Integrated Care for Multimorbidity Population in Asian Countries: A Scoping Review.

Background: The complex needs of patients with multiple chronic diseases call for integrated care (IC). This scoping review examines several published Asian IC programmes and their relevant components and elements in managing multimorbidity patients. Method: A scoping review was conducted by searching electronic databases encompassing Medline, Embase, Scopus, and Web of Science. Three key concepts - 1) integrated care, 2) multimorbidity, and 3) Asian countries - were used to define searching strategies. Studies were included if an IC programme in Asia for multimorbidity was described or evaluated. Data extraction for IC components and elements was carried out by adopting the SELFIE framework. Results: This review yielded 1,112 articles, of which 156 remained after the title and abstract screening and 27 studies after the full-text screening - with 23 IC programmes identified from seven Asian countries. The top 5 mentioned IC components were service delivery (n = 23), workforce (n = 23), leadership and governance (n = 23), monitoring (n = 15), and environment (n = 14); whist financing (n = 9) was least mentioned. Compared to EU/US countries, technology and medical products (Asia: 40%, EU/US: 43%-100%) and multidisciplinary teams (Asia: 26%, EU/US: 50%-81%) were reported less in Asia. Most programmes involved more micro-level elements that coordinate services at the individual level (n = 20) than meso- and macro-level elements, and programmes generally incorporated horizontal and vertical integration (n = 14). Conclusion: In the IC programmes for patients with multimorbidity in Asia, service delivery, leadership, and workforce were most frequently mentioned, while the financing component was least mentioned. There appears to be considerable scope for development. Highlights: First scoping review to synthesise the key components and elements of integrated care programmes for multimorbidity in Asia.All programmes emphasized 'distinctive service delivery', 'leadership', and 'workforce' components.'Financing' component was least mentioned in identified integrated care programmes.

Evaluating an integrated care pathway for frail elderly patients in Norway using multi-criteria decision analysis.

BACKGROUND: To provide value-based care for patients with multi-morbidity, innovative integrated care programmes and comprehensive evaluations of such programmes are required. In Norway, a new programme called "Holistic Continuity of Patient Care" (HCPC) addresses the issue of multi-morbidity by providing integrated care within learning networks for frail elderly patients who receive municipal home care services or a short-term stay in a nursing home. This study conducts a multi-criteria decision analysis (MCDA) to evaluate whether the HCPC programme performs better on a large set of outcomes corresponding to the 'triple aim' compared to usual care. METHODS: Prospective longitudinal survey data were collected at baseline and follow-up after 6-months. The assessment of HCPC was implemented by a novel MCDA framework. The relative weights of importance of the outcomes used in the MCDA were obtained from a discrete choice experiment among five different groups of stakeholders. The performance score was estimated using a quasi-experimental design and linear mixed methods. Performance scores were standardized and multiplied by their weights of importance to obtain the overall MCDA value by stakeholder group. RESULTS: At baseline in the HCPC and usual care groups, respectively, 120 and 89 patients responded, of whom 87 and 41 responded at follow-up. The average age at baseline was 80.0 years for HCPC and 83.6 for usual care. Matching reduced the standardized differences between the groups for patient background characteristics and outcome variables. The MCDA results indicated that HCPC was preferred to usual care irrespective of stakeholders. The better performance of HCPC was mostly driven by improvements in enjoyment of life, psychological well-being, and social relationships and participation. Results were consistent with sensitivity analyses using Monte Carlo simulation. CONCLUSION: Frail elderly with multi-morbidity represent complex health problems at large costs for society in terms of health- and social care. This study is a novel contribution to assessing and understanding HCPC programme performance respecting the multi-dimensionality of desired outcomes. Integrated care programmes like HCPC may improve well-being of patients, be cost-saving, and contribute to the pursuit of evidence based gradual reforms in the care of frail elderly.

Health-related quality of life of long-term patients receiving opioid agonist therapy: a nested prospective cohort study in Norway.

BACKGROUND: Opioid dependence carries the highest disease burden of all illicit drugs. Opioid agonist therapy (OAT) is an evidence-based medical intervention that reduces morbidity and mortality. There is limited knowledge on the health-related quality of life (HRQoL) of long-term patients in OAT. This study measures HRQoL and self-perceived health of long-term patients on OAT, compares the scores to a Norwegian reference population, and assesses changes in these scores at 1-year follow up. METHODS: We conducted a nested prospective cohort study among nine OAT outpatient clinics in Norway. 609 OAT patients were included, 245 (40%) followed-up one year later. Data on patient characteristics, HRQoL, and self-perceived health was collected. HRQoL was assessed with the EQ-5D-5L, which measures five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) on a five-point Likert scale (from "no problems" to "extreme problems"). An UK value set was applied to calculate index values (from 0 to 1) for the EQ-5D-5L and compare them to a Norwegian reference population. Self-perceived health was measured with EQ-VAS (from 0 to 100). RESULTS: Mean (standard deviation (SD)) EQ-5D-5L index value at baseline was 0.699 (0.250) and EQ-VAS 57 (22) compared to 0.848 (0.200) and 80(19) for the Norwegian reference population. There were large variations in EQ-5D-5L index values, where 43% had > 0.8 and 5% had < 0.2 at baseline. The lowest EQ-5D-5L index values were observed for female patients, age groups older than 40 years and for methadone users. At follow-up, improvements in HRQoL were observed across almost all dimensions and found significant for mobility and pain/discomfort. Mean (SD) overall index value and EQ-VAS at follow up were 0.729 (0.237) and 59 (22) respectively. CONCLUSION: The average HRQoL and self-perceived health of OAT patients is significantly lower than that of the general population, and lower than what has been found among other severe somatic and psychiatric conditions. Around 34% had very good HRQoL, higher than average Norwegian values, and around 5% had extremely poor HRQoL.

Skill mix and patient outcomes: A multi-country analysis of heart disease and breast cancer patients.

Policymakers are becoming aware that increasing the size of the healthcare workforce is no longer the most viable way to address the increasing demand for healthcare. Consequently, a focus of recent healthcare workforce reform has been extending existing roles and creating new roles for health professionals. However, little is known of the influence on outcomes from this variation in labour inputs within hospital production functions. Using a unique combination of primary and administrative data, this paper provides evidence of associations between the composition of care delivery teams and patient outcomes. The primary data enabled the construction of a task component-based measure of skill mix. This novel measure of skill mix has the advantage of capturing how workforce planning can restructure the relative input of nurses or physicians into task components while keeping the overall level of staff fixed. The analysis focuses on specific care pathways and individual hospitals, thus controlling for an under-investigated source of heterogeneity. Additionally, stratifying by country (England, Scotland, and Norway) enabled analysis of skill mix within different health systems. We provide evidence that variations in labour inputs within the breast cancer and heart disease care pathways are associated with both positive and adverse outcomes. The results illustrate the scope for substitution of task components within care pathways as a potential method of healthcare reform.

Digital Health Transformation of Integrated Care in Europe: Overarching Analysis of 17 Integrated Care Programs.

BACKGROUND: Digital health tools comprise a wide range of technologies to support health processes. The potential of these technologies to effectively support health care transformation is widely accepted. However, wide scale implementation is uneven among countries and regions. Identification of common factors facilitating and hampering the implementation process may be useful for future policy recommendations. OBJECTIVE: The aim of this study was to analyze the implementation of digital health tools to support health care and social care services, as well as to facilitate the longitudinal assessment of these services, in 17 selected integrated chronic care (ICC) programs from 8 European countries. METHODS: A program analysis based on thick descriptions-including document examinations and semistructured interviews with relevant stakeholders-of ICC programs in Austria, Croatia, Germany, Hungary, the Netherlands, Norway, Spain, and the United Kingdom was performed. A total of 233 stakeholders (ie, professionals, providers, patients, carers, and policymakers) were interviewed from November 2014 to September 2016. The overarching analysis focused on the use of digital health tools and program assessment strategies. RESULTS: Supporting digital health tools are implemented in all countries, but different levels of maturity were observed among the programs. Only few ICC programs have well-established strategies for a comprehensive longitudinal assessment. There is a strong relationship between maturity of digital health and proper evaluation strategies of integrated care. CONCLUSIONS: Notwithstanding the heterogeneity of the results across countries, most programs aim to evolve toward a digital transformation of integrated care, including implementation of comprehensive assessment strategies. It is widely accepted that the evolution of digital health tools alongside clear policies toward their adoption will facilitate regional uptake and scale-up of services with embedded digital health tools.

New professional roles and patient satisfaction: Evidence from a European survey along three clinical pathways.

This paper reports the results of an empirical analysis exploring the impact of new professions (eg a physician associate) and new professional roles on patient experiences of and satisfaction with care. A sub set of data from a patient survey conducted as part of the MUNROS programme of work was used. The overall survey aim was to describe and quantify the use of new professionals and new roles for established health care professionals other than medical doctors, in primary and secondary care sectors in three care pathways in nine European countries Ordered logit models were used to investigate the association between: (1) patient satisfaction with the last visit; (2) with their care provider; (3) with the information provided and a set of covariates explaining the involvement of new professional roles in three clinical pathways: type 2 diabetes, heart disease and breast cancer. For patients with breast cancer, high levels of satisfaction are associated with the involvement of new professions/professional roles in the provision of conditions specific education and monitoring. For patients with heart disease, the involvement of new professions/professional roles is likely to have a negative impact on satisfaction. For patients with Type 2 diabetes results are ambivalent. Patients belonging to countries experiencing innovative models of healthcare delivery and with high levels of involvement of new professions/professional roles are generally more satisfied. In conclusion, the introduction of new professions does not affect patient satisfaction negatively, therefore introducing new health professional roles is a pursuable strategy from a patient satisfaction perspective, at least for breast cancer and type 2 diabetes.

Strengthening the evidence-base of integrated care for people with multi-morbidity in Europe using Multi-Criteria Decision Analysis (MCDA).

BACKGROUND: Evaluation of integrated care programmes for individuals with multi-morbidity requires a broader evaluation framework and a broader definition of added value than is common in cost-utility analysis. This is possible through the use of Multi-Criteria Decision Analysis (MCDA). METHODS AND RESULTS: This paper presents the seven steps of an MCDA to evaluate 17 different integrated care programmes for individuals with multi-morbidity in 8 European countries participating in the 4-year, EU-funded SELFIE project. In step one, qualitative research was undertaken to better understand the decision-context of these programmes. The programmes faced decisions related to their sustainability in terms of reimbursement, continuation, extension, and/or wider implementation. In step two, a uniform set of decision criteria was defined in terms of outcomes measured across the 17 programmes: physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person-centeredness, continuity of care, and total health and social care costs. These were supplemented by programme-type specific outcomes. Step three presents the quasi-experimental studies designed to measure the performance of the programmes on the decision criteria. Step four gives details of the methods (Discrete Choice Experiment, Swing Weighting) to determine the relative importance of the decision criteria among five stakeholder groups per country. An example in step five illustrates the value-based method of MCDA by which the performance of the programmes on each decision criterion is combined with the weight of the respective criterion to derive an overall value score. Step six describes how we deal with uncertainty and introduces the Conditional Multi-Attribute Acceptability Curve. Step seven addresses the interpretation of results in stakeholder workshops. DISCUSSION: By discussing our solutions to the challenges involved in creating a uniform MCDA approach for the evaluation of different programmes, this paper provides guidance to future evaluations and stimulates debate on how to evaluate integrated care for multi-morbidity.

How do Hospitals Respond to Price Changes? Evidence from Norway.

Many publicly funded health systems use activity-based financing to increase hospital production and efficiency. The aim of this study is to investigate whether price changes for different treatments affect the number of patients treated and the mix of activity provided by hospitals. We exploit the variations in prices created by the changes in the national average treatment cost per diagnosis-related group (DRG) offered to Norwegian hospitals over a period of 5 years (2003-2007). We use the data from Norwegian Patient Register, containing individual-level information on age, gender, type of treatment, diagnosis, number of co-morbidities and the national average treatment costs per DRG. We employ fixed-effect models to examine the changes in the number of patients treated within the DRGs over time. The results suggest that a 10% increase in price leads to about 0.8-1.3% increase in the number of patients treated for DRGs, which are medical (for both emergency and elective patients). In contrast, we find no price effect for DRGs that are surgical (for both emergency and elective patients). Moreover, we find evidence of upcoding. A 10% increase in the ratio of prices between patients with and without complications increases the proportion of patients coded with complications by 0.3-0.4 percentage points.

Productivity losses in chronic obstructive pulmonary disease: a population-based survey.

OBJECTIVES: We aimed to estimate incremental productivity losses (sick leave and disability) of spirometry-defined chronic obstructive pulmonary disease (COPD) in a population-based sample and in hospital-recruited patients with COPD. Furthermore, we examined predictors of productivity losses by multivariate analyses. METHODS: We performed four quarterly telephone interviews of 53 and 107 population-based patients with COPD and controls, as well as 102 hospital-recruited patients with COPD below retirement age. Information was gathered regarding annual productivity loss, exacerbations of respiratory symptoms and comorbidities. Incremental productivity losses were estimated by multivariate quantile median regression according to the human capital approach, adjusting for sex, age, smoking habits, education and lung function. Main effect variables were COPD/control status, number of comorbidities and exacerbations of respiratory symptoms. RESULTS: Altogether 55%, 87% and 31% of population-based COPD cases, controls and hospital patients, respectively, had a paid job at baseline. The annual incremental productivity losses were 5.8 (95% CI 1.4 to 10.1) and 330.6 (95% CI 327.8 to 333.3) days, comparing population-recruited and hospital-recruited patients with COPD to controls, respectively. There were significantly higher productivity losses associated with female sex and less education. Additional adjustments for comorbidities, exacerbations and FEV1% predicted explained all productivity losses in the population-based sample, as well as nearly 40% of the productivity losses in hospital-recruited patients. CONCLUSIONS: Annual incremental productivity losses were more than 50 times higher in hospital-recruited patients with COPD than that of population-recruited patients with COPD. To ensure a precise estimation of societal burden, studies on patients with COPD should be population-based.

The impact of different prioritisation policies on waiting times: case studies of Norway and Scotland.

We investigate the distributional consequences of two different waiting times initiatives, one in Norway, and one in Scotland. The primary focus of Scotland's recent waiting time reforms, introduced in 2003, and modified in 2005 and 2007, has been on reducing maximum waiting times through the imposition of high profile national targets accompanied by increases in resources. In Norway, the focus of the reform introduced in September 2004, has been on assigning patients referred to hospital a maximum waiting time based on disease severity, the expected benefit and the cost-effectiveness of the treatment. We use large, national administrative datasets from before and after each of these reforms and assign priority groups based on the maximum waiting times stipulated in medical guidelines. The analysis shows that the lowest priority patients benefited most from both reforms. This was at the cost of longer waiting times for patients that should have been given higher priority in Norway, while Scotland's high priority patients remained unaffected.

An economic model to evaluate cost-effectiveness of computer assisted knee replacement surgery in Norway.

BACKGROUND: The use of Computer Assisted Surgery (CAS) for knee replacements is intended to improve the alignment of knee prostheses in order to reduce the number of revision operations. Is the cost effectiveness of computer assisted surgery influenced by patient volume and age? METHODS: By employing a Markov model, we analysed the cost effectiveness of computer assisted surgery versus conventional arthroplasty with respect to implant survival and operation volume in two theoretical Norwegian age cohorts. We obtained mortality and hospital cost data over a 20-year period from Norwegian registers. We presumed that the cost of an intervention would need to be below NOK 500,000 per QALY (Quality Adjusted Life Year) gained, to be considered cost effective. RESULTS: The added cost of computer assisted surgery, provided this has no impact on implant survival, is NOK 1037 and NOK 1414 respectively for 60 and 75-year-olds per quality-adjusted life year at a volume of 25 prostheses per year, and NOK 128 and NOK 175 respectively at a volume of 250 prostheses per year. Sensitivity analyses showed that the 10-year implant survival in cohort 1 needs to rise from 89.8% to 90.6% at 25 prostheses per year, and from 89.8 to 89.9% at 250 prostheses per year for computer assisted surgery to be considered cost effective. In cohort 2, the required improvement is a rise from 95.1% to 95.4% at 25 prostheses per year, and from 95.10% to 95.14% at 250 prostheses per year. CONCLUSIONS: The cost of using computer navigation for total knee replacements may be acceptable for 60-year-old as well as 75-year-old patients if the technique increases the implant survival rate just marginally, and the department has a high operation volume. A low volume department might not achieve cost-effectiveness unless computer navigation has a more significant impact on implant survival, thus may defer the investments until such data are available.

Monitoring prioritisation in the public health-care sector by use of medical guidelines. The case of Norway.

This paper presents a new way to monitor priority settings in public health-care systems. We take departure in medical guidelines prescribing acceptable waiting times for different medical descriptions. Allocating ICD10 codes to the medical descriptions, we are able to compare actual waiting times to the recommended maximum waiting times. This way we use the medical guidelines as a tool for monitoring prioritisation in the health sector. In an application, using data from the Norwegian Patient Register, we test statistically for compliance with the guidelines. The results indicate that patients suffering from the most severe conditions are receiving too low priority in the Norwegian health-care sector relative to patients of lower priority.

Excessive costs of COPD in ever-smokers. A longitudinal community study.

AIM: We aimed to estimate the societal treatment-related costs of COPD in hospital- and population-based subjects with spirometry defined COPD, relative to a control group. METHODS: 81 COPD cases and 132 controls without COPD were randomly recruited from a general population, as were 205 COPD patients from a hospital register. All participants were ever-smokers of at least 40 years of age, followed for 12 months. Data on comorbid conditions and spirometry were collected at baseline. Standardized telephone interviews every third month gave information on use of healthcare services and exacerbations of respiratory symptoms. RESULTS: The increased (excessive) median annual costs per case having stage II, stage III and stage IV COPD were € (95% CI) 400 (105-695), 1918 (1268-2569) and 1870 (1031-2709), respectively, compared to the population-based controls. Costs increased with €81 (95% CI 50-112) per exacerbation of respiratory symptoms and €461 (95% CI 354-567) per comorbid condition. Excessive costs for hospital COPD patients were threefold that of the population-based COPD cases. CONCLUSION: The excessive treatment-related cost of COPD stage II+ in ever-smokers of at least 40 years was estimated to €105 million for Norway. Comorbidity was a dominant predictor of excessive cost in COPD.

Prioritization and patients' rights: analysing the effect of a reform in the Norwegian hospital sector.

The right to equal treatment, irrespective of age, gender, ethnicity, socio-economic status and place of residence, is an important principle for several health care systems. A reform of the Norwegian hospital sector of 2002 may be used as a relevant experiment for investigating whether centralization of ownership and management structures will lead to more equal prioritization practices over geographical regions. One concern was variation in waiting times across the country. The reform was followed up in subsequent years by some other policy initiatives that also aimed at reducing waiting lists. We measure prioritization practice by a method that takes departure in recommended maximum waiting times from medical guidelines. We merge the information from the guidelines with individual patient data on actual waiting times for the period 1999-2005. This way we can monitor whether each patient in the available register of actual hospital visits has waited shorter or longer than what is considered medically acceptable by the guideline. The results indicate no equalization between the five new health regions, but we find evidence of more equal prioritization within four of the health regions. Our method of measuring prioritizations allows us to analyse how prioritization practice evolved over time after the reform, thus covering some further initiatives with the same objective. The results indicate that an observed reduction in waiting times after the reform have favoured patients of lower prioritization status, something we interpret as a general worsening of prioritization practices over time.

Aspects of healthcare utilisation in self-reported obstructive lung disease.

INTRODUCTION: Utilisation of healthcare resources because of pulmonary diseases have previously been presented according to lung function or symptom severity. We aimed to compare the associations of symptoms and lung function to healthcare and social service utilisation in subjects with self-reported obstructive lung diseases (OLDs) (asthma, chronic obstructive pulmonary disease, chronic bronchitis, emphysema). MATERIALS AND METHODS: Of 2819 participants aged 27-82 years in the Hordaland County Respiratory Health Survey, 200 subjects (7.1%) self-reported OLD. They answered 13 questions on respiratory symptoms and 5 questions on use of healthcare and social services. Altogether, 161 participants (81%) completed post-bronchodilation spirometry. RESULTS: Use of anti-asthmatic drugs, regular physician's appointment, sick leave payment for the last 12 months, hospital admission for the last 12 months and disability pension were reported by 68%, 63%, 18%, 8% and 7% of those with self-reported OLD, respectively. Twenty per cent of subjects with self-reported OLD had not received any healthcare or social services. In adjusted multivariate logistic regression analyses, increase in the respiratory symptom score was significantly associated with more healthcare and social services. Lower forced expiratory volume in 1 s in % predicted, however, was not significantly associated with more use of healthcare and social services. CONCLUSION: The majority (80%) of subjects in a general population with self-reported OLD received healthcare services. The utilisation of healthcare and social services was strongly associated to the burden of respiratory symptoms, and, to a lesser degree, to the level and pattern of lung function.

Unemployment, labor force composition and sickness absence: a panel data study.

Sickness absence tends to be negatively correlated with unemployment rates. In addition to pure health effects, this may be due to moral hazard behavior by workers who are fully insured against income loss during sickness and to physicians who meet demand for medical certificates. Alternatively, it may reflect changes in the composition of the labor force, with more sickness-prone workers entering the labor force in upturns. A panel of Norwegian register data is used to analyze long-term sickness absences. The unemployment rate is shown to be negatively associated with the probability of absence, and with the number of days of sick leave. Restricting the sample to workers who are present in the whole sample period, the negative relationship between absence and unemployment becomes clearer. This indicates that procyclical variations in sickness absence are caused by established workers and not by the composition of the labor force.

Wage policy in the health care sector: a panel data analysis of nurses' labour supply.

Shortage of nurses is a problem in several countries. It is an unsettled question whether increasing wages constitute a viable policy for extracting more labour supply from nurses. In this paper we use a unique matched panel data set of Norwegian nurses covering the period 1993-1998 to estimate wage elasticities. The data set includes detailed information on 19,638 individuals over 6 years totalling 69,122 observations. The estimated wage elasticity after controlling for individual heterogeneity, sample selection and instrumenting for possible endogeneity is 0.21. Individual and institutional features are statistically significant and important for working hours. Contractual arrangements as represented by shift work are also important for hours of work, and omitting information about this common phenomenon will underestimate the wage effect.