The cause for action? Decision making and priority setting in integrated care. A multidisciplinary approach

The expectations of patients have dramatically changed since the introduction of the first public health services more than a decade ago, as have the surrounding conditions a health system has to tackle. The grown health systems of the industrialised countries counter the challenges of an ageing society, technological advancement and chronic disease by a state of constant reform, which has been present for the last few years, without the abolition of the basic principles of affordability, accessibility and solidarity. One solution to answer all these expectations and requirements is so-called "integrated care", a patient-centred model, which propagates better processes, coordination and cooperation between the different service providers and sectors in health care. Based on a comprehensive discussion of the existing theories on health systems analysis, decision making and performance measurement in health as well as the trade-offs emerging therefrom, the first part of this thesis examines the changing conditions and expectations as well as problem areas of organisation and restructuring in health care systems. This analysis serves as a foundation for the introduction of the integrated care concept, an international expert questionnaire on the decision making in integrated care and conclusions on priority setting of decision makers in health. The analysis of the results demonstrates the high value that is placed on a clear political framework and incentives for the promotion of integrated care, as well as the substantive demand for improved communication, coordination and information structures. (author's abstract)


Introduction
Based on a comprehensive discussion of the existing theories on health systems analysis, decision-making and performance measurement in health as well as the trade-offs emerging therefrom, the first part of this thesis examined the changing conditions and expectations as well as problem areas of organisation and restructuring in health care systems. This analysis served as a foundation for the introduction of the integrated care concept, an international expert questionnaire on the decision-making in integrated care and conclusions on priority setting of decision-makers in health.
The theoretical layout of a literature review was transferred into the specific context of integrated care, first establishing the status quo of integrated care research and identifying open research questions of the field, being the results of an international scientific workshop. With these, the research question and the methodologies for the elaboration of the hypotheses were described, as well as the quantitative analysis with which the hypotheses were tested. For that matter, an international survey was conducted via an expert questionnaire, contacting integrated care managers and decision-makers in Europe, North America and Australasia. The response rate was 18% with the majority of responses coming from Germany, The Netherlands, UK and the USA.

Results and findings
Integrated care is stipulated to offer solutions to the demographic changes, the concurring increase of chronic disease and the pressures on restricted resources experienced in the modern health systems of today. The survey conducted during this research project, along with the literature presented, suggested a more diversified picture regarding the expectations and priorities set into the concept by health care decision-makers. While all of these challenges are perceived by them, their undisputed priority is on the introduction and enhancement of management structures on all levels. They do not value financial restrictions as severely as may have been anticipated and they revealed that neither active patient participation nor the introduction of outcome measurement are high priorities when introducing integrated care. Also, despite the propagation of being a new and improved form of service delivery, it has scarcely made the transition from project to programme implementation. Whether this fact stands in relation to the constant state of reform in which many health systems seem International Journal of Integrated Care -Vol. 10, 28 July 2010-ISSN 1568 to be caught up in, or whether this is an immanent trait of current integrated care models remains to be investigated.
In conclusion, two levels of priority setting have been identified as highly important for integrated care initiation: on the policy level, prioritisation of integrated care along with specific promotion measures influence decision-making; on the organisational level, the need for clear structures and better management tools both in the organisation itself and in the management of the targeted patient population, reflect the highest priorities for the decisionmaking process.

Implication for integrated care
Integrated care has come a long way from the first projects implemented by health insurance organisations to a colourful array of projects and permanent programmes, spanning from local to national level and from very targeted to very broad inclusion criteria, initiated, owned and financed by a mix of all stakeholders and agents in the system. Hence, integrated care developed into a 'Jack-ofall-trades' approach, stimulating change and confusion at the same time. Still, in most countries, it has not entered mainstream health care organisation and management and continues to struggle in proving its value. More data need to be collected on the influencing factors and interrelationships of agents and systems with regard to integrated care.
The results presented in this review are based on the author's thesis presented at the Vienna University of Economics and Business Administration on 1st July 2010.