An economic evaluation of a programme for chronic complex patients in a context of integration

Introduction: Serveis de Salut Integrats Baix Emporda, SSIBE (Integrated Health Services Baix Emporda) is a healthcare organization which provides primary, acute and chronic care to a population of 130,000 inhabitants (17% aged 65 and over) in Catalonia, Spain. SSIBE put into effect a Proactive Attention Programme for patients with chronic, complex conditions in 2011. The population was identified as Chronic Complex Patient (CCP) by a predictive model which was based on health status (provided by Clinical Risk Group –CRG- system), pharmaceutical expenditure, and utilization of health resources. The interventions of the programme were: 1- Identification label (2011): it was available in the electronic medical record to identify CCP; 2- CCP lists (2012): delivered to primary doctors encouraging them to do a proactive attention; 3- CCP Day Hospital (2012): it was put into effect for preventing emergency admissions; 4- Shared Individual Intervention Plan (2012) health professionals wrote down physical, psychic, and social necessities of the patients. 5- Support Programme for Discharges (from 2010 to 2013): specialised care notified primary care of discharges; In order to carry out the evaluation of the programme we grouped the target population into three groups randomly: the Partial Intervention Group (PIG): interventions 1 and 3-5 were applied; the Total Intervention Group (TIG): interventions from 1 to 5 were applied; and the Control Group (CG), usual care. Previously, we assessed the processes and clinical effectiveness of the programme and the findings didn’t show relevant differences among groups. That encouraged us to close the whole evaluation process through an economic evaluation to measure the economic impact of it. Theory / Methods: The objectives were: to determine which intervention group was the better option, to obtain basic information about costs and how these had evolved in time horizon; and to know better the consumption patterns of the interventions groups in the integration context. Method: economic evaluation - minimization-cost analysis. Catchment: 4 areas in Baix Emporda managed by SSIBE. Population target: 6,490 patients aged 18 and over. Time horizon: 2011 (zero year); 2012 (put into effect of the interventions); 2013 (consolidation of the programme). Perspective from analysis: 1) activity, individual contacts (visits, admissions, re-admissions, medical sessions, etc.) of patients done during the time horizon, and 2) costs, the activity expressed in monetary units. Both perspectives had the following approaches: - Annual analysis: it was considered the annual activity of target population. - Time-series analysis: it was considered the whole activity of non-exitus population who were assigned to the same group each year. Results: For the zero year, the per-capita cost (net of drug cost) was: CG: 2.300€, PIG: 2.500€, and TIG: 2.540€. For the following years, it increased in CG / TIG while in PIG, it decreased only in 2012. For the time-series, the per-capita cost increased in all groups. The range cumulative variation of percentage was: PIG: 20%; CG: 31%, TIG: 35%. Approximately 60% of patients with chronic, complex conditions needed one or two resources. Nearly 35% needed from three to four resources and only the 2% of them needed all resources available. Discussion: In spite of our findings which are similar to ones of the other research, we know better how the cost has change over time and which combination of resources was more common among all those with chronic, complex conditions. Conclusion: Nonetheless the per-capita cost increased in all groups during the time analysed, there is not a clear evidence to determine which intervention group is the better option. 1. Key findings to date: The factors which could have increased the per-capita cost can be: the exacerbations suffered by patients, the combination of three or more health resources, the major complexity of patients treated. 2. Lessons learned: To know about the consumption patterns of the patients can be a clue when we decide to put into effect health programmes. 3. Limitations: The factors which could have affected the programme can be the organizational culture, the behaviour consumption of patients, the time to consolidate the interventions of the programme, and the external factors such as economic crisis. 4. Future research: The consumption patterns of all those with chronic, complex problems could be a key to understand better how the integration, coordination context works.


Introduction: Serveis de Salut Integrats Baix Empordà, SSIBE (Integrated Health Services Baix
Empordà) is a healthcare organization which provides primary, acute and chronic care to a population of 130,000 inhabitants (17% aged 65 and over) in Catalonia, Spain. SSIBE put into effect a Proactive Attention Programme for patients with chronic, complex conditions in 2011.
The population was identified as Chronic Complex Patient (CCP) by a predictive model which was based on health status (provided by Clinical Risk Group -CRG-system), pharmaceutical expenditure, and utilization of health resources.
The interventions of the programme were: In order to carry out the evaluation of the programme we grouped the target population into three groups randomly: the Partial Intervention Group (PIG): interventions 1 and 3-5 were applied; the Total Intervention Group (TIG): interventions from 1 to 5 were applied; and the Control Group (CG), usual care.
Previously, we assessed the processes and clinical effectiveness of the programme and the findings didn't show relevant differences among groups. That encouraged us to close the whole evaluation process through an economic evaluation to measure the economic impact of it.
Theory / Methods: The objectives were: to determine which intervention group was the better option, to obtain basic information about costs and how these had evolved in time horizon; and to know better the consumption patterns of the interventions groups in the integration context.

Catchment: 4 areas in Baix Empordà managed by SSIBE.
Population target: 6,490 patients aged 18 and over. Perspective from analysis: 1) activity, individual contacts (visits, admissions, re-admissions, medical sessions, etc.) of patients done during the time horizon, and 2) costs, the activity expressed in monetary units.
Both perspectives had the following approaches: -Annual analysis: it was considered the annual activity of target population.
-Time-series analysis: it was considered the whole activity of non-exitus population who were assigned to the same group each year.
Results: For the zero year, the per-capita cost (net of drug cost) was: CG: 2.300€, PIG: 2.500€, and TIG: 2.540€. For the following years, it increased in CG / TIG while in PIG, it decreased only in 2012.
For the time-series, the per-capita cost increased in all groups. The range cumulative variation of percentage was: PIG: 20%; CG: 31%, TIG: 35%.
Approximately 60% of patients with chronic, complex conditions needed one or two resources. Nearly 35% needed from three to four resources and only the 2% of them needed all resources available.
Discussion: In spite of our findings which are similar to ones of the other research, we know better how the cost has change over time and which combination of resources was more common among all those with chronic, complex conditions. Conclusion: Nonetheless the per-capita cost increased in all groups during the time analysed, there is not a clear evidence to determine which intervention group is the better option.

Key findings to date:
The factors which could have increased the per-capita cost can be: the exacerbations suffered by patients, the combination of three or more health resources, the major complexity of patients treated.

Lessons learned:
To know about the consumption patterns of the patients can be a clue when we decide to put into effect health programmes.