In pursuit of evidence based integrated care
International Journal of Integrated Care, 1 November 2000 - ISSN 1568-4156
Editorial
In pursuit of evidence based integrated care

All over the world the need to improve the cost effectiveness and functioning of health services is seen to be of considerable importance. As part of this effort the removal of barriers and differences between systems providing preventive services, primary care, long term care and hospital care are disappearing. Preventive programs dealing with diseases such as cancer, coronary vascular diseases and AIDS are now closely linked to clinical treatment of these diseases. Primary care doctors and nurses care for patients who, in earlier years, stayed in facilities of long term care. Hospitals have shorter lengths of in-patient stays, discharging patients more rapidly to their own homes or to a nursing home. Patients with chronic conditions receive a variety of services, not only informal care, but also general and specialist medical treatment, nursing care as well as social care. Terminal patients receive all these health services simultaneously.

Most countries have their own words for integrated care. The Americans use the term “integrated care systems” as described in this IJIC issue by Kodner and Kay. In the United Kingdom the words “shared care” and “Primary Care Groups” are popular. The Netherlands uses the term “transmural” care. Other countries in Europe speak about “seamless care”, “continuous care” or just “integrated care”.

Although integrated care is a broad concept there are some developments outside the scope of this journal. For instance, we are only interested in American managed care and disease management, if they change the financing system but also integrate the provision of the different health care systems. Of course we are interested in multifactorial public health policy and interventions, but only as far as health care delivery is involved. European integration of health services and health policy is a theme for the IJIC, only if it links or coordinates aspects of two or more national health care systems. Finally, multidisciplinary teamwork within one and the same health care system is interesting for the IJIC, if this is seen to lead to a change in the relations with other health care systems.

The structures for integrated health services are different everywhere. In the Nordic countries, Southern Europe and in the United Kingdom health regions are important, within which comprehensive care is pursued. In the United States, old fashioned staff owned Health Maintenance Organizations as Kaiser Permanente coordinate preventive services, primary health care and hospital care. In the Rijnland democracies (Belgium, France, Germany, Switzerland and The Netherlands) social health insurance agencies or sick funds play an important role in the integration of health services. Comparing the outcome in terms of access, clinical effectiveness, continuity of care, patient assessments, efficiency and management assessments is of value.

Integrated health services seem to have some advantages over separate services. Most important is the shift for managers and professionals from responsibility for only delivered care to responsibility for the public health of the served population. There are also some organizational advantages. The entry to the system is easier to find because of a better overview for the public. The continuity of care is better guaranteed. It is easier to realize economies of scale and of scope. The quality of care increases because of easier multidisciplinary contacts.

On the other hand disadvantages seem to arise. The freedom of choice for the patient is challenged, if all care paths are too protocolized. An integrated health system may behave as a monopoly, being the only care provider in a town. An integrated health system that is too large confuses health care providers, it does not have its own culture and misses out on the small-was-beautiful-setting. There seems to be an optimum for integration: before and after that optimum is reached the quality of care diminishes. Where that optimum is, is a leading question of this Journal.

Not much empirical research has been done on access, quality and costs of integrated health care. To promote that kind of research and to distribute knowledge, is one of the objectives of the Journal. We are in pursuit of evidence based integrated care. Our mission is to be an eminent, international electronic journal in the area of integrated care for academics and professionals in the field. Our role model for the long run is to contain news, original papers, case reports, discussion notes and comments on developments. But we focus only on integrated care matters and do that electronically.

The Editors