Health care pathways and expert patients: Do they improve outcomes?/Rutas asistenciales y paciente experto: ¿mejoran resultados?

One of the greatest challenges for health systems now and in the near future is caring for people with chronic conditions [1]. This is going to involve not only providing specific solutions for various groups of patients, but also working and, in particular, tackling challenging situations in a different way. Any one organisation or professional group alone cannot give a ‘magical’ or ‘universal’ answer to this problem. The approach must change, be multidisciplinary and subsidiary. It requires settings to be developed in which organisations and professionals not just fulfil their duties but do so in a cooperative, integrated manner, in an organisational model that is different from the current one [2]. In this context, in a territory of 124.65 km2, with catchment population of 180,000, one secondary care hospital and seven primary care teams (PCT), one of which has formed a consortium with the local council, a joint project was designed to approach the most common chronic diseases. The aims are to improve the quality and continuum of healthcare provided, holding a first meeting between healthcare levels, primary care (PC) and specialised care (SC), in order to establish care pathways (CPs) for the following diseases: type 2 diabetes mellitus (DM2), heart failure (HF), and chronic obstructive pulmonary disease (COPD).


Introduction
One of the greatest challenges for health systems now and in the near future is caring for people with chronic conditions [1]. This is going to involve not only providing specific solutions for various groups of patients, but also working and, in particular, tackling challenging situations in a different way. Any one organisation or professional group alone cannot give a 'magical' or 'universal' answer to this problem. The approach must change, be multidisciplinary and subsidiary. It requires settings to be developed in which organisations and professionals not just fulfil their duties but do so in a cooperative, integrated manner, in an organisational model that is different from the current one [2].
In this context, in a territory of 124.65 km 2 , with catchment population of 180,000, one secondary care hospital and seven primary care teams (PCT), one of which has formed a consortium with the local council, a joint project was designed to approach the most common chronic diseases. The aims are to improve the quality and continuum of healthcare provided, holding a first meeting between healthcare levels, primary care (PC) and specialised care (SC), in order to establish care pathways (CPs) for the following diseases: type 2 diabetes mellitus (DM2), heart failure (HF), and chronic obstructive pulmonary disease (COPD).
The overall objective of the project team was to improve the follow-up of chronic patients, using the International Journal of Integrated Care -Volume 12, 29 May -URN:NBN:NL:UI:10-1-112966 / ijic2012-31 -http://www.ijic.org/ CPs and involving nurses in the education of the COPD and HF patients, through an expert patient (EP) programme of the Catalan Institute of Health (ICS), that promotes self-care by exchanging knowledge between the EP and other participants with COPD and HF.

Description of the intervention
Working groups were established between professionals in SC and PC (a GP and a PC nurse). During 2010, these groups had regular meetings with others involved in the care pathways to establish the action protocols, based on clinical practice guidelines, and these were then presented to the rest of the PC and SC professionals.
In the team, the following specific objectives were set: for COPD, to increase the percentage of patients who, in the previous two years, have undergone spirometry and have been advised to give up smoking, and to decrease the number of admissions for exacerbations; HF: to increase the percentage of patients whose BMI has been measured in the previous year and whose status has been categorised according to the NYHA (New York Heart Association) functional classification, to visit patients under home care 2-3 times per year, to achieve appropriate prescription of beta-blockers, to improve the monitoring of blood pressure (BP), and to decrease the number of admissions for decompensation; and for DM, to increase the percentage of patients with cardiovascular risk assessments, with two measurements of weight and glycated haemoglobin (HbA1C )per year, and with acceptable control of HbA1C, blood pressure and BMI.
For this purpose, meetings were held between the members of the team in charge of the pathways, the management and the other health professionals involved. The aim of the these meetings being to make everyone aware of the pathways, provide disease updates and clinical follow-up; in which lists of patients poorly controlled according to the assessment indicators and incidents were distributed.

Discussion
Since the establishment of disease-specific care pathways, there has been an increase in the rates of detection and monitoring of the corresponding three diseases.
With regards to DM, it should also be highlighted that there was an increase in compliance with the protocol agreed between PC and SC, improving the 6-monthly measurements and recording of glycated haemoglobin levels, weight, and blood pressure, as well as calculation of BMI and assessment of cardiovascular risk. On the other hand, it may seem surprising that there was no increase in the percentage of patients with an acceptable control of their condition; indeed, the rate decreased. We attribute this to the increase in detection of new cases since the establishment of the care pathway.
As for HF, there was a notable the reduction in the number of hospital admissions for HF as well as the average hospital stay, which may be explained due to the increase in follow-up home visits by the end of the year, better control of blood pressure, spectacular increase in the review and modification of treatment with beta-blockers and monitoring of weight as an indicator of possible clinical worsening.
In the case of COPD, we highlight the increase in the rates of spirometry tests (in line with recommendations) and detection of cases with an obstructive pattern, although the rate of emergency admissions for exacerbations did not significantly change.
In addition, together with the care pathways, the EP programme of the ICS has had an impact: improving patient knowledge on their own disease and increasing self-care (lower scores on the European selfcare scale indicating better self-care). In turn, these two factors may also have helped achieve the reduction in the rate of the hospital admissions for HF. Finally, there was a notably high level of satisfaction among patients who participated in the EP programme.

Conclusions
Care pathways are a valid tool for achieving coordination between levels of care and increasing the involvement of professionals, leading to a clear improvement in process indicators. The EP programme does help patients increase their understanding of their condition and enable them to improve their quality of life.
Así mismo, el equipo tuvo como objetivo mejorar el seguimiento de los pacientes crónicos, a partir de las RA e implicar a enfermería en la educación del paciente EPOC e IC, mediante el programa paciente experto (PE) del "Institut Català de la Salut" que potencia el autocuidado mediante el intercambio de conocimientos entre un Paciente Experto (PE) y el resto de participantes con EPOC o IC.

Discusión
Desde la instauración de las RA cabe destacar el aumento de la detección y registro de las tres patologías para las cuales se han establecido las rutas.
En referencia a la IC, llama la atención la reducción del número de ingresos hospitalarios por IC y también la estancia media hospitalaria, que se podría explicar por el incremento de visitas domiciliarias de seguimiento al año, el mejor control de la TA, el espectacular incremento de la adecuación del tratamiento betabloqueante y el seguimiento del peso como indicador de descompensación.