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Rinnakkaistallenteet Yhteiskuntatieteiden ja kauppatieteiden tiedekunta
2018
Managing multimorbidity: Profiles of integrated care approaches targeting people with multiple chronic conditions in Europe
Rijken M
Elsevier BV
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CC BY-NC-ND https://creativecommons.org/licenses/by-nc-nd/4.0/
http://dx.doi.org/10.1016/j.healthpol.2017.10.002
https://erepo.uef.fi/handle/123456789/5157
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Health Policy
jo u rn al h om ep a ge :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l
Managing multimorbidity: Profiles of integrated care approaches targeting people with multiple chronic conditions in Europe 夽
Mieke Rijken
a,∗, Anneli Hujala
b, Ewout van Ginneken
c,d, Maria Gabriella Melchiorre
e, Peter Groenewegen
a,f, Fran ois Schellevis
a,gaNIVEL(Netherlandsinstituteforhealthservicesresearch),P.O.Box1568,3500BNUtrecht,TheNetherlands
bDepartmentofHealthandSocialManagement,UniversityofEasternFinland,P.O.Box1627,FI-70211Kuopio,Finland
cBerlinUniversityofTechnology,FacultyofEconomicsandManagement,DepartmentofHealthCareManagement,Straßedes17.Juni135,10623Berlin, Germany
dEuropeanObservatoryonHealthSystemsandPolicies,BerlinArea,Germany
eCentreforSocio-EconomicResearchonAgeing,NationalInstituteofHealthandScienceonAgeing(INRCA),ViaS.Margherita5,60124Ancona,Italy
fUtrechtUniversity,FacultyofGeoscience,FacultyofSocialScience,P.O.Box80125,3508TCUtrecht,TheNetherlands
gDepartmentofGeneralPracticeandElderlyCareMedicine,EMGOInstituteforHealthandCareResearch,VUUniversityMedicalCentre,Vander Boechorststraat7,1081BTAmsterdam,TheNetherlands
a r t i c l e i n f o
Articlehistory:
Received1December2016 Receivedinrevisedform 27September2017 Accepted13October2017
Keywords:
Multimorbidity Integratedcare Europe Chronicdisease
a b s t r a c t
Inresponsetothegrowingpopulationsofpeoplewithmultiplechronicdiseases,newmodelsofcareare currentlybeingdevelopedinEuropeancountriestobettermeettheneedsofthesepeople.Thispaperaims todescribetheoccurrenceandcharacteristicsofvarioustypesofintegratedcarepracticesinEuropean countriesthattargetpeoplewithmultimorbidity.
DatawereanalysedfrommultimorbiditycarepracticesparticipatingintheInnovatingcareforpeople withmultiplechronicconditions(ICARE4EU)project,coveringall28EUMemberStates,Iceland,Norway andSwitzerland.
Atotalof112practicesin24countrieswereincluded:65focusonpatientswithanycombination ofchronicdiseases,30onpatientswithaspecificchronicdiseasewithallkindsofcomorbiditiesand 17onpatientswithacombinationofspecificchronicdiseases.Practicesthatfocusonaspecificindex diseaseoracombinationofspecificdiseasesarelessextensiveregardingthetype,breadthanddegreeof integrationthanpracticesthatfocusonanycombinationofdiseases.Thelattertypeismoreoftenseenin countrieswheremoredisciplines,e.g.communitynurses,physiotherapists,socialworkers,workinthe sameprimarycarepracticeasthegeneralpractitioners.
Non-diseasespecificpracticesputmoreemphasisonpatientinvolvementandprovidemorecompre- hensivecare,whichareimportantpreconditionsforperson-centeredmultimorbiditycare.
©2017TheAuthors.PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Europeancountries,asmanyothercountriesworldwide,face arapidincreaseinthenumberofinhabitantslivingwithchronic conditions,whichputsahighpressureontheirhealthsystems[e.g.
1,2].Awarenesshasraisedthatmultimorbidity,i.e.theco-existence oftwoormorechronicdiseasesinaperson,maybeanevengreater challengeforhealthcare[e.g.3,4].Notonlydodatashowthatan
夽OpenAccessforthisarticleismadepossiblebyacollaborationbetweenHealth PolicyandTheEuropeanObservatoryonHealthSystemsandPolicies.
∗Correspondingauthor.
E-mailaddress:m.rijken@nivel.nl(M.Rijken).
increasingproportionofthechronicallyillismultimorbid[e.g.4,5], caringforpeoplewithmultimorbidityalsoseemstobemorecom- plicated.
Asa response totherising numbersof peoplewith(single) chronicdiseasessuchasdiabetesandCOPD,manyEuropeancoun- trieshave implementeddisease managementprograms (DMPs) overthelastdecades[e.g.6,7].Althoughdefinitionsofdiseaseman- agementdiffer,itisgenerallyconsideredaprogrammaticapproach tocareprovidedbymultidisciplinaryteamsofcareproviders,sup- portingpatients’self-managementandcollectingdataonpatient outcomestomonitorindividualprogressandprogramresults[e.g.
8,9].However,mostDMPsarenotdesignedtomeetthevarious healthneedsofpeoplewithmultimorbidity,astheyfocusonsin- glediseases[6,7,10].Incountrieswherepeopleareenlistedwitha https://doi.org/10.1016/j.healthpol.2017.10.002
0168-8510/©2017TheAuthors.PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by- nc-nd/4.0/).
generalpractitionerinprimarycare,patientswithmultimorbidity maybebetteroff,astheprinciplesofprimarycare,i.e.,firstcontact, continuous,comprehensiveandcoordinatedcare[11],maybetter fittheirneeds.Hansenandcolleagues[12]foundbetter(self-rated) healthoutcomesinpeoplewithmultimorbiditylivingincountries withastrongprimarycarestructure,highcontinuityofcareand acomprehensiveprimarycaresystem.Nevertheless,manypeople withmultimorbidity(also)needspecializedcare,andinter-sectoral coordinationaswellascollaborationbetweenprimarycareand specializedcarestillshowmanyobstaclestoovercome[e.g.13].
Inaddition,ambulatoryspecialistandhospitalcareinEuropean countriesarealmostentirelyorganizedaroundmedicalspecialties focusingonspecificorgansystems,whichcarrieswithittheriskof losingsightofapatient’sintegralhealthcondition.Theso-called verticalsilosareanimportantreason whycareforpeoplewith multimorbidityissuboptimalinmanycountries.
Toreducefragmentationofcareandbettermeettheneedsof peoplewithmultimorbidity, alternativecaremodels havebeen developed[e.g.14–16]andseveralofthesemodelsarecurrently beingimplementedatalocallevelinEuropeancountries[17].A commonalityofthesemodelsisthattheyallcapturethenotion ofintegrated care.Theconceptofcareintegrationmayreferto varioustheoreticallydistinguisheddimensions,suchasthetypeof integration(e.g.functional,organizational,clinical),thebreadthof servicesprovidedandthedegreeofintegration(fromcollaboration ofseparateservicestofullintegration)[9,11].Asthesedimensions illustratethewiderangeofapproaches coveredbytheconcept, weadoptthebroadworkingdefinitionofNolte&Pitchforth[18]
thatbuildsonthegoalofintegratedcare:“anyinitiativeseekingto improveoutcomesforthosewith(complex)chronichealthprob- lemsandneeds,byovercomingissuesoffragmentationthrough linkageorcoordinationofservicesofdifferentprovidersalongthe continuumofcare.”
NolteandMcKee[9]initiallysuggestedthatdiseasemanage- mentandintegratedcaremightreflecttwoendsofaspectrumof approaches,withontheonehanddiseasemanagementtargeting personswithasinglechronicdiseaseandontheotherintegrated careprogramstargetingpersonswithmultiplechronicdiseases whooftenexperiencefunctionalimpairmentsaswell.However, thisunidimensionalviewmaynotfitthevarietyofcurrentcare approachestargetingpeoplewithmultiplechronicconditions,as NolteandPitchforthlaterrecognized[18].Moreover,itmaynotdo justicetothevariousneedsofpeoplewithmultimorbidity.Hopman andcolleagues[19]showedthatpeoplewithmultimorbidityvary greatlyregardingtheirneedsforcareandsupport:manyofthem do notexperiencemore healthproblems thanpeoplewithone chronicdisease,whereasothershavemanyproblemsandindiffer- entdomainsoflife,whichmayaskformoreextensive(integrated) careandsupport,e.g.includingmentalhealthcare,socialcareor communityservices.Assubpopulationsofpeoplewithmultimor- bidityhavedifferentneedsforcareandsupport,wealsoexpect careapproachestargetingthesesubgroupstoshowdifferentchar- acteristics.
Theaimofthispaperistogainmoreinsightinvariousintegrated carepracticesthathavebeendevelopedinEuropeancountriesto improve carefor populations withmultiple chronicconditions.
Ratherthanprofilingthesepracticesaccordingtodimensionsof theoretical models of integrated care, we describe and profile themaccordingtothewaymultimorbidityisapproachedinthese practices.Roughly speaking,three typesof multimorbiditycare practicescouldbedistinguishedinthisrespect:
1.practices thatfocus ona specificchronicdisease(‘indexdis- ease’)withotherchronicconditionsconsideredas(relatedor unrelated)comorbidities;suchpracticesmaydevelopfromsin- gleDMPsbyprovidingadditionalcareandsupportservicesfor
patientswhoneedextracareorsupportbecauseoftheircomor- bidities;
2.practiceswherethefocusisona specificcombinationoftwo orthreechronicdiseases,inwhichthiscombinationofdiseases couldbeconsideredasaspecificconditionanditsmanagement mightfollowdiseasemanagementprinciples;
3.practicesthatdonotfocusonspecific(combinationsof)chronic diseases,buthaveadoptedprinciplesofperson-centeredcare, inwhichassessingandprioritizingthehealthneedsofpersons withmultimorbidityguideindividualcaretrajectories.
In this paper we explore the occurrence of these types of practicesinEuropeancountriesandexaminewhethertheyshow specific characteristics, for instance whether practices with a disease-specificfocusofmultimorbidity(type1and2)havedif- ferent objectives or involve other types of care providersthan practiceswithanon-diseasespecificfocus(type3).Therefore,our firstresearchquestionsare:
1Which types of multimorbidity care practices, distinguished accordingtotheirmultimorbidityfocus,occurinEuropeancoun- tries?
2Dothesedifferenttypesofmultimorbiditycarepracticesshow specificcharacteristics,i.e.dotheydifferregardingtheirobjec- tives,providedcareorcareprovidersinvolved?
In addition to this profiling of integrated care practices for patientswithmultimorbidity, weaimtoexplore whetherchar- acteristicsofthenationalcontextrelatetothetypeofpractices thatoccurinEuropeancountries.Ideally,onewould expectthe healthneedsofapopulationtodetermine,atleasttosomeextent, thetype ofcarepracticesthathavebeendevelopedinacertain context.For instance,in countrieswitha relativelyhighpreva- lenceofspecificchronicdiseases,disease-specificmultimorbidity carepracticesmaybedevelopedmoreoften.Andincountrieswith arelativelyhighproportionofthepopulationaged80andover, onemightexpectnon-diseasespecificapproachestodominate,as especiallyamongtheelderlyamultiplicityofinterrelatedhealth problemsrequiringamoreholisticapproachisoftenseen.Schäfer andcolleagues[20]foundsomeevidencethatEuropeancountries haveindeedrespondedtochangesintheirpopulationsoverthe period1993–2012byincreasingtheinvolvementofgeneralprac- titionersinthetreatmentof(mainly)chronicdiseasesinthelast decade.
Apartfrompopulationcharacteristicsorneeds,characteristics ofthehealthsystemanditshealthworkforcemayalsorelateto thetype ofmultimorbidity carepractices thatoccurin acoun- try.Forinstance,weexpectnon-diseasespecificpracticestooccur moreoftenin countrieswhere primarycareservicescontribute moresubstantiallytothemanagementofchronicdiseasesandin countrieswitharelativelylargeproportionofgeneralistmedical practitioners,suchasgeneralpractitionersorprimaryhealthcare physicians.Non-diseasespecificpracticesmayalsobeseenmore oftenincountrieswithataxbasedfinancingsystemthanincoun- trieswithaninsurancebasedsystem,astheremaybelessbarriers betweendifferentsectorsofthehealthsystemandtherangeof servicestheycover(e.g.socialservices)intaxbasedsystems.Dif- ferenttypesofmultimorbiditycarepracticesmayalsobeseenin centralizedanddecentralizedhealthsystems,althoughitisdifficult toformulateanyhypothesesinthisrespect,giventhegreatvariety indecentralizedhealthsystems.Localgovernancemightfacilitate inter-sectoralintegration,whichcouldsupporttheimplementa- tionofnon-diseasespecificpractices.Forthepurposeofthispart ofourstudyweformulatedathirdresearchquestion:
3Do different types of multimorbidity care practices relate to characteristicsofthecountriesinwhichtheyoccur;morespecif- ically,tocharacteristicsoftheirpopulation,healthworkforceand healthsystem?
2. Methods
ForthisstudyweuseddatafromtheEuropeanICARE4EU(Inno- vatingcareforpeoplewithmultiplechronicconditions)project [21].Thisprojectwasinitiatedin2013tocontributetotheinnova- tionofcareforEuropeancitizenswithmultiplechronicconditions by gaining more insight into potentially effective and efficient patient-centered, multi-disciplinary care approaches that have beendevelopedandimplementedinEuropeancountriesorregions.
2.1. Datacollection
Expertorganizationsin31Europeancountriesidentifiedprac- ticesorprograms(furtherreferredtoas‘practices’)thatprovided careforpeoplewithmultimorbidity.Inclusion criteriaforthese practiceswere:
1.targetadultpeoplewithmultimorbidity,definedastwoormore medically(i.e. somaticand/or psychiatric) diagnosed chronic (notfullycurable)orlonglasting(atleastsixmonths)diseases, ofwhichatleastoneofa(primarily)somaticnature;
2.includeformalizedcollaboration(s)betweenatleasttwo ser- vices,includingmedicalservices;
3.evaluatedorplannedtobeevaluableinsomeway;
4.currentlyrunningorfinishedlessthan24monthsagoorstarting withinthenext12months.
Theeligibilityoftheidentifiedpractices wascheckedbythe ICARE4EUprojectteam.Subsequently,expertorganizationswere askedtosendinformationabouttheICARE4EUprojectandalink toanonlinequestionnairetothemanagersofalleligiblepractices theyhadidentifiedintheircountry.Thesemanagerswereaskedto
fillinthequestionnaire,whichwasavailableinelevenlanguages andcontainedquestionsonthemultimorbidityfocusoftheprac- ticeandabroadvarietyofcharacteristics,includingitsobjectives, thecareprovidersinvolvedandthetypesofcareprovided.
For thepurposeofthis study(research question3),wealso retrieveddatafromEuropeandatabaseswithcountrycharacter- istics,suchascharacteristicsoftheirpopulation,healthworkforce andhealthsystem.
2.2. Measures
2.2.1. Multimorbidityfocus
Afteranopenquestiontodescribebrieflyhowmultimorbid- itywasdefinedinthepractice,respondentsonthesurveywere askedtoindicatewhetherinthepracticemultimorbidityreferred to‘multimorbidityingeneral’,‘acombinationofspecificdiagnoses, namely...’(e.g.,type2diabetesanddepression)or‘aspecificdiag- nosis(“index disease”)witha varietyofpossiblecomorbidities, namely...’(e.g.,type 2diabeteswithanyotherchroniccondi- tion(s)).
2.2.2. Practicecharacteristics
2.2.2.1. Main objectives. We composed a list of 22 objectives that covered several areas for improvement of chronic care, such as access to services, identification of target groups, evidence-basedpractice, integrationofservices,quality ofcare, patient-centeredness, patient outcomes, service utilization and costs(seeTable1forspecificitems).Respondentswereaskedto tickallboxesthatappliedtothemainobjectivesofthepractice.
2.2.2.2. Providedcare. Respondentswereaskedtoindicatewhich typesofcare forpeoplewithmultimorbiditywere providedby thepractice.The18includedtypesofcarerelatedtoprevention, diagnostics,medicalcare,nursingcare,socialcare,informalcare, homecare,medicalandnon-medicaltreatments,medicationman- agement,adherence,casemanagement,careafterdischargefrom Table1
Mainobjective(s)ofthemultimorbiditycarepractices.
Total (N=112)
Disease-specific multimorbidityapproach (N=47)
Non-specific
multimorbidityapproach (N=65)
P-value (Chi-squaretest)
% % %
Improvingaccessibilityofservices 59.8 51.1 66.2 0.108
Reducinginequalitiesinaccesstocareandsupport services
47.3 40.4 52.3 0.214
Identificationoftargetgrouppatients 52.7 53.3 52.3 0.926
Promotingevidence-basedpractice 51.8 63.8 43.1 0.030
Improvingcarecoordination 71.4 70.2 72.3 0.809
Increasingmulti-disciplinarycollaboration 78.6 76.6 80.0 0.665
Improvingintegrationofdifferentunits(withinan organization)
54.5 46.8 60.0 0.167
Improvingintegrationofdifferentorganizations 48.2 34.0 58.5 0.011
Improvingpatientinvolvement 73.2 61.7 81.5 0.019
Improvinginvolvementofinformalcarers(e.g.family, friends,neighboursand/orvolunteers)
46.4 40.4 50.8 0.279
Improvingpatientsafety 56.3 46.8 63.1 0.087
Improvingearlydetectionofadditional/co-morbid diseases
42.0 48.9 36.9 0.204
Decreasing/delayingcomplications 64.3 70.2 60.0 0.266
Improvingfunctionalstatus(preventingorreducing functionaldisability)
55.4 57.4 53.8 0.705
Decreasingmorbidity 59.8 66.0 55.4 0.260
Decreasingmortality 47.3 55.3 41.5 0.149
Preventingorreducingmisuseofservices 38.4 36.2 40.0 0.681
Preventingorreducingover-useofservices 50.0 44.7 53.8 0.338
Reducinghospitaladmissions 67.9 66.0 69.2 0.714
Reducingemergency/acutecarevisits 58.9 57.4 60.0 0.786
Reducing(public)costs 60.7 59.6 61.5 0.834
hospital,rehabilitationandreintegration,andmonitoring.Respon- dentswereaskedtotickallboxesthatappliedtothepractice.
2.2.2.3. Careproviders involved. TheICARE4EU surveycontained one questionabout thetypes of servicesinvolved in theprac- tice(10 typesspecified and an option toadd othertypes; e.g., universityhospital,generalhospital,primarycarepractice,nurs- inghome,socialcareservice,pharmacy).Inaddition,thesurvey containeda questionaboutthetypesofcareprovidersinvolved (12options;e.g.,generalpractitioners,medicalspecialists,physio- therapists,socialworkers,informalcaregivers).Respondentswere askedtotickallboxesthatappliedtothepractice.Twoadditional itemswereincludedtoassesswhethersometypesofcareinte- grationappliedtothepractice,i.e.,coordinationofmedicalcare servicesandcollaborationbetweenmedicalandnon-medicalser- vices(answeringoptions:yes/no).
2.2.3. Countrycharacteristics
2.2.3.1. Populationcharacteristics/needs. Weincludedthreeindica- torstoassesstheneedsforintegratedcareofacountry’spopulation.
First,theproportionofthepopulationaged80andoverin2013.This indicatorwasretrievedfromthesetofEuropeanCoreHealthIndi- cators(ECHI)providedbyEurostat[22].Second,the(age-adjusted) prevalenceofdiabetesamongmenandwomenaged18andoverin 2014.ThisindicatorwasretrievedfromtheNCDRiskFactorCollab- oration(NCD-RisC)database[23].Andthird,theestimatedmean numberofself-reportedchronicconditionsamongacountry’spop- ulation.Thisindicatorwascomputedfromindividual-leveldata fromtheEurobarometersurveyoftheEuropeanCommission,wave 66.2,conductedin2006in29Europeancountries(26,778respon- dentsin27EUMemberStates)[24].Toassessthemeannumberof self-reportedchronicconditions13healthproblemsoftheEuro- barometer survey were takeninto account: diabetes; allergies;
asthma;hypertension(highbloodpressure);long-standingprob- lemswithmuscles, bones,andjoints (rheumatismor arthritis);
cancer;cataract;migrainesorfrequentheadaches;chronicbron- chitisoremphysema;osteoporosis;strokeorcerebralhemorrhage;
pepticulcer(gastricorduodenalulcer);and chronicanxietyor depression.
2.2.3.2. Healthworkforcecharacteristics. Weincludedthreechar- acteristicsofacountry’shealthworkforce.First,theproportionof generalistmedicalpractitionersamongthetotalnumberofphysicians in2013.ThisindicatorwascomputedfromEurostatdata:thenum- berofgeneralistmedicalpractitionersinacountryin2013divided bythetotalnumberofphysiciansinacountryonJanuary1,2013 [25].ForBulgariaandCyprusweuseddataof2014,asthenum- berofgeneralistmedicalpractitionersinthesecountrieswasnot availablefor2013.
Second,themediannumberofdisciplinesworkinginthe same primarycarepracticein2012,inadditiontogeneralpractitioner(s) (GP(s)).ThisvariablewasderivedfromtheQUALICOPCstudy[26]
andbasedonasurveyamonggeneralpractitionersin28European countries(responsetarget220GPspercountry)[e.g.27].Thesur- veyquestionwas:‘Whichofthefollowingdisciplinesareworking inyour practice/centre?’GPscouldselectfromalistof12pro- fessionalgroups:receptionist/medicalsecretary; practicenurse;
community/homecarenurse;psychiatricnurse;nursepractitioner (functionbetweenphysicianandnurse);assistantforlaboratory work;managerofthecentreorpractice(notaphysician);mid- wife;physiotherapist;dentist;pharmacist;socialworker.Foreach countrythemediannumberofdisciplinesworkingintheprimary carepractice,inadditiontotheGP(s), wascomputed(theoreti- calrange:0–12).Thethirdworkforcecharacteristicweincluded wasderivedfromthesamesurveyamongGPs:involvementofgen- eral practitionersin the treatmentof diseases in 2012. GPs were
asked to ratetheir involvement, on a scale from 1 ‘seldomor never’to4‘(almost)always’, inthetreatmentand follow-upof patientsbelongingtotheirpracticepopulationwiththefollow- ing12diseases:chronicbronchitis/COPD,hordeolum(stye),peptic ulcer, herniatic disclesion,congestive heart failure, pneumonia, peritonsillarabcess,Parkinson’sdisease,uncomplicateddiabetes (type2),rheumatoidarthritis,depression,andmyocardialinfarc- tion.Ascalescoreforeachcountrywascalculatedusingecometric analysis(latentmultilevelvariableanalysis),correctingfordiffer- encesinthenumberofrespondentspercountryandinindividual differencesamongtherespondents,andforvariationduetomea- surementerror[28,29].Scalescorescouldrangebetween1and4;
ahigherscoreindicatedmoreinvolvementofGPsinthetreatment ofthesediseases.
2.2.3.3. Healthsystemcharacteristics. Wealsoincludedthreebasic characteristicsofacountry’shealthsystem.Thefirstonewasthe totalexpendituresonhealthcareasproportionofthegrossdomes- ticproductofacountryin2013.Thisvariablewasretrievedfrom theWHOHealthAccountsdatabase[30].Second,weusedarough typologyofacountry’slevelof(de)centralizationofitshealthsystem:
eithera(more)centralizedora(more)decentralizedhealthsystem.
Thisvariablewasbasedonwhatleveldecisionmakingandexec- utivepowersweresituatedinacountry.Thethirdvariablewasa roughtypologyofacountry’sfinancingsystemofhealthcare:either (predominantly)taxbasedorinsurancebased/mixed.Thelasttwo variableswerederivedfromdescriptivedataincountries’latest (in2013)healthsystemreviewpublishedintheHealthSystemin Transitionseries[31].
2.3. Statisticalanalyses
Weconductedunivariate(frequencies)andbivariateanalyses (crosstabs with chi-square tests)to answer research questions 1 and 2 respectively. To answer research question 3, we con- ducted multilevel logistic regression analyses. We estimated a two-levelregressionmodel(level1:integratedcarepractices;level 2:countries)predictingthetypeofpractice:disease-specificversus non-specific(dependentvariable).Startingwithanullmodel,we estimated thetotal varianceat countrylevel. Subsequently,we estimatedasecondmodelincludingacountrycharacteristic(stan- dardizedincaseofacontinuousorcountvariable)asapredictor variableatcountrylevel.Theoddsratiowith95%confidenceinter- val,theZ-statisticandresultingP-valuewereprovidedforthefixed effectofthecountrycharacteristic.Inaddition,wecomputedthe proportionofvarianceatcountrylevelexplainedbythecountry characteristicincludedinthemodel.Thiswasdonebysubtracting theremainingvarianceatcountrylevelofthesecondmodelfrom thetotalvarianceatcountrylevelofthenullmodel,dividingthisby thevarianceatcountrylevelofthenullmodelandmultiplyingthe resultwith100(proportionalchangeofvariance(PCV))[32].Anal- yseswereconductedforeachcountrycharacteristicseparately.
3. Results
3.1. OccurrenceofmultimorbiditycarepracticesinEuropean countries
The31expertorganizationsidentified123practicesthatmetall inclusioncriteriain25countries.Insixcountriesnoeligibleprac- ticeswerefound;thesewereallEasternEuropeancountries.Most practiceswerefoundinSpain(15),theUK(12)andFrance(11).
However,duetostaffproblemsoftheFrenchexpertorganization, dataofthe11practicesidentifiedinFrancearemissing,resulting indataof112practicesavailableforanalysis.Thesepracticeswere operationalin south Europe(n=42),northwest Europe(n=26),
Table2
Typesofpreventionandcareprovidedbymultimorbiditycarepractices.
Total (N=112)
Disease-specific multimorbidity approach(N=47)
Non-specific multimorbidity approach(N=65)
P-value (Chi-squaretest)
% % %
Lifestyleandhealthbehaviour 65.2 63.8 66.2 0.799
Earlydetectionofnewcomorbidities 43.8 44.7 43.1 0.866
Prevention/delayofdeterioration 68.8 74.5 64.6 0.267
Prevention/reductionoffunctionaldisability 57.1 59.6 55.4 0.658
Diagnostics 47.3 57.4 40.0 0.068
Medicalcare 73.2 76.6 70.8 0.492
Nursingcare 64.3 55.3 70.8 0.092
Socialcare 43.8 34.0 50.8 0.078
Informalcare,workingwithcarersasco-careproviders 26.8 23.4 29.2 0.492
Informalcare,targetingcarersasco-clients 19.6 8.5 27.7 0.012
Homecare 48.2 36.2 56.9 0.030
Medicaltreatmentinterventions 62.5 68.1 58.5 0.299
Non-medicaltreatmentinterventions 50.0 51.1 49.2 0.848
Adherencetomedication 63.4 63.8 63.1 0.935
Adherencetonon-pharmaceuticalinterventions 48.2 51.1 46.2 0.608
Polypharmacymanagement 44.6 38.3 49.2 0.251
Casemanagement 39.3 29.8 46.2 0.080
Careafterdischarge 45.5 42.6 47.7 0.590
Rehabilitationandreintegration 50.9 48.9 52.3 0.725
Monitoring 55.4 57.4 53.8 0.705
Scandinavia(n=23),centralEurope(n=10),theBalticstates(n=6) andeasternEurope(n=5).
3.2. Multimorbidityfocus
Regardingtheir focus onmultimorbidity, 65 practices (58%) focusedonmultimorbidityingeneral,thustargetingpeoplewith anycombinationofchronicdiseasesorconditions.Thirtypractices (27%)focusedonaspecificchronicdisease(indexdisease)incombi- nationwithsomeoranyotherchronicconditions.Diabetesmellitus (type2)wasbyfarthemostfrequentlyreportedindexdisease, followedbyCOPD,asthmaandobesity. Mentaldisordersand/or behavioralproblemswerereportedthreetimesastheindexdis- easeandcancertwotimes.Hypertension,ischemicheartdisease, renaldisease,osteoarthritis,anxietyanddepressionwerethemost frequentlyreportedcomorbiditiesthatweretakenintoaccount.
Finally,17practices(15%)focusedonaspecificcombinationoftwo orthreechronicdiseases.Combinationsmostoftenincludeddia- betesmellitus,ischemicheartdisease,heartfailure,hypertension, renaldisease,COPDand/orasthma.Depressionanddementiawere bothreportedtwiceinthesecombinations.
Forfurtheranalyses,thepracticesfocusingonaspecificindex diseaseoronacombinationofspecificchronicdiseasesweretaken together,allowingustodistinguishtwotypesofpracticesaccord- ingtotheirmultimorbidityfocus:disease-specific(n=47)versus non-specific(n=65)practices. Peopleaged 65 andover aswell asfrailelderlyweresignificantlymoreoftenreportedtobespe- cifictargetgroupsofthelattertype;respectively55%versus29%
(P=0.007)and49%versus30%(P=0.039).
3.3. Characteristicsofdisease-specificversusnon-specific integratedcarepractices
3.3.1. Mainobjectives
In general,most frequently reportedmain objectives of the practicesweretoincreasemultidisciplinarycollaboration(79%), improvepatientinvolvement(73%)andcarecoordination (71%) (seeTable1).Practiceswithadisease-specificmultimorbidityfocus alsohadthepromotionofevidence-basedpracticeoftenasoneof theirmainobjectives(64%),whereasthiswassignificantlylessthe caseforpracticeswithanon-specificmultimorbidityfocus(43%).
Incontrast,thelatterpracticessignificantlymoreoftenaimedto
improvetheintegrationofdifferentorganization(59%vs34%)and theyalsomorefrequentlyaimedtoimprovepatientinvolvement (82%vs62%).
3.3.2. Preventionandcareincluded
Regardingthetypesofpreventionand/orcareprovidedbythe practices,Table2showsnosignificantdifferencesinpreventive activities(firstfouritems)anddiagnostics(fifthitem)betweenthe twotypesofmultimorbiditycarepractices,althoughthereseemed tobeslightlymoreemphasisonpreventionanddiagnosticsinthe practiceswithadisease-specificmultimorbidityfocus.Regarding thecareprovided,thepracticeswithanon-specificmultimorbid- ityfocus seemedtobemore comprehensive,asthesepractices moreoftenprovidedsupportforinformalcarers(28%vs9%)and homecare(57%vs36%).Nursingandsocialcarewerealsorela- tivelyfrequentlyprovidedbythepracticestargetinganon-specific multimorbiditypopulation,butthedifferenceswiththepractices withadisease-specificfocuswerenotsignificant.Thesameholds forcasemanagement,whichwasprovidedbyalmosthalfofthe practiceswithanon-specificmultimorbidityfocus(46%).
3.3.3. Servicesandcareprovidersinvolved
Primarycarewasmostofteninvolvedinbothtypesofmulti- morbiditycarepractices(71%),buttherewasatrendtowardsa morefrequentinvolvementofprimarycareinthepracticeswitha non-specificmultimorbidityfocus(77%vs62%).Ontheotherhand, inpracticesthatweretargetingpatientswithaspecificindexdis- easeorcombinationofdiseasesuniversityhospitalswererelatively frequentlyinvolved(47%),whilethesewereinvolvedinonlyone third(34%)ofthenon-specificmultimorbiditypractices.Significant differencesbetweenthetwopracticetypesexistedwithregardto theinvolvementofpharmacy(29%vs13%,P=0.039),socialservices (39%vs19%,P=0.028),communityorhomecareservices(43%vs 17%,P=0.004)andnursinghomes(31%vs13%,P=0.026).These differencesreflectthecomprehensivenessofthecareprovidedby thenon-specifictypeofmultimorbiditycarepractice.
Withregardtothecareprovidersinvolved,thesamepicture comestothefore.GPsweremostofteninvolvedinthemultimor- biditycarepractices(81%),regardlessoftheirmultimorbidityfocus.
Medicalspecialistsweresignificantlymoreofteninvolvedinthe practicesfocusingonaspecificindexdiseaseorcombinationof diseases(81%vs54%,P=0.003),whereashomehelpsanddistrict
M.Rijkenetal./HealthPolicy122(2018)44–5249 Relationshipsbetweencountry-levelcharacteristicsandthemultimorbidityfocusofthecarepractice;resultsoftwo-levellogisticregressionmodel;separateanalysesforeachcountrycharacteristic.
Dependentvariable:diseasespecificfocus(versusnon-specificfocus) Numberof
countries
Numberof practices
Oddsratio (95%-CI)
Z-statistic (P-value)
Varianceatcountrylevel
Nullmodel Modelwithcountry characteristicaspredictor variable
Proportionofvariance explainedbycountry characteristic Populationcharacteristics
Proportionofpopulationaged80andoverin2013 24 112 1.417
(0.696–2.887)
0.96(.337) 1.431 1.401 2.2
-Prevalenceofdiabetesinpopulationaged18and olderin2014:
-Men
24 112 0.741
(0.388–1.415)
−0.91(.364) 1.431 1.201 16.1
-Women 24 112 0.753
(0.403–1.406
−0.89(.373) 1.431 1.289 10.0
Meannumberofself-reportedchronicconditionsin 2006
20 98 0.755
(0.324–1.759)
−0.65(.515) 1.625 1.568 3.5
Healthworkforcecharacteristics
Proportionofgeneralistmedicalpractitionersin2013 24 112 1.046 (0.534–2.050)
0.13(.895) 1.431 1.436a 0.0
Mediannumberofextradisciplinesintheprimarycare practicein2012
23 108 0.465
(0.249–0.868)
−2.40(.016) 1.477 0.684 53.7
InvolvementofGPsintreatmentofdiseasesin2012 23 108 0.818 (0.404–1.658)
−1.12(.262) 1.477 1.420 3.9
Healthsystemcharacteristics
HealthexpendituresasproportionofgrossDMPin 2013
24 112 1.250
(0.670–2.329)
0.70(.483) 1.431 1.358 5.2
Centralizedhealthsystem(versusdecentralized) 23 111 2.029
(0.547–7.530)
1.06(.290) 1.424 1.169 17.9
Taxbasedfinancing(versusinsurancebased/mixed) 23 111 0.551
(0.140–2.173)
−0.85(.395) 1.424 1.340 5.9
aDuetoestimation,thisvariancecomponentisslightlylargerthantheestimatedvariancecomponentofthenullmodel.
orcommunitynursesweremoreofteninvolvedinthepractices withanon-specificmultimorbidityfocus,respectively49%versus 19%(P=0.001)and66%versus36%(P=0.002).
Coordinationof medicalserviceswasmoreoftenpartofthe practiceswithanon-specificmultimorbidity focus(68%vs49%, P=.046).Also,collaborationbetweenmedicalandnon-medicalser- viceswasmoreoftenpartofpracticesofthenon-specifictype(69%
versus47%,P=0.017).
3.4. Countrycharacteristicsrelatedtotypeofmultimorbidity carepractice
Theintraclasscorrelationcoefficientcomputedfromthetwo- level logisticregression model was0.303(se 0.150), indicating thatthewaymultimorbiditywasapproachedinthe112practices (eitherdisease-specificornon-specific)couldbeexplainedtosome extentbythecountriesinwhichtheyoccur.Thisimpliesthatprac- ticeswithadisease-specificfocusonmultimorbidity(compared toanon-specificfocus)weremoreoftenfoundinsomecountries thaninothers.Table3showsthattheonlycharacteristicthatwas ofpredictivevalueinthisrespectwasthenumberofdisciplines workinginthesameprimarycarepracticeastheGP(s).Incountries inwhichmoreotherdisciplinesworkintheprimarycareprac- tice,itismorelikelythatmultimorbiditycareapproacheswitha non-diseasespecificfocusoccur.
4. Discussion
4.1. Occurrenceofmultimorbiditycarepractices
InmanyEuropeancountriesintegratedcarepracticesthattar- getpeoplewithmultiplechronicdiseasesoccur,butnotalreadyon alargescale.Inmostcountriesonlyafewofsuchpracticescould beidentified.Insixofthe31countriesincludedinthisstudy,no suchpracticeswerefound.ThesewereallEasternEuropeancoun- tries,wheremultimorbiditymaybeevenmoreprevalentthanin otherEuropeanregions.For instance,resultsfromtheEuropean SHAREsurvey2010/2011showthehighestproportionsofpeople aged50orolderreportingmultiplechronicconditionsinHungary (58%),Estonia(56%)andPoland(55%)[33],allcountrieswhereno multimorbiditypracticeshad beenidentified bynationalexpert organisations.
4.2. Multimorbidityfocus
Morethanhalfoftheidentifiedpractices(58%)providecarefor multimorbidpatientswithanycombinationofchronicdiseases.
Halfofthesespecificallytarget(frail)olderpeoplewithmultiple chronicconditions.Thirtypractices(27%)focusonaspecificchronic disease(‘indexdisease’)incombinationwithsomeoranyother chroniccondition,and17practices(15%)focusonacombination oftwoorthreespecificchronicdiseases.
4.3. Non-specificmultimorbiditycarepractices
Practices of the non-specific type show characteristics that reflect a person-centered care approach. Key elements of person-centeredcare are (1) active participation of patients in goal-setting and decision-making about the care provided and self-managementof their conditions, (2) involvement of infor- malcarers,and(3)provisionofcoordinatedmultidisciplinarycare [34]. This studyshows that practices with a non-specific mul- timorbidity focus put more emphasis on patient involvement, involvementofinformalcarersasco-clients,involvementofnon- medicaldisciplinessuchasnursing,homecareandsocialcare,and oninter-organizationalcollaboration.Assuch,theymaybewell
preparedtoaddresssocialproblemsaswell,andtakevariationsin patients’needsoverthepatientjourneyintoaccount.
4.4. Disease-specificmultimorbiditycarepractices
Practicesthatfocusonmultimorbidityinpeoplewitha spe- cificchronicdisease(‘indexdisease’)mostoftentarget patients withtype2diabeteswhodevelopcomplicationsorcomorbidities.
Asdiabetestype2ishighlyprevalentinallEuropeancountries [35],thisisnotsurprising.Thereportedcomorbiditiessuggestthat manyofthepracticesofthistype,regardlessoftheirspecificindex disease,focusoncomorbiditiesrelatedtotheindexdisease.This findingsupportsthesurmisethatthesemultimorbiditycareprac- ticeshavedevelopedfromsinglediseaseDMPs.
Practicesthat focusonacombinationofspecificchronicdis- eases(withoutconsideringoneofthemastheindexdisease)do notdeviatemuchfromtheprevioustypeofpracticeswithregard tothechronicdiseasestheyfocuson,whichmakesdistinguishing thetwotypesarbitrary.Therefore,combiningthesetwotypesinto onecategoryofdisease-specificmultimorbiditypractices,aswedid inourbivariateanalyses,seemsjustified.
Disease-specific multimorbiditypractices areintegrated care practices just as well, as areDMPs for singlechronic diseases.
However,regardingthetype,breadthanddegreeof integration [9,11],thesepracticesreflectalessextensiveintegrationofcare.
Clinicalintegration,i.e.coordinationofcareandmultidisciplinary collaborationforindividualpatients,seemsasfrequentasinthe non-specificmultimorbiditycarepractices,butintegrationoforga- nizationsislessoftenseenandthebreadthofservicesprovidedis morelimited.Collaborationseemstobeconfinedtomedicaldisci- plines;non-medicalservicessuchassocialcareandhomecareare lessofteninvolved.Asmanypeoplewithtype2diabetes[e.g.,35,36]
and/orcardiovasculardisease[e.g.,37]and/orCOPD [e.g.,38]are olderpeople,itis unlikelythatthesepeoplearelessinneedof socialcareorcommunityservicesthanotherpeoplewithmulti- plechronicconditions.Forinstance,a studyintheNetherlands showedthatonlyalimitedpartofthetotalcareconsumptionof type2diabetespatientswascoveredbytheDutchcarestandard fordiabetestype2,whichdefinesthecareincludedintheregional DMPs[39].Thehighrateofmultimorbidity(60%)amongthedia- betespatientswasanimportantexplanationforthisfinding.DMPs aimtoimprovecarecoordinationforchronicdiseasepatients,but focusingonasinglediseaseor,inourcase,onalimitednumberof relatedcomorbiditiesmightincreasetheriskofneglectinghealth needsthatrequirecareandcoordinationbeyondtheDMP.Assuch, DMPsorotherintegratedcaremodelswithalimitedscopemay evenbecounter-productivetoimprovecareforpeoplewithmul- tiplechronicconditions.
4.5. Multimorbidityfocusinrelationtocharacteristicsofa country
Thecurrentstudyshowsthatnon-diseasespecificapproaches aremorelikelytooccurincountrieswheremoredisciplinesworkin thesameprimarycarepractice.Infact,themediannumberofdisci- plinesworkingintheprimarycarepractice,inadditiontoGPs,was theonlycountrycharacteristicincludedinthisstudythatsignifi- cantlyrelatedtothemultimorbidityfocusofthepracticeswefound inEuropeancountries.Forpeoplewithmultiplehealth(andsocial) problems,whoareoftenmistakenlylabeledascomplexpatients, suchprimarycarepracticesmightreducecarefragmentation,as thesecouldfunctionasa‘one-stopshop’.
Othercharacteristicsofthehealthsystemandhealthworkforce werenotdistinctive.Populationcharacteristicssuchasthepropor- tionofpeopleaged80orolderortheprevalenceofdiabetesina countrydidnotmakeadifferenceeither.Thismightreflectalack
ofpolicyregardingmultimorbiditycareatanationalorregional levelinmanyEuropeancountries[40].Futureplanningandpri- oritysettingregardingtheimplementationofintegratedcarefor peoplewithmultimorbidityinEuropeancountriescouldbenefit fromregularpopulationneedsassessments.
4.6. Strengthsandlimitations
The(lackof)findingsmentionedabovemaybeduetothelim- itednumber of practiceswe couldinclude,which resultedin a lackofpowertodemonstratesmalleffectsoftheincludedcountry characteristics.Moreover,thelimitednumberofpracticesdidnot allowustoconductanalyseswithmorerefinedcountrycharacter- isticsaspredictorvariables,forinstancemorerefinedmeasuresof acountry’shealthsystemoritsfinancingsystem.
Astrengthofthisstudyisthatexpertorganizationsfrom31 European countries were involved, which resulted in a broad overviewof multimorbiditycarepractices in Europe.Neverthe- less,wecannotbesurethatallpracticesthatmetourcriteriawere identifiedin acountry. However,wedo believethatthemulti- morbiditycarepracticesidentifiedintheICARE4EUprojectgivea goodimpressionoftherelativeoccurrenceanddistributionofsuch practicesacrossEuropeancountries,asacalltoreportonmultimor- biditycarepracticesinEuropeancountriesaspartoftheEUJoint Actiononchronicdiseasesandhealthyageingacrossthelifecycle (JA-CHRODIS)resultedinmanypracticesalreadyidentifiedbythe ICARE4EUexpertorganizations[41].Additionalpractices(N=18) identifiedbytheJA-CHRODISpartnersmostlyoccurredinSpain, whichhadalreadybeenidentifiedasthecountrywiththemost multimorbiditycarepracticesinEuropeintheICARE4EUproject.A limitationalreadymentionedintheResultssectionisthatthedata collectionofthemultimorbiditycarepracticesidentifiedinFrance failedduetostaffproblems.
Furthermore,thefactthatwedidnotusevalidatedquestion- nairestoassess thepracticecharacteristics(e.g.objectives,care providersinvolved)couldbeconsideredaweaknessofthestudy.
In2014,whenwecollectedthedata,questionnairescoveringour researchthemeswereneitheravailableinthemanylanguagesspo- kenin theEUnorvalidated inall countries.Therefore, we had todevelop thesurvey questions ourselves, which wasdoneby astepwiseapproach,inwhichtheresearchthemes(e.g.person- centeredness,integratedcare,financing)werefirstidentifiedbyall projectpartnerstogether,thenoperationalizedbasedontheoreti- calmodelsandempiricalstudiesbytheprojectpartnerwithexpert knowledgeoftheparticulartheme,andsubsequentlyformulated insurveyquestions,whichwerecommenteduponbyallproject partners.The(adapted)surveyquestionswerethenpretestedby theICARE4EUprojectpartnersintheirowncountry,andtranslated inelevenlanguages.
In this studywe used a quantitative analytical approach to answerourresearchquestions,whichsuitedtheexploratorypur- posewehad.Inthisway,wewereabletodescribeandcompare different types of multimorbidity care practices according to a numberofbasiccharacteristics.Togetabetterunderstandingof how these multimorbidity care practices have developed, how theyperformandwhichfactorsfacilitateorhindertheirimple- mentation,we also made site visits toeight of these practices andcollectedqualitativedatabymeansofinterviews,observation anddocumentanalysis.Theresultsofthequalitativedata-analysis provide more detailed insights in the actual performance and implementationstatusoftheseeightpractices[42–49](available fromwww.icare4eu.org), which couldsupport furtherdevelop- ment and implementation of multimorbidity care in European countries.
4.7. Considerationsforfutureresearchandpolicy
Although the limited number of practices included in this studycannotbeconsideredaweaknessofthestudyitself(itsim- plyreflectsthecurrentstateof multimorbiditycareinEurope), it restricted ouroptionstoanswerthe thirdresearch question.
However,astheburdenofmultimorbidityand thechallengeof providinggood-quality,effectiveandefficientcareformultimor- bidpatientsisrapidlyrisingonthepolicyagendainmanyEuropean countries,weexpectthenumberofmultimorbiditycarepractices toincreaseinthenearfuture.Thiswouldallowstudyingtherela- tionshipsbetweencharacteristicsofEuropeancountriesandthe characteristicsofthemultimorbiditycarepracticesfoundinthese countriesinmoredetail.However,forthispurposecompleteand comparabledataoncharacteristicsofEuropeancountriesarealso needed.Inaddition,thereisalackofdataallowingcross-country comparisonsonimportantindicatorsofmultimorbidity(e.g.preva- lence,healthcarequalityindicators),bothintheEuropeanUnion andworldwide.Aslongassuchdataarenotavailable,itisvery difficulttomonitordevelopments in theoccurrenceand distri- butionofmultimorbidityacrosscountriesandtocollaborate,for instanceintheEuropeanUnion,onmultimorbiditypreventionand management.
5. Conclusions
Inmany Europeancountriesintegrated careapproachesthat targetpeoplewithmultiplechronicconditionshavebeendevel- oped. Practices that focus on a specific index disease or a combinationofspecificchronicdiseasesarelessextensiveregard- ingthetype,breadthanddegreeofintegrationthanpracticesthat focusonanycombinationofchronicdiseases.Thesenon-disease specificpracticesputmoreemphasisonpatientinvolvementand providemorecomprehensivecare,whichareimportantprecon- ditionsforperson-centeredcare.Thistypeofmultimorbiditycare ismoreoftenseenincountrieswheremoredisciplinesworkin theprimarycarepracticewhereGPsareworking.Countriescould benefitfromthedevelopmentofindicatorsthat canbeusedto monitorandcomparetheprevalenceandburdenofmultimorbid- ityincountriesorregionsaswellastheprocessesandoutcomesof multimorbiditycare.
Conflictofintereststatement
Theauthorsdeclarethattheyhavenocompetinginterests.
Acknowledgements
ThispaperresultsfromtheInnovatingcareforpeoplewithmul- tiple chronic conditions (ICARE4EU)project, which has received fundingfromtheHealthProgrammeoftheEuropeanUnion.The contentofthispaperisthesoleresponsibilityoftheauthors;itcan- notbeconsideredtoreflecttheviewsoftheEuropeanCommission oranyotherbodyoftheEuropeanUnion.
Theauthorswishtothankallcountryexpertsandprogramman- agerswhocontributedtotheICARE4EUproject.Theauthorsalso thankdr.JohanHansenforhishelpinconstructingtheindicator ofthenumberofself-reportedchronicconditionsfromtheEuro- barometersurveydata.
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