加泰罗尼亚综合护理服务评估：基于人群和基于服务的真实生活部署方案。
Evaluation of integrated care services in Catalonia: population-based and service-based real-life deployment protocols.
机构信息
Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.
Center for Biomedical Network Research in Respiratory Diseases (CIBERES), Madrid, Spain.
出版信息
BMC Health Serv Res. 2019 Jun 11;19(1):370. doi: 10.1186/s12913-019-4174-2.
BACKGROUND
Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016-2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011-2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation. They reflect different implementation maturity levels. While full coverage of the entire urban health district of Barcelona-Esquerra (520 k inhabitants) is the main aim of home hospitalization, demonstration of sustainability at Hospital Clinic of Barcelona constitutes the core goal of the prehabilitation service. Likewise, full coverage of integrated care services addressed to frail chronic patients is aimed at the city of Badalona (216 k inhabitants).
METHODS
The population-based analysis, as well as the three service-based protocols, follow observational and experimental study designs using a non-randomized intervention group (integrated care) compared with a control group (usual care) with a propensity score matching method. Evaluation of cost-effectiveness of the interventions using a Quadruple aim approach is a central outcome in all protocols. Moreover, multi-criteria decision analysis is explored as an innovative method for health delivery assessment. The following additional dimensions will also be addressed: i) Determinants of sustainability and scalability of the services; ii) Assessment of the technological support; iii) Enhanced health risk assessment; and, iv) Factors modulating service transferability.
DISCUSSION
The current study offers a unique opportunity to undertake a comprehensive assessment of integrated care fostering deployment of services at regional level. The study outcomes will contribute refining service workflows, improving health risk assessment and generating recommendations for service selection.
TRIALS REGISTRATION
NCT03130283 (date released 04/06/2018), NCT03768050 (date released 12/05/2018), NCT03767387 (date released 12/05/2018).
背景
综合评估整合护理的实施情况是一项重大挑战，需要确保医疗政策和服务的质量、可持续性和可转移性，以实现协调服务提供的转变。为此，本文提出了四项不同的方案，旨在评估综合护理的大规模实施情况，这些方案正在区域项目 Nextcare（2016-2019 年）的框架内制定，旨在促进加泰罗尼亚（ES）技术支持服务的创新，为慢性病多病患者提供服务（750 万居民）。其中一个评估方案旨在评估 2011-2017 年期间区域一级的护理协调情况，而另外三个方案则是基于服务的方案，涉及：i）家庭住院；ii）大手术前康复；以及，iii）脆弱老年慢性病患者的社区干预。所有这三项服务都证明了其有效性和产生健康价值的潜力。它们反映了不同的实施成熟度水平。虽然巴塞罗那-Esquerra 整个城市卫生区（520 万居民）的全覆盖是家庭住院的主要目标，但巴塞罗那诊所前康复服务的核心目标是可持续性。同样，针对脆弱慢性病患者的综合护理服务的全覆盖是在巴达洛纳市（216 万居民）进行的。
方法
基于人群的分析以及三项基于服务的方案，均采用观察性和实验研究设计，使用非随机干预组（整合护理）与对照组（常规护理）进行比较，并采用倾向评分匹配法。所有方案的核心结果均为采用四重目标方法评估干预措施的成本效益。此外，还探索了多标准决策分析作为一种创新的医疗服务评估方法。还将解决以下附加维度：i）服务的可持续性和可扩展性的决定因素；ii）技术支持的评估；iii）增强健康风险评估；以及，iv）调节服务可转移性的因素。
讨论
本研究为在区域一级开展综合护理服务提供了一个独特的机会。研究结果将有助于完善服务工作流程，改进健康风险评估，并为服务选择提供建议。
试验注册
NCT03130283（2018 年 6 月 4 日发布），NCT03768050（2018 年 5 月 12 日发布），NCT03767387（2018 年 5 月 12 日发布）。
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