scispace - formally typeset
Search or ask a question

Showing papers in "International Journal of Integrated Care in 2002"


Journal ArticleDOI
TL;DR: The authors explore the intellectual territory of integrated care, and underscore the need for a patient-centric imperative and meaning, and the practical applications and implications arising from their views.
Abstract: Integrated care is a burgeoning field. As is often the case in new areas of inquiry and action, conceptual clarification is demanded. Without such attention, it would be difficult to advance theory and practice in this increasingly important professional arena. In the following discussion paper, the authors explore the intellectual territory of integrated care, and underscore the need for a patient-centric imperative and meaning. They also examine the practical applications and implications arising from their views. The intention is to stimulate fruitful dialogue and debate about what ‘integrated care’ could and should be.

996 citations


Journal ArticleDOI
TL;DR: From an historical and sociological perspective, integrated care has emerged as part of institutional efforts to break up professional fiefdoms, especially of subspecialists entrenched in hospitals, and to reorganise services around clinically integrated pathways and services for the patients as mentioned in this paper.
Abstract: From an historical and sociological perspective, ‘integrated care’ has emerged as part of institutional efforts to break up professional fiefdoms, especially of subspecialists entrenched in hospitals, and to reorganise services around clinically integrated pathways and services for the patients. It was the more enlightened part of what I have called the ‘buyers’ revolt’, which occurred in the 1980s when those who had long paid the bills (insurers, governments, employers) became so fed up by the waste, excesses, and variability of services delivered under professional dominance that they started to take forceful action w1x. This book is a masterpiece of historical work and organisational analysis of that revolt at its centre, the San Francisco Bay area.

773 citations


Journal ArticleDOI
TL;DR: This paper demonstrates a simple method to avoid over- or underestimation of the magnitude of intervention-related change over time due to the correlation between baseline and outcome assessments.
Abstract: This paper aims to identify problems in estimating and the interpretation of the magnitude of intervention-related change over time or responsiveness assessed with health outcome measures. Responsiveness is a problematic construct and there is no consensus on how to quantify the appropriate index to estimate change over time between baseline and post-test designs. This paper gives an overview of several responsiveness indices. Thresholds for effect size (or responsiveness index) interpretation were introduced some thirty years ago by Cohen who standardised the difference-scores ( d ) with the pooled standard deviation ( d /SDpooled). However, many effect sizes (ES) have been introduced since Cohen's original work and in the formula of one of these ES, the mean change scores are standardised with the SD of those change scores ( d /SDchange). When health outcome questionnaires are used, this effect size is applied on a wide scale and is represented as the Standardized Response Mean (SRM). However, its interpretation is problematic when it is used as an estimate of magnitude of change over time and interpreted with the thresholds, set by Cohen for effect size (ES) which is based on SDpooled. Thus, in the case of using the SRM, application of these well-known cut-off points for pooled standard deviation units namely: ‘trivial’ (ES Consequently, taking Cohen's thresholds for granted for every version of effect size indices as estimates of intervention-related magnitude of change, may lead to over- or underestimation of this magnitude of intervention-related change over time. For those researchers who use Cohen's thresholds for SRM interpretation, this paper demonstrates a simple method to avoid over-or underestimation.

399 citations


Journal ArticleDOI
TL;DR: The Care Transition Measure was developed with substantial input from older patients and their caregivers and may serve to fill an important gap in health system performance evaluation by measuring the quality of care delivered across settings.
Abstract: Background: To improve the quality of care delivered to older persons receiving care across multiple settings, interventions are needed. However, the absence of a patient-centred measure specifically designed to assess this care has constrained innovation. Objective: To develop a rigorously designed and tested measure, the Care Transition Measure (CTM). Setting: A large, integrated managed care organisation in Colorado with approximately 55,000 members over the age of 65 years. Participants: Patients 65 years and older who were recently discharged from hospital and received subsequent skilled nursing care in a facility or in the home. Methods: Six focus groups of older persons and their caregivers (n=49) were established. Standard qualitative analytic techniques were applied to written transcripts and four key domains were identified: (1) information transfer; (2) patient and caregiver preparation; (3) self-management support; and (4) empowerment to assert preferences. Specific CTM items were developed, pilot tested, and refined. Psychometric testing, conducted in a different population but selected using the same entry criteria (n=60), included content and construct validity, intra-item variation, and floor/ceiling properties. Results: Older patients and clinicians found the measure to be highly relevant and comprehensive (i.e. content validity). Construct validity was assessed by comparing items from the CTM to selected items from a measure developed by Hendriks and colleagues (Medical Care 2001; 39(3): 270–283). Inter-item Spearman correlations ranged 0.388–0.594. No significant floor or ceiling effects were detected. Conclusions: The CTM was developed with substantial input from older patients and their caregivers. Psychometric testing suggested that the measure was valid. The CTM may serve to fill an important gap in health system performance evaluation by measuring the quality of care delivered across settings.

215 citations


Journal ArticleDOI
TL;DR: The workshop of the EUPHA section Health Services Research took place on Thursday, December 8th, 2001 in Brussels at the annual conference of theEUPHA (European Public Health Association).
Abstract: The workshop of the EUPHA section Health Services Research took place on Thursday, December 8th, 2001 in Brussels at the annual conference of the EUPHA (European Public Health Association). The theme of the workshop was integrated care in an international perspective. Integrated care can be defined as a concept bringing together inputs, delivery, management and organisation of services related to diagnosis, treatment, care, rehabilitation and health promotion w1x.

66 citations


Journal ArticleDOI
TL;DR: A review of the Polish experience in integration/disintegration of health care systems is the main part of the article, which discusses the typologies, expected outcomes and forces aiming at health care integration.
Abstract: At the beginning of the article the typologies, expected outcomes and forces aiming at health care integration are discussed. Integration is recognised as a multidimensional concept. The suggested typologies of integration are based on structural configurations, co-ordination mechanisms (including clinical co-ordination), and driving forces. A review of the Polish experience in integration/disintegration of health care systems is the main part of the article. Creation of integrated health care management units (ZOZs) in the beginning of the 1970s serves as an example of structural vertical integration missing co-ordination mechanisms. ZOZs as huge, costly and inflexible organisations became subjects of public criticism and discredited the idea of health care integration. At the end of the 1980s and in the decade of the 1990s, management of public health care was decentralised, the majority of ZOZs dismantled, and many health care public providers got the status of independent entities. The private sector developed rapidly. Sickness funds, which in 1999 replaced the previous state system, introduced “quasi-market” conditions where health providers have to compete for contracts. Some providers developed strategies of vertical and horizontal integration to get a competitive advantage. Consolidation of private ambulatory clinics, the idea of “integrated care” as a “contracting package”, development of primary health care and ambulatory specialist clinics in hospitals are the examples of such strategies. The new health policy declared in 2002 has recognised integration as a priority. It stresses the development of payment mechanisms and information base (Register of Health Services – RUM) that promote integration. The Ministry of Health is involved directly in integrated emergency system designing. It seems that after years of disintegration and deregulation the need for effective integration has become obvious.

22 citations


Journal Article
TL;DR: In this article, the authors identify problems in estimating and the interpretation of the magnitude of intervention-related change over time or responsiveness assessed with health outcome measures and demonstrate a simple method to avoid over-or underestimation.
Abstract: This paper aims to identify problems in estimating and the interpretation of the magnitude of intervention-related change over time or responsiveness assessed with health outcome measures. Responsiveness is a problematic construct and there is no consensus on how to quantify the appropriate index to estimate change over time between baseline and post-test designs. This paper gives an overview of several responsiveness indices. Thresholds for effect size (or responsiveness index) interpretation were introduced some thirty years ago by Cohen who standardised the difference-scores (d) with the pooled standard deviation (d/SDpooled). However, many effect sizes (ES) have been introduced since Cohen's original work and in the formula of one of these ES, the mean change scores are standardised with the SD of those change scores (d/SDchange). When health outcome questionnaires are used, this effect size is applied on a wide scale and is represented as the Standardized Response Mean (SRM). However, its interpretation is problematic when it is used as an estimate of magnitude of change over time and interpreted with the thresholds, set by Cohen for effect size (ES) which is based on SDpooled. Thus, in the case of using the SRM, application of these well-known cut-off points for pooled standard deviation units namely: ‘trivial’ (ES<0.20), ‘small’ (ES≥0.20<0.50), ‘moderate’ (ES≥0.50<0.80), or large (ES≥0.80), may lead to over- or underestimation of the magnitude of intervention-related change over time due to the correlation between baseline and outcome assessments. Consequently, taking Cohen's thresholds for granted for every version of effect size indices as estimates of intervention-related magnitude of change, may lead to over- or underestimation of this magnitude of intervention-related change over time. For those researchers who use Cohen's thresholds for SRM interpretation, this paper demonstrates a simple method to avoid over-or underestimation.

20 citations


Journal ArticleDOI
TL;DR: In a series of studies, collaboration processes and health outcome for patients with musculoskeletal disorders between health centres with co-financing projects and control health centres without co- Financing projects are compared.
Abstract: In this paper, we present an ongoing research project aimed to determine the impact of co-financing on collaboration around patients with musculoskeletal disorders. A trial legislation that allows the social insurance, social services and health care services to unite in co-financing under joint political steering has been tested in different areas in Sweden. In a series of studies, we compare collaboration processes and health outcome for patients with musculoskeletal disorders between health centres with co-financing projects and control health centres without co-financing projects. In this paper the studies are described and some preliminary results are discussed.

19 citations


Journal ArticleDOI
TL;DR: The public Finnish social and health care system has been challenged by the economic crisis, administrative reforms and increased demands, and welfare clusters have been established, where the different sectors and the levels of care are seen as one entity.
Abstract: The public Finnish social and health care system has been challenged by the economic crisis, administrative reforms and increased demands. Better integration as a solution includes many examples, which have been taken to use. The most important are the rewritten national and municipals strategies and quality recommendations, where the different sectors and the levels of care are seen as one entity. Many reorganisations have taken place, both nationally and locally, and welfare clusters have been established. The best examples of integrated care are the forms of teamwork, care management, emphasis on non-institutional care and the information technology.

19 citations


Journal ArticleDOI
TL;DR: It is suggested that faster progress is being made in the horizontal integration of services between health and social care organisations than is the case for vertical integration between primary health care and specialist mental health care services.
Abstract: The development of integrated care through the promotion of 'partnership working' is a key policy objective of the Scottish Executive, the administration responsible for health services in Scotland. This paper considers the extent to which this goal is being achieved in mental health services, particularly those for people with severe and enduring mental illness. Distinguishing between the horizontal and vertical integration of services, exploratory research was conducted to assess progress towards this objective by examining how far a range of functional activities in Primary Care Trusts (PCTs) and their constituent Local Health Care Co-operatives (LHCCs) were themselves becoming increasingly integrated. All PCTs in Scotland were surveyed by postal questionnaire, and followed up by detailed telephone interviews. Six LHCC areas were selected for detailed case study analysis. A Reference Group was used to discuss and review emerging themes from the fieldwork. The report suggests that faster progress is being made in the horizontal integration of services between health and social care organisations than is the case for vertical integration between primary health care and specialist mental health care services; and that there are significant gaps in the extent to which functional activities within Trusts are changing to support the development of integrated care. A number of models are briefly considered, including the idea of 'intermediate care' that might speed the process of integration.

15 citations


Journal ArticleDOI
TL;DR: Existing measures of care co-ordination were not associated with inappropriate ED use in this study of older adults with complex care needs, and future research should focus on the development of new measures and on approaches that better isolate the role of careCoordination from other potential variables that influence utilisation.
Abstract: Objective: To investigate the association between care co-ordination and use of the Emergency Department (ED) in older managed care enrollees. Design: Nested case-control with 103 cases (used the ED) and 194 controls (did not use the ED). Patients and methods: Older patients with multiple chronic illnesses enrolled in a care management programme of a large group-model health maintenance organisation with more than 50,000 members over the age of 64. Better care co-ordination was defined as timely follow-up after a change in treatment; fewer decision-makers involved with the care plan; and a higher patient-perceived rating of overall care co-ordination. Logistic regression was used to assess the relationship between ED use (the outcome variable) and measures of care co-ordination (the predictor variables). Results: Self-reported care co-ordination was not significantly different between cases and controls for any of the four classifications of inappropriate ED use. Similarly, no differences were found in the number of different physicians or medication prescribers involved in the patients' care. Four-week follow-up after potentially high-risk events for subsequent ED use, including changes in chronic disease medications, missed encounters, and same day encounters, did not differ between subjects with inappropriate ED use and controls. Conclusion: Existing measures of care co-ordination were not associated with inappropriate ED use in this study of older adults with complex care needs. The absence of an association may, in part, be attributable to the paucity of validated measures to assess care co-ordination, as well as the methodological complexity inherent in studying this topic. Future research should focus on the development of new measures and on approaches that better isolate the role of care co-ordination from other potential variables that influence utilisation.

Journal ArticleDOI
TL;DR: It is argued that cultural and behavioural change is probably a far more appropriate and important requirement for success than a centrally directed approach that emphasises the rearrangement of structural furniture in delivering the NHS Plan.
Abstract: The current Labour Government has embarked on radical public sector reform in England. A so-called 'Modernisation Agenda' has been developed that is encapsulated in the NHS Plan--a document that details a long-term vision for health care. This plan involves a five-fold strategy: investment through greater public funding; quality assurance; improving access; service integration and inter-professional working; and providing a public health focus. The principles of Labour's vision have been broadly supported. However, achieving its aims appears reliant on two key factors. First, appropriate resources are required to create capacity, particularly management capacity, to enable new functions to develop. Second, promoting access and service integration requires the development of significant co-ordination, collaboration and networking between agencies and individuals. This is particularly important for health and social care professionals. Their historically separate professions suggest that a significant period of change management is required to allow new roles and partnerships to evolve. In an attempt to secure delivery of its goals, however, the Government has placed the emphasis on further organisational restructuring. In doing so, the Government may have missed the key challenges faced in delivering its NHS Plan. As this paper argues, cultural and behavioural change is probably a far more appropriate and important requirement for success than a centrally directed approach that emphasises the rearrangement of structural furniture.

Journal ArticleDOI
TL;DR: The factors predicting a negative attitude of Dutch GPs towards disease management dominate the Factors predicting a positive attitude, which are matters of belief, for example concerning improvements in the quality of care.
Abstract: Objective: To investigate the extent to which GPs in the Netherlands participate in disease management and how personal opinions, impeding and promoting incentives as well as physician characteristics influence their attitude towards disease management. Methods: The attitude-model of Fishbein and Ajzen was used to describe the attitude of GPs towards disease management and main influencing factors. After interviewing seventeen representatives of the GPs and testing a questionnaire, the final questionnaire was sent to all GPs in the Netherlands (7680 GPs) barring those involved in the testing of the questionnaire. Results: At least 10.4% of all Dutch GPs are active in disease management. The main factors predicting a positive attitude towards disease management are the following: GPs' opinion that they are improving quality and efficiency of care when executing disease management, presence of a good quality network between actors involved prior to the start of disease management, working in a health centre, and performing sideline activities besides their daily activities as GPs. The main factors predicting a negative attitude are: GPs' opinion that the investment-time is too high, lack of reimbursement for disease management activities, working in a solo practice, and not performing any sideline activities beside their daily activities as GP. Conclusions: The factors predicting a negative attitude of Dutch GPs towards disease management dominate the factors predicting a positive attitude. The arguments in favour of disease management are matters of belief, for example concerning improvements in the quality of care, while arguments against are more concrete barriers e.g. high workload and financial reimbursement. Placed on the innovation timeline, the 10.4% participation might be taken to represent the start of a trend.

Journal ArticleDOI
TL;DR: The Stroke Service Maastricht resulted in a higher number of patients who returned home after stroke, but not in a better health status, since patients in the usual care group received a higher volume of healthcare in the period of rehabilitation, which might be more efficient.
Abstract: Objective: To assess whether shared care for stroke patients results in better patient outcome, higher patient satisfaction and different use of healthcare services. Design: Prospective, comparative cohort study. Setting: Two regions in the Netherlands with different healthcare models for stroke patients: a shared care model (stroke service) and a usual care setting. Patients: Stroke patients with a survival rate of more than six months, who initially were admitted to the Stroke Service of the University Hospital Maastricht (experimental group) in the second half of 1997 and to a middle sized hospital in the western part of the Netherlands between March 1997 and March 1999 (control group). Main outcome measures: Functional health status according to the SIP-68, EuroQol, Barthel Index and Rankin Scale, patient satisfaction and use of healthcare services. Results: In total 103 patients were included in this study: 58 in the experimental group and 45 in the control group. Six months after stroke, 64% of the surviving patients in the experimental group had returned home, compared to 42% in the control group (p Conclusions: The Stroke Service Maastricht resulted in a higher number of patients who returned home after stroke, but not in a better health status. Since patients in the usual care group received a higher volume of healthcare in the period of rehabilitation, the Stroke Service Maastricht might be more efficient.

Journal Article
TL;DR: The workshop of the EUPHA section Health Services Research took place on Thursday, December 8th, 2001 in Brussels at the annual conference of theEUPHA (European Public Health Association).
Abstract: The workshop of the EUPHA section Health Services Research took place on Thursday, December 8th, 2001 in Brussels at the annual conference of the EUPHA (European Public Health Association) The theme of the workshop was integrated care in an international perspective Integrated care can be defined as a concept bringing together inputs, delivery, management and organisation of services related to diagnosis, treatment, care, rehabilitation and health promotion The theme was chosen because of its relevance to European health care systems In several European health systems, a development towards integrated care can be observed Partly, this takes place under the banner of 'managed care' experiments (eg in Switzerland), in which case an American form of integrated care is imported and moulded into the own, national health care system In other cases, however, the same type of development is named differently throughout European health care systems: eg 'shared care' (in Great Britain), or 'Vernetzung' (in Germany), or 'transmurale zorg' (in the Netherlands)

Journal ArticleDOI
TL;DR: In improving quality seen from a client perspective, one should focus on what is actually done for the client, rather than looking at the RIOs structure.
Abstract: Purpose: to determine if and how the outcome quality from a client perspective is related to process characteristics and structure of Regional Individual Needs Assessment Agencies (RIOs) regulating access to long-term care services in the Netherlands. Theory: because of decentralised responsibilities, ultimo 1999 85 RIOs were set up. RIOs differ in their structural and process characteristics. This could lead to differences in client quality. Insight into factors relating to client quality (e.g. client satisfaction) can improve the needs assessment process. Methods: Eighteen RIOs participated in this study. These RIOs each selected 120 clients, filled in forms about their needs assessment procedures and sent them a questionnaire assessing judgements, experiences and satisfaction with the RIO. Results: We received 1916 RIO-forms and 1062 client questionnaires. Eighty-two percent of the clients were satisfied with the RIO, the percentages not satisfied clients varied from 10 to 29% among items and working procedures. Satisfaction is mostly related to what is actually done for the client. Information aspects and providing choices are important determinants of client quality with the RIO. Conclusion: In improving quality seen from a client perspective, one should focus on what is actually done for the client, rather than looking at the RIOs structure.

Journal ArticleDOI
TL;DR: Recently a Dutch higher court judged that physicians should not be allowed to end the lives of patients for non-medical reasons.
Abstract: Recently a Dutch higher court judged that physicians should not be allowed to end the lives of patients for non-medical reasons. In the case before the court a general practitioner had ended the life of an elderly patient—a former member of the Dutch Senate—at the latter’s urgent and repeated requests. Although he had not been seriously ill and a consultant psychiatrist had not found any indications of psychiatric illness, the patient did not wish to go on living any longer.


Journal ArticleDOI
TL;DR: In 2011 the US National Health Expenditure is estimated to amount to $ 9,216 per capita: that is 17.0% of Gross Domestic Product (GDP) w1x.
Abstract: In 2011 the US National Health Expenditure is estimated to amount to $ 9,216 per capita: that is 17.0% of Gross Domestic Product (GDP) w1x. The authors Heffler c.s. give the warning that for 2001 health spending grew faster than expected. In that year and in 2002 the real health spending growth, that is growth without inflation, is expected to average 6.6% per year. Nevertheless they used as a yearly growth rate 3.8% for the period 2001–2011 because of a continued impact of managed care.

Journal ArticleDOI
TL;DR: The authors feel that achieving a consensus among players in the health care field remains elusive and suggest that the political solution may be in convincing the provinces to give over jurisdiction on health care to the federal government to carry out crucial reforms and policies.
Abstract: Steven Lewis and colleagues have produced a thoughtful article in the British Medical Journal w1x on the challenges facing the Canadian health care system. Lewis et al. point out that the Canadian health care system, an icon of Canadian values, is going through a period of turbulence and a crisis of confidence. They rightly point out that Canadians continue to favour a publicly funded, comprehensive health care system, but seem pessimistic about whether it is sustainable; and that increasing privatisation, in numerous forms, has crept into the system. Though numerous reports from federal and provincial governments have called for substantial reforms, the authors feel that achieving a consensus among players in the health care field remains elusive. To date, after withdrawing money from the health care system in the 1990s, the federal and provincial governments now have simply started to put more resources back into the system without carrying out the fundamental necessary reforms. Lewis and colleagues indicate that privatisation, seen by some as a solution, is really a red herring. They are right to be concerned about privatisation judging by recently published reports by a federal government senate committee w2,3x and an advisory commission to the Premier of the province of Alberta w4x. Lewis et al. suggest the need for primary care reform, implementation of population and health strategies, development and use of performance measures and other important reforms. They then suggest that the political solution may be in convincing the provinces to give over jurisdiction on health care to the federal government to carry out crucial reforms and policies. Lewis and colleagues may have in fact raised a red herring of their own suggesting that the federal government would somehow be more capable than the provinces in carrying out the important needed reforms to the Canadian health care system. In fact, it is interesting to note that in their article, Lewis et al. have not mentioned the fact that both Quebec w5x and Saskatchewan w6x have created independent ‘‘Royal-type’’ Commissions which, in the past year, have produced major recommendations for reform of their health care systems respecting the major principles and values of the Canadian health care system. In fact, the report of the Commission in Quebec (known as the Clair Commission) created a surprisingly major consensus among all the actors in the Quebec health care system. Consensus, therefore, is possible. The problem is not which level of government will carry out the necessary reforms but the capacity of governments to develop and implement medium and long-term strategy and planning, as well as the necessary investment in order to carry out these reforms. This is particularly true for carrying out primary care reform, an essential element in promoting greater integration of health care delivery at the local and regional levels. There is nothing to suggest that the federal government would be less driven by the immediate political electoral agenda and the day-to-day crisis management than the provincial governments.

Journal ArticleDOI
TL;DR: In a randomised trial of treatment in 610 patients with SCLC, 19 patients who had symptomatic cerebral metastases at presentation were treated initially with chemotherapy, and cranial irradiation withheld.

Journal ArticleDOI
TL;DR: People in the Western world are now living longer and leading healthier lifestyles than ever before, and, because of falling birth rates and lengthening life expectancy, populations are ageing.
Abstract: People in the Western world are now living longer and leading healthier lifestyles than ever before. And, because of falling birth rates and lengthening life expectancy, populations are ageing. A range of indicators ranging from life expectancy, infant mortality and maternal mortality confirm this trend. In Western Europe it is estimated that in another 5 years, i.e. by 2020, there will be 40% more people aged 75 and above than in 1990.

Journal ArticleDOI
TL;DR: Basing their policy on this theory, the New York Police and New York Transit Authority lowered the incidence of serious crimes from 626,182 in 1992 to 355,893 in 1997 w4x.
Abstract: The theory of the broken windows can explain much of the low incidence of integrated care. This theory of the criminologists (Kelling and Coles w3x) states that the incidence of crime depends more on the context than on personal characteristics of the criminal such as sex, age, race, education and cultural background. The theory got its name from the metaphor of a house with one broken window. When this window is not repaired, soon a second window will be broken. Then ordinary citizens become criminals by stealing everything valuable from the house. Basing their policy on this theory, the New York Police and New York Transit Authority lowered the incidence of serious crimes from 626,182 in 1992 to 355,893 in 1997 w4x. The new approach started in the subway and after its success it was expanded to the whole of New York. Each subway train was immediately repaired and repainted. Graffiti were removed during the night after discovery. Simultaneously, a zero tolerance policy was introduced with severe penalties for passengers who continued to demolish the trains. As a result, most of the passengers started to behave as good citizens. Total crime diminished, as the above mentioned figures indicate.