be conducted using the MAST multi-dimensional evaluation methodology adapted to the needs of CareWell project, focusing on integrated healthcare. MAST includes assessment of the outcomes divided into the following seven domains: 1) Health problem and characteristics of the application; 2) Safety; 3) Clinical effectiveness; 4) Patient perspectives; 5) Economic aspects; 6) Organisational aspects; and 7) Socio-cultural, ethical and legal aspects . This communication will be focused on the baseline assessment of the recruited subjects. Methods : CareWell is a quasi-experimental study with a control group, targeting community-dwelling frail subjects suffering from one of the following disease: chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM) (both insulin-dependent and noninsulin-dependent) or chronic heart failure (CHF) as well as one other comorbidity. Subjects in the intervention group have received the IHC and the control group, the usual care provided by their health system. The project is being developed in six pilot sites through Europe. All pilot sites have conducted a baseline assessment of the study population prior to the deployment of the new organisational model, which will serve as the basis for comparison (usual care), and again at the end of the follow-up, one year after the deployment (new care). Descriptive analysis have been performed for each variable included in this study using mean and standard deviation for quantitative variables, and frequencies and percentages for categorical variables. Variables collected in the basal assessment include socio-demographic variables (age, sex, education level, occupation, income); health related habits (alcohol and tobacco consumption, physical activity); health status (comorbidities, functionality status using Barthel Index, mental health status using Geriatric Depression Scale); and self-perceived experience with care provision measured by PIRU Questionnaire. Results : Overall, 859 care recipients have been recruited for the Carewell project. Of these, 477 have been assigned to the intervention group. Patients were equally distributed regarding gender (50.5% of men), with a mean age of 77.6, 95% CI (77.1, 78.1). The most frequent disease in the project population was DM (66.4%) followed by CHF (61.8%) and COPD (54.1%). The care recipients have a high degree of independence with a Barthel index median of 100, IQR (80,100). Conclusions : Evaluation of integrated healthcare service delivery processes will improve the current scientifically based knowledge on barriers and facilitators towards integrated healthcare delivery.

Integrated Healthcare Delivery: A Qualitative Research Approach to Identifying and Harmonizing Perspectives of Integrated Neglected Tropical Disease Programs.

BackgroundWhile some evidence supports the beneficial effects of integrating neglected tropical disease (NTD) programs to optimize coverage and reduce costs, there is minimal information regarding when or how to effectively operationalize program integration. The lack of systematic analyses of integration experiences and of integration processes may act as an impediment to achieving more effective NTD programming. We aimed to learn about the experiences of NTD stakeholders and their perceptions of integration.MethodologyWe evaluated differences in the definitions, roles, perceived effectiveness, and implementation experiences of integrated NTD programs among a variety of NTD stakeholder groups, including multilateral organizations, funding partners, implementation partners, national Ministry of Health (MOH) teams, district MOH teams, volunteer rural health workers, and community members participating in NTD campaigns. Semi-structured key informant interviews were conducted. Coding of themes involved a mix of applying in-vivo open coding and a priori thematic coding from a start list.FindingsIn total, 41 interviews were conducted. Salient themes varied by stakeholder, however dominant themes on integration included: significant variations in definitions, differential effectiveness of specific integrated NTD activities, community member perceptions of NTD programs, the influence of funders, perceived facilitators, perceived barriers, and the effects of integration on health system strength. In general, stakeholder groups provided unique perspectives, rather than contrarian points of view, on the same topics. The stakeholders identified more advantages to integration than disadvantages, however there are a number of both unique facilitators and challenges to integration from the perspective of each stakeholder group.ConclusionsQualitative data suggest several structural, process, and technical opportunities that could be addressed to promote more effective and efficient integrated NTD elimination programs. We highlight a set of ten recommendations that may address stakeholder concerns and perceptions regarding these key opportunities. For example, public health stakeholders should embrace a broader perspective of community-based health needs, including and beyond NTDs, and available platforms for addressing those needs.

Economic burden related to chemotherapy-related adverse events in patients with metastatic breast cancer in an integrated health care system.

BackgroundBreast cancer is treated with many different modalities, including chemotherapy that can be given as a single agent or in combination. Patients often experience adverse events from chemotherapy during the cycles of treatment which can lead to economic burden.ObjectiveThe objective of this study was to evaluate costs related to chemotherapy-related adverse events in patients with metastatic breast cancer (mBC) in an integrated health care delivery system.MethodsPatients with mBC newly initiated on chemotherapy were identified and the first infusion was defined as the index date. Patients were ≥18 years old at time of index date, had at least 6 months of health plan membership and drug eligibility prior to their index date. The chemotherapy adverse events were identified after the index date and during first line of chemotherapy. Episodes of care (EOC) were created using healthcare visits. Chart review was conducted to establish whether the adverse events were related to chemotherapy. Costs were calculated for each visit, including medications related to the adverse events, and aggregated to calculate the total EOC cost.ResultsA total of 1,682 patients with mBC were identified after applying study criteria; 54% of these patients had one or more adverse events related to chemotherapy. After applying the EOC method, there were a total of 5,475 episodes (4,185 single episodes [76.4%] and 1,290 multiple episodes [23.6%]) related to chemotherapy-related adverse events. Within single episodes, hematological (1,387 EOC, 33.1%), musculoskeletal/pain related (1,070 EOC, 25.6%), and gastrointestinal (775 EOC, 18.5%) were the most frequent adverse events. Patients with adverse events related to single EOC with anemia and neutropenia had the highest total outpatient costs with 901 EOC ($81,991) and 187 EOC ($17,017); these patients also had highest total inpatient costs with 46 EOC ($542,798) and 16 EOC ($136,768). However, within multiple episodes, hematological (420 EOC, 32.6%), followed by infections/pyrexia (335 EOC, 25.9%) and gastrointestinal (278 EOC, 22.6%) were the most frequent adverse events.ConclusionThe economic burden related to chemotherapy adverse events in patients with mBC is substantial.

Effectiveness of a Wellness Program for Individuals With Spina Bifida and Spinal Cord Injury Within an Integrated Delivery System

ObjectiveTo determine whether an evidence-based wellness program for individuals with spina bifida and spinal cord injury would improve health outcomes and patient experience of care, result in a positive return on investment (ROI), and provide evidence for scalability. DesignNonrandomized, noncontrolled cohort study; 2 years of enrollment. SettingAcademic hospital-based outpatient physiatry clinic partnered with an insurance division within an integrated health care delivery and financing system. ParticipantsIndividuals (N=69) with spina bifida and spinal cord injury were consented; 4 were excluded (5.7%), and the remaining 65 (94.2%) participated in the intervention. InterventionsEvidence-based wellness program consisting of care coordination from a mobile nurse, patient education, and patient incentives. Main Outcome MeasuresValidated measures of function, mood, quality of life, and perception of care delivery; knowledge of preventable conditions; self-rating of health; and utilization and cost. ResultsImprovements in all main outcome measures were seen after 2 years of enrollment. Although cost in year 1 of enrollment increased because of hospitalizations and the overall ROI was negative, a small positive ROI was seen in year 2 of enrollment. ConclusionsParticipation in an evidence-based wellness program was associated with improved health and experience of care. Scaling the program to larger numbers may result in an overall positive ROI.

Diabetes and Prior Coronary Heart Disease are Not Necessarily Risk Equivalent for Future Coronary Heart Disease Events.

For more than a decade, the presence of diabetes has been considered a coronary heart disease (CHD) "risk equivalent". The objective of this study was to revisit the concept of risk equivalence by comparing the risk of subsequent CHD events among individuals with or without history of diabetes or CHD in a large contemporary real-world cohort over a period of 10 years (2002 to 2011). Population-based prospective cohort analysis. We studied a cohort of 1,586,061 adult members (ages 30-90 years) of Kaiser Permanente Northern California, an integrated health care delivery system. We calculated hazard ratios (HRs) from Cox proportional hazard models for CHD among four fixed cohorts, defined by prevalent (baseline) risk group: no history of diabetes or CHD (None), prior CHD alone (CHD), diabetes alone (DM), and diabetes and prior CHD (DM + CHD). We observed 80,012 new CHD events over the follow-up period (~10,980,800 person-years). After multivariable adjustment, the HRs (reference: None) for new CHD events were as follows: CHD alone, 2.8 (95% CI, 2.7-2.85); DM alone 1.7 (95% CI, 1.66-1.74); DM + CHD, 3.9 (95% CI, 3.8-4.0). Individuals with diabetes alone had significantly lower risk of CHD across all age and sex strata compared to those with CHD alone (12.2 versus 22.5 per 1000 person-years). The risk of future CHD for patients with a history of either DM or CHD was similar only among those with diabetes of long duration (≥10 years). Not all individuals with diabetes should be unconditionally assumed to be a risk equivalent of those with prior CHD.