A 14-Year Longitudinal Analysis of Healthcare Expenditure on Dementia and Related Factors (DEMENCOST Study).

BACKGROUND: The large number of dementia cases produces a great pressure on health and social care services, which requires efficient planning to meet the needs of patients through infrastructure, equipment, and financial, technical, and personal resources adjusted to their demands. Dementia analysis requires studies with a very precise patient characterization of both the disease and comorbidities present, and long-term follow-up of patients in clinical aspects and patterns of resource utilization and costs generated. OBJECTIVE: To describe and quantify direct healthcare expenditure and its evolution from three years before and up to ten years after the diagnosis of dementia, compared to a matched group without dementia. METHODS: Retrospective cohort design with follow-up from 6 to 14 years. We studied 996 people with dementia (PwD) and 2,998 controls matched for age, sex, and comorbidity. This paper adopts the provider's perspective as the perspective of analysis and refers to the costs actually incurred in providing the services. Aggregate costs and components per patient per year were calculated and modelled. RESULTS: Total health expenditure increases in PwD from the year of diagnosis and in each of the following 7 years, but not thereafter. Health status and mortality are factors explaining the evolution of direct costs. Dementia alone is not a statistically significant factor in explaining differences between groups. CONCLUSION: The incremental direct cost of dementia may not be as high or as long as studies with relatively short follow-up suggest. Dementia would have an impact on increasing disease burden and mortality.

Morbilidad y estado de salud autopercibido, dos aproximaciones diferentes al estado de salud / Morbidity and self-perception of health, two different approaches to health status

OBJETIVO: Determinar el grado de asociación entre el estado de salud percibido y el obtenido a partir de información sobre morbilidad atendida. MÉTODO: Se estudió la población de cuatro áreas básicas de salud de la comarca del Baix Empordà (N=91.067), en el año 2016, con una muestra de 1202 personas a las que se realizó una encuesta de salud. Paralelamente, las personas encuestadas se clasificaron en estados de salud mediante el agrupador Clinical Risk Groups. El grado de asociación se analizó mediante regresión logística. RESULTADOS: Un 27% de las personas con más de dos enfermedades crónicas mayores o con condiciones de salud complejas afirmaron tener buena salud. Se detectó asociación entre percepción de salud y carga de enfermedad. El sexo, la situación laboral, la clase social y especialmente la edad también mostraron asociación con la percepción de salud. CONCLUSIONES: La inferencia del estado de salud a partir de registros clínicos sobre morbilidad atendida aproxima la percepción subjetiva de la salud, y viceversa. No obstante, determinados factores sociodemográficos modulan la percepción individual. Los resultados obtenidos son esperanzadores en relación con el desarrollo de nuevas metodologías de cálculo de indicadores de calidad de vida

OBJECTIVE: To determine the degree of association between perceived health status and that obtained from information on attended morbidity. METHOD: The population of four health areas of the Baix Empordà region (Catalonia, Spain) (N=91,067) was studied in 2016, by means of a sample of 1202 individuals. A health survey was conducted on sample individuals. At the same time, the respondents were classified by health status through the Clinical Risk Groups system. The degree of association was analysed by logistic regression. RESULTS: 27% of patients with more than two major chronic diseases or with complex health conditions stated they were in good health. An association was detected between health perception and disease burden. Sex, work situation, social class and especially age also showed association with the perception of health. CONCLUSIONS: The inference of health status from clinical records on attended morbidity approximates to the subjective perception of health and vice versa. However, certain sociodemographic factors modulate individual perception. The results obtained are encouraging in relation to the development of new methodologies for calculating quality of life indicators

[Morbidity and self-perception of health, two different approaches to health status]. / Morbilidad y estado de salud autopercibido, dos aproximaciones diferentes al estado de salud.

OBJECTIVE: To determine the degree of association between perceived health status and that obtained from information on attended morbidity. METHOD: The population of four health areas of the Baix Empordà region (Catalonia, Spain) (N=91,067) was studied in 2016, by means of a sample of 1202 individuals. A health survey was conducted on sample individuals. At the same time, the respondents were classified by health status through the Clinical Risk Groups system. The degree of association was analysed by logistic regression. RESULTS: 27% of patients with more than two major chronic diseases or with complex health conditions stated they were in good health. An association was detected between health perception and disease burden. Sex, work situation, social class and especially age also showed association with the perception of health. CONCLUSIONS: The inference of health status from clinical records on attended morbidity approximates to the subjective perception of health and vice versa. However, certain sociodemographic factors modulate individual perception. The results obtained are encouraging in relation to the development of new methodologies for calculating quality of life indicators.

Doctors' opinions on clinical coordination between primary and secondary care in the Catalan healthcare system / Opinión de los médicos sobre coordinación entre atención primaria y especializada en el sistema de salud catalán

Objective: To analyse doctors' opinions on clinical coordination between primary and secondary care in different healthcare networks and on the factors influencing it. Methods: A qualitative descriptive-interpretative study was conducted, based on semi-structured interviews. A two-stage theoretical sample was designed: 1) healthcare networks with different management models; 2) primary care and secondary care doctors in each network. Final sample size (n = 50) was reached by saturation. A thematic content analysis was conducted. Results: In all networks doctors perceived that primary and secondary care given to patients was coordinated in terms of information transfer, consistency and accessibility to SC following a referral. However, some problems emerged, related to difficulties in acceding non-urgent secondary care changes in prescriptions and the inadequacy of some referrals across care levels. Doctors identified the following factors: 1) organizational influencing factors: coordination is facilitated by mechanisms that facilitate information transfer, communication, rapid access and physical proximity that fosters positive attitudes towards collaboration; coordination is hindered by the insufficient time to use mechanisms, unshared incentives in prescription and, in two networks, the change in the organizational model; 2) professional factors: clinical skills and attitudes towards coordination. Conclusions: Although doctors perceive that primary and secondary care is coordinated, they also highlighted problems. Identified factors offer valuable insights on where to direct organizational efforts to improve coordination

Objetivo: Analizar la opinión de los médicos sobre la coordinación entre la atención primaria (AP) y la atención especializada (AE) en diferentes redes de servicios de salud, e identificar los factores relacionados. Método: Estudio cualitativo descriptivo-interpretativo basado en entrevistas semiestructuradas. Se diseñó una muestra teórica en dos etapas: 1) redes de servicios de salud con diferentes modelos de gestión; 2) en cada red, médicos de AP y AE. El tamaño muestral se alcanzó por saturación (n = 50). Se realizó un análisis temático de contenido. Resultados: En las tres redes, los médicos expresaron que la atención está coordinada en términos de intercambio de información, consistencia y accesibilidad de AE tras derivación urgente. Sin embargo, emergieron problemas relacionados con el acceso no urgente y cambios en prescripciones, y en dos redes la inadecuación clínica de las derivaciones entre ambos niveles. Se identificaron los siguientes factores relacionados: 1) organizativos: facilitan la coordinación, la existencia de mecanismos de transferencia de información, de comunicación y de acceso rápido, y la proximidad física que promueve actitudes positivas a la colaboración; la obstaculizan el tiempo insuficiente para el uso de mecanismos, incentivos no compartidos en la prescripción y, en dos redes, un cambio del modelo organizativo; 2) relacionados con los profesionales: habilidades clínicas y actitudes frente a la coordinación. Conclusiones: Aunque los médicos perciben que la atención entre niveles está coordinada, también señalan problemas. Los factores identificados muestran hacia dónde dirigir los esfuerzos organizativos para su mejora

Doctors' opinions on clinical coordination between primary and secondary care in the Catalan healthcare system.

OBJECTIVE: To analyse doctors' opinions on clinical coordination between primary and secondary care in different healthcare networks and on the factors influencing it. METHODS: A qualitative descriptive-interpretative study was conducted, based on semi-structured interviews. A two-stage theoretical sample was designed: 1) healthcare networks with different management models; 2) primary care and secondary care doctors in each network. Final sample size (n = 50) was reached by saturation. A thematic content analysis was conducted. RESULTS: In all networks doctors perceived that primary and secondary care given to patients was coordinated in terms of information transfer, consistency and accessibility to SC following a referral. However, some problems emerged, related to difficulties in acceding non-urgent secondary care changes in prescriptions and the inadequacy of some referrals across care levels. Doctors identified the following factors: 1) organizational influencing factors: coordination is facilitated by mechanisms that facilitate information transfer, communication, rapid access and physical proximity that fosters positive attitudes towards collaboration; coordination is hindered by the insufficient time to use mechanisms, unshared incentives in prescription and, in two networks, the change in the organizational model; 2) professional factors: clinical skills and attitudes towards coordination. CONCLUSIONS: Although doctors perceive that primary and secondary care is coordinated, they also highlighted problems. Identified factors offer valuable insights on where to direct organizational efforts to improve coordination.

Correction to: Relational continuity with primary and secondary care doctors: a qualitative study of perceptions of users of the Catalan national health system.

Following publication of the original article [1], the authors reported a correction in affiliation of Maria Luisa Vázquez, who is affiliated with Health Policy and Health Services Research Group, which is number 1 instead of being affiliated with Grup de Recerca en Serveis Sanitaris i Resultats en Salut, Serveis de Salut Integrats Baix Empordà, Carrer Hospital 17-19 Edifici Fleming, 17,230 Palamós, Spain.

Relational continuity with primary and secondary care doctors: a qualitative study of perceptions of users of the Catalan national health system.

BACKGROUND: In the current context of increasingly fragmented healthcare systems where patients are seen by multiple doctors in different settings, patients' relational continuity with one doctor is regaining relevance; however little is known about relational continuity with specialists. The aim of this study is to explore perceptions of relational continuity with primary care and secondary care doctors, its influencing factors and consequences from the viewpoint of users of the Catalan national health system (Spain). METHODS: We conducted a descriptive-interpretative qualitative study using a two-stage theoretical sample; (i) contexts: three healthcare areas in the Catalan national health system with differing characteristics; (ii) informants: users 18 years or older attended to at both care levels. Sample size (n = 49) was reached by saturation. Data were collected by individual semi-structured interviews, which were audio recorded and transcribed. A thematic content analysis was carried out segmenting data by study area, and leaving room for new categories to emerge from the data. RESULTS: Patients across the areas studied generally experienced consistency of primary care doctors (PCD), alongside some inconsistency of specialists. Consistency of specialists did not seem to be relevant to some patients when their clinical information was shared and used. Patients who experienced consistency and frequent visits with the same PCD or specialist described and valued having established an ongoing relationship characterised by personal trust and mutual accumulated knowledge. Identified consequences were diverse and included, for example, facilitated diagnosis or improved patient-doctor communication. The ascription to a PCD, a health system-related factor, facilitated relational continuity with the PCD, whereas organizational factors (for instance, the size of the primary care centre) favoured consistency of PCD and specialists. Doctor-related factors (for example, high technical competence or commitment to patient care) particulary fostered the development of an ongoing relationship. CONCLUSIONS: Consistency of doctors differs depending on the care level as does the relevance attributed to it. Most influencing factors can be applied to both care levels and might be addressed by healthcare managers to foster relational continuity. More research is needed to fully understand the relevance patients assign to relational continuity with specialists.

Evaluación de la efectividad de un programa de atención integrada y proactiva a pacientes crónicos complejos / Assessment of the effectiveness of a proactive and integrated healthcare programme for chronic complex patients

Objetivo: Evaluar la efectividad de un programa de atención integrada y proactiva para adecuar el uso de recursos sanitarios en pacientes crónicos complejos con riesgo de alto consumo según un modelo predictivo basado en morbilidad y utilización previa. Métodos: Ensayo clínico controlado aleatorizado con grupo control enmascarado, grupo de intervención parcial informado en la historia clínica y grupo de intervención total informado además a atención primaria, en una organización sanitaria integrada con 128.281 residentes en 2011. Variables dependientes: visitas de atención primaria, urgencias hospitalarias, hospitalización, coste farmacéutico y muerte. Variables independientes: grupo de intervención, edad, sexo, área básica, morbilidad (según grupo de riesgo clínico) y recurrencia como paciente crónico complejo. Análisis bivariado con ANOVA y t de Student, y multivariado mediante regresión logística y regresión lineal múltiple, con un nivel de confianza del 95%. Resultados: Se incluyeron 4.236 y 4.223 pacientes crónicos complejos en el primer y el segundo año de intervención, respectivamente. El 72% eran recurrentes. Edad media: 73,2 años. El 54,2% eran mujeres. Más del 70% tenían al menos dos enfermedades crónicas. El número de visitas a atención primaria fue significativamente mayor en el grupo de intervención total respecto al grupo de intervención parcial y el grupo control. La intervención solo tuvo un efecto significativo independiente en las estancias hospitalarias, que fueron menos en el grupo de intervención parcial. Este efecto diferencial se dio en el primer año y en los pacientes crónicos complejos nuevos del segundo año. Los indicadores asistenciales generales de la organización sanitaria integrada eran buenos, antes y durante la intervención. Conclusiones: Una buena situación general previa y mantenida, y una inevitable contaminación entre grupos, dificultaron la demostración de efectividad marginal del programa (AU)

Objective: To assess the effectiveness of a proactive and integrated care programme to adjust the use of health resources by chronic complex patients (CCP) identified as potential high consumers according to a predictive model based on prior use and morbidity. Methods: Randomized controlled clinical trial with three parallel groups of CCP: a blinded control group (GC), usual care; a partial intervention group (GIP) reported in the EMR; a total intervention group (GIT), also reported to primary care (PC). Conducted in an integrated health care organization (IHCO), N=128,281 individuals in 2011. Dependent variables: PC visits, emergency attention, hospitalizations, pharmaceutical cost and death. Independent variables: intervention group, age, sex, area of residence, morbidity (by clinical risk group) and recurrence as CCP. Statistical analysis: ANOVA, student's t test; logistic and multiple linear regressions at the 95% confidence level. Results: 4,236 CCP included for the first intervention year and 4,223 for the second; recurrence as CCP 72%. Mean age 73.2 years, 54.2% women and over 70% with 2 or more chronic diseases. The number of PC visits was significantly higher for GIT than for GIP and GC. The hospital stays were significantly lower in GIP. This effect was observed in the first year and in the second year only in the new CCP. The general indicators of the IHCO were good, before and during the intervention. Conclusions: A high standard of quality, previous and during the study, and the inevitable contamination between groups, hindered the assessment of the marginal effectiveness of the program (AU)

Urgencias hospitalarias procedentes de residencias geriátricas de una comarca: evolución, características y adecuación / Hospital emergencies arising from nursing homes in a region: evolution, characteristics and appropriateness

Objetivo: Las urgencias hospitalarias (UH) procedentes de residencias asistidas (RA) aumentan. Se analizan la evolución, las características y la adecuación de las UH de personas institucionalizadas en RA de una comarca, y las hospitalizaciones generadas por ellas. Métodos: Estudio descriptivo retrospectivo entre 2010 y 2013 con personas institucionalizadas en 11 RA del Baix Empordà (704 plazas) y el Hospital de Palamós. Variables: Sexo, edad, morbilidad y peso relativo según grupos de riesgo clínico (CRG, clinical risk groups), RA, días de estancia, diagnóstico de la urgencia, adecuación de las UH según los criterios de Bermejo y el protocolo de adecuación de UH (PAUH), y de las hospitalizaciones según el Appropriateness Evaluation Protocol (AEP). Muestra para evaluar la adecuación: 159 UH y 91 hospitalizaciones. Análisis estadístico: frecuencias, media, desviación típica, percentiles, test exacto de Fisher y ANOVA, con un nivel de confianza del 95% y utilizando IBM SPSS Statistics 23. Resultados: Se incluyeron 1474 personas (73% mujeres), el grupo ≥85 años aumentó al 60,3% y el peso medio de la morbilidad fue de 3,2 a 4,0 (p <0,001). Generaron 1805 UH. La tasa anual por 1.000 estancias de RA aumentó de 1,64 a 2,05, siendo adecuadas el 90,6% según los criterios de Bermejo y el 93,7% según el PAUH. De estas, 502 se hospitalizaron. La tasa anual por 10 urgencias descendió de 2,96 a 2,64, siendo adecuadas el 98,9% según el AEP. Conclusiones: Las urgencias y las hospitalizaciones de personas institucionalizadas en RA aumentan y son adecuadas. El incremento de la edad y de la carga de morbilidad podrían explicar este fenómeno. Las RA y los hospitales deberían afrontarlo apropiadamente, considerando las necesidades de este sector (AU)

Objective: Hospital emergencies (HE) arising from nursing homes (NH) are on the rise. We analyse the evolution, characteristics and appropriateness of HE of NH residents in a region, as well as resulting hospital admissions. Method: Retrospective descriptive study between 2010 and 2013 of institutionalised residents of 11 NH located in Baix Empordà (704 beds) and Palamós Hospital. Variables: Gender, age, morbidity and relative weight according to clinical risk groups (CRG), NH, length of stay, diagnosis of the emergency, appropriateness of HE according to Bermejo's criteria and the HE appropriateness protocol (HEAP), and appropriateness of hospitalisations according to the Appropriateness Evaluation Protocol (AEP). Sample to evaluate appropriateness: 159 HE and 91 hospitalisations. Statistical analysis: frequency, mean, standard deviation, percentiles, Fisher's exact test and ANOVA, with a confidence interval of 95% and using IBM SPSS Statistics 23. Results: 1,474 people were enrolled, of which 73% were women. Group ≥85 years increased to 60.3% and the mean weight of morbidity was 3.2 to 4.0 (p <0.001). 1,805 HE were generated. The annual rate per 1,000 stays arising from NH increased from 1.64 to 2.05, of which 90.6% were appropriate according to Bermejo's criteria and 93.7% according to the HEAP. Of these, 502 involved hospitalisation. The annual rate per 10 emergencies fell from 2.96 to 2.64 and 98.9% were appropriate according to the AEP. Conclusions: Hospital emergencies and hospitalisations of NH residents are increasing and are appropriate. Increasing age and disease burden could explain this phenomenon. NH and hospitals should react appropriately, considering the specific needs of this population sector (AU)

[Assessment of the effectiveness of a proactive and integrated healthcare programme for chronic complex patients]. / Evaluación de la efectividad de un programa de atención integrada y proactiva a pacientes crónicos complejos.

OBJECTIVE: To assess the effectiveness of a proactive and integrated care programme to adjust the use of health resources by chronic complex patients (CCP) identified as potential high consumers according to a predictive model based on prior use and morbidity. METHODS: Randomized controlled clinical trial with three parallel groups of CCP: a blinded control group (GC), usual care; a partial intervention group (GIP) reported in the EMR; a total intervention group (GIT), also reported to primary care (PC). Conducted in an integrated health care organization (IHCO), N=128,281 individuals in 2011. Dependent variables: PC visits, emergency attention, hospitalizations, pharmaceutical cost and death. INDEPENDENT VARIABLES: intervention group, age, sex, area of residence, morbidity (by clinical risk group) and recurrence as CCP. STATISTICAL ANALYSIS: ANOVA, student's t test; logistic and multiple linear regressions at the 95% confidence level. RESULTS: 4,236 CCP included for the first intervention year and 4,223 for the second; recurrence as CCP 72%. Mean age 73.2 years, 54.2% women and over 70% with 2 or more chronic diseases. The number of PC visits was significantly higher for GIT than for GIP and GC. The hospital stays were significantly lower in GIP. This effect was observed in the first year and in the second year only in the new CCP. The general indicators of the IHCO were good, before and during the intervention. CONCLUSIONS: A high standard of quality, previous and during the study, and the inevitable contamination between groups, hindered the assessment of the marginal effectiveness of the program.

[Hospital emergencies arising from nursing homes in a region: evolution, characteristics and appropriateness]. / Urgencias hospitalarias procedentes de residencias geriátricas de una comarca: evolución, características y adecuación.

OBJECTIVE: Hospital emergencies (HE) arising from nursing homes (NH) are on the rise. We analyse the evolution, characteristics and appropriateness of HE of NH residents in a region, as well as resulting hospital admissions. METHOD: Retrospective descriptive study between 2010 and 2013 of institutionalised residents of 11 NH located in Baix Empordà (704 beds) and Palamós Hospital. VARIABLES: Gender, age, morbidity and relative weight according to clinical risk groups (CRG), NH, length of stay, diagnosis of the emergency, appropriateness of HE according to Bermejo's criteria and the HE appropriateness protocol (HEAP), and appropriateness of hospitalisations according to the Appropriateness Evaluation Protocol (AEP). Sample to evaluate appropriateness: 159 HE and 91 hospitalisations. STATISTICAL ANALYSIS: frequency, mean, standard deviation, percentiles, Fisher's exact test and ANOVA, with a confidence interval of 95% and using IBM SPSS Statistics 23. RESULTS: 1,474 people were enrolled, of which 73% were women. Group ≥85 years increased to 60.3% and the mean weight of morbidity was 3.2 to 4.0 (p <0.001). 1,805 HE were generated. The annual rate per 1,000 stays arising from NH increased from 1.64 to 2.05, of which 90.6% were appropriate according to Bermejo's criteria and 93.7% according to the HEAP. Of these, 502 involved hospitalisation. The annual rate per 10 emergencies fell from 2.96 to 2.64 and 98.9% were appropriate according to the AEP. CONCLUSIONS: Hospital emergencies and hospitalisations of NH residents are increasing and are appropriate. Increasing age and disease burden could explain this phenomenon. NH and hospitals should react appropriately, considering the specific needs of this population sector.

Doctors' opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system.

BACKGROUND: Clinical coordination is considered a health policy priority as its absence can lead to poor quality of care and inefficiency. A key challenge is to identify which strategies should be implemented to improve coordination. The aim is to analyse doctors' opinions on the contribution of mechanisms to improving clinical coordination between primary and outpatient secondary care and the factors influencing their use. METHODS: A qualitative descriptive study in three healthcare networks of the Catalan national health system. A two-stage theoretical sample was designed: in the first stage, networks with different management models were selected; in the second, primary care (n = 26) and secondary care (n = 24) doctors. Data were collected using semi-structured interviews. Final sample size was reached by saturation. A thematic content analysis was conducted, segmented by network and care level. RESULTS: With few differences across networks, doctors identified similar mechanisms contributing to clinical coordination: 1) shared EMR facilitating clinical information transfer and uptake; 2) mechanisms enabling problem-solving communication and agreement on clinical approaches, which varied across networks (joint clinical case conferences, which also promote mutual knowledge and training of primary care doctors; virtual consultations through EMR and email); and 3) referral protocols and use of the telephone facilitating access to secondary care after referrals. Doctors identified organizational (insufficient time, incompatible timetables, design of mechanisms) and professional factors (knowing each other, attitude towards collaboration, concerns over misdiagnosis) that influence the use of mechanisms. DISCUSSION: Mechanisms that most contribute to clinical coordination are feedback mechanisms, that is those based on mutual adjustment, that allow doctors to exchange information and communicate. Their use might be enhanced by focusing on adequate working conditions, mechanism design and creating conditions that promote mutual knowledge and positive attitudes towards collaboration.

¿Son los grupos de morbilidad ajustados concordantes con el criterio clínico de intervención en una estrategia de crónicos? / Are adjusted morbidity groups concordant with the clinical judgment of intervention in a chronic strategy?

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Efectividad e impacto económico de un programa de atención integrada con soporte de telemedicina a pacientes diabéticos tipo 2 tratados con insulina (estudio GITDIABE) / Effectiveness and economic impact of a program of integrated care with telemedicine support on insulin-treated type 2 diabetic patients (Study GITDIABE)

OBJETIVO: Evaluar si pacientes diabéticos tipo 2 con insulina y autocontrol (DIA) incluidos en un programa de gestión integrada de la diabetes mellitus (DM) con seguimiento telemático alcanzan un grado de control metabólico a los 12 meses mejor que los no incluidos, así como el impacto en la utilización y el coste de servicios sanitarios, consumo de fármacos y tiras reactivas. DISEÑO: Estudio prospectivo de cohortes paralelas. Emplazamiento: Cuatro áreas básicas de salud de una organización sanitaria integrada. PARTICIPANTES: Ciento veintiséis pacientes DIA de 15 o más años en tratamiento con insulina rápida o intermedia con autocontroles: 42 casos y 84 controles emparejados según edad, sexo, grado de control de la DM y perfil de morbilidad. Intervención: Comunicación telemática médico-paciente y volcado de glucemias mediante la plataforma Emminens eConecta®; suministro a domicilio de tiras reactivas según consumo. Controles ocultos, con seguimiento habitual. Mediciones principales: Hemoglobina glucosilada (% HbA1c); percepción de calidad de vida (EuroQol-5 y EsDQOL); riesgo cardiovascular; utilización de recursos sanitarios; consumo de tiras reactivas y medicamentos; gasto sanitario total. RESULTADOS: Reducción de %HbA1c en casos respecto a controles de 0,38% (IC95% −0,89% a 0,12%). Sin diferencias significativas respecto a ninguna de las actividades registradas, ni cambios significativos en la calidad de vida. CONCLUSIONES: Los resultados obtenidos no difieren de otros estudios equiparables. El perfil es de un paciente anciano y pluripatológico que tiene todavía limitaciones tecnológicas. Para superar estas barreras se debería dedicar más tiempo a la formación y a la resolución de problemas tecnológicos

AIM: To evaluate if insulin-treated type 2 diabetic patients with blood glucose self-monitoring (DIA), included in a program of integrated management of diabetes mellitus (DM), achieve a better level of metabolic control with telemedicine support than with conventional support, after 12 months follow-up. The impact on the use and cost of healthcare services, pharmaceutical expenditure, and consumption of test strips for blood glucose, was also assessed. DESIGN: A prospective parallel cohorts study. Field: Four basic health areas of an integrated healthcare organisation. PARTICIPANTS: The study included 126 DIA patients aged 15 or more years, treated with rapid or intermediate Insulin and blood glucose self-monitoring, grouped into 42 cases and 84 controls, matched according to age, sex, level of metabolic control, and morbidity profile. Intervention: Telematics physician-patient communication and download of blood glucose self-monitoring data through the Emminens eConecta® platform; test strips home delivered according to consumption. Hidden controls with usual follow-up. MAIN MEASUREMENTS: Glycosylated haemoglobin (%HbA1c); perception of quality of life (EuroQol-5 and EsDQOL); cardiovascular risk; use of healthcare resources; consumption of test strips; pharmaceutical and healthcare expenditure. RESULTS: Reduction of 0.38% in HbA1c in the cases (95% CI:−0.89% to 0.12%). No significant differences with regard to any of the activities registered, or any significant change in the quality of life. CONCLUSIONS: The results obtained are similar to other equivalent studies. The profile of the patient is elderly and with multiple morbidities, who still have technological limitations. To surpass these barriers, it would be necessary to devote more time to the training and to the resolution of possible technological problems

[Effectiveness and economic impact of a program of integrated care with telemedicine support on insulin-treated type 2 diabetic patients (Study GITDIABE)]. / Efectividad e impacto económico de un programa de atención integrada con soporte de telemedicina a pacientes diabéticos tipo 2 tratados con insulina (estudio GITDIABE).

AIM: To evaluate if insulin-treated type 2 diabetic patients with blood glucose self-monitoring (DIA), included in a program of integrated management of diabetes mellitus (DM), achieve a better level of metabolic control with telemedicine support than with conventional support, after 12 months follow-up. The impact on the use and cost of healthcare services, pharmaceutical expenditure, and consumption of test strips for blood glucose, was also assessed. DESIGN: A prospective parallel cohorts study. FIELD: Four basic health areas of an integrated healthcare organisation. PARTICIPANTS: The study included 126 DIA patients aged 15 or more years, treated with rapid or intermediate Insulin and blood glucose self-monitoring, grouped into 42 cases and 84 controls, matched according to age, sex, level of metabolic control, and morbidity profile. INTERVENTION: Telematics physician-patient communication and download of blood glucose self-monitoring data through the Emminens eConecta® platform; test strips home delivered according to consumption. Hidden controls with usual follow-up. MAIN MEASUREMENTS: Glycosylated haemoglobin (%HbA1c); perception of quality of life (EuroQol-5 and EsDQOL); cardiovascular risk; use of healthcare resources; consumption of test strips; pharmaceutical and healthcare expenditure. RESULTS: Reduction of 0.38% in HbA1c in the cases (95% CI:-0.89% to 0.12%). No significant differences with regard to any of the activities registered, or any significant change in the quality of life. CONCLUSIONS: The results obtained are similar to other equivalent studies. The profile of the patient is elderly and with multiple morbidities, who still have technological limitations. To surpass these barriers, it would be necessary to devote more time to the training and to the resolution of possible technological problems.

Continuity of clinical management and information across care levels: perceptions of users of different healthcare areas in the Catalan national health system.

BACKGROUND: The integration of health care has become a priority in most health systems, as patients increasingly receive care from several professionals in various different settings and institutions, particularly those with chronic conditions and multi-morbidities. Continuity of care is defined as one patient experiencing care over time as connected and coherent with his or her health needs and personal circumstances. The objective is to analyse perceptions of continuity of clinical management and information across care levels and the factors influencing it, from the viewpoint of users of the Catalan national health system. METHODS: A descriptive-interpretative qualitative study was conducted using a phenomenological approach. A two-stage theoretical sample was selected: (i) the study contexts: healthcare areas in Catalonia with different services management models; (ii) users ≥ 18 years of age who were attended to at both care levels for the same health problem. Data were collected by means of individual semi-structured interviews with patients (n = 49). All interviews were recorded and transcribed. A thematic content analysis was conducted segmented by study area, with a mixed generation of categories and triangulation of analysts. RESULTS: Patients in all three areas generally perceived that continuity of clinical management across levels existed, on referring to consistent care (same diagnosis and treatment by doctors of both care levels, no incompatibilities of prescribed medications, referrals across levels when needed) and accessibility across levels (timeliness of appointments). In terms of continuity of information, patients in most areas mentioned the existence of information sharing via computer and its adequate usage. Only a few discontinuity elements were reported such as long waiting times for specific tests performed in secondary care or insufficient use of electronic medical records by locum doctors. Different factors influencing continuity were identified by patients, relating to the health system itself (clear distribution of roles between primary and secondary care), health services organizations (care coordination mechanisms, co-location, insufficient resources) and physicians (willingness to collaborate, commitment to patient care, the primary care physician's technical competence). CONCLUSIONS: Care continuity across care levels is experienced by patients in the areas studied, with certain exceptions that highlight where there is room for improvement. Influencing factors offer valuable insights on where to direct coordination efforts.

Analysing the Costs of Integrated Care: A Case on Model Selection for Chronic Care Purposes.

BACKGROUND: The objective of this study is to investigate whether the algorithm proposed by Manning and Mullahy, a consolidated health economics procedure, can also be used to estimate individual costs for different groups of healthcare services in the context of integrated care. METHODS: A cross-sectional study focused on the population of the Baix Empordà (Catalonia-Spain) for the year 2012 (N = 92,498 individuals). A set of individual cost models as a function of sex, age and morbidity burden were adjusted and individual healthcare costs were calculated using a retrospective full-costing system. The individual morbidity burden was inferred using the Clinical Risk Groups (CRG) patient classification system. RESULTS: Depending on the characteristics of the data, and according to the algorithm criteria, the choice of model was a linear model on the log of costs or a generalized linear model with a log link. We checked for goodness of fit, accuracy, linear structure and heteroscedasticity for the models obtained. CONCLUSION: The proposed algorithm identified a set of suitable cost models for the distinct groups of services integrated care entails. The individual morbidity burden was found to be indispensable when allocating appropriate resources to targeted individuals.

Morbilidad y costes sanitarios: hacia un benchmarking? / Morbidity and healthcare costs: towards a benchmarking?

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