Evaluation framework for healthcare integration pilots in the Basque Country/Marco evaluativo de las experiencias de integración asistencial en el País Vasco

The Basque Health Service is currently running a series of pilots in healthcare integration with the objective of obtaining better outcomes in the management of chronic patients, through an improvement in the quality of care and in resource use efficiency. Despite evidence that the effectiveness of specific interventions in the management of chronic patients, there is no sound evidence to assess the extent to which models and policies on health integration contribute to improvements in quality of care and cost reduction within health systems. In this context, it is essential to evaluate healthcare integration pilots to determine to what extent expected outcomes are achieved in the medium to long term and, therefore, how integration may contribute to the sustainability of health systems. Description


Introduction
The Basque Health Service is currently running a series of pilots in healthcare integration with the objective of obtaining better outcomes in the management of chronic patients, through an improvement in the quality of care and in resource use efficiency. Despite evidence that the effectiveness of specific interventions in the management of chronic patients, there is no sound evidence to assess the extent to which models and policies on health integration contribute to improvements in quality of care and cost reduction within health systems. In this context, it is essential to evaluate healthcare integration pilots to determine to what extent expected outcomes are achieved in the medium to long term and, therefore, how integration may contribute to the sustainability of health systems.

Description
The objective is to establish an evaluation framework to assess the healthcare integration pilots in the Basque Country that will make it possible to compare results at regional, national and international levels. The evaluation has structure, process and outcome elements (see Figure 1).

Methods
A series of indicators (see Table 1) for each of the dimensions were selected, on the basis of the international literature and clinical guidelines, by a group of multidisciplinary experts including primary and specialised care professionals (clinicians and managers), psychologists, pharmacists, economists and epidemiologists, among others.

Development
We have defined outcome indicators from a population perspective, bearing in mind that there is no single type of patient. Indeed, on the contrary, there is a wide range of types of patients with varying clinical risk and complexity. To consider this, we have stratified the population into three levels, identifying ad-hoc indicators for each level based on variables related to monitoring of patients, clinical effectiveness and quality of life (see Figure 2). Level 1 represents the general population for whom the focus is on promotion and prevention activities, while at Level 2 we need to consider disease management. Specifically, for this middle level, four medical conditions have been identified that, according to the literature, can benefit from an integrated approach to healthcare: diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), and heart failure (HF), as well as the presence of cardiovascular risk factors. Finally, Level 3 corresponds to patients with multiple diseases. In assessing patient satisfaction, the segment of the population a patient is in will be taken into account.
Both the indicator of "interprofessional collaboration" and those for "patient satisfaction" and "professional satisfaction" will be measured using questionnaires designed for the purpose. For the first of these, a questionnaire has been developed based on the D'amour model of interprofessional collaboration [1], with the collaboration of the original author. As for patient and professional satisfaction, we are currently translating and adapting (following the methodology recommended by WHO) the questionnaires developed by RAND, Ernst and Young, the Nuffield Trust and the English Department of Health to evaluate the integrated care pilots in England [2].
All the indicators of the "structure" and "process" elements have a scale ranging from 0 to 3: "degree of development: none-low-medium-high" while for "outcomes", the scale also ranges from 0 to 3: 0 meaning that the situation worsens, 1 that there has been no change, 2 that the situation has improved but objectives have not been met and 3 that objectives have been met or exceeded compared to the previous period.

Discussion and conclusions
Despite some international evidence that healthcare integration may improve the performance of systems, and patient quality of life and satisfaction, it is not clear that it will reduce costs (at least in the short term) or that any single combination of structures and methods will lead to optimal outcomes [3]. Given the fact that it is not possible to predict the outcomes of healthcare integration pilots, it is important that there is an evaluation process considering the various different aspects of integration. Accordingly, we have prepared an evaluation framework for the integration pilots running in the Basque Country, and this may be applicable to the evaluation of healthcare integration initiatives in other regions in Spain and beyond.

Introducción
Hoy en día, el Sistema Sanitario Vasco está desarrollando una serie de experiencias en el ámbito de la integración asistencial con el objetivo de conseguir mejores resultados en la gestión del paciente crónico, a través de la mejora de la calidad de la atención y de un uso más eficiente de los recursos. A pesar de que existe evidencia de la efectividad de intervenciones específicas en la gestión del paciente crónico, no hay estudios sólidos que determinen hasta qué punto los modelos y las políticas de integración asistencial pueden contribuir a la mejora de la calidad y la reducción de costes en el sistema sanitario. En este contexto, la evaluación de las experiencias de integración asistencial es clave de cara a mostrar en qué medida los resultados esperados se consiguen a medio y largo plazo y por tanto, la integración puede contribuir a la sostenibilidad del sistema sanitario.
En Marzo del año 2011 se ha iniciado el análisis de la situación basal de las experiencias de integración. A partir de ahí, se procederá a la evaluación anual de las mismas y de esta forma se podrán analizar sus resultados en los años subsiguientes.