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Identifying the target population for a people-centered, integrated chronic care program: a needs-based approach


Niels Hameleers ,

Maastricht University, NL
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Arianne Elissen,

Maastricht University, NL
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Mariëlle Kroese,

Maastricht University, NL
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Dirk Ruwaard

Maastricht University, NL
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Introduction: An estimated 50 million people in Europe suffer from chronic multimorbidity [1]. In the Netherlands, approximately 2 million people (13% of the population) have multiple chronic diseases [2]. Patients with multimorbidity are likely to have relatively high and complex healthcare demands [3].

Internationally, disease management (DM) programs are the norm for chronic care. These programs are based on disease-specific guidelines and tend to be highly standardized, which is often unsuitable for patients suffering from multimorbidity. The interacting effects of chronic diseases and their management require more complex and individualized care than simply the sum of separate, disease-specific guidelines [4]. Therefore, as the number of people with multimorbidity rises, finding disease-transcending solutions becomes increasingly important.

One initiative to find such a solution was taken last year by a primary care group (HZD) in the Netherlands. A primary care group is a collective of general practitioners (GPs) similar to Clinical Commissioning Groups in the UK, which supports GPs in the organization and delivery of DM programs. HZD caters to 129 GP-practices in the region, and covers a population of 481,842 patients. In response to GPs’ desire to work more holistically and efficiently - especially for patients suffering from multimorbidity - the care group decided to develop a generic (disease-transcending), people-centered, integrated chronic care program. Unique about the program is that patients’ actual care needs, rather than their specific conditions, are taken as starting point for program development.

The aim of this study is to define a suitable target group for the integrated care program, by investigating the characteristics of patients likely to benefit from the program. This is achieved by gaining insight into: (1) the prevalence of chronic diseases and multimorbidity in the population; and (2) the relations between patients’ healthcare use and their personal characteristics. Based on these insights, a relevant target group (including specific subgroups) for the integrated care program will be conceptualized.

Methods: The project was designed as a cross-sectional study, using anonymized data from GP information systems. Sixty-six GP practices authorized the use of their data, resulting in a research population of 291,031 patients. Descriptive analyses were performed on data from July 2014 to July 2016, to determine the prevalence of 28 chronic diseases and multimorbidity based on historic GP service use. Relations with healthcare use were analysed for age, sex, type and nature of chronic disease, multimorbidity (number of conditions), and socioeconomic status.

Results and discussion: Within the research population, 97,175 patients suffered from one (68% of these patients) or more (32%) chronic diseases, and/or partook in DM programs (43%). These patients had on average 10.7 (SD 9.3) consultations in the GP practice per year. Results showed an association between GP healthcare use and age, sex, number and type of chronic diseases. Moreover, chronic multimorbidity seemed to be associated with a higher overall GP healthcare use, also for non-chronic issues. Detailed results of the study will be presented during the conference.


1. van der Heide I, Snoeijs S, Melchiorre M et al. Innovating care for people with multiple chronic conditions in Europe. Brussels: ICARE4EU 2015.

2. Van Oostrom S, Picavet HSJ, Van Gelder B et al. Multimorbiditeit en comorbiditeit in de Nederlandse bevolking: gegevens van huisartsenpraktijken. 2011.

3. Salisbury C, Johnson L, Purdy S et al. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract 2011; 61: e12-e21.

4. van Weel C, Schellevis FG. Comorbidity and guidelines: conflicting interests. Lancet 2006; 367: 550-1.
How to Cite: Hameleers N, Elissen A, Kroese M, Ruwaard D. Identifying the target population for a people-centered, integrated chronic care program: a needs-based approach. International Journal of Integrated Care. 2017;17(5):A125. DOI:
Published on 17 Oct 2017.


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