General Strategy of Evaluation
The essence of IC is ‘overlapping’ services in the secondary/primary interface after discharge in contrast to coordination at the management level alone (Gröne, 2002, p. 2). IC should apply only as far as quality outcomes are improved with the overall aim to improve equitably distributed population health (Gröne, 2002, p. 3). He illustrates the causal relationships derived from IC as reproduced in figure 1.
Figure 1. Action model for integrated care (IC)
Operational quality outcomes are crucial for the design of IC. Mortality is seldom a major indicator for IC. Typically, studies of effectiveness on IC address activities of daily living (ADL) as:
- 1.
Referrals to permanent institutional care (i.e. nursing homes)
- 2.
Independence in ADL as indicated by functional indices as Barthel Index (BI) or Functional Independence Measure (FIM)
- 3.
Shortened length-of-stay at hospitals / less readmissions
Evaluation of the relationship between IC and outcomes will follow best international practice as formalised in the international operation of Health Technology Assessment (HTA). According to the definition of HTA by EUnetHTA:
Health technology assessment (HTA) is a multidisciplinary process that summarises information about the medical, social, economic and ethical issues related to the use of a health technology in a systematic, transparent, unbiased, robust manner. It aims to inform the formulation of safe and effective health policies that are patient focused and seek best value.
HTA may address direct and intended consequences of technologies as well as indirect and unintended consequences. The main purpose of an HTA is to assist informed technology-based policymaking in health care. Most health professionals and many decision-makers in health care might comply with the conclusions from an HTA as far as it investigates all of the following aspects:
- 1.
Effectiveness regarding the physiologic outcome of the intervention
- 2.
Patient safety and satisfaction, solicited i.e. by focus group interviews
- 3.
Economic efficiency based on the principle of alternative costs
- 4.
Organizational implementation of the intervention